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Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study
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FAS-821; No. of Pages 6 Foot and Ankle Surgery xxx (2015) xxx–xxx
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Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study Jens Ulrik Wester *, Ellen Hamborg-Petersen, Niels Herold, Palle Bo Hansen, Johnny Froekjaer Foot and Ankle Section, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Soendre Boulevard 29, 5000 Odense C, Denmark
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 July 2013 Received in revised form 16 March 2015 Accepted 19 April 2015
Background: Different techniques of proximal osteotomies have been introduced to correct severe hallux valgus. The open wedge osteotomy is a newly introduced method for proximal osteotomy. The aim of this prospective randomized study was to compare the radiological and clinical results after operation for severe hallux valgus, comparing the open wedge osteotomy to the crescentic osteotomy which is our traditional treatment. Methods: Forty-five patients with severe hallux valgus (hallux valgus angle >35?, and intermetatarsal angle >15?) were included in this study. The treatment was proximal open wedge osteotomy and fixation with plate (Hemax), group 1, or operation with proximal crescentic osteotomy and fixation with a 3 mm cannulated screw, group 2. The mean age was 52 years (19–71). Forty-one females and four males were included. Clinical and radiological follow-ups were performed 4 and 12 months after the operation. Results: In group 1 the hallux valgus angle decreased from 39.0? to 24.1? after 4 months and 27.9? after 12 months. In group 2 the angle decreased from 38.3? to 21.4? after 4 months and 27.0? after 12 months. The intermetatarsal angle in group 1 was 19.0? preoperatively, 11.6? after 4 months and 12.6? after 12 months. In group 2 the mean intermetatarsal angle was 18.9? preoperatively, 12.0? after 4 months and 12.6? after 12 months. The AOFAS score improved from 59.3 to 81.5 in group 1 and from 61.8 to 84.8 in group 2 respectively measured 12 months postoperatively. The relative length of the 1 metatarsal compared to 2 metatarsal bone was 0.88 and 0.87 preoperatively and 0.88 and 0.86 for group 1 and 2 respectively measured after 12 months. Conclusion: Crescentic osteotomy and open wedge osteotomy improve AOFAS score and VAS scores on patients operated with severe hallux valgus. No significant difference was found in the two groups looking at the postoperative improvement of HVA and IMA measured 4 and 12 months postoperatively. The postoperative VAS score and AOFAS score were comparable for the two groups with no significant difference. An expected tendency to gain better length of the first metatarsal using the open wedge osteotomy compared to the crescentic osteotomy was not found. Even though the IMA and HVA reduction was only suboptimal the improvement in AOFAS score was comparable to other similar clinical trials. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus Proximal osteotomy Clinical trial Prospective randomized trial Open wedge osteotomy Crescentic osteotomy
1. Introduction Hallux valgus surgery is a very common forefoot operation, and several techniques have been introduced to correct the deformity
* Corresponding author at: Aborgvej 13, DK-5610 Assens, Denmark. Tel.: +45 2621 4216. E-mail address: [email protected] (J.U. Wester).
[1–11]. Hallux valgus often leads to pain, deformity of the big toe and secondary complications such as abnormal gait and ulcers on the foot. Numerous techniques have been introduced and published regarding correcting hallux valgus. The operation techniques can be divided into distal metatarsal osteotomy (DMO), mid-shaft osteotomies or proximal metatarsal osteotomy (PMO) [1,12–16]. The Akin procedure is used to correct the pronation deviation of the proximal phalanx and to correct hallux valgus interphalangealis, when this is still persisting after
http://dx.doi.org/10.1016/j.fas.2015.04.006 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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correcting the hallux valgus (HVA) and inter-metatarsal (IMA) angle [17]. Only very few prospective randomized investigations comparing different operation methods for hallux valgus have been published [8,12,13]. In our department the distal chevron procedure is used for patients with a HVA less than 35 degrees and an IMA less than 15 degrees [8]. For patients with HVA larger than 35 degrees or IMA larger than 15 degrees, we use the PMO to correct the hallux valgus deformity [1], the PMO is in general considered technically more demanding and is more likely to give complications. The DMO is considered mainly to be advisable in operations correcting hallux valgus with a limited HVA and IMA. The aim of the operation for hallux valgus is to diminish pain and to correct the IMA and HVA with a very low incidence of complications. The hypothesis of this study was that the open wedge osteotomy procedure was equivalent or superior to the crescentic osteotomy, measured by the parameters: postoperative HVA, IMA, AOFAS score, VAS score and relative length of 1 compared to 2 metatarsal, measured preoperative, 4 and 12 months postoperatively. 2. Materials and methods During the period 1st January 2009 to 1st January 2011, 45 consecutive patients were included in the prospective study, which was approved by the Danish Ethical Committee. The inclusion criteria were aged 15–70 years, hallux valgus angle >35 degrees and inter-metatarsal angle >15 degrees, the measurement was evaluated on anterior–posterior (AP) weight bearing radiographs. Patients with rheumatoid arthritis, osteoarthritis of the MTP joint, spasticity of any kind, vascular diseases or pregnancy (elective surgery was not performed on pregnant women) were excluded from the study. All patients had a body mass index of less than 30. None of the patients were diagnosed with osteoporosis, and no patients had a history of any forefoot surgery prior to joining the study. All patients were operated using a popliteal block or general anaesthesia as an outpatient procedure according to the protocol. After informed consent, the patients were randomized to one of two groups by drawing of lots. The allocation was done double blinded. The mean age was 52 years (19–70). The cohort consisted of 41 women and 4 men. Twenty-three patients were randomized to group 1 (crescentic osteotomy) and 22 patients were randomized to group 2 (open wedge osteotomy). Demographic data suggested no difference between the two groups (mean age and sex ratio).
