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Background: Chevron osteotomy, a commonly performed procedure for the treatment of hallux valgus, results in osteonecrosis of the first metatarsal head in 0% to 20% of cases. The aim of this study was to map out the arrangement of the vascular supply to the first metatarsal head and its relationship to the limbs of the chevron osteotomy.
Methods: Ten cadaveric lower limbs were injected with an India ink-latex mixture, and the feet were dissected to assess the blood supply to the first metatarsal head. The dissection was carried out by tracing the branches of the dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy was mapped, with the limbs of the osteotomy set at an angle of 60° from the geometric center of the first metatarsal head. The relationship of the limbs of the osteotomy to the blood vessels was recorded.
Results: The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal, and medial plantar arteries. The first dorsal metatarsal artery was the dominant vessel among the three arteries in eight specimens. All of the vessels formed a plexus at the plantar-lateral aspect of the metatarsal neck, just proximal to the capsular attachment, with a varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck.
Conclusions: The identification of the plantar-lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long plantar limb exiting well proximal to the capsular attachment may decrease the postoperative prevalence of osteonecrosis of the first metatarsal head.
Re: Blood vessels at risk with a Chevron Osteotomy
0-20%! I believe the zero, 20% though?
I have done, literally, thousands of chevron (or Austin's) with not a single AVN of the head.
My best guestamation of why surgeons may have problems is that the apex of the osteotomy is too far distal and the angle to large.
Anyone else out there with no real problem with this procedure?
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Re: Blood vessels at risk with a Chevron Osteotomy
Increased displacement maximizes the utility of the distal chevron osteotomy for hallux valgus deformity correction.
Murawski DE, Beskin JL. Foot Ankle Int. 2008 Feb;29(2):155-63.
Quote:
BACKGROUND: Correction of hallux valgus deformity with distal chevron osteotomy is limited by the amount of lateral translation achieved. Since 1999, the senior author has performed a modified technique referred to as increased displacement distal chevron osteotomy in which the distal fragment is translated laterally as far as necessary to obtain correction. This technique can be applied to a deformity with an intermetatarsal angle of up to 18 degrees. The surgical technique and results of this modified procedure are reported.
MATERIALS AND METHODS: The senior author's (JLB) database was searched for correction of hallux valgus deformity by distal chevron osteotomy performed over a 2-year period. Patients having undergone lateral displacement greater than 50% of the width of the head were studied. At a minimum of two years after surgery, patients were invited to participate in a telephone interview and a final followup office visit.
RESULTS: Sixty-two patients underwent 72 procedures during the investigation period. Thirty-three patients having undergone 39 procedures completed comprehensive followup at an average of 34 (range, 24 to 47) months. No patients were dissatisfied and all patients would have surgery again under similar circumstances. AOFAS score averaged 93 with a standard deviation of 8.7 (range, 65 to 100). Radiographic union occurred in all 39 feet. Lateral translation averaged 8.2 mm (60%). No cases of radiographic avascular necrosis or advancement of degenerative joint disease were noted. Correction of the hallux valgus angle (HVA) averaged 22.2 degrees, intermetatarsal angle (IMA) 7.9 degrees, and sesamoid position 1.6 stages. Nine complications were identified in nine feet, two of which required additional surgery.
CONCLUSION: Increasing the displacement achieved with distal chevron osteotomy resulted in reliable correction including moderate to severe deformity. At 2 years, patients displayed a high rate of satisfaction, good clinical outcomes scores, and a complication rate similar to other techniques.
Re: Blood vessels at risk with a Chevron Osteotomy
Quote:
Originally Posted by drsarbes
0-20%! I believe the zero, 20% though?
I have done, literally, thousands of chevron (or Austin's) with not a single AVN of the head.
My best guestamation of why surgeons may have problems is that the apex of the osteotomy is too far distal and the angle to large.
Anyone else out there with no real problem with this procedure?
Steve
Steve,
If the surgeon runs as high a risk of AVN as 1:5 is it not fair to to critique the skills of the surgeon, perhaps more so than the procedure ? Any capital osteotomy can produce AVN but I have only ever seen a couple of cases, from another surgeon in 15 + years. My guess is you would need to be astonishingly aggressive and strip a lot of tissue away to produce AVN, as a rule.
