Chevron Bunionectomy Research Articles

The chevron bunionectomy for moderate to severe hallux valgus deformity: Effects of procedural factors on hallux valgus correction

BackgroundEffects of procedural factors on chevron bunionectomy outcomes were studied. MethodsIncluded were 109 feet with distal chevron osteotomy and preoperative intermetatarsal angle (IMA) greater than 15 degrees. IMA and hallux valgus angles (HVA), release type, fixation, second-digit procedures, and risk factors were evaluated. ResultsEighty-three percent (91/109 feet) had satisfactory outcomes; nine had moderate pain. From preoperative, IMA improved 7.2 and HVA 20.5 degrees. Risk factors or second-digit procedures had no effect. Lateral release improved IMA (p < 0.01), with no difference between open lateral and transarticular release; 86% percent (64/74) were satisfied with open lateral release compared with 83% (19/23) and 66% (8/12) with no release and transarticular release, respectively. Fixation did not affect outcomes. ConclusionChevron bunionectomy corrected IMA and HVA to normal with few complications. Lateral release increased IMA correction. Transarticular release had lower satisfaction than open lateral release or no release. Level of EvidenceLevel III, retrospective

Early Radiographic Outcomes of Minimally Invasive Chevron Bunionectomy Compared to the Modified Lapidus Procedure.

Background:Minimally invasive (MIS) bunion surgery has become increasingly popular. Although early reports on outcomes have been encouraging, no study to date has compared outcomes from the MIS chevron and Akin procedures to the modified Lapidus procedure. Our primary aim was to compare early radiographic outcomes of the MIS chevron and Akin osteotomies to those of the modified Lapidus procedure in patients with comparable deformities, and secondarily to compare clinical outcomes.Methods:Patients were retrospectively reviewed for inclusion from a prospectively collected foot and ankle registry. Patients were eligible if they underwent either the MIS bunionectomy or modified Lapidus procedure and had preoperative and minimum 5-month postoperative weightbearing radiographs. Forty-one patients who underwent MIS bunionectomy were matched to 41 patients who underwent Lapidus bunionectomy based on radiographic parameters. Demographics, radiographic parameters, complications, reoperations, and PROMIS scores were compared between groups.Results:Both groups achieved similar radiographic correction. There was no significant difference in pre- or postoperative PROMIS scores between groups. Procedure duration was significantly faster in the MIS group (P < .001). Bunion recurrence (hallux valgus angle ≥20 degrees) occurred in 1 MIS patient and 2 Lapidus patients, with all patients asymptomatic. The most common reason for reoperation was removal of hardware (4 patients in the MIS group, 2 patients in the Lapidus group).Conclusion:This is the first study to our knowledge to compare early radiographic outcomes between MIS bunionectomy and the modified Lapidus procedure in patients matched for bunion severity. We found that patients with similar preoperative deformities experience similar radiographic correction following MIS chevron and Akin osteotomies vs modified Lapidus bunionectomy. Further research is needed to investigate satisfaction differences between the procedures, longer-term outcomes, and which deformities are best suited to each procedure.Level of Evidence:Level III, Retrospective case control study.

The Weil Osteotomy for Angular Correction of Axial Plane Deformities of the Lesser MTP Joints: A Radiographic Analysis