The osteotomy was done in a plane perpendicular to the first metatarsal bone. A 3 mm cannulated AO titanium screw was used for stabilization, directed from proximal–medial–dorsal to distal– lateral. Capsule tightening was performed (Fig. 1). Before skin closure the tourniquet was removed and haemostasis was secured. The HVA and IMA corrections were verified by fluoroscopy intraoperatively. 3.2. Group 2 A transverse proximal osteotomy of the metatarsal bone 1.5 cm distal to the TMT joint performed made with a small saw blade, leaving the lateral cortex and periosteum intact. The distal part of the first metatarsal was pushed laterally towards the second metatarsal, until the desired correction had been achieved resulting in an opening of the medial cortex (3–5 mm). The L shaped non-locking Hemax plate was used for fixing the osteotomy. It was inserted on the medial side of the metatarsal to assure best possible mechanical stability of the osteotomy and least possible hardware irritation. The Hemax plate was placed with the ‘‘L’’ in a proximal position, pointing dorsally. Four nonlocking screws, 2.3 mm self-tapping, were inserted bicortically in the drill holes, two screws proximally and 2 distally. Cancellous bone from the medial eminence was packed into the osteotomy site (Fig. 2). The correction was verified by fluoroscopy intraoperatively. (Fig. 3) If there was a tendency to collision between the first and second toe after the osteotomy procedure, the operations in both groups were complemented with Akin procedure at the proximal phalanx. 3.2.1. Postoperative treatment Both groups followed the same postoperative procedure, which was 1 week with partial weight bearing and 5 weeks in static walker, gradually allowing full weight bearing. Sutures were removed 14 days postoperatively and a toe alignment splint was used permanently for 6 weeks after removal of the stitches. All patients returned to postoperative evaluation after 6 weeks, 4 months and 12 months, respectively. MTP joint mobility exercises were initiated 3 to 4 weeks after surgery. No physiotherapy rehabilitation programme was initiated for any of the groups.
3. Surgical technique Both the open wedge osteotomy and the crescentic osteotomy consist of a distal lateral release and bunionectomy prior to the proximal osteotomy. Firstly, a dorsal incision was made in the inter-metatarsal space between 1st and 2nd ray. Release of the adductor hallucis tendon, the deep transverse inter-metatarsal ligament and lateral capsule were executed. The second incision was made midline medial over the medial eminence to remove the medial eminence and perform a capsulorrhaphy. The third incision was made dorsally over the proximal end of the first metatarsal and extended a few millimetres over the medial cuneiforme. The proximal osteotomy for each group was made through this incision. 3.1. Group 1 A proximal crescentic osteotomy about 15 mm distal to the TMT-joint, with the concavity pointing proximal was made.
Fig. 1. Pre- and postoperative weight bearing X-rays after crescentic osteotomy.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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Fig. 3. Pre- and postoperative weight bearing X-rays after open wedge osteotomy.
was available on the X-rays, thus the relation between the 1st and 2nd metatarsal was used as a measure instead of absolute length. 4. Statistics Analysis of the data distribution was done making probit plots. Data were found to be normally distributed, and for this reason, parametric tests were used. An independent t-test was used to compare the results after the proximal crescentic osteotomy and the open wedge osteotomy. Significance was reached with a p-value less than 0.05 (p < 0.05). 5. Results
Fig. 2. Intra-operative pictures during the opening wedge osteotomy.
Twenty-three patients were randomized to group 1 and 22 patients were randomized to group 2. The patients were followed with clinical and radiological evaluation after 6 weeks, 4 and 12 months. All operations were performed by 4 senior orthopaedic foot and ankle surgeons. Clinical evaluation was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS). Scores and radiological measures were recorded preoperatively and 4 and 12 months following the operation (Table 1). Antero-posterior (AP) weight bearing views were taken preoperatively, 4 and 12 months postoperatively. Fluoroscopy was used during the operation to assure the desired correction. The X-rays were evaluated by the same foot and ankle surgeon measuring the hallux valgus angle (HV), inter-metatarsal angle (IM), radiological healing and length of the 1 compared to 2 metatarsal length. No absolute length parameter (tracking ball)
Mean hallux valgus angle in group 1 (crescentic osteotomy) decreased from 39.00˚ preoperatively to 24.10˚ after 4 months and 27.90˚ after 12 months. Mean hallux valgus angle in group 2 (open wedge osteotomy) decreased from 38.30˚ preoperatively to 21.40˚ after 4 months and 27.00˚ after 12 months (Table 1). Mean inter-metatarsal angle in group 1 was 19.00˚ preoperatively, 11.60˚ after 4 months and 12.60˚ after 12 months. Mean intermetatarsal angle in group 2 was 18.90˚ preoperatively, 12.00˚ after 4 months and 12.60˚ after 12 months (Table 2). The HVA and IMA improved significantly (p < 0.05) in both groups after 4 and 12 months following the operation compared to the preoperative values. The AOFAS score improved from 59.3 preoperatively to 83.4 and 81.5 measured 4 and 12 months postoperatively. For group 2 the improvement was found to be from 61.7 to 78.3 and 84.8, respectively. No significant difference (p > 0.05) in the AOFAS
Table 1 Hallux valgus angle. Hallux valgus angle (HVA)
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
39.08 (36.7–41.4) 24.18 (21.6–26.7) 27.98 (24.3–30.0)
38.38 (35.5–41.1) 21.48 (17.4–25.5) 27.08 (22.2–31.8)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative HV angle in group 1 and group 2. b Non-significant difference of HV angle in group 1 and group 2 after 4 months. c Non-significant difference of HV angle in group 1 and group 2 after 12 months.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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4 Table 2 Intermetatarsal angle. Intermetatarsal angle (IMA)
Preoperative 4 months postoperative 12 months postoperative
Table 5 Relative lengths of 1 metatarsal compared to 2 metatarsal. Group 1
Group 2
Cr. osteotomy
OW osteotomy
19.08 (18.0–20.0) 11.68 (9.9–13.3) 12.68 (10.8–14.0)
18.98 (18.0–19.7) 12.08 (9.8–14.1) 12.68 (10.6–14.6)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative IM angle in group 1 and group 2. b Non-significant difference of IM angle in group 1 and group 2 after 4 months. c Non-significant difference of IM angle in group 1 and group 2 after 12 months.
score was found between the two groups after 4 and 12 months (Table 3). VAS decreased from 4.9 preoperatively to 1.7 after 12 months in group 1, and 4.7 to 1.5 for group 2 respectively, measured after 12 months (Table 4) No significant difference in the VAS score was found between the two groups after 4 and 12 months (p > 0.05) (Table 4). A highly significant improvement (p < 0.05) was found as expected, looking at the AOFAS score and VAS score preoperatively and after 4 and 12 months. Relative length of the 1st metatarsal relative to 2nd metatarsal bone was 0.88 and 0.87 preoperatively and 0.88 and 0.86 after 12 months for group 1 and 2, respectively (Table 5). No significant difference (p > 0.05) was found here, looking at difference between the two groups and the 4 and 12 months outcome for each group. Mean operation time for the crescentic osteotomy (group 1) was 88.9 min and 88.8 min for the open wedge osteotomy (group 2). No statistical difference was found in the mean operating time (p > 0.05). Median, maximum and minimum operating time was found to be 90, 125 and 50 min for group 1 and 95, 160 and 30 min for group 2, respectively. 6. Complications Implant removal was performed in 5 of 23 patients in group 1, and in 4 out of 22 patients in group 2. The screw used in group 1 for Table 3 AOFAS score 0–100 points. AOFAS score 0–100
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
59.3 (55.4–63.1) 83.4 (77.3–89.6) 81.5 (74.4–78.6)
61.8 (57.9–65.6) 78.3 (73.8–82.8) 84.8 (78.2–91.4)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative AOFAS score in group 1 and group 2. b Non-significant difference of AOFAS score in group 1 and group 2 after 4 months. c Non-significant difference of AOFAS score in group 1 and group 2 after 12 months.