The solution is quite simple, isn't it ? Know the anatomy, the principal vessels and avoid / protect.
Re: Blood vessels at risk with a Chevron Osteotomy
Modified chevron osteotomy fixed with stofella pin for hallux valgus.
Kürklü M, Demiralp B, Yurttaş Y, Ciçek EI, Ateşalp AS. Foot Ankle Int. 2008 May;29(5):478-82
Quote:
BACKGROUND: The purpose of this study was to present the mid-term results of hallux valgus patients who underwent a modified chevron osteotomy.
MATERIALS AND METHODS: Fifty-six patients (73 feet) with mild to moderate hallux valgus underwent a modified chevron osteotomy and Stoffella pin fixation between January 1999 and December 2004. Patients were evaluated clinically by the American Orthopedic Foot and Ankle Society (AOFAS) score. Pre- and postoperative radiographs were evaluated for the hallux valgus and intermetatarsal angles and sesamoid position.
RESULTS: An improvement of 44.8 points in the AOFAS score was found. A change of 17.4 degrees in the hallux valgus angle and by 5.3 degrees in the intermetatarsal angle was achieved (p < 0.05). The change in the sesamoid position was significantly improved. Superficial skin infection in 3 cases, transient hypoesthesia in 2 cases, and bursitis due to screw irritation in 4 cases were the complications.
CONCLUSION: Stable and rigid fixation by modified chevron osteotomy using Stoffella pins allows early mobilization and weightbearing without a cast. We believe early mobilization of the joint provides better functional outcomes with fewer complications compared to other fixation techniques.
Re: Blood vessels at risk with a Chevron Osteotomy
Mobility changes of the first ray after hallux valgus surgery: clinical results after proximal metatarsal chevron osteotomy and distal soft tissue procedure.
Kim JY, Park JS, Hwang SK, Young KW, Sung IH Foot Ankle Int. 2008 May;29(5):468-72
Quote:
BACKGROUND: The purpose of this study was to evaluate the change of the first ray mobility after PMCO and DSTP in hallux valgus patients.
MATERIALS AND METHODS: From May 2004 to December 2005, 82 PMCO with DSTP surgeries were performed for the management of hallux valgus deformity. The dorsiflexion mobility of the first ray of the foot was measured both preoperatively and 1 year after surgery using a modified Klaue device. The data were statistically analyzed with a paired t-test. An American Orthopedic Foot and Ankle Society (AOFAS) forefoot hallux score and patient satisfaction were also evaluated.
RESULTS: Subjects consisted of 9 male and 73 female patients with an average age of 47.7 years (range, 19 to 74 years). The mean preoperative dorsiflexion mobility was 6.8 (range, 2.32 to 15.02) mm and the mean dorsiflexion mobility at one year after operation was 3.2 (range, from 1.7 to 5.4) mm. This decrease was statistically significant (p < 0.01). The mean preoperative AOFAS forefoot hallux score was 66.2 (range, 44 to 90) and improved to 89.1 (range, 72 to 100) by the 1-year followup (p < 0.01).
CONCLUSION: Clinically, the dorsiflexion mobility of the first ray was significantly reduced after correction of hallux valgus with PMCO with DSTP. Because the stability of the first ray can be improved with PMCO with DSTP, the surgical indication for this procedure could include some patients showing hypermobility of the first ray.
Re: Blood vessels at risk with a Chevron Osteotomy
Range of motion of the first metatarsophalangeal joint after chevron procedure reinforced by a modified capsuloperiosteal flap.
Ozkurt B, Aktekin CN, Altay M, Belhan O, Tabak Y. Foot Ankle Int. 2008 Sep;29(9):903-9.
Quote:
BACKGROUND: This study analyzed the range of motion of the first metatarsophalangeal joint following the chevron procedure with increased stabilization using a modified capsuloperiosteal flap in the treatment of hallux valgus cases.
MATERIALS AND METHODS: Forty-three feet of 40 patients were treated with modified chevron osteotomies. The patient selection criteria included failure of conservative treatment, painful deformity, age between 18 and 50, hallux valgus and intermetatarsal angles less than 40 degrees and 17 degrees, respectively, and no osteoarthritic changes of the metatarsophalangeal joint. The passive range of motion of the first metatarsophalangeal joint was compared to the hallux valgus and intermetatarsal angles.
