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Chevron Osteotomy

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  #1  
Old 3rd September 2007, 11:26 AM
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Default Chevron Osteotomy

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Blood Supply to the First Metatarsal Head and Vessels at Risk with a Chevron Osteotomy
J.J. George Malal, J. Shaw-Dunn and C. Senthil Kumar
The Journal of Bone and Joint Surgery (American). 2007;89:2018-2022.
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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.
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  #2  
Old 4th September 2007, 09:23 AM
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Default 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
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  #3  
Old 6th March 2008, 05:15 PM
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Default 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.
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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.
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  #4  
Old 9th March 2008, 04:13 AM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

Quote:
Originally Posted by drsarbes View Post
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.

Dieter
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  #5  
Old 31st May 2008, 04:00 PM
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Default 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
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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.
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  #6  
Old 31st May 2008, 04:11 PM
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Default 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.
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  #7  
Old 10th September 2008, 06:08 AM
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Default 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.
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Old 26th June 2009, 02:22 PM
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Default 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.
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Old 5th November 2009, 04:00 PM
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Default 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.
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Old 22nd July 2010, 10:58 PM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

Ninety-degree chevron osteotomy for correction of hallux valgus deformity: clinical data and finite element analysis.
Matzaroglou C, Bougas P, Panagiotopoulos E, Saridis A, Karanikolas M, Kouzoudis D.
Open Orthop J. 2010 Apr 22;4:152-6.
Quote:
Hallux valgus is a very common foot disorder, with its prevalence estimated at 33% in adult shoe-wearing populations. Conservative management is the initial treatment of choice for this condition, but surgery is sometimes needed. The 60(0) angle Chevron osteotomy is an accepted method for correction of mild to moderate hallux valgus in adults less than 60 years old. A modified 90(0) angle Chevron osteotomy has also been described; this modified technique can confer some advantages compared to the 60(0) angle method, and reported results are good. In the current work we present clinical data from a cohort of fifty-one female patients who had surgery for sixty-two hallux valgus deformities. In addition, in order to get a better physical insight and study the mechanical stresses along the two osteotomies, Finite Element Analysis (FEA) was also conducted. FEA indicated enhanced mechanical bonding with the modified 90(0) Chevron osteotomy, because the compressive stresses that keep the two bone parts together are stronger, and the shearing stresses that tend to slide the two bone parts apart are weaker, compared to the typical 60(0) technique. Follow-up data on our patient cohort show good or excellent long-term clinical results with the modified 90(0) angle technique. These results are consistent with the FEA-based hypothesis that a 90(0) Chevron osteotomy confers certain mechanical advantages compared to the typical 60(0) procedure.
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Old 8th January 2011, 02:04 PM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

The clinical efficacy of treatment on the cases of severe hallux valgus by the first metatarsal basal osteotomy combined with Chevron-Gerbert operation
Chen ZJ, Wang ZY, Wang QP, Zhu GY, Jiang J, Qi YZ, Zeng YF.
Zhonghua Wai Ke Za Zhi. 2010 Nov;48(21):1633-1636.
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OBJECTIVE: To evaluate the clinical efficacy of treatment on the cases of severe hallux valgus by the first metatarsal basal osteotomy combined with Chevron-Gerbert operation.

METHODS: From June 2004 to August 2008, 37 cases of severe hallux valgus (66 feet) underwent first metatarsal basal osteotomy combined with Chevron-Gerbert operation. There were 5 males (10 feet) and 21 females (38 feet), aged 21 - 76 years (mean 58 years). For all patients with follow-up, radiographic measurements of frontal and lateral position of foot were taken to measure the hallux valgus angle (HVA), the IMA (intermetatarsal angle) and the proximal articular set angle (PASA) preoperatively, postoperatively and in follow-up respectively. The measuring results were compared among the preoperative, the 6-week postoperative and the final follow-up. At the same time the patients were evaluated with the AOFAS Maryland score.

RESULTS: Of the original 37 patients, 26 patients (48 feet) were followed up. The mean durations of follow-up was 2.3 years (range from 1 to 4 years). At final follow-up, HVA corrected 25.6° ± 3.8°, IMA corrected 8.6° ± 2.4°, and PASA corrected 4.7° ± 4.2°. According to AOFAS rating system, 91.7% patients were rated as excellent or good with excellent in 15 patients (28 feet), good in 8 patients (16 feet), and fair in 3 patients (4 feet).

