Proximal Chevron Osteotomy Research Articles

Comparative Analysis of Hallux Valgus Surgical Techniques: A Systematic Review

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus is a foot deformity where the distal portion of the hallux deviates laterally, forming a bunion. Here we review three surgical techniques for correction of the deformity: lapidus arthrodesis (LA), minimally invasive surgery (MIS), or proximal chevron osteotomy (PCO). The purpose of this study was to compare the hallux valgus angle (HVA) and intermetatarsal angle (IMA) for radiologic outcomes, and the American Orthopaedic Foot & Ankle Society Score (AOFAS) score for quality of life outcomes, between treatment groups. Methods: We performed a literature search, with strict inclusion and exclusion criteria, for identifying pertinent references. After review, and resolution of any disagreements by consensus among 5 raters, a total of 42 studies were included in this analysis. Results: The mean HVA difference (postoperative to preoperative) was 23.68 for PCO and 21.40 for LA. The mean IMA difference was 9.53 for PCO and 8.12 for LA. The mean of postoperative HVA was calculated to be11.81 for MIS and 9.13 for LA. The mean of postoperative IMA was calculated to be 8.39 for MIS and 6.60 for LA. The postoperative AOFAS mean was 86.00 for MIS and 86.46 for LA. No studies directly compared surgical methods; the results that follow describe each technique summarized separately. Conclusion: We discovered that HVA and IMA difference means were higher in PCO vs LA, with a larger difference signifying better radiologic correction. HVA and IMA postoperative means were lower in LA vs MIS. A smaller postoperative angle signifies more physiologic correction. Postoperative AOFAS means were similar in MIS vs LA. Further research should be done to evaluate an ideal procedure and explore better techniques for hallux valgus correction.

Biomechanical evaluation of the proximal chevron osteotomy in comparison to the Lapidus arthrodesis for the correction of hallux valgus deformities

PurposeThe proximal chevron osteotomy and the modified Lapidus arthrodesis are both procedures utilized for deformity correction in patients with severe symptomatic hallux valgus. The aim of the current study was to compare their biomechanical stability when using locking plate fixation.MethodsTwelve matched pairs of human anatomical lower leg specimens underwent on one side a proximal chevron osteotomy with a medial locking plate and on the other side a modified Lapidus arthrodesis with a plantar locking plate utilizing an interfragmentary compression screw. All specimens underwent bone mineral density (BMD) assessment and were tested in a servohydraulic load frame which applied a load on the centre of the metatarsal head over 1000 loading cycles with subsequently ultimate load testing. Displacement of the proximal and distal bone segment, ultimate load, and bending stiffness were analyzed.ResultsMean displacement of both procedures showed no statistically significant difference throughout all the loading cycles (0.213 ≤ p ≤ 0.834). The mean ultimate load of the proximal chevron osteotomy was 227.9 N (± 232.4) and of the modified Lapidus arthrodesis 162.9 N (± 74.6) (p = 0.754). The proximal chevron osteotomy (38.2 N/mm (± 24.9)) had a significantly higher bending stiffness compared to the modified Lapidus arthrodesis (17.3 N/mm (± 9.9)) (p = 0.009). There was no correlation between BMD and displacement in all loading cycles, ultimate load, and bending stiffness of either procedure (p > 0.05).ConclusionAlthough the bending stiffness of the chevron osteotomy was higher, there was no statistically significant difference between the surgical techniques in mean displacement and ultimate load. The BMD did not influence the overall stability of either reconstruction. Locking plate fixation increases the clinical value of the modified Lapidus arthrodesis by outweighing most of the biomechanical disadvantages in comparison to the proximal chevron osteotomy.