Category:Lesser Toes; Midfoot/ForefootIntroduction/Purpose:The oblique shortening (Weil) osteotomy of the distal metatarsal neck has been described as an effective means of correcting lesser toe metatarsophalangeal joint deformity. Previous studies have focused on clinical outcomes, complications, and the magnitude of plantar displacement and shortening. The aim of this study was to quantify the magnitude of axial plane correction obtainable when a medial or lateral displacing Weil osteotomy was used in conjunction with other procedures in forefoot reconstruction surgery.Methods:Consecutive patients with a minimum 12-month follow-up who were treated by the senior surgeon from January 1, 2008, to September 1, 2018, were included. Review of the medical records identified 234 toes in 190 patients that had medial or lateral displacement Weil osteotomies as a part of their treatment for metatarsalgia and lesser toe deformity. Concomitant procedures were recorded. Pre- and post-operative weightbearing radiographs were analyzed to determine the amount of transverse plane change and residual varus/valgus alignment. Radiographs were then classified as good (<10 degrees of angulation), intermediate (10-15 degrees), or bad (>15 degrees). Any worsening of the post-operative alignment compared to the pre- operative alignment was noted. Follow-up notes were reviewed for clinical observations of floating toe, resting alignment, persistent pain and swelling at 3 months, complications, and need for revision surgery.Results:The average transverse plane correction was 12.5 degrees (range 0-45 degrees). Most toes remained in some degree of radiographic varus or valgus alignment as a true neutral toe was rare. Over a third, (35%, n=81) had increased postoperative angulation; 42% of radiographs were graded as good alignment (n=99), 20% as intermediate (n=46), and 38% as bad (n=90). The most common concomitant procedures were PIP joint resection arthroplasty and distal chevron bunionectomy. Review of clinic notes revealed low incidences of floating toe (7%, n=16), clinical malalignment (8%, n=18), and need for revision surgery (3%, n=8). Persistent swelling was the most common complication, present in 44% of patients at the 3-month follow-up.Conclusion:The medial and lateral displacing Weil osteotomy can be a powerful tool to correct lesser toe MTP joint transverse plane deviation. It was typically used with PIP joint resection and hallux valgus procedures to improve the lesser toes and overall forefoot alignment. Interestingly, most toes had a neutral or good clinical alignment regardless of the radiographic alignment. Further studies to correlate radiographic and clinical outcome measures may help define its role in correcting lesser toe deformity.

Clinical and Radiographic Outcomes of Minimally Invasive Chevron Bunionectomy Compared to the Modified Lapidus Procedure

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Minimally invasive bunion surgery is relatively new in the United States, with the requisite burrs only approved for use by the FDA in 2017. Early reports on outcomes have been encouraging. However, no study to date has compared outcomes from the minimally invasive chevron and Akin procedures (MICA) to the modified Lapidus procedure. Our goal was to compare clinical and radiographic outcomes of MICA to those of the modified Lapidus procedure in patients with comparable deformities. We hypothesized that radiographic parameters of hallux valgus would be superior in the Lapidus group, but that there would be no significant difference in clinical outcomes or satisfaction between the two groups.Methods:Patients were retrospectively reviewed for inclusion from a prospectively-collected foot and ankle registry at our institution. Patients were eligible if they underwent either the MICA or modified Lapidus procedure, were 18 years or older, and had preoperative and minimum 5 month postoperative weightbearing radiographs. Exclusion criteria included prior forefoot surgery, additional surgeries (such as metatarsal shortening), and concomitant foot conditions (such as flatfoot deformity). Each surgery was performed by one of six fellowship-trained orthopedic foot and ankle surgeons. Demographics, PROMIS scores, and satisfaction data were collected from the registry. Complications and reoperations were collected from chart review. The hallux valgus angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (SP) were measured pre- and postoperatively.Patients in the MICA group were matched to patients who underwent Lapidus bunionectomy based on radiographic parameters. Differences between the groups were assessed with paired t-tests for continuous variables and chi-square tests for categorical variables.Results:41 patients who underwent MICA and 81 patients who underwent Lapidus bunionectomy met the inclusion criteria. Of the Lapidus patients, 41 were included, matched to the MICA patients. There were no significant differences in demographics or preoperative parameters between groups aside from sex (Table). Both groups achieved similar radiographic correction (Table). Bunion recurrence (HVA >=20°) occurred in one MICA patient and two Lapidus patients, with all patients asymptomatic. The most common reason for reoperation was removal of hardware (4 patients in the MICA group, 2 patients in the Lapidus group). One additional patient in the MICA group required reoperation for wound closure, and one additional patient in the Lapidus group required a derotational proximal phalanx osteotomy.Conclusion:This is the first study to our knowledge to compare outcomes between MICA and the modified Lapidus procedure in patients matched for bunion severity. We found that patients with similar preoperative deformities experience similar radiographic outcomes following MICA versus modified Lapidus bunionectomy. Our analysis of PROMIS scores and satisfaction data is currently underway. Although this is short-term data, it provides additional support for minimally invasive techniques which allow for faster, less painful recoveries. Further research is needed to investigate longer term outcomes and to establish which deformities are best suited to each procedure.