CONCLUSIONS: First metatarsal basal osteotomy combined with Chevron-Gerbert operation has good efficacy to the patients with severe hallux valgus. However there are disadvantages such as complexity relatively for multi-stage osteotomy and internal fixation.
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Old 12th January 2011, 04:27 AM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

Quote:
Originally Posted by drsarbes View Post
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
Hi Steve, I have also performed thousands of modified Austin bunionectomies over the past two decades with only one known case of AVN. I prefer slightly longer plantar arms for increased loading stability of the osteotomy but I am not convinced this is the reason for a low AVN rate since most of my colleagues also report negligible AVN outcomes with chevron osteotomies. Cheers, Andrew Kingsford.
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Old 21st January 2011, 02:46 PM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

Plantar loading after chevron osteotomy combined with postoperative physical therapy.
Schuh R, Adams S, Hofstaetter SG, Krismer M, Trnka HJ.
Foot Ankle Int. 2010 Nov;31(11):980-6.

Quote:
BACKGROUND: Recent pedobarographic studies have demonstrated decreased loading of the great toe region and the first metatarsal head at a short- and intermediate-term followup. The purpose of the present study was to determine if a postoperative rehabilitation program helped to improve weightbearing of the first ray after chevron osteotomy for correction of hallux valgus deformity.

MATERIALS AND METHODS: Twenty-nine patients with a mean age of 58 years with mild to moderate hallux valgus deformity who underwent a chevron osteotomy were included. Postoperatively, the patients received a multimodal rehabilitation program including mobilization, manual therapy, strengthening exercises and gait training. Preoperative and one year postoperative plantar pressure distribution parameters including maximum force, contact area and force-time integral were evaluated. Additionally the AOFAS score, ROM of the first MTP joint and plain radiographs were assessed. The results were compared using Student's t-test and level of significance was set at p < 0.05.

RESULTS: In the great toe, the mean maximum force increased from 72.2 N preoperatively to 106.8 N 1 year after surgery. The mean contact area increased from 7.6 cm(2) preoperatively to 8.9 cm(2) 1 year after surgery and the mean force-time integral increased from 20.8 N(*)sec to 30.5 N(*)sec. All changes were statistically significant (p < 0.05). For the first metatarsal head region, the mean maximum force increased from 122.5 N preoperatively to 144.7 N one year after surgery and the mean force-time integral increased from 42.3 N(*)sec preoperatively to 52.6 N(*)sec 1 year postoperatively (p = 0.068 and p = 0.055, respectively). The mean AOFAS score increased from 61 points preoperatively to 94 points at final followup (p < 0.001). The average hallux valgus angle decreased from 31 degrees to 9 degrees and the average first intermetatarsal angle decreased from 14 degrees to 6 degrees (p < 0.001 for both).

CONCLUSION: Our results suggest that postoperative physical therapy and gait training with a Chevron osteotomy may help to improve weightbearing of the great toe and first ray. Therefore, we believe there is a restoration of more physiological gait patterns in patients who receive this postoperative regimen.
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Old 8th July 2011, 11:46 AM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

Stabilization of chevron bunionectomy with a capsuloperiosteal flap.
Guclu B, Kaya A, Akan B, Koken M, Kemal Us A.
Foot Ankle Int. 2011 Apr;32(4):414-8.
Quote:
BACKGROUND:
Distal chevron osteotomy (DCO) for mild to moderate hallux valgus deformity is inherently more stable than the other forms of distal metatarsal osteotomy, but complications such as loss of correction, infection, joint stiffness, delayed union, malunion and nonunion can occur. In this study, we evaluated the use of a capsuloperiosteal flap for stabilization of DCO in the treatment of hallux valgus.

MATERIALS AND METHODS:
A retrospective study was conducted on 59 patients (88 feet) that underwent distal Chevron osteotomy stabilized only with a capsuloperiosteal flap for mild and moderate hallux valgus deformity with a mean followup of 11.3 years. Clinical evaluation was calculated using the hallux score of the American Orthopaedic Foot and Ankle Society (AOFAS).

RESULTS:
The score improved from a preoperative mean of 52 to a mean of 91.5 points at last followup. Average hallux valgus angle changed from 30.3 degrees preoperatively to 14.2 degrees postoperatively at the last followup. Intermetatarsal angle 1-2 changed from 13.6 degrees preoperatively to 10.2 degrees postoperatively. The correction proved to be consistent with only an average of 3.4-degree correction loss and 4.9-degree loss in the range of motion. Eighty-six feet (97.7%) were pain free. Discomfort with shoewear was absent in 84 feet (95.5%) postoperatively and 24 of 25 (96%) patients were satisfied cosmetically.