Comparison Between Mini-Invasive Distal and Proximal Chevron Osteotomies in the Correction of Hallux Valgus Deformity

Category:BunionIntroduction/Purpose:The potential advantages of minimal incision surgery for hallux aboducto valgus (HAV) correction are to reduce surgical exposure, diminish soft-tissue stripping, and lessen blood supply impairment. The purpose of this study was to assess the safety and efficacy of minimally invasive techniques. Currently, there are insufficient studies to recommend one minimally invasive technique over another.Methods:From 2018 to 2020, 141 cases with hallux abducto valgus were treated with minimal incision osteotomy using Kirschner wire fixation. 120 patients had distal chevron osteotomies and 21 patients had proximal first metatarsal osteotomies. The patient age range was between 29 yo and 96 yo, with 118 female and 23 male patients. 48 patients were 65 yo and over, and 93 patients were less than 65yo. The preoperative and postoperative hallux abducto valgus angles (HVA), intermetatarsal angles (IMA), American Orthopaedic Foot & Ankle Society (AOFAS) scores were measured and evaluated.Results:The average AOFAS scores improved from a preoperative median of 41.4 points to a postoperative median of 88.6 points. The mean HVA and IMA angles significantly decreased after the operation. There were no complications of nonunion or delayed union, avascular necrosis, infection, or hallux varus. The technique has been largely accepted by the patients due to the short procedure time, the reduced postoperative pain, and the fast functional recovery. For the hallux aboducto valgus deformity with HVA over 35 and IMA over 16 degrees, the procedure with proximal chevron osteotomy achieved better corrections.Conclusion:Both proximal and distal chevron osteotomy techniques showed comparable results. The distal percutaneous osteotomy was effective for the treatment of mild to moderate hallux abducto valgus deformity, and the proximal percutaneous osteotomy was effective for the treatment of severe hallux abducto valgus deformity. This study indicated that the minimal incision osteotomy was a simple and reliable technique for treating hallux abducto valgus with minimal complications. Through minimally invasive approaches, the hallux abducto valgus corrections performed in this study resulted in minimal soft tissue injury, less postoperative pain, and good cosmetic results.

Mid-Term Results of Two Different Fixation Methods for Chevron Osteotomy for Correction of Hallux Valgus

We compared 2 different fixation methods (bioabsorbable pins and cannulated screws) after chevron osteotomy for the treatment of hallux valgus. We reviewed consecutive proximal chevron osteotomies in 80 patients (100 feet) performed by 2 surgeons. Of the 100 feet (80 patients), 48 feet (40 patients) were stabilized with bioabsorbable pins, and 52 feet (40 patients) were stabilized with cannulated screws. In the pin group, 8 patients were male (20%) and 32 were female (80%). In the screw group, 10 patients were male (25%) and 30 were female (75%). The mean patient age was 43.1 (range 24 to 60) years in the pin group and 43.5 (range 20 to 60) years in the cannulated screw group. The visual analog scale, intermetatarsal angle, and hallux valgus angle decreased significantly and the American Orthopaedic Foot and Ankle Society scores increased significantly in all patients in both groups after surgery (p < .05). No statistically significant differences were found between the 2 groups (p > .05). Both fixation methods were found to be safe and reliable under the appropriate conditions and when performed by an experienced surgeon.

Is Generalized Ligamentous Laxity a Prognostic Factor for Recurred Hallux Valgus Deformity?

Category: Bunion Introduction/Purpose: It is still unclear whether generalized ligamentous laxity is a risk factor for recurred hallux valgus deformity. This study was performed to evaluate the intermediate-term clinical outcomes after proximal chevron osteotomy for hallux valgus in patients with generalized ligamentous laxity, and to determine the effect on postoperative recurrence of deformity. Methods: A total of 198 feet from 169 female patients were treated with a proximal chevron osteotomy for hallux valgus with a mean follow-up of 46.3 months. When generalized ligamentous laxity was defined as Beighton score ≥ 5 points, there were 18 patients (10.7%) in laxity group and 151 patients (89.3%) in non-laxity group. Clinical evaluation consisted of the American Orthopaedic Foot and Ankle Society (AOFAS) scores, Foot and Ankle Ability Measure (FAAM), and radiographic measurement of hallux alignment. Risk factors associated with postoperative recurrence were evaluated using univariate analysis. Results: Recurrence rates were 21.7% in the laxity group and 17.1% in non-laxity group (p = 0.218), when defined as hallux valgus angle ≥ 20°. No significant differences of measurement at final follow-up were found between the 2 groups in terms of AOFAS score, FAAM, recurrence rate, hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA). Preoperative HVA and IMA were found to be predictive factors of recurrence (OR = 6.3, 4.2; P = .001, .018, respectively). Conclusion: There were no statistical differences in the clinical and radiographic outcomes between hallux valgus with and without generalized ligamentous laxity. Generalized ligamentous laxity demonstrated no definitive effects on postoperative recurrence of hallux valgus deformity.