RESULTS: The mean age of patients was 30.9 +/- 9.0 (range, 18 to 46) years. The preoperative mean hallux valgus angle was 32.2 (range, 22 to 40 degrees), whereas postoperatively it was 13.1 (range, 3 to 22 degrees). The preoperative mean passive total range of motion, dorsiflexion and plantar flexion were found to be 80.2 (range, 71 to 99 degrees), 66.8 (51 to 86) degrees and 13.4 (range, 7 to 23 degrees), respectively, whereas postoperatively these values were 69.2 (range, 48 to 85 degrees), 58.6 (range, 43 to 75) degrees and 10.8 (range, 1 to 20 degrees). According to Bonney and MacNab subjective scores, the feet were evaluated as follows: 12 as excellent, 26 as good, and 5 as moderate. According to objective scores, the evaluation was as follows: 27 as excellent, 14 as good, 1 as moderate, and 1 as poor.
CONCLUSION: We believe that the chevron procedure reinforced by modified capsuloperiosteal flap causes minimal irritation and damage to adjacent soft tissues. Furthermore, we conclude that this method is a benefical means of managing moderate hallux vagus deformities by decreasing the stiffness after surgery.
Re: Blood vessels at risk with a Chevron Osteotomy
The risk of avascular necrosis following chevron osteotomy: a prospective study using bone scintigraphy.
Shariff R, Attar F, Osarumwene D, Siddique R, Attar GD. Acta Orthop Belg. 2009 Apr;75(2):234-8.
Quote:
Controversy exists with regard to the effects of chevron osteotomy on blood supply and subsequent development of avascular necrosis (AVN) of the first metatarsal head. The aim of this study was to assess the incidence of avascular necrosis in our centre following chevron osteotomy for hallux valgus, using bone scintigraphy. Thirty nine patients who had a chevron osteotomy for treatment of hallux valgus were prospectively studied. Mean follow-up was 14 months. Bone scintigraphy was used to assess metatarsal head perfusion at an average 8.5 weeks post operatively. Three patients (7.7%) showed abnormal bone scan around the metatarsal head. Further evaluation of these patients did not show any sign of AVN. We conclude there appears to be a risk of circulatory disturbance to the metatarsal head following chevron osteotomy of the first metarsal (7.7% in this study); however this does not translate into clinically significant AVN.
Re: Blood vessels at risk with a Chevron Osteotomy
No midterm benefit from low intensity pulsed ultrasound after chevron osteotomy for hallux valgus.
Zacherl M, Gruber G, Radl R, Rehak PH, Windhager R. Ultrasound Med Biol. 2009 Aug;35(8):1290-7.
Quote:
Chevron osteotomy is a widely accepted method for correction of symptomatic hallux valgus deformity. Full weight bearing in regular shoes is not recommended before 6 weeks after surgery. Low intensity pulsed ultrasound is known to stimulate bone formation leading to more stable callus and faster bony fusion. We performed a randomized, placebo-controlled, double-blinded study on 44 participants (52 feet) who underwent chevron osteotomy to evaluate the influence of daily transcutaneous low intensity pulsed ultrasound (LIPUS) treatment at the site of osteotomy. Follow-up at 6 weeks and 1 year included plain dorsoplantar radiographs, hallux-metatarsophalangeal-interphalangeal scale and a questionnaire on patient satisfaction. There was no statistical difference in any pre- or postoperative clinical features, patient satisfaction or radiographic measurements (hallux valgus angle, intermetatarsal angle, sesamoid index and metatarsal index) except for the first distal metatarsal articular angle (DMAA). The DMAA showed statistically significant (p = 0.046) relapse in the placebo group upon comparison of intraoperative radiographs after correction and fixation (5.2 degrees) and at the 6-week follow-up (10.6 degrees). Despite potential impact of LIPUS on bone formation, we found no evidence of an influence on outcome 6 weeks and 1 year after chevron osteotomy for correction of hallux valgus deformity.
Blood vessels at risk with a Chevron Osteotomy
is it not fair to to critique the skills of the surgeon, perhaps more so than the procedure ? Any capital osteotomy can produce AVN but I have only ever seen a couple of cases, from another surgeon in 15 + years. My guess is you would need to be astonishingly aggressive and strip a lot of tissue away to produce AVN, as a rule. 
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