CONCLUSION:
Capsuloperiosteal flap stabilization of distal chevron osteotomy for mild-moderate hallux valgus yielded excellent clinical results at long-term followup.
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Old 21st July 2011, 04:12 AM
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Default Re: Blood vessels at risk with a Chevron Osteotomy

Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus.
Choi KJ, Lee HS, Yoon YS, Park SS, Kim JS, Jeong JJ, Choi YR.
J Bone Joint Surg Br. 2011 Aug;93(8):1079-83.
Quote:
We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from -11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from -0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.
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Old 16th February 2012, 06:50 PM
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Minimally Invasive Chevron Osteotomy; Functional Outcome and Comparison with Open Chevron Osteotomy
Samer S. Morgan, Ibrahim Roushdi, Simon Palmer
Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
Quote:
INTRODUCTION
Symptomatic hallux valgus is a common clinical problem, current trend is towards minimally invasive procedures. The goal of this study is to evaluate the outcome of minimally invasive chevron ostoetomy, comparing it with a matched group who had open chevron osteotomy.

METHODS
Prospective study with 54 patients. MIS group 25 patients between October 2009 and November 2010. Open group 29 patients between February 2008 and October 2010. Inclusion criteria included mild to moderate hallux valgus, no previous history of foot surgery, no history of inflammatory arthritis, or metatasophalangeal joint (MTPJ) arthritis. All the operations were peformed by the senior author. Functional outcome and pain were evaluated using pre and post operative Manchester Oxford Foot and ankle questionnaire (MOXFQ). It is a 16 item questionnaire assessing three domains, walking, footpain and social interaction, the lower the score the better. Radiologically, pre and post operative intermetatarsal angle (IMA) and hallux valgus angle (HVA), avascular necrosis and union were assessed. Complications and satisfaction were recorded.

RESULTS
In the MIS group (25 patients) two patients lost to follow up, 23 were available for analysis. Mean age at operation was 55 (23-79). Twenty-four patients were female and the operation was on the left side in 14 patients. The MIS group showed significant improvement in all the domains of the MOXFQ. Walking (preop. 48/100 (SD 26), postop 28 (SD 32) <0.018), foot pain (preop. 54(SD 24), postop. 33(SD 29) <0.013), social interaction (preop. 56 (SD 26), postop 22 (SD 32) <0.001). Radiologically the mean HVA and IMA corrections were 11.8° and 6.3°, respectively, which is statistically significant (p < 0.001). There were no cases with nonunion, malunion, overcorrection, transfer metatarsalgia or osteonecrosis. In the open group (29 patients) four patients lost to follow up, 25 patients were available for analysis. Mean age at operation was 55 years (34-75). Twenty-three patients were female and the operation was on the left side in 16 patients. The open group showed significant improvement in all domains of the MOXFQ, walking (pre 52(SD 23), post. 27 (SD 22) <0.0001), foot pain (pre. 52 (SD22). Post 33(SD23) <0.002) , social interaction (pre. 56 (SD17), post 22 (SD17) <0.0001). The HVA and IMA were 10.5 and 5.9 degrees respectively and was statistically significant. The improvement in MOXFQ and HVA and IMA corrections were not statistically significant between the MIS and open groups.

DISCUSSION AND CONCLUSION
Recently chevron osteotomy is being performed using minimally invasive techniques. It has the advantage of minimal soft tissue dissection and consequently less risk of avascular necrosis, less pain and faster recovery. Our results showed that the MIS chevron osteotomy is an effective procedure with minimal complications and satisfactory functional outcome and comparable to the open standard chevron osteotomy. Larger sample size is required to confirm our findings. The results of our randomized controlled trial are awaited.
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Old 16th February 2012, 06:53 PM
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Default Re: Chevron Osteotomy

Randomized Controlled Trial of Halux Valgus Treated with Medial-opening vs. Chevron Metatarsal Osteotomy
Peter G. Copithorne, Karl Lalond, Timothy R. Daniels, Gordon Boyd, Mark Glazebrook,
Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
Quote:
INTRODUCTION
Hallux valgus with an increased intermetatarsal is usually treated with a proximal metatarsal osteotomy. The proximal first metatarsal chevron (CHEV) osteotomy is commonly utilized but technically difficult. This study compares the opening-wedge osteotomy (OWO) of the proximal first metatarsal to the CHEV osteotomy in the treatment of hallux valgus with increased intermetatarsal angle.