Importance of postoperative sesamoid reduction on the outcomes of proximal chevron osteotomy for moderate to severe hallux valgus deformity

BackgroundThe purpose of this study was to compare the clinical and radiographic outcomes between feet with or without postoperative sesamoid reduction of proximal metatarsal chevron osteotomy for moderate to severe hallux valgus deformity. MethodsAll of 110 feet were allocated into two groups (reduction group; 66 feet, non-reduction group; 44 feet) according to the reduction status of sesamoid at 6 months after surgery. The clinical and radiographic results of the two groups were compared preoperatively, 6 months follow-up, and at last follow-up. ResultsThe overall improvement in clinical outcomes was similar in both groups at average 4-year follow-up. However, the radiographic outcomes and recurrence rate were significantly worse in the sesamoid non-reduction group. ConclusionsOur results suggested that postoperative incomplete reduction of sesamoid may increase a risk for the recurrence of hallux valgus deformity.

Is Double Metatarsal Osteotomy Superior to Proximal Chevron Osteotomy in Treatment of Hallux Valgus With Increased Distal Metatarsal Articular Angle?

We compared the results of proximal chevron osteotomy and double metatarsal osteotomy for hallux valgus with an increased distal metatarsal articular angle (DMAA). From October 2008 to December 2012, first metatarsal osteotomies were performed in 64 patients (69 feet) with symptomatic hallux valgus associated with an increased DMAA. Proximal chevron with Akin osteotomy and lateral soft tissue release was performed in 46 feet (PCO group); double metatarsal osteotomy and Akin osteotomy without lateral soft tissue release was performed in 23 feet (DMO group). Clinical assessments were performed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and visual analog scale (VAS). The hallux valgus angles, intermetatarsal angles, sesamoid positions, metatarsus adductus angles, and DMAAs were compared at different postoperative times. Postoperative shortening of first the metatarsal and complications were compared. The mean AOFAS scale and VAS scores showed significant improvement in both groups after surgery; however, no significant difference was observed between the 2 groups. The immediate postoperative hallux valgus angle and sesamoid position were significantly larger in DMO group; however, no intergroup difference was observed at the last follow-up visit, with the hallux valgus angle gradually increasing in the PCO group. The postoperative DMAA was significantly smaller in the DMO group. The mean shortening of the first metatarsal after surgery was significantly larger in the DMO group than in the PCO group. Transfer metatarsalgia developed in 1 foot (2.2%) in the PCO group and 2 feet (8.7%) in the DMO group. Partial avascular necrosis of the metatarsal head with advanced arthritis of the first metatarsophalangeal joint developed in 1 foot (4.3%) in the DMO group. In conclusion, no differences in the clinical and radiographic results were observed between the 2 groups for hallux valgus deformity with an increased DMAA.

Is generalized ligamentous laxity a prognostic factor for recurred hallux valgus deformity?

BackgroundThis study was performed to evaluate the intermediate-term clinical outcomes after proximal chevron osteotomy for hallux valgus in patients with generalized ligamentous laxity, and to determine the effect on postoperative recurrence of deformity. MethodsThere were 23 cases in laxity group (Beighton score ≥5 points) and 175 in non-laxity group with a mean followup of 46.3 months. Clinical evaluation consisted of the AOFAS score, Foot and Ankle Ability Measure (FAAM), and radiographic measurement of hallux alignment. Risk factors associated with postoperative recurrence were evaluated using univariate analysis. ResultsRecurrence rates were 21.7% in the laxity group and 17.1% in non-laxity group (P=.218). There were no significant differences in clinical and radiographic measurements at final followup between the 2 groups. Preoperative HVA and IMA were found to be predictive factors of recurrence (OR=6.3, 4.2; P=.001, .018, respectively). ConclusionThere were no statistical differences in the clinical and radiographic outcomes between hallux valgus with and without generalized ligamentous laxity. Generalized ligamentous laxity demonstrated no definitive effects on postoperative recurrence of hallux valgus deformity.

