Though there are many techniques utilised in the correction of hallux valgus (HV), no single approach has been reported to be ideal for all patients to date. A great deal of controversy remains concerning the type of osteotomy, method of fixation, and inclusion of soft tissue procedures. Herein, we compared the outcomes of two different operative techniques, the minimally-invasive modified percutaneous technique and the distal chevron osteotomy, used to treat mild to moderate hallux valgus. This study was conducted in line with the CONSORT 2010 guidelines. 41 patients (58 feet) with mild to moderate hallux valgus were randomly assigned by computer to two different groups. The first group containing 24 patients (33 feet) was treated by the modified percutaneous technique, whereas the second group included 17 patients (25 feet) treated by distal chevron osteotomy. In the modified percutaneous group, after a mean follow up of 43 months, the mean correction of hallux valgus angle (HVA) was 26.69° (P=0.00001), the mean correction of intermetatarsal angle (IMA) was 9.45° (P=0.00001), and the mean improvement of AOFAS score was 47.94 points (P=0.00001). In the chevron osteotomy group, after a mean follow up of 44 months, the mean correction of hallux valgus angle was 26.72° (P=0.00001), the mean correction of intermetatarsal angle was 9° (P=0.00001), and the mean improvement of AOFAS score was 44.76 points (P=0.00001). In our study, the modified percutaneous technique proved to be equally effective as the distal chevron osteotomy, but with fewer complications and a higher rate of patient satisfaction

Aims. The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus. Patients and Methods. We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51). Results. The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6. o. to 12.8. o. (p < 0.001) and from 22.1. o. to 7.1. o. , respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23. o. to 9.7. o. The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients). Conclusion. These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202–7

Moderate to severe hallux valgus is conventionally treated by proximal metatarsal osteotomy. Several recent studies have shown that the indications for distal metatarsal osteotomy with a distal soft-tissue procedure could be extended to include moderate to severe hallux valgus. The purpose of this prospective randomised controlled trial was to compare the outcome of proximal and distal Chevron osteotomy in patients undergoing simultaneous bilateral correction of moderate to severe hallux valgus. The original study cohort consisted of 50 female patients (100 feet). Of these, four (8 feet) were excluded for lack of adequate follow-up, leaving 46 female patients (92 feet) in the study. The mean age of the patients was 53.8 years (30.1 to 62.1) and the mean duration of follow-up 40.2 months (24.1 to 80.5). After randomisation, patients underwent a proximal Chevron osteotomy on one foot and a distal Chevron osteotomy on the other. At follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score, patient satisfaction, post-operative complications, hallux valgus angle, first-second intermetatarsal angle, and tibial sesamoid position were similar in each group. Both procedures gave similar good clinical and radiological outcomes. This study suggests that distal Chevron osteotomy with a distal soft-tissue procedure is as effective and reliable a means of correcting moderate to severe hallux valgus as proximal Chevron osteotomy with a distal soft-tissue procedure. Cite this article: Bone Joint J 2015;97-B:202–7

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity. Cite this article: Bone Joint J 2013;95-B:510–16