METHODS
This prospective, randomized, multi-centered study conducted at three centers was powered for 75 patients based clinical outcome scores using SF-36, AOFAS forefoot score and Visual Analogue Scale (VAS) for pain, activity and patient satisfaction. Subjects were assessed prior to surgery and at 12 months. Surgeon preference was evaluated based on questionnaires and surgical times. Radiologic outcome measurements were also assessed.

RESULTS
No significant difference was found in any of the patients’ clinical outcome measures between the two procedures. OWO lengthens and CHEV shortens the first metatarsal length. OWO takes on average longer to complete compared to CHEV ostetotomy. OWO is preferred by participating orthopedic surgeons.

DISCUSSION AND CONCLUSION
Opening-wedge and proximal chevron osteotomies have comparable patient pain, satisfaction, and functional outcomes. OWO lengthens and CHEV shortens the first metatarsal. OWO was deemed to be less technically demanding, quicker to perform and preferred by orthopedic surgeons participating in this study.
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Old 10th April 2012, 12:17 AM
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Default Re: Chevron Osteotomy

Scarf Versus Chevron Osteotomy for the Correction of 1–2 Intermetatarsal Angle in Hallux Valgus: A Systematic Review and Meta-analysis
Simon E. Smith, Karl B. Landorf, Paul A. Butterworth, Hylton B. Menz
Journal of Foot and Ankle Surgery; Article in Press
Quote:
The chevron and scarf osteotomies are commonly used for the surgical management of hallux valgus (HV). However, there is debate as to whether one osteotomy provides more 1–2 intermetatarsal (1–2 IMA) correction than the other. The objective of this systematic review and meta-analysis was to compare the effectiveness of 3 types of first metatarsal osteotomy for reducing the 1–2 IMA in HV correction: the chevron osteotomy, the long plantar arm (modified) chevron osteotomy, and the scarf osteotomy. A systematic search for eligible studies was performed of the following databases: Medline, Embase (Ovid), CINAHL (EBSCO Host), and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials. Only English-language studies previous to May 2010 were included in the review. Additional hand and electronic content searches of relevant foot and orthopaedic journals were performed. Criteria for inclusion in this analysis included systematic reviews of randomized controlled trials, prospective and retrospective cohort studies, and case-control studies, as well as case-series studies involving the chevron, scarf, or long plantar arm chevron osteotomy of >20 participants with a minimum of 80% follow-up. Quality of evidence of the included studies was assessed with the Grading of Recommendations Assessment, Development and Evaluation system. All pooled analyses were based on a fixed effects model. There was a total of 1351 participants who underwent either a chevron (n = 1028), scarf (n = 300), or long plantar arm chevron osteotomy (n = 23). Only one study for the long plantar arm chevron group fitted the eligibility criteria for this review; however, it was not amenable to meta-analysis. The chevron osteotomy was associated with a mean reduction of 1–2 IMA from preoperative to postoperative of 5.33° (95% confidence interval, 5.12 to 5.54, p < .001), and the scarf osteotomy was associated with a mean reduction of 6.21° (95% confidence interval, 5.70 to 6.72, p < .001). There was a statistically significant 0.88° increase in the correction of the 1–2 IMA in favor of the scarf osteotomy compared with the chevron osteotomy. The studies included in this review were of very low- to low-quality evidence. Our findings indicate that the scarf osteotomy provides greater correction of the 1–2 IMA when used for HV correction. However, only a weak recommendation in favor of the scarf osteotomy can be made based on the low quality of evidence of the studies included in this analysis.
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Old 24th July 2012, 01:32 PM
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Default Re: Chevron Osteotomy

Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy for correction of mild-to-moderate hallux valgus deformity.
Radwan YA, Mansour AM.
Arch Orthop Trauma Surg. 2012 Jul 22.
Quote:
PURPOSE:
A lot of procedures were described for managing hallux valgus deformity. Percutaneous metatarsal osteotomies have received increasing recognition in the previous decade. The proposed benefits revolve primarily around the shorter surgical time, lower incidence of complications, and higher patient satisfaction. However, there is insufficient evidence to determine whether this technique is comparable to traditional open approaches.

MATERIALS AND METHODS:
A total of 64 consecutive feet (53 patients) with mild-to-moderate symptomatic hallux valgus were randomly assigned into two groups to compare the results of percutaneous distal metatarsal osteotomy (group I, 31 feet) and distal chevron osteotomy (group II, 33 feet). All patients were clinically assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scoring system. Radiographical assessment was done using the hallux valgus angle (HVA) and intermetatarsal angle (IMA).