Comparison between proximal chevron and distal chevron osteotomy in moderate to severe hallux valgus patients undergoing simultaneous bilateral correction

Comparison between proximal chevron and distal chevron osteotomy in moderate to severe hallux valgus patients undergoing simultaneous bilateral correction

Is double metatarsal osteotomy superior to proximal chevron osteotomy in the treatment of hallux valgus with increased DMMA

Is double metatarsal osteotomy superior to proximal chevron osteotomy in the treatment of hallux valgus with increased DMMA

Effect of incomplete sesamoid reduction on outcomes of proximal chevron osteotomy for moderate to severe hallux valgus deformity

Effect of incomplete sesamoid reduction on outcomes of proximal chevron osteotomy for moderate to severe hallux valgus deformity

Recurrence of Hallux Valgus Can Be Predicted from Immediate Postoperative Non-Weight-Bearing Radiographs.

The aims of this study were to identify risk factors for the recurrence of hallux valgus deformity and to clarify whether recurrence after surgery to treat hallux valgus can be predicted using radiographic parameters assessed on immediate postoperative non-weight-bearing radiographs. A proximal chevron osteotomy combined with a distal soft-tissue procedure was performed by a single surgeon to treat moderate to severe hallux valgus deformity in 93 patients (117 feet). The feet were grouped according to nonrecurrence or recurrence. Changes in the hallux valgus angle, the intermetatarsal angle, and sesamoid position over time were analyzed by comparing values measured during each postoperative period. The relative risks of recurrence as indicated by preoperative and postoperative radiographic parameters were determined. Twenty (17.1%) of the 117 feet showed hallux valgus recurrence at the time of the last follow-up. The hallux valgus angle and the intermetatarsal angle stabilized at 6 months after surgery in the nonrecurrence group. An immediate postoperative hallux valgus angle of ≥8°, an immediate postoperative sesamoid position of grade 4 or greater, a preoperative metatarsus adductus angle of ≥23°, and a preoperative hallux valgus angle of ≥40° were significantly associated with recurrence. Recurrence of hallux valgus after a proximal chevron osteotomy can be reliably predicted from immediate postoperative non-weight-bearing radiographs. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Bipartite Hallucal Sesamoid on Hallux Valgus Surgery.

Bipartite hallucal sesamoids are often found in patients with hallux valgus. However, it is unknown whether bipartite hallucal sesamoids affect the results of hallux valgus surgery or not. The purpose of the present study was to evaluate the outcomes of chevron osteotomy for hallux valgus with and without bipartite hallucal sesamoid. A total of 152 patients (168 feet) treated with distal or proximal chevron osteotomy for hallux valgus constituted the study cohort. The 168 feet were divided into 2 groups: bipartite hallucal sesamoid (31 feet) and without bipartite hallucal sesamoid (137 feet). Hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), tibial sesamoid position, and first metatarsal length were measured for radiographic outcomes and the American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (MTP-IP) score was measured for clinical outcomes. All radiographic measurements and the AOFAS score showed significant ( P < .05) improvement at the time of final follow-up compared with preoperative measurements in both groups. No significant differences ( P > .05) were found between the 2 groups in terms of HVA, IMA, DMAA, tibial sesamoid position, metatarsal shortening, and AOFAS score on final follow-up. This study suggests that bipartite hallucal sesamoids do not affect the results of hallux valgus surgery. Level III, retrospective comparative study.

Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies: a reliable technique.

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. 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). 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). 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.

Consequences of Avulsion Fracture of the Proximal Phalanx Caused by a Technical Failure of Hallux Valgus Surgery

