distal versus proximal metatarsal osteotomy for the ...€¦ · distal versus proximal metatarsal...
TRANSCRIPT
Distal versus Proximal Metatarsal
Osteotomy for the Correction of
Hallux Varus as Complication of
Hallux Valgus Surgery
Joowon Joh, M.D., Kyungjin Choi, M.D.
Dr. Choi's Orthopedic Surgery Clinic, Seoul, Korea
AOFAS Annual Meeting 2015, Long Beach, California
Distal versus Proximal Metatarsal
Osteotomy for the Correction of
Hallux Varus as Complication of
Hallux Valgus Surgery
Joowon Joh, M.D.
My disclosure is in the Final AOFAS Mobile App.
I have no potential conflicts with this presentation.
No Conflict to Disclose
Introduction
Surgical options of hallux varus following surgery for hallux valgus
• Medial capsular release
• Corrective osteotomy
• Tendon transfer
• Arthrodesis
No studies comparing
the results of
corrective metatarsal
osteotomy at different
level
The Purpose of this study
To compare the clinical and radiological outcomes of two types of
metatarsal osteotomy in hallux varus deformity as complication of hallux
valgus surgery
: Distal chevron vs Proximal chevron
Hallux varus after hallux valgus surgery
Material and Methods(I)
Hallux varus correction following hallux valgus surgery by a single surgeon
Underwent chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release, but without tendon transfer
Two groups based on their operative treatment
• Distal chevron metatarsal osteotomies
• 22 patients
• Mean F/U of 23 months(14 to 42)
• All females
• Mean age 46.7 years
Group A
• Proximal chevron metatarsal osteotomies
• 26 patients
• Mean F/U of 20 months(12 to 47)
• All females
• Mean age 42.5yrs
Group B
Case
Pre-op. Pre-op. Post-op. Post-op.
F/52 F/49
Group A Group B
Material and Methods(II)
Clinical and radiographic assessment • American Orthopaedic Foot and Ankle Society(AOFAS) scoring system
• Hallux valgus angle(HVA)
• First-second intermetatarsal angle(IMA)
• Distal metatarsal articular angle(DMAA)
• Mean relative length ratio of the first and second metatarsals
Statistical analysis
• Paired t-test and independent t-test
• Mann-Whitney’s U-test
• P<0.05
• SPSS 12.0 for windows
Results(II) – Intragroup comparison
Pre OP Post OP
P value
Group A 1.01 0.98 P<0.05
Group B 0.98 0.97 P<0.05
0
20
40
60
80
100
Group A Group B
Pre-op.
Post-op.
-20
-10
0
10
20
HVA IMA DMAA
-20
-10
0
10
HVA IMA DMAA
Clinical Assessment
Group A Group B
Mean relative length ratio of the 1st. and 2nd. metatarsals
Radiographic Assessment
AOFAS score
• P<0.05
° °
° ° *
* , Paired t-test. The p values are for intragroup comparisons.
Results(II) – Intergroup comparison
Pre- and Post-operative data Group A
(N = 22) Group B
(N = 26) P-value
AOFAS 77 → 92 72 → 90 0.482
HVA, degree -11.9 → 5.1 -13.1 → 4.8 0.885
IMA, degree -0.5 → 2.7 -1.5 → 8.3 0.041
DMAA, degree 11.7 → 1.2 8.5 → 5.7 0.033
Mean relative length ratio of the
1st. and 2nd. metatarsals 1.01 → 0.98 0.98 → 0.97 0.297
*
*, Mann-Whitney U-test & independent t-test. The p values are for intergroup comparisons.
Discussion(I)
Combined causes of hallux varus following surgery for hallux valgus
• Excessive lateral release
• Excision of the lateral sesamoid or latereal head of the FHB
• Overcorrection of the IMA
• Excessive medial capsulorrhaphy
• Excessive resection of the medial eminence
Main cause from the radiographs of the 48 feet in our study
Overcorrection of the IMA
Excessive excision of the medial eminence with
overcorrection of the IMA
Soft-tissue imbalance with an IMA > 0° 31 feet(65%)
7 feet(15%)
10 feet(20%)
∴ We performed metatarsal osteotomy rather than
soft tissue procedure alone.
Discussion(II)
Chevron ostetotomy with a medial closing wedge is a reliable operation for improvement of the DMAA, IMA and joint congruity.
We found that
Proximal chevron osteotomy with medial closing wedge
“ 6.6° greater increase in the correction of the 1st. And 2nd. IMA”
Distal chevron osteotomy with medial closing wedge “ 7.7° greater decrease in the correction of DMAA ”
Hallux valgus had been treated by scarf osteotomy in 30 patients(63%) and proximal chevron osteotomy in 18 patients(37%), but we could not determine which type of osteotomy is more likely to lead to hallux varus.
Conclusion
Both distal chevron and proximal chevron osteotomy…
• Capable of adequately correcting hallux varus
• Not significantly different except for the correction power of the first-second IMA and DMAA
∴ Precautious review should be taken into
consideration when choosing the level of
metatarsal osteotomy due to different correction
power associated with each technique.
Reference
1. Bilotti MA, Caprioli R, Testa J, Cournoyer Jr, Esposito FJ.: Reverse Austin osteotomy for correction of hallux varus. J. Foot Surg., 26(1):51-5, 1987.
2. CHOI, K. J., et al.: Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus. J Bone Joint Surg Br August 2011 vol. 93-B no. 8 1079-1083. http://dx.doi: 10.1302/0301-620X.93B8.26430
3. Davies, MC; Parker, BC: Idiopathic hallux varus. Foot Ankle Int 16:210-211, 1995.
4. Donley, BG: Acquired hallux varus. Foot Ankle Int 18:586-592, 1997.
5. Groulier, P; Curvale, G; Coillard, JY; Franceschi, JP: [Post-operative iatrogenic hallux varus. Surgical treatment. Apropos of 19 cases]. Rev Chir Orthop Reparatrice Appar Mot 78:449-455, 1992.
6. Hawkins, F.B.: Acquired hallux varus: cause, prevention and correction. Clin. Orthop., 76:169-176, 2971.
7. Joseph, B.; Jacob, T.: and Chacko, V: Hallux varus – a study of thirty cases. J. Foot Surg., 23: 392-397, 1984.
8. Miller, J. W.: Acquired hallux varus: preventable and correctable disorder. J. Bone and Joint Surg., 57-A:183-188, March 1975.
9. Rochwerger A, Curvale G, Groulier P.: Application of a bone graft to the medial side of the first metatarsal head in the treatment of hallux varus. The Journal of Bone and Joint Surgery 1999;81A(12):1730-5.
10. Saraiya, H: Post-burn hallux varus: a case report and management of a rare deformity. Burns 26:593- 598, 2000. http://dx.doi.org/10.1016/S0305-4179(00)00032-2
11. Vanore.. JV; Christensen, JC; Kravitz, SR, et al.: Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: Hallux varus. J Foot Ankle Surg 42:137-142, 2003. http://dx.doi.org/10.1016/S1067-2516(03)70016-7