Short-Term, Retrospective Radiographic Evaluation Comparing Pre- and Postoperative Measurements in the Chevron and Minimally Invasive Distal Metatarsal Osteotomy for Hallux Valgus Correction

Various techniques exist for correction of mild to moderate hallux valgus (HAV) deformity. Recently, minimally invasive distal metatarsal osteotomy (MIDMO) has gained popularity for HAV correction. This retrospective radiographic review aims to report the surgical correction obtained by the chevron and MIDMO osteotomies at a single institution between January 2012 and December 2017. Radiographic parameters, such as intermetatarsal angle (IMA), hallux abductus angle (HAA), and tibial sesamoid position (TSP), were compared on weight-bearing anterior-posterior and lateral radiographs. Sixty-one patients who underwent distal first metatarsal osteotomies were separated into 2 groups. Group A included 30 patients with a chevron bunionectomy performed by Surgeon A; Group B consisted of 31 patients who had MIDMO performed by Surgeon B. Mean follow-up was 26.6 months for Group A and 18.7 months for Group B. Both groups had statistically significant radiographic correction for pre- and postoperative IMA, HAA, and TSP. Group A: IMA measured preoperatively 11.6° ± 4.0° to 6.8° ± 4.1° postoperatively, HAA preoperative 22.2° ± 9.1° to 12.3° ± 6.9° postoperative, and TSP preoperative 1.3 ± 0.9 to 0.7 ± 0.6 postoperative. Group B: IMA measured preoperatively 12.0° ± 2.9° to 5.9° ± 3.3° postoperatively, HAA preoperative 27.9° ± 8.6° to 12.0° ± 6.6° postoperative, and TSP preoperative 2.0 ± 0.8 to 0.7 ± 0.6 postoperative. Postsurgical retrospective radiographic review demonstrated chevron and MIDMO procedures provide comparable radiographic correction of IMA, HAA, and TSP.

Effects of the Lapidus Arthrodesis and Chevron Bunionectomy on Plantar Forefoot Pressures

Hallux valgus with or without first ray insufficiency has been strongly implicated as a contributing factor in lesser metatarsal overload. The principle goals of a bunionectomy are to relieve the pain, correct the deformity, and restore first metatarsophalangeal joint congruity. Until now, little evidence has been available to assess the effects of bunionectomy procedures on forefoot pressure. The primary aim of the present prospective study was to evaluate the preoperative and postoperative plantar pressures after 2 specific bunionectomies: the chevron bunionectomy and Lapidus arthrodesis. A total of 68 subjects, 34 in each group, were included for radiographic and pedographic evaluation. Both procedures demonstrated radiographic improvements in the mean intermetatarsal and hallux abductus angles. The mean hallux plantar pressure decreased significantly in both procedure groups (p < .001). However, Lapidus group exhibited an increase in the mean fifth metatarsal head plantar pressure (p = .008) and pressure under the fifth metatarsal as a percentage of the total forefoot pressure (p = .01). Furthermore, the pressure under the second metatarsal as a percentage of the total forefoot pressure decreased significantly (p = .01). This study suggests that the Lapidus arthrodesis and chevron bunionectomy both provide correction for hallux valgus deformity, but when comparing forefoot load sharing pressures, the Lapidus arthrodesis appeared to have greater influence on the load sharing distribution of forefoot pressure than did the bunionectomy employing the chevron osteotomy.