Several cases of avulsion fracture of the proximal phalanx of the big toe during the lateral capsular release procedure were observed. However, these fractures have not been reported as a complication of hallux valgus surgery. The purpose of the present study was to report the proximal phalanx base fracture as an unrecognized complication and to evaluate the clinical and radiographic consequences of this complication. We retrospectively reviewed 225 feet that had undergone hallux valgus surgery involving proximal chevron osteotomy and distal soft tissue release from May 2009 to December 2012. Of these 225 feet (198 patients), 12 (5.3%) developed proximal phalanx base fracture postoperatively. These patients were assigned to the fracture group. The remaining patients were assigned to the nonfracture group. Patients were followed to observe whether the fractures united and whether degenerative changes developed at the first metatarsophalangeal joint because of this fracture. The mean follow-up period was 36 (range 12 to 72) months. All the subjects in the fracture and nonfracture groups underwent weightbearing anteroposterior and lateral radiographs of the foot at the initial presentation and final follow-up point. The 2 groups were compared with respect to the hallux valgus angle, intermetatarsal angle, range of motion, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes. No significant differences were found in age, follow-up period, hallux valgus angle, intermetatarsal angle, range of motion of the first metatarsophalangeal joint, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes between the 2 groups. Ten (83.3%) of the 12 fractures healed, 2 (16.7% of the fractures, 0.89% of the operated feet) progressed to asymptomatic nonunion, and 3 (1.33%) developed first metatarsophalangeal joint degeneration. Avulsion fracture of the proximal phalanx of the big toe is an uncommon complication of hallux valgus surgery. It seems to be caused by excessive tension placed on the lateral soft tissues that attach to the base of the proximal phalanx at the time of plantarlateral soft tissue release. However, this fracture does not seem to cause significant clinical problems.

Change of Reliability for Distal Metatarsal Articular Angle Measurement before and after Proximal Chevron Osteotomy

Change of Reliability for Distal Metatarsal Articular Angle Measurement before and after Proximal Chevron Osteotomy

When Do Clinical and Radiographic Results Stabilize after Proximal Chevron Osteotomy in Hallux Valgus?

When Do Clinical and Radiographic Results Stabilize after Proximal Chevron Osteotomy in Hallux Valgus?

Biomechanical analysis of two fixation methods for proximal chevron osteotomy of the first metatarsal

The proximal chevron osteotomy provides high correctional power. However, relatively high rates of dorsiflexion malunion of up to 17 % are reported for this procedure. This leads to insufficient weight bearing of the first ray and therefore to metatarsalgia. Recent biomechanical and clinical studies pointed out the importance of rigid fixation of proximal metatarsal osteotomies. Therefore, the aim of the present study was to compare biomechanical properties of fixation of proximal chevron osteotomies with variable locking plate and cancellous screw respectively. Ten matched pairs of human fresh frozen cadaveric first metatarsals underwent proximal chevron osteotomy with either variable locking plate or cancellous screw fixation after obtaining bone mineral density. Biomechanical testing included repetitive plantar to dorsal loading from 0 to 31 N with the 858 Mini Bionix(®) (MTS(®) Systems Corporation, Eden Prairie, MN, USA). Dorsal angulation of the distal fragment was recorded. The variable locking plate construct reveals statistically superior results in terms of bending stiffness and dorsal angulation compared to the cancellous screw construct. There was a statistically significant correlation between bone mineral density and maximum tolerated load until construct failure occurred for the screw construct (r = 0.640, p = 0.406). The results of the present study indicate that variable locking plate fixation shows superior biomechanical results to cancellous screw fixation for proximal chevron osteotomy. Additionally, screw construct failure was related to levels of low bone mineral density. Based on the results of the present study we recommend variable locking plate fixation for proximal chevron osteotomy, especially in osteoporotic bone.

Comment on Schuh et al.: Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

To the Editor, In this meta-analysis, Schuh et al. [1] compared correction of intermetatarsal and hallux valgus angles and complications of proximal crescentic, Ludloff, proximal opening wedge, proximal closing wedge, proximal chevron and other proximal first metatarsal osteotomies. They found that there was a mean correction of hallux valgus angle of 20.1° [confidence interval (CI) 18.7–21.4] and of intermetatarsal angle of 8.1° (CI 7.7–8.9). The overall complication rate reached 18.7 %. It is a valuable study. Nevertheless, there are some comments we would like to raise related to this article. The authors included 62 primary studies eligible for meta-analysis. However, we found several repeated studies in the meta-analysis (Table 1). Coughlin et al. reported their studies about proximal crescentic osteotomy [2, 3] twice in 2005 and 2007. Lee et al. also reported their studies about proximal chevron osteotomy [4, 5] twice from 2007 to 2008, and Sammarco et al. reported about proximal chevron osteotomy [6, 7] twice in 1993 and 1995. Schuh et al. included all these studies in their meta-analysis. In our opinion, some repeated data might exist among their studies [2–7]. To solve these problems, we suggest that these studies [2, 4, 6] should be excluded from the meta-analysis. Publication language was limited to English and German in the meta-analysis. Therefore, the authors should mention the potential importance of language bias in the limitations of their meta-analysis. The authors described that “funnel plots were drawn to check for publication bias. Inspection of the funnel plots showed no sign of publication bias.” However, we cannot find the funnel plots in the paper. The author should provide us all the funnel plots. We agree with the following conclusions of the authors, i.e. the proximal crescentic osteotomy provided the highest amount of HVA correction. However, regarding angular correction as well as complications, the proximal chevron osteotomy revealed the most favourable results. Rigid fixation is mandatory in order to reduce complications, and further high-quality prospective comparative studies are required and might change the observed effects.