Background: The purpose of this study was to evaluate the results after hallux valgus surgery by transar-ticular adductor tenotomy, distal Chevron metatarsal osteotomy and Akin phalangeal osteotomy using medial one incision. Materials and Methods: From June 2004 to June 2007, eighty feet of 54 patients were included in this study. During the same period, other cases of hallux valgus correction were excluded. Thirty seven patients underwent both feet operation at the same time and 17 patients underwent single foot operation. Among the 37 patients who underwent both feet operation, proximal metatarsal osteotomy was performed for contralateral 11 feet at same time, and these cases with proximal metatarsal osteotomy were excluded from this study. Postoperatively, all patients were allowed immediate full weight bearing walking. Patients were evaluated according to the American Orthopedic Foot and Ankle Society(AOFAS) hallux metatarsophalangeal-interpha-langeal scale, VAS(visual analogue scale), post-operative complications and radiologic parameters such as hallux valgus angle, intermetatarsal angle, T-test was used to evaluate the degree of hallux valgus and intermetatarsal angles. The mean follow up period was 25.9 months. Results: At the last follow up, the mean AOFAS hallux metatarsophalangeal-interphalangeal scale increased from 48.7 to 91.9. The Mean VAS score decreased from 7.1 to 0.8 post-operatively. The mean hallux valgus angle of 31.4° (range, 22° to 46°) improved to 5.3 ° (range, 0° to 20°) after the operation. The mean intermetatarsal angle also showed improvement from 12.3° (range, 7° to 16°) to 5.5 ° (range, 2° to 11°). Comparison between preoperative and postoperative hallux valgus and intermetatarsal angles was done by T test in dependent groups, which showed statistical significance (p< 0.05). There were three cases of mild hallux varus and three cases of recurred valgus deormity. No avascular necrosis or union problem was observed on the radiographs in any of the patients. Conclusion: Hallux valgus deformity correction by transarticular adductor tenotomy, distal Chevron metatarsal osteotomy and Akin phalangeal osteotomy using medial one incision has the advantages of lower morbidity and less scar without avascular necrosis of the metatarsal head

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus

The purpose of this study was to compare the results of proximal and distal chevron osteotomy in patients with moderate hallux valgus. We retrospectively reviewed 34 proximal chevron osteotomies without lateral release (PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a single surgeon. There were no differences between the groups with regard to age, length of follow-up, demographic or radiological parameters. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the radiological results were compared between the groups. At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid position were the same in both groups. The metatarsal declination angle decreased significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal was significantly greater in the DCO group (p < 0.001). We conclude that the clinical and radiological outcome after a DCO is comparable with that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis. Cite this article: Bone Joint J 2013;95-B:649–56

We performed distal chevron osteotomy of the second, third, or fourth metatarsal for painful plantar callosities in 19 non-rheumatoid patients (16 women, 3 men; 21 feet); their mean age was 59 years (32 to 85). The mean follow-up was four years (2 to 7). The overall results were good in 16 feet, fair in two, and poor in three, with four patients still having painful plantar callosities. There was union in all feet, but transfer metatarsalgia developed in three and three required an orthosis. Distal chevron osteotomy for intractable plantar callosities was successful both clinically and radiologically in most patients

Chevron osteotomy is a commonly performed procedure for the treatment of hallux valgus and results in AVN of the first metatarsal head in up to 20% of cases. This study aims to map out the arrangement of vascular supply to the first metatarsal head and its relationship to the limbs of the chevron cuts. Ten cadaveric lower limbs were injected with an Indian ink/latex mixture and the feet dissected to evaluate the blood supply to the first metatarsal. The dissection was carried out by tracing the branches of dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy through the neck of the metatarsal was mapped and the relationship of the limbs of the osteotomy to the blood vessels was recorded. The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal and medial plantar arteries of which the first one was the dominant vessel in 8 of the specimens studied. All the vessels formed a plexus at the plantar-lateral aspect of the metatarsal neck, just proximal to the capsular attachment with varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck. The identification of the plantar-lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long and thick plantar arm exiting well proximal to the capsular attachment may decrease the incidence of AVN

Hallux varus is a rare cause of pain in the foot mostly occurring after failed hallux valgus surgery. We reviewed 12 patients with unilateral hallux varus treated with soft tissue techniques (4x), arthrodesis of the first metatarso-phalangeal joint (3x) or with a distal chevron osteotomy (5x) with medial transposition of the first metatarsal head and reconstruction of the soft tissues on the lateral side of the metatarsophalangeal joint. 10 patients had previous hallux valgus surgery, in 2 cases the deformities were of unknown origin. 1 male and 11 female patients were followed up on average 26.4 months postoperatively. AOFAS hallux score improved from 46 (range 10–75) to 86 (range 72–95) points. The metatarsophalangeal angle measured with the center-head to center-base method was reduced from −16.1° (range −35° to −8°) to 5.1° (range −15° to 21°). The intermetatarsal angle increased from 5.8° (0–11°) t o 10.5° (0–19°). All patients were subjectively satisfied with the procedure. Our results indicate that joint preserving operation techniques are viable methods in the correction of mild and moderate symptomatic hallux varus deformities. Mild remaining varus deformities are well tolerated. In case of severe varus deformity or major signs of osteoarthritis in the first metatarsophalangeal joint MTP arthrodesis provides good results