Table 4 VAS score. VAS score 0–10 cm
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
4.9 cm (4.2–5.7) 1.9 cm (1.2–2.7) 1.7 cm (0.8–2.5)
4.7 cm (3.8–5.5) 2.2 cm (1.4–3.0) 1.5 cm (0.9–2.2)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative VAS score group 1 and group 2. b Non-significant difference of VAS score in group 1 and group 2 after 4 months. c Non-significant difference of VAS score in group 1 and group 2 after 12 months.
Relative metatarsal length
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
0.88 0.88 0.88
0.87 0.87 0.86
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative relative lengths of 1 compared to 2 metatarsal in group 1 and 2. b Non-significant difference between relative lengths of 1 compared to 2 metatarsal in groups 1 and 2 after 4 months. c Non-significant difference between preoperative relative lengths of 1 compared to 2 metatarsal in groups 1 and 2 after 12 months.
the crescentic osteotomy was directed from proximal–medial–dorsal to a distal–lateral direction. The aim was to place the screw so far medially that irritation from the extensor tendon did not occur, but soft tissue irritation can still be a problem. Screw irritation was the reason for hardware removal in 2 of 5 patients in group 1. The other 3 patients in group 1 had screw removal done at the same time as having a Lapidus procedure done [2] and MTP arthrodesis [1]. Reoperations, except for only screw removal, were performed due to insufficient correction of HVA and IMA. In group 2, where the Hemax plate was placed on the medial proximal part of the 1st metatarsal bone, 4 patients had hardware removed. Local irritation from the Hemax plate was the reason for three patients and one patient experienced pull-out of some of the screws in the plate before osseous healing.
7. Discussion Only very few prospective randomized trials have been made comparing different kinds of operations in hallux valgus surgery. No significant difference was found between groups 1 and 2 comparing preoperative angle values (39.10˚ and 38.30˚) 4 months postoperatively (24.10˚ and 21.40˚) and 12 months postoperatively (27.20˚ and 27.00˚) (Table 1). Similarly, no significant difference was found looking at the IM angle improvement of the two groups comparing preoperative values of groups 1 and 2 (19.00˚ and 18.90˚) and 4 months postoperatively (11.60˚ and 12.00˚) and 12 months postoperatively (12.5 and 12.6) (Table 2). These results show no clearly better outcome of the open wedge osteotomy compared to the crescentic osteotomy. As expected, a significant improvement of the HVA and IMA was reached through operation in both groups looking at the values preoperatively, 4 months postoperatively and 12 months postoperatively. No radiological assessment was done immediately after the operation. The first weight bearing X-rays were taken 4 months postoperatively. HV and IM angles of the two groups respectively after 4 months (24.10˚, 21.40˚ and 11.60˚, 12.00˚) were not as good as expected. Twelve months postoperatively the HVA and IMA had increased further for both groups (27.20˚, 27.00˚ and 12.50˚, 12.60˚). The loss of correction between 4 and 12 month was found to be significant for the HV angle in both groups. It is unknown whether the desired angle correction for HV and IM angle was ever reached or whether loss of correction occurred during the first 4 month and continued further until follow up after 12 months. Radiologically, the total HVA correction in this study was comparable to other hallux valgus correcting studies using similar operation methods [7,13,18,19]. In these studies, the preoperative HVA was only ranging from 7 to 320˚ resulting in a final HVA considerably lower postoperatively compared to our study. In a previous study, it has been verified that a HVA >400˚ results in a significantly higher risk for HVA recurrence after proximal
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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metatarsal osteotomy [20]. In our study 9 patients in each group had a HVA >400˚. A significant improvement was seen comparing pre- and postoperative (4 and 12 months) VAS and AOFAS score for both groups, but there was not a significant difference between the two groups (Tables 3 and 4). The improvements in AOFAS- and VAS-scores were found to be comparable to other studies [17–19,21]. The AOFAS score improvement in our study was slightly inferior to some of the other studies referred to. This could be due to the not fully corrected angle, although Rose et al. found no correlation in their study between improvement in HVA and AOFAS score [18]. The significant AOFAS score improvement suggests that patients were symptomatically and functionally better after surgery even with non-optimal corrected HVA and IMA. The time for bone healing is often longer for older people with lower bone density. By using only four 3 mm non-locking screws, two on each side of the osteotomy, there is a risk of implant failure and pull out before osseous healing. Using a plate with locking screws, the risk of implant failure is diminished as the mechanical performance of locking plate constructs, using only two screws, is comparable to three non-locking screw constructs in osteoporotic bone and thereby giving the small plate better stability [22]. The relative length of the first metatarsal bone compared to the second metatarsal bone was unchanged following both crescentic osteotomy and the open wedge osteotomy. Due to the mechanical features of an open wedge osteotomy and the correction of the HV and IM angle it was expected to find a slight elongation of the 1st metatarsal compared to the 2nd metatarsal for the patients in group 2 as have been found in similar studies [16,23,24]. In these studies the lengthening has been reported to be 1.2–2.3 mm. As hallux valgus surgery can lead to metatarsalgia due to shortening of the first ray, it should be better to gain length by using the open wedge osteotomy compared to the crescentic osteotomy [7,8,20]. To´th et al. found a positive correlation between of the metatarsalgia and the shortening of the first ray [25]. It has been found to be of better value using the relative length change of the first metatarsal compared to actual total change in mm [2]. Correcting the HVA with a proximal osteotomy and lateral release can increase the hallux valgus interphalangeal angle and course the need of an Akin osteotomy. This has been shown in a previous study by Park et al., where they found a need of an Akin osteotomy as a supplement in 44 of 54 operated patients to avoid collision between the1st and 2nd toe [17]. 