Response to the comment on Schuh et al.: Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

Dear Prof. Pecina, We greatly appreciate the comments offered by Dr. He and Dr. Peng regarding the recent publication “Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity” [1]. To the raised claims I would like to comment as follows: He and Peng detected six studies included in our meta-analysis to be suspicious for double-counting patients [2–7]. I reviewed these publications once again and concluded that for the publications from Coughlin et al. [2, 3] this is not the case. Coughlin’s publication from 2005 entitled “Proximal metatarsal osteotomy and distal soft tissue reconstruction as treatment for hallux valgus deformity” was a review article which contains results of 27 juvenile patients (33 feet) with hallux valgus. These patients were operated over an 11-year period and were part of the patient cohort from Coughlin’s study concerning juvenile hallux valgus published in 1995 [8]. The 103 patients (122 feet) treated with proximal crescentic osteotomy whose results were presented in 2007 [3] were all operated between September 1999 and May 2002. Therefore, the authors did not include overlapping patient data from Coughlin et al. Sammarco et al. reported results of the proximal chevron osteotomy in 1993 and in 1998 [4, 5]. The first study comprised 43 patients (51 feet) with a mean age of 48 years (range 12–81) [4]. The second study included 55 patients (72 feet) with a mean age of 56 years (range 24–81) [5]. In this case there are perhaps some patients who were included in both studies. However, in the study cohort from 1998 they reviewed the case records of 69 patients and, due to the deaths of unrelated causes of two patients (two feet), the lack of adequate follow-up from six patients (eight feet) and the exclusion of six patients with adolescent bunion or rheumatoid arthritis (six feet), 55 patients with 72 operated feet remained. This demonstrates that not the whole patient cohort from the former published study was included in the later study. Lee at al. published a prospective randomized study comparing two axial K-wires with a supplementary transverse K-wire for proximal chevron osteotomy fixation [6]. The two cohorts contained 32 patients (41 feet) and 33 patients (44 feet), respectively. One year later Lee et al. published a retrospective comparative study with a patient group treated with unilateral and a group operated upon simultaneously for hallux valgus correction (52 patients, 69 feet) [7]. All patients in this study underwent the same surgical technique, in particular axial K-wire fixation with two K-wires. The apprehension of He and Peng could indeed be correct in that we included some of Lee’s patients in duplicate into meta-analysis. Concerning the publication language, the authors did not restrict our systemic search to any languages. During the review process all publications revealed by the online databases MEDLINE, EMBASE, CINAHIL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, using the MeSH terms “(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR ludloff) AND osteotomy” have been reviewed. Studies had to meet the inclusion criteria and a manual reference check of all accepted papers was performed to supplement the electronic search. Finally, only English- and German-language studies were eligible for meta-analysis We would like to provide the funnel plots for delta IMA (Fig. 1) and delta HVA (Fig. 2). In consequence of a limitation in figure submission and publication the authors renounced the attachment of the drawn funnel plots in our original paper. Fig. 1 Funnel plot for the delta intermetatarsal angle (IMA) meta-analysis Fig. 2 Funnel plot for the delta hallux valgus angle (HVA) meta-analysis He and Peng raised some legitimate thoughts regarding our publication “Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity” [1]. After careful reflection we concluded that the study from Sammarco et al. [4] and the axial K-wire fixation group from Lee et al. [6] should be excluded from meta-analysis. As already mentioned, further high-quality prospective comparative studies are required and might change the observed effects.