Stabilization of Chevron Bunionectomy with a Capsuloperiosteal Flap

Distal chevron osteotomy (DCO) for mild to moderate hallux valgus deformity is inherently more stable than the other forms of distal metatarsal osteotomy, but complications such as loss of correction, infection, joint stiffness, delayed union, malunion and nonunion can occur. In this study, we evaluated the use of a capsuloperiosteal flap for stabilization of DCO in the treatment of hallux valgus. A retrospective study was conducted on 59 patients (88 feet) that underwent distal Chevron osteotomy stabilized only with a capsuloperiosteal flap for mild and moderate hallux valgus deformity with a mean followup of 11.3 years. Clinical evaluation was calculated using the hallux score of the American Orthopaedic Foot and Ankle Society (AOFAS). The score improved from a preoperative mean of 52 to a mean of 91.5 points at last followup. Average hallux valgus angle changed from 30.3 degrees preoperatively to 14.2 degrees postoperatively at the last followup. Intermetatarsal angle 1-2 changed from 13.6 degrees preoperatively to 10.2 degrees postoperatively. The correction proved to be consistent with only an average of 3.4-degree correction loss and 4.9-degree loss in the range of motion. Eighty-six feet (97.7%) were pain free. Discomfort with shoewear was absent in 84 feet (95.5%) postoperatively and 24 of 25 (96%) patients were satisfied cosmetically. Capsuloperiosteal flap stabilization of distal chevron osteotomy for mild-moderate hallux valgus yielded excellent clinical results at long-term followup.

Blood Flow to the Metatarsal Head After Chevron Bunionectomy

Avascular necrosis (AVN) of the metatarsal head is a known, but infrequent, complication of a chevron bunionectomy. An increased incidence of AVN has been reported with the addition of an adductor tenotomy and lateral release. The purpose of this study was to document the vascular insult to the metatarsal head during a chevron bunionectomy with adductor tenotomy and lateral release through direct blood flow measurements during the procedure. A prospective study of 20 patients was performed. A chevron bunionectomy was performed under regional anesthesia without tourniquet control by two surgeons. Blood flow recordings were documented during key portions of the procedure: baseline, medial capsulotomy, adductor tenotomy and lateral release, and chevron osteotomy. The Periflux PF3 laser Doppler probe (Perimed, Inc., North Royalton, OH) was used to record blood flow. Mauchly's test of Sphericity and a pairwise comparison were performed with significance defined as p < 0.05. All patients had radiographs 3 months postoperatively to assess AVN. There was a statistically significant decrease in blood flow to the metatarsal head at each portion of the procedure. The greatest insult occurred with the medial capsulotomy (45% decrease). The lateral release and adductor tenotomy caused a 13% decrease and the chevron osteotomy caused a 13% decrease, totaling 71% decrease from the baseline. There was no evidence of AVN at 3 months, and all patients had radiographic evidence of union without recurrence or over-correction. The addition of the adductor tenotomy with lateral release often is crucial to obtain the desired correction and avoid the complication of recurrence. The disruption of microvascular blood flow to the metatarsal head after a chevron bunionectomy with adductor tenotomy and lateral release was not complete, totaling 71% in the study population. The greatest insult occurred with the medial capsulotomy. There were no occurrences of AVN. Despite the fear of AVN, this study demonstrated that an adductor tenotomy and lateral release could be done safely completed with a chevron bunionectomy.

Venous thrombosis after hallux valgus surgery.

Although surgery for the treatment of hallux valgus is frequently performed, the exact rate of deep vein thrombosis following this procedure is unknown. We performed a single-center, prospective, phlebographically controlled study to quantify the rate of venous thrombosis following operative correction of hallux valgus. Consecutive patients undergoing chevron bunionectomy for correction of hallux valgus deformity were enrolled in the study. Patients with clinical or hematological risk factors for venous thrombosis were excluded. One hundred patients with a mean age of 48.9 years were operated on and did not receive medical prophylaxis against thrombosis. All patients were assessed with phlebography at a mean of twenty-nine days postoperatively. Venous thrombosis was found in four patients (4%). The mean age of these patients (and standard deviation) was 61.7 +/- 6.1 years compared with a mean age of 48.4 +/- 13.9 years for the patients in whom thrombosis did not develop (p = 0.034). Patients are at a low risk for venous thrombosis following surgical treatment of hallux valgus. The need for prophylaxis against thrombosis should be calculated individually for each patient according to his or her known level of risk. Routine medical prophylaxis against thrombosis might be justified for patients over the age of sixty years.

Fixation with bioabsorbable pins in chevron bunionectomy.