8. Perspective As the open wedge osteotomy is found to be equivalent to the crescentic osteotomy, this will be our standard in the future when correcting severe hallux valgus with a proximal osteotomy as the procedure is less technically challenging. For both groups a loss of correction was seen in the interval from 4 to 12 months. This could be due to instability of the TMT joint. If this is the case a Lapidus procedure might be more relevant than a proximal osteotomy in patients with a large IM and HV angle. As a consequence of not reaching the desired correction of the HV angle intra-operatively in both groups, more attention will be drawn in correcting the IMA and HVA sufficiently by verifying the corrected angles using X-ray intra-operatively. 9. Limitations Our study has several limitations. The four senior surgeons were aiming for ‘‘desired’’ correction when performing the two
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different types of osteotomies, verifying the correction with fluoroscopy but with no specific aim of angle correction. The Akin procedure was done, when the surgeon felt there was a ‘‘need,’’ a risk of collision between 1st and 2nd toe. If more precise objective goals, especially radiologically, had been standardized, maybe better correction would have been achieved, and maybe a difference in the osteotomy types could have been found. The metatarsal lengths and angles were measured by one of our four operating senior surgeons and not by a radiologist. A limitation of accuracy occurs evaluating normal X-rays compared to MR and CT. A follow-up period of 12 months is similar to some of the studies used for comparison in the article. Optimally, the follow-up period should continue until loss of correction of the osteotomies no longer occurred. 10. Conclusion Crescentic osteotomy and open wedge osteotomy improves AOFAS score and VAS scores on patients operated with severe hallux valgus. No significant difference was found in the two groups looking at the postoperative improvement of HVA and IMA measured 4 and 12 months postoperatively. The postoperative VAS score and AOFAS score were comparable for the two groups with no significant difference. An expected tendency to gain better length of the first metatarsal using the open wedge osteotomy compared to the crescentic osteotomy was not found. A significant loss of correction of hallux valgus angle was found for both groups in the postoperative interval 4–12 months. Even though the IMA and HVA reduction was only suboptimal, the improvement in AOFAS score was comparable to other similar clinical trials. Conflict of interest None of the authors have any conflicts of interest to declare. Acknowledgement We want to thank PhD Jens Lauridsen, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, for his inspiring and unsurpassed help with the statistical calculations. References [1] Coughlin MJ, Smith BW. Hallux valgus and first ray mobility. Surgical technique. J Bone Joint Surg Am 2008;90(Suppl. 2 Pt 2):153–70. [2] Day T, Charlton TP, Thordarson DB. First metatarsal length change after basilar closing wedge osteotomy for hallux valgus. Foot Ankle Int 2011;32(5):S513–8. [3] Deenik A, van Mameren H, de Visser E, de Waal Malefijt M, Draijer F, de Bie R. Equivalent correction in scarf and chevron osteotomy in moderate and severe hallux valgus: a randomized controlled trial. Foot Ankle Int 2008;29(12): 1209–15. [4] Ellington JK, Myerson MS, Coetzee JC, Stone RM. The use of the Lapidus procedure for recurrent hallux valgus. Foot Ankle Int 2011;32(7):674–80. [5] Kayiaros S, Blankenhorn BD, Dehaven J, Van Lancker H, Sardella P, Pascalides JT, et al. Correction of metatarsus primus varus associated with hallux valgus deformity using the arthrex mini tightrope: a report of 44 cases. Foot Ankle Spec 2011;4(4):212–7. [6] Moon JY, Lee KB, Seon JK, Moon ES, Jung ST. Outcomes of proximal chevron osteotomy for moderate versus severe hallux valgus deformities. Foot Ankle Int 2012;33(8):637–43. [7] Nedopil A, Rudert M, Gradinger R, Schuster T, Bracker W. Closed wedge osteotomy in 66 patients for the treatment of moderate to severe hallux valgus. Foot Ankle Surg 2010;16(1):9–14. [8] Okuda R, Kinoshita M, Yasuda T, Jotoku T, Shima H. Proximal metatarsal osteotomy for hallux valgus: comparison of outcome for moderate and severe deformities. Foot Ankle Int 2008;29(7):664–70. [9] Paczesny L, Kruczynski J, Adamski R. Scarf versus proximal closing wedge osteotomy in hallux valgus treatment. Arch Orthop Trauma Surg 2009;129(10): 1347–52.
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[10] Park HW, Lee KB, Chung JY, Kim MS. Comparison of outcomes between proximal and distal chevron osteotomy, both with supplementary lateral soft-tissue release, for severe hallux valgus deformity: a prospective randomised controlled trial. Bone Joint J 2013;95-B(4):510–6. [11] Adam SP, Choung SC, Gu Y, O’Malley MJ. Outcomes after scarf osteotomy for treatment of adult hallux valgus deformity. Clin Orthop Relat Res 2011;469(3):854–9. [12] Chiang CC, Lin CF, Tzeng YH, Huang CK, Chen WM, Liu CL. Distal linear osteotomy compared to oblique diaphyseal osteotomy in moderate to severe hallux valgus. Foot Ankle Int 2012;33(6):479–86. [13] Choi WJ, Yoon HK, Yoon HS, Kim BS, Lee JW. Comparison of the proximal chevron and Ludloff osteotomies for the correction of hallux valgus. Foot Ankle Int 2009;30(12):1154–60. [14] Chuckpaiwong B. Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus. Int Orthop 2012;36(11):2275–8. [15] Cooper MT, Berlet GC, Shurnas PS, Lee TH. Proximal opening-wedge osteotomy of the first metatarsal for correction of hallux valgus. Surg Technol Int 2007;16:215–9. [16] Badekas A, Georgiannos D, Lampridis V, Bisbinas I. Proximal opening wedge metatarsal osteotomy for correction of moderate to severe hallux valgus deformity using a locking plate. Int Orthop 2013;37(9):1765–70. [17] Park JY, Jung HG, Kim TH, Kang MS. Intraoperative incidence of hallux valgus interphalangeus following basilar first metatarsal osteotomy and distal soft tissue realignment. Foot Ankle Int 2011;32(10):962–7.