RESULTS:
The mean correction of HVA and IMA achieved in group I was 14.4° and 4.8°, respectively, while in group II, it was 13.1° and 3.9°, respectively. The mean AOFAS score improved from a pre-operative of 44.6 points to 90.2 points in group I, and from 47.5 points to 87.7 points in group II. In group I, 26/29 patients (89.6 %) were happy with the cosmetic results of the surgery, compared to 20/31 patients (64.5 %) in group II.

CONCLUSION:
The results of this study support the idea that percutaneous distal metatarsal osteotomy yields good functional and radiological result and is associated with a high degree of postoperative patient satisfaction.
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Old 19th September 2012, 01:01 PM
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Default Re: Chevron Osteotomy

Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus.
Chuckpaiwong B.
Int Orthop. 2012 Sep 19.
Quote:
PURPOSE:
This study compared results of distal and proximal metatarsal osteotomy for moderate to severe hallux valgus in terms of radiographic correction and functional outcome.

METHODS:
We analyzed 125 moderate to severe hallux valgus surgeries. Patients were divided into two groups. Group 1 underwent distal metatarsal osteotomy, and group 2 underwent proximal metatarsal osteotomy. Patients were interviewed for functional scores before and one year after surgery. The anteroposterior (AP) weight-bearing radiography of the foot was taken before and one year after surgery.

RESULTS:
There were no significant differences in pain and function after one year in either group. Both groups experienced significant pain reduction and increase in all functional scores. There was significant improvement of hallux valgus and intermetatarsal angle corrections in group 2. There was less improvement in radiographic correction in group 1.

CONCLUSION:
Either distal or proximal metatarsal osteotomy is an appropriate pain-relieving procedure and can increase functional outcome in moderate to severe hallux valgus. However, distal metatarsal osteotomy provides lower correction power.
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Old 22nd September 2012, 06:08 AM
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Default Re: Chevron Osteotomy

Outcomes of proximal chevron osteotomy for moderate versus severe hallux valgus deformities.
Moon JY, Lee KB, Seon JK, Moon ES, Jung ST.
Foot Ankle Int. 2012 Aug;33(8):637-43.
Quote:
BACKGROUND:
Proximal chevron osteotomy with a distal soft tissue procedure has been widely used to treat moderate to severe hallux valgus deformities. However, there have been no studies comparing the results of proximal chevron osteotomy between patients with moderate and severe hallux valgus. We compared the results of this procedure among these groups.

METHODS:
A retrospective review of 95 patients (108 feet) that underwent proximal chevron osteotomy and distal soft tissue procedure for moderate and severe hallux valgus was conducted. The 108 feet were divided into two groups: moderate hallux valgus (Group A) and severe hallux valgus (Group B). Group A was composed of 57 feet (52 patients) and Group B of 51 feet (43 patients). Average followup was 45 months.

RESULTS:
Mean American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal scores were 54.1 points in Group A and 53.0 points in Group B preoperatively, and these improved to 90.8 and 92.6, respectively, at the last followup. Mean hallux valgus angles in Groups A and B reduced from 32.3 and 40.8 degrees, preoperatively to 10.7 and 13.2 degrees, postoperatively. Similarly, mean first intermetatarsal angles in Groups A and B reduced from 15.0 and 19.2 degrees, preoperatively to 9.0 and 9.2 degrees, postoperatively.

CONCLUSION:
The clinical and radiographic outcomes of proximal chevron osteotomy with a distal soft tissue procedure were found to be comparable for moderate and severe hallux valgus. Accordingly, our results suggest that this procedure provides an effective and reliable means of correcting hallux valgus regardless of severity of deformity.
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Old 26th October 2012, 04:30 PM
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Default Re: Chevron Osteotomy

MINIMALLY INVASIVE CHEVRON OSTEOTOMY; FUNCTIONAL OUTCOME AND COMPARISON WITH OPEN CHEVRON OSTEOTOMY
S. Morgan, I. Roushdi, R. Benerjee and S. Palmer
J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XLIII 67
Quote:
Introduction Symptomatic hallux valgus is a common clinical problem, current trends is towards minimally invasive procedures. The goal of this study is to evaluate the outcome of minimally invasive chevron ostoetomy, comparing it with a matched group who had open chevron osteotomy.

Methods Prospective study, 54 patients. MIS group 25 patients between October 2009 and November 2010. Open group 29 patients between Feb 2008 and October 2010. Inclusion criteria included, mild