The Lindgren and Chevron Osteotomies Were Not Different in Repair of Hallux Valgus

Abstract

Question: In patients with hallux valgus, how does the Lindgren osteotomy compare with the distal chevron osteotomy? Design: Randomized (allocation concealed), blinded (outcome assessor), controlled trial with mean 4.7-year follow-up. Setting: A hospital in Stockholm, Sweden. Patients: 100 patients, 16 to 80 years of age (mean age 48 y, 94% women), with a hallux valgus angle (HVA) of 20° to 44°, a first-second intermetatarsal angle (IMA) of up to 20°, a distal metatarsal articular angle of up to 25°, no radiographic evidence of degenerative metatarsophalangeal (MTP) arthritis, and persistent symptoms. Exclusion criteria were a previous operation on the affected foot or a history of diabetes, peripheral vascular disease, peripheral neuropathy, rheumatoid arthritis, or other inflammatory diseases. Ninety percent of patients were available for a mean 4.7-year follow-up. Intervention: Patients were allocated to receive an osteotomy according to the Lindgren method (n= 50) or the chevron method (n = 50). The Lindgren osteotomy was subcapital and extra-articular. The straight skin incision was done medial to the extensor hallucis longus tendon. The dissection was to the bone with the saw blade aligned halfway between the perpendicular long axis of the first metatarsal and the plantar aspect of the foot. A transverse osteotomy was made at a 30° angle from the long axis of the metatarsal shaft. The distal fragment was displaced laterally, up to 8 to 10 mm. Pronation of the hallux was corrected as needed. The distal fragment was fixed with a 2.7-mm lag screw. The chevron osteotomy involved an incision over the MTP joint, placed straight medially without a tenotomy. The distal fragment was displaced laterally about 4 to 6 mm, and the osteotomy site was impacted on itself. The plantar and dorsal aspects of the flap were tightly closed before the capsular flap was reattached. No fixation was used. Main outcome measures: Functional outcome was graded with the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating system (pain [40 points], function [45 points], and alignment [15 points]); degree of pronation of the great toe (0 [no rotation] to 3 [>45° rotation]); pain on the 100-mm visual analog scale (VAS) (0 [no pain] to 100 [worst pain imaginable]); health-related quality of life in 5 dimensions (EuroQol-5D [EQ-5D]): mobility, self care, usual activities, pain or discomfort, and anxiety or depression; and radiographic parameters (HVA, IMA, and intermetatarsal distance [IMD]). Main results: At 1 year, both the Lindgren and chevron groups improved significantly in AOFAS scores (Table), VAS scores, and degree of great toe pronation, showing no difference between groups. Patients who were not satisfied with the cosmetic result (5 patients in each group) and those who had trouble wearing shoes at the time of follow-up (4 patients in each group) had lower EQ-5D scores. The HVA, IMA, and IMD decreased significantly in both groups but to a greater extent in the Lindgren group (Table). At 4.7 years, both groups showed partial loss of correction. Conclusion: In patients with hallux valgus, no significant differences in clinical improvement were seen between osteotomy performed with the Lindgren procedure or the distal chevron procedure, although a better radiographic correction was obtained with the Lindgren method.