Fixation with bioabsorbable pins in distal chevron bunionectomy reduces the inconvenience and the risk of infection associated with fixation with stainless-steel Kirschner wires, which leaves a portion of the wires protruding from the skin. However, use of bioabsorbable implants has been reported to be associated with osteolysis and formation of a sinus with a sterile discharge. We studied the outcome and complications seen with use of poly-p-dioxanone pins and those seen with use of stainless-steel Kirschner wires after chevron bunionectomy in 114 patients (144 feet). We found no difference between the treatment groups with regard to the prevalence of complications or the stability of fixation. Notably, the prevalence of osteolysis was quite similar between the treatment groups; none of the feet that had had fixation with bioabsorbable pins had formation of a sinus with a sterile discharge. We believe that bioabsorbable pins can be used reliably to fix the site of the osteotomy for a distal chevron bunionectomy without undue risk of osteolysis or other complications.

Modified Mitchell's Bunionectomy (Wu's Bunionectomy)

A standard Wu's bunionectomy consists of an oblique first metatarsal neck osteotomy with a lateral, proximal, and plantar displacement of the first metatarsal head and firm fixation of the osteotomy site with two Herbert screws. The outstanding features of this surgical technique include its surgical simplicity, secure fixation of the osteotomy site, no need for subsequent screw removal, ease of screw insertion, complete absence of screw breakage, little postoperative pain, and a relatively greater degree of correcting the various deformities associated with a hallus valgus foot than those normally achieved by either a Mitchell's bunionectomy or a Chevron bunionectomy.

Chevron bunionectomy with microplate and screw fixation: A retrospective follow-up of 26 feet

The authors report the results of 21 patients (26 feet) who had Chevron osteotomy of the first metatarsal head to correct hallux valgus. Fixation was achieved by using a small plating system consisting of one L-plate (8.5 mm x 17 mm x 0.8 mm) and four screws (1.6 mm). Results showed no capital fragment displacement, avascular necrosis, or plate deformation. One case of screw loosening was noted on x-rays. This patient noted occasional irritation over the plate while wearing shoes. Symptoms did not cause the patient to seek removal of the plate and screws. The small plate system allows the surgeon to perform the osteotomy as originally described by Austin, with the added security of rigid internal fixation.

Chevron bunionectomy fixation: In vitro stability assessment of plate-and-screw system compared with kirschner wire

Many methods for internal fixation of the Chevron bunionectomy have been described. Currently available fixation devices stabilize the osteotomy sufficiently to ensure healing. Each has unique advantages and disadvantages. A low-profile plate buried beneath capsular tissue eliminates some complications of other forms of fixation. The authors compared the structural characteristics of a low-profile plate-and-screw system and of a single Kirschner wire. Testing was performed on dissected human cadaveric specimens by using a Telos strain gauge. Loads were applied both from the medial to the lateral aspect and from the plantar to the dorsal aspect at the capital fragment. Results indicate that both modes of fixation can resist Chevron osteotomy displacement in vitro.

The Chevron Bunionectomy: A Trigonometric Analysis to Predict Correction

A trigonometric analysis was developed in an attempt to predict the postoperative hallux valgus angles and intermetatarsal angles after Chevron bunionectomy. This analysis was used in 20 feet to predict postoperative angles, and these predicted values were compared with actual measured roentgenographic values. The postoperative intermetatarsal angles were evaluated to determine their correction to postoperative hallux valgus angles of 20 degrees or less. Using the trigonometric analysis, the postoperative intermetatarsal angles were highly predictable, but the hallux valgus angle could not be reliably predicted for individual patients. The intermetatarsal angle obtained at surgery, however, was indicative of the final hallux valgus angle: 75% of feet with intermetatarsal angles of more than 11 degrees had postoperative hallux valgus angles of more than 20 degrees. Thus, when an intermetatarsal angle of 11 degrees or less can be obtained surgically, the hallux valgus angle can be corrected to 20 degrees or less in most patients.

Bunionectomies and related surgery in the elite female middle-distance and marathon runner

When contemplating bunion surgery in the elite athlete, serious consideration should be given to its effects on the overall function and biomechanics of the forefoot. Many surgical treatment options are available, but their use in the high performance athlete has not previously been reported in the literature. In this paper we report on the successful use of the chevron bunionectomy procedure and related surgery in two world class female middle-distance and marathon runners.