[18] Rose B, Bowman N, Edwards H, Rajaratnam SS, Armitage AR, Skyrme AD. Lengthening scarf osteotomy for recurrent hallux valgus. Foot Ankle Surg 2014;20(1):20–5. [19] Nery C, Ressio C, de Azevedo Santa Cruz G, de Oliveira RS, Chertman C. Proximal opening-wedge osteotomy of the first metatarsal for moderate and severe hallux valgus using low profile plates. Foot Ankle Surg 2013;19(4):276–82. [20] Okuda R, Kinoshita M, Yasuda T, Jotoku T, Shima H, Takamura M. Hallux valgus angle as a predictor of recurrence following proximal metatarsal osteotomy. J Orthop Sci 2011;16(6):760–4. [21] Choi JH, Zide JR, Coleman SC, Brodsky JW. Prospective study of the treatment of adult primary hallux valgus with scarf osteotomy and soft tissue realignment. Foot Ankle Int 2013;34(5):684–90. [22] Grawe B, Le T, Williamson S, Archdeacon A, Zardiackas L. Fracture fixation with two locking screws versus three non-locking screws: a biomechanical comparison in a normal and an osteoporotic bone model. Bone Joint Res 2012;1(6):118–24. [23] Saragas NP. Proximal opening-wedge osteotomy of the first metatarsal for hallux valgus using a low profile plate. Foot Ankle Int 2009;30(10):976–80. [24] Smith WB, Hyer CF, DeCarbo WT, Berlet GC, Lee TH. Opening wedge osteotomies for correction of hallux valgus: a review of wedge plate fixation. Foot Ankle Spec 2009;2(6):277–82. [25] Toth K, Huszanyik I, Kellermann P, Boda K, Rode L. The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy. Foot Ankle Int 2007;28(1):61–3.
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Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study Jens Ulrik Wester *, Ellen Hamborg-Petersen, Niels Herold, Palle Bo Hansen, Johnny Froekjaer Foot and Ankle Section, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Soendre Boulevard 29, 5000 Odense C, Denmark
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 July 2013 Received in revised form 16 March 2015 Accepted 19 April 2015
Background: Different techniques of proximal osteotomies have been introduced to correct severe hallux valgus. The open wedge osteotomy is a newly introduced method for proximal osteotomy. The aim of this prospective randomized study was to compare the radiological and clinical results after operation for severe hallux valgus, comparing the open wedge osteotomy to the crescentic osteotomy which is our traditional treatment. Methods: Forty-five patients with severe hallux valgus (hallux valgus angle >35?, and intermetatarsal angle >15?) were included in this study. The treatment was proximal open wedge osteotomy and fixation with plate (Hemax), group 1, or operation with proximal crescentic osteotomy and fixation with a 3 mm cannulated screw, group 2. The mean age was 52 years (19–71). Forty-one females and four males were included. Clinical and radiological follow-ups were performed 4 and 12 months after the operation. Results: In group 1 the hallux valgus angle decreased from 39.0? to 24.1? after 4 months and 27.9? after 12 months. In group 2 the angle decreased from 38.3? to 21.4? after 4 months and 27.0? after 12 months. The intermetatarsal angle in group 1 was 19.0? preoperatively, 11.6? after 4 months and 12.6? after 12 months. In group 2 the mean intermetatarsal angle was 18.9? preoperatively, 12.0? after 4 months and 12.6? after 12 months. The AOFAS score improved from 59.3 to 81.5 in group 1 and from 61.8 to 84.8 in group 2 respectively measured 12 months postoperatively. The relative length of the 1 metatarsal compared to 2 metatarsal bone was 0.88 and 0.87 preoperatively and 0.88 and 0.86 for group 1 and 2 respectively measured after 12 months. Conclusion: Crescentic osteotomy and open wedge osteotomy improve AOFAS score and VAS scores on patients operated with severe hallux valgus. No significant difference was found in the two groups looking at the postoperative improvement of HVA and IMA measured 4 and 12 months postoperatively. The postoperative VAS score and AOFAS score were comparable for the two groups with no significant difference. An expected tendency to gain better length of the first metatarsal using the open wedge osteotomy compared to the crescentic osteotomy was not found. Even though the IMA and HVA reduction was only suboptimal the improvement in AOFAS score was comparable to other similar clinical trials. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus Proximal osteotomy Clinical trial Prospective randomized trial Open wedge osteotomy Crescentic osteotomy
1. Introduction Hallux valgus surgery is a very common forefoot operation, and several techniques have been introduced to correct the deformity
* Corresponding author at: Aborgvej 13, DK-5610 Assens, Denmark. Tel.: +45 2621 4216. E-mail address: [email protected] (J.U. Wester).
[1–11]. Hallux valgus often leads to pain, deformity of the big toe and secondary complications such as abnormal gait and ulcers on the foot. Numerous techniques have been introduced and published regarding correcting hallux valgus. The operation techniques can be divided into distal metatarsal osteotomy (DMO), mid-shaft osteotomies or proximal metatarsal osteotomy (PMO) [1,12–16]. The Akin procedure is used to correct the pronation deviation of the proximal phalanx and to correct hallux valgus interphalangealis, when this is still persisting after
http://dx.doi.org/10.1016/j.fas.2015.04.006 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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correcting the hallux valgus (HVA) and inter-metatarsal (IMA) angle [17]. Only very few prospective randomized investigations comparing different operation methods for hallux valgus have been published [8,12,13]. In our department the distal chevron procedure is used for patients with a HVA less than 35 degrees and an IMA less than 15 degrees [8]. For patients with HVA larger than 35 degrees or IMA larger than 15 degrees, we use the PMO to correct the hallux valgus deformity [1], the PMO is in general considered technically more demanding and is more likely to give complications. The DMO is considered mainly to be advisable in operations correcting hallux valgus with a limited HVA and IMA. The aim of the operation for hallux valgus is to diminish pain and to correct the IMA and HVA with a very low incidence of complications. The hypothesis of this study was that the open wedge osteotomy procedure was equivalent or superior to the crescentic osteotomy, measured by the parameters: postoperative HVA, IMA, AOFAS score, VAS score and relative length of 1 compared to 2 metatarsal, measured preoperative, 4 and 12 months postoperatively. 2. Materials and methods During the period 1st January 2009 to 1st January 2011, 45 consecutive patients were included in the prospective study, which was approved by the Danish Ethical Committee. The inclusion criteria were aged 15–70 years, hallux valgus angle >35 degrees and inter-metatarsal angle >15 degrees, the measurement was evaluated on anterior–posterior (AP) weight bearing radiographs. Patients with rheumatoid arthritis, osteoarthritis of the MTP joint, spasticity of any kind, vascular diseases or pregnancy (elective surgery was not performed on pregnant women) were excluded from the study. All patients had a body mass index of less than 30. None of the patients were diagnosed with osteoporosis, and no patients had a history of any forefoot surgery prior to joining the study. All patients were operated using a popliteal block or general anaesthesia as an outpatient procedure according to the protocol. After informed consent, the patients were randomized to one of two groups by drawing of lots. The allocation was done double blinded. The mean age was 52 years (19–70). The cohort consisted of 41 women and 4 men. Twenty-three patients were randomized to group 1 (crescentic osteotomy) and 22 patients were randomized to group 2 (open wedge osteotomy). Demographic data suggested no difference between the two groups (mean age and sex ratio).