Recent Department of Health guidelines have recommended that bunion surgery should be performed as a day case in a bid to reduce hospital costs, yet concurrently improving patient outcomes. Following an audit in 2012/3, we implemented a number of measures in a bid to improve the rates of day case first ray surgery. In this paper, we look to see if these measures were effective in reducing the length of stay in first ray surgery. We performed a prospective case note review of all patients undergoing first ray surgery between 01/01/2012 and 01/02/2013, and found the rates of same day discharge in this group to be lower than expected at just 24.19%. We recognised that the most commonly cited reasons for delayed discharge were that patients not being assessed by physiotherapy, and were unable to have their take home medication (TTO's) dispensed as pharmacy had closed. To address this, we implemented a pre-operative therapy led foot school, and organised ward analgesia packs which may be dispensed by ward staff, thus bypassing the need for pharmacy altogether. Together, we coined the term “care package” for these measures. We then performed a post implementation audit between 01/01/2014 to 01/01/2015 to ascertain if these measures had been effective. We identified 62 first ray procedures in the preliminary audit, with an average age of 50.5 years (range 17–78 years) and a M:F ratio of 1:5. The most commonly performed procedures were Scarf osteotomy, 1st MTPJ fusion, and distal Chevron osteotomy. We compared this to 63 first ray procedures post implementation of the care package. The average age was 55.3 years (range 15–78 years) and the M:F ratio was 1:2.5, and there was a similar distribution in terms of specific procedures. We found the length of stay had reduced from 1.00 to 0.65 days (p= 0.0363), and the rate of same day discharge had increased from 24.6% to 44.6% (p= 0.0310). We also noted that St Helens Hospital (SHH), the dedicated day case surgery unit, had a significantly increased rate of same day discharge than Whiston Hospital (WH- the main hospital) at 87.5% and 28.89% respectively (p= 0.0002). Preoperative physiotherapy assessment is an important tool in reducing length of stay for first ray surgery. The use ward analgesia packs has a synergistic effecting in increasing day case first ray surgery. We therefore commend its use to other centers. Additionally, we have shown dedicated day case surgery units are more effective at achieving same day discharge than general hospitals

Aim: Chevron osteotomy is a commonly performed procedure for the treatment of hallux valgus and results in AVN of the first metatarsal head in up to 20% of cases. This study aims to map out the arrangement of vascular supply to the first metatarsal head and its relationship to the limbs of the chevron cuts. Methods: 10 cadaveric lower limbs were injected with an Indian ink – latex mixture and the feet dissected to evaluate the blood supply to the first metatarsal. The dissection was carried out by tracing the branches of dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy through the neck of the metatarsal was mapped and the relationship of the limbs of the osteotomy to the blood vessels was recorded. Results: The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal and medial plantar arteries of which the first one was the dominant vessel in 8 of the specimens studied. All the vessels formed a plexus at the plantar – lateral aspect of the metatarsal neck, just proximal to the capsular attachment with varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck. Conclusion: The identification of the plantar – lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long and thick plantar arm exiting well proximal to the capsular attachment may decrease the incidence of AVN

The June 2015 Foot & Ankle Roundup³⁶⁰ looks at: Syndesmosis and outcomes in ankle fracture; Ankle arthrodesis or arthroplasty: a complications-based analysis; Crosslinked polyethylene and ankle arthroplasty; Reducing screw removal in calcaneal osteotomies; Revisiting infection control policies; Chevron osteotomy: proximal or distal?; Ankle distraction for osteoarthritis

As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ-1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarso-metatarsal joint.

Cite this article: Bone Joint J 2013;95-B:1222–6.