The osteotomy was done in a plane perpendicular to the first metatarsal bone. A 3 mm cannulated AO titanium screw was used for stabilization, directed from proximal–medial–dorsal to distal– lateral. Capsule tightening was performed (Fig. 1). Before skin closure the tourniquet was removed and haemostasis was secured. The HVA and IMA corrections were verified by fluoroscopy intraoperatively. 3.2. Group 2 A transverse proximal osteotomy of the metatarsal bone 1.5 cm distal to the TMT joint performed made with a small saw blade, leaving the lateral cortex and periosteum intact. The distal part of the first metatarsal was pushed laterally towards the second metatarsal, until the desired correction had been achieved resulting in an opening of the medial cortex (3–5 mm). The L shaped non-locking Hemax plate was used for fixing the osteotomy. It was inserted on the medial side of the metatarsal to assure best possible mechanical stability of the osteotomy and least possible hardware irritation. The Hemax plate was placed with the ‘‘L’’ in a proximal position, pointing dorsally. Four nonlocking screws, 2.3 mm self-tapping, were inserted bicortically in the drill holes, two screws proximally and 2 distally. Cancellous bone from the medial eminence was packed into the osteotomy site (Fig. 2). The correction was verified by fluoroscopy intraoperatively. (Fig. 3) If there was a tendency to collision between the first and second toe after the osteotomy procedure, the operations in both groups were complemented with Akin procedure at the proximal phalanx. 3.2.1. Postoperative treatment Both groups followed the same postoperative procedure, which was 1 week with partial weight bearing and 5 weeks in static walker, gradually allowing full weight bearing. Sutures were removed 14 days postoperatively and a toe alignment splint was used permanently for 6 weeks after removal of the stitches. All patients returned to postoperative evaluation after 6 weeks, 4 months and 12 months, respectively. MTP joint mobility exercises were initiated 3 to 4 weeks after surgery. No physiotherapy rehabilitation programme was initiated for any of the groups.
3. Surgical technique Both the open wedge osteotomy and the crescentic osteotomy consist of a distal lateral release and bunionectomy prior to the proximal osteotomy. Firstly, a dorsal incision was made in the inter-metatarsal space between 1st and 2nd ray. Release of the adductor hallucis tendon, the deep transverse inter-metatarsal ligament and lateral capsule were executed. The second incision was made midline medial over the medial eminence to remove the medial eminence and perform a capsulorrhaphy. The third incision was made dorsally over the proximal end of the first metatarsal and extended a few millimetres over the medial cuneiforme. The proximal osteotomy for each group was made through this incision. 3.1. Group 1 A proximal crescentic osteotomy about 15 mm distal to the TMT-joint, with the concavity pointing proximal was made.
Fig. 1. Pre- and postoperative weight bearing X-rays after crescentic osteotomy.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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Fig. 3. Pre- and postoperative weight bearing X-rays after open wedge osteotomy.
was available on the X-rays, thus the relation between the 1st and 2nd metatarsal was used as a measure instead of absolute length. 4. Statistics Analysis of the data distribution was done making probit plots. Data were found to be normally distributed, and for this reason, parametric tests were used. An independent t-test was used to compare the results after the proximal crescentic osteotomy and the open wedge osteotomy. Significance was reached with a p-value less than 0.05 (p < 0.05). 5. Results
Fig. 2. Intra-operative pictures during the opening wedge osteotomy.
Twenty-three patients were randomized to group 1 and 22 patients were randomized to group 2. The patients were followed with clinical and radiological evaluation after 6 weeks, 4 and 12 months. All operations were performed by 4 senior orthopaedic foot and ankle surgeons. Clinical evaluation was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS). Scores and radiological measures were recorded preoperatively and 4 and 12 months following the operation (Table 1). Antero-posterior (AP) weight bearing views were taken preoperatively, 4 and 12 months postoperatively. Fluoroscopy was used during the operation to assure the desired correction. The X-rays were evaluated by the same foot and ankle surgeon measuring the hallux valgus angle (HV), inter-metatarsal angle (IM), radiological healing and length of the 1 compared to 2 metatarsal length. No absolute length parameter (tracking ball)
Mean hallux valgus angle in group 1 (crescentic osteotomy) decreased from 39.00˚ preoperatively to 24.10˚ after 4 months and 27.90˚ after 12 months. Mean hallux valgus angle in group 2 (open wedge osteotomy) decreased from 38.30˚ preoperatively to 21.40˚ after 4 months and 27.00˚ after 12 months (Table 1). Mean inter-metatarsal angle in group 1 was 19.00˚ preoperatively, 11.60˚ after 4 months and 12.60˚ after 12 months. Mean intermetatarsal angle in group 2 was 18.90˚ preoperatively, 12.00˚ after 4 months and 12.60˚ after 12 months (Table 2). The HVA and IMA improved significantly (p < 0.05) in both groups after 4 and 12 months following the operation compared to the preoperative values. The AOFAS score improved from 59.3 preoperatively to 83.4 and 81.5 measured 4 and 12 months postoperatively. For group 2 the improvement was found to be from 61.7 to 78.3 and 84.8, respectively. No significant difference (p > 0.05) in the AOFAS
Table 1 Hallux valgus angle. Hallux valgus angle (HVA)
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
39.08 (36.7–41.4) 24.18 (21.6–26.7) 27.98 (24.3–30.0)
38.38 (35.5–41.1) 21.48 (17.4–25.5) 27.08 (22.2–31.8)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative HV angle in group 1 and group 2. b Non-significant difference of HV angle in group 1 and group 2 after 4 months. c Non-significant difference of HV angle in group 1 and group 2 after 12 months.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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4 Table 2 Intermetatarsal angle. Intermetatarsal angle (IMA)
Preoperative 4 months postoperative 12 months postoperative
Table 5 Relative lengths of 1 metatarsal compared to 2 metatarsal. Group 1
Group 2
Cr. osteotomy
OW osteotomy
19.08 (18.0–20.0) 11.68 (9.9–13.3) 12.68 (10.8–14.0)
18.98 (18.0–19.7) 12.08 (9.8–14.1) 12.68 (10.6–14.6)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative IM angle in group 1 and group 2. b Non-significant difference of IM angle in group 1 and group 2 after 4 months. c Non-significant difference of IM angle in group 1 and group 2 after 12 months.
score was found between the two groups after 4 and 12 months (Table 3). VAS decreased from 4.9 preoperatively to 1.7 after 12 months in group 1, and 4.7 to 1.5 for group 2 respectively, measured after 12 months (Table 4) No significant difference in the VAS score was found between the two groups after 4 and 12 months (p > 0.05) (Table 4). A highly significant improvement (p < 0.05) was found as expected, looking at the AOFAS score and VAS score preoperatively and after 4 and 12 months. Relative length of the 1st metatarsal relative to 2nd metatarsal bone was 0.88 and 0.87 preoperatively and 0.88 and 0.86 after 12 months for group 1 and 2, respectively (Table 5). No significant difference (p > 0.05) was found here, looking at difference between the two groups and the 4 and 12 months outcome for each group. Mean operation time for the crescentic osteotomy (group 1) was 88.9 min and 88.8 min for the open wedge osteotomy (group 2). No statistical difference was found in the mean operating time (p > 0.05). Median, maximum and minimum operating time was found to be 90, 125 and 50 min for group 1 and 95, 160 and 30 min for group 2, respectively. 6. Complications Implant removal was performed in 5 of 23 patients in group 1, and in 4 out of 22 patients in group 2. The screw used in group 1 for Table 3 AOFAS score 0–100 points. AOFAS score 0–100
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
59.3 (55.4–63.1) 83.4 (77.3–89.6) 81.5 (74.4–78.6)
61.8 (57.9–65.6) 78.3 (73.8–82.8) 84.8 (78.2–91.4)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative AOFAS score in group 1 and group 2. b Non-significant difference of AOFAS score in group 1 and group 2 after 4 months. c Non-significant difference of AOFAS score in group 1 and group 2 after 12 months.
Table 4 VAS score. VAS score 0–10 cm
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
4.9 cm (4.2–5.7) 1.9 cm (1.2–2.7) 1.7 cm (0.8–2.5)
4.7 cm (3.8–5.5) 2.2 cm (1.4–3.0) 1.5 cm (0.9–2.2)
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative VAS score group 1 and group 2. b Non-significant difference of VAS score in group 1 and group 2 after 4 months. c Non-significant difference of VAS score in group 1 and group 2 after 12 months.
Relative metatarsal length
Preoperative 4 months postoperative 12 months postoperative
Group 1
Group 2
Cr. osteotomy
OW osteotomy
0.88 0.88 0.88
0.87 0.87 0.86
p value
>0.05a >0.05b >0.05c
a Non-significant difference between preoperative relative lengths of 1 compared to 2 metatarsal in group 1 and 2. b Non-significant difference between relative lengths of 1 compared to 2 metatarsal in groups 1 and 2 after 4 months. c Non-significant difference between preoperative relative lengths of 1 compared to 2 metatarsal in groups 1 and 2 after 12 months.
the crescentic osteotomy was directed from proximal–medial–dorsal to a distal–lateral direction. The aim was to place the screw so far medially that irritation from the extensor tendon did not occur, but soft tissue irritation can still be a problem. Screw irritation was the reason for hardware removal in 2 of 5 patients in group 1. The other 3 patients in group 1 had screw removal done at the same time as having a Lapidus procedure done [2] and MTP arthrodesis [1]. Reoperations, except for only screw removal, were performed due to insufficient correction of HVA and IMA. In group 2, where the Hemax plate was placed on the medial proximal part of the 1st metatarsal bone, 4 patients had hardware removed. Local irritation from the Hemax plate was the reason for three patients and one patient experienced pull-out of some of the screws in the plate before osseous healing.
7. Discussion Only very few prospective randomized trials have been made comparing different kinds of operations in hallux valgus surgery. No significant difference was found between groups 1 and 2 comparing preoperative angle values (39.10˚ and 38.30˚) 4 months postoperatively (24.10˚ and 21.40˚) and 12 months postoperatively (27.20˚ and 27.00˚) (Table 1). Similarly, no significant difference was found looking at the IM angle improvement of the two groups comparing preoperative values of groups 1 and 2 (19.00˚ and 18.90˚) and 4 months postoperatively (11.60˚ and 12.00˚) and 12 months postoperatively (12.5 and 12.6) (Table 2). These results show no clearly better outcome of the open wedge osteotomy compared to the crescentic osteotomy. As expected, a significant improvement of the HVA and IMA was reached through operation in both groups looking at the values preoperatively, 4 months postoperatively and 12 months postoperatively. No radiological assessment was done immediately after the operation. The first weight bearing X-rays were taken 4 months postoperatively. HV and IM angles of the two groups respectively after 4 months (24.10˚, 21.40˚ and 11.60˚, 12.00˚) were not as good as expected. Twelve months postoperatively the HVA and IMA had increased further for both groups (27.20˚, 27.00˚ and 12.50˚, 12.60˚). The loss of correction between 4 and 12 month was found to be significant for the HV angle in both groups. It is unknown whether the desired angle correction for HV and IM angle was ever reached or whether loss of correction occurred during the first 4 month and continued further until follow up after 12 months. Radiologically, the total HVA correction in this study was comparable to other hallux valgus correcting studies using similar operation methods [7,13,18,19]. In these studies, the preoperative HVA was only ranging from 7 to 320˚ resulting in a final HVA considerably lower postoperatively compared to our study. In a previous study, it has been verified that a HVA >400˚ results in a significantly higher risk for HVA recurrence after proximal
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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metatarsal osteotomy [20]. In our study 9 patients in each group had a HVA >400˚. A significant improvement was seen comparing pre- and postoperative (4 and 12 months) VAS and AOFAS score for both groups, but there was not a significant difference between the two groups (Tables 3 and 4). The improvements in AOFAS- and VAS-scores were found to be comparable to other studies [17–19,21]. The AOFAS score improvement in our study was slightly inferior to some of the other studies referred to. This could be due to the not fully corrected angle, although Rose et al. found no correlation in their study between improvement in HVA and AOFAS score [18]. The significant AOFAS score improvement suggests that patients were symptomatically and functionally better after surgery even with non-optimal corrected HVA and IMA. The time for bone healing is often longer for older people with lower bone density. By using only four 3 mm non-locking screws, two on each side of the osteotomy, there is a risk of implant failure and pull out before osseous healing. Using a plate with locking screws, the risk of implant failure is diminished as the mechanical performance of locking plate constructs, using only two screws, is comparable to three non-locking screw constructs in osteoporotic bone and thereby giving the small plate better stability [22]. The relative length of the first metatarsal bone compared to the second metatarsal bone was unchanged following both crescentic osteotomy and the open wedge osteotomy. Due to the mechanical features of an open wedge osteotomy and the correction of the HV and IM angle it was expected to find a slight elongation of the 1st metatarsal compared to the 2nd metatarsal for the patients in group 2 as have been found in similar studies [16,23,24]. In these studies the lengthening has been reported to be 1.2–2.3 mm. As hallux valgus surgery can lead to metatarsalgia due to shortening of the first ray, it should be better to gain length by using the open wedge osteotomy compared to the crescentic osteotomy [7,8,20]. To´th et al. found a positive correlation between of the metatarsalgia and the shortening of the first ray [25]. It has been found to be of better value using the relative length change of the first metatarsal compared to actual total change in mm [2]. Correcting the HVA with a proximal osteotomy and lateral release can increase the hallux valgus interphalangeal angle and course the need of an Akin osteotomy. This has been shown in a previous study by Park et al., where they found a need of an Akin osteotomy as a supplement in 44 of 54 operated patients to avoid collision between the1st and 2nd toe [17]. 8. Perspective As the open wedge osteotomy is found to be equivalent to the crescentic osteotomy, this will be our standard in the future when correcting severe hallux valgus with a proximal osteotomy as the procedure is less technically challenging. For both groups a loss of correction was seen in the interval from 4 to 12 months. This could be due to instability of the TMT joint. If this is the case a Lapidus procedure might be more relevant than a proximal osteotomy in patients with a large IM and HV angle. As a consequence of not reaching the desired correction of the HV angle intra-operatively in both groups, more attention will be drawn in correcting the IMA and HVA sufficiently by verifying the corrected angles using X-ray intra-operatively. 9. Limitations Our study has several limitations. The four senior surgeons were aiming for ‘‘desired’’ correction when performing the two
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different types of osteotomies, verifying the correction with fluoroscopy but with no specific aim of angle correction. The Akin procedure was done, when the surgeon felt there was a ‘‘need,’’ a risk of collision between 1st and 2nd toe. If more precise objective goals, especially radiologically, had been standardized, maybe better correction would have been achieved, and maybe a difference in the osteotomy types could have been found. The metatarsal lengths and angles were measured by one of our four operating senior surgeons and not by a radiologist. A limitation of accuracy occurs evaluating normal X-rays compared to MR and CT. A follow-up period of 12 months is similar to some of the studies used for comparison in the article. Optimally, the follow-up period should continue until loss of correction of the osteotomies no longer occurred. 10. Conclusion Crescentic osteotomy and open wedge osteotomy improves AOFAS score and VAS scores on patients operated with severe hallux valgus. No significant difference was found in the two groups looking at the postoperative improvement of HVA and IMA measured 4 and 12 months postoperatively. The postoperative VAS score and AOFAS score were comparable for the two groups with no significant difference. An expected tendency to gain better length of the first metatarsal using the open wedge osteotomy compared to the crescentic osteotomy was not found. A significant loss of correction of hallux valgus angle was found for both groups in the postoperative interval 4–12 months. Even though the IMA and HVA reduction was only suboptimal, the improvement in AOFAS score was comparable to other similar clinical trials. Conflict of interest None of the authors have any conflicts of interest to declare. Acknowledgement We want to thank PhD Jens Lauridsen, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, for his inspiring and unsurpassed help with the statistical calculations. References [1] Coughlin MJ, Smith BW. Hallux valgus and first ray mobility. Surgical technique. J Bone Joint Surg Am 2008;90(Suppl. 2 Pt 2):153–70. [2] Day T, Charlton TP, Thordarson DB. First metatarsal length change after basilar closing wedge osteotomy for hallux valgus. Foot Ankle Int 2011;32(5):S513–8. [3] Deenik A, van Mameren H, de Visser E, de Waal Malefijt M, Draijer F, de Bie R. Equivalent correction in scarf and chevron osteotomy in moderate and severe hallux valgus: a randomized controlled trial. Foot Ankle Int 2008;29(12): 1209–15. [4] Ellington JK, Myerson MS, Coetzee JC, Stone RM. The use of the Lapidus procedure for recurrent hallux valgus. Foot Ankle Int 2011;32(7):674–80. [5] Kayiaros S, Blankenhorn BD, Dehaven J, Van Lancker H, Sardella P, Pascalides JT, et al. Correction of metatarsus primus varus associated with hallux valgus deformity using the arthrex mini tightrope: a report of 44 cases. Foot Ankle Spec 2011;4(4):212–7. [6] Moon JY, Lee KB, Seon JK, Moon ES, Jung ST. Outcomes of proximal chevron osteotomy for moderate versus severe hallux valgus deformities. Foot Ankle Int 2012;33(8):637–43. [7] Nedopil A, Rudert M, Gradinger R, Schuster T, Bracker W. Closed wedge osteotomy in 66 patients for the treatment of moderate to severe hallux valgus. Foot Ankle Surg 2010;16(1):9–14. [8] Okuda R, Kinoshita M, Yasuda T, Jotoku T, Shima H. Proximal metatarsal osteotomy for hallux valgus: comparison of outcome for moderate and severe deformities. Foot Ankle Int 2008;29(7):664–70. [9] Paczesny L, Kruczynski J, Adamski R. Scarf versus proximal closing wedge osteotomy in hallux valgus treatment. Arch Orthop Trauma Surg 2009;129(10): 1347–52.
Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006
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Please cite this article in press as: Wester JU, et al. Open wedge metatarsal osteotomy versus crescentic osteotomy to correct severe hallux valgus deformity – A prospective comparative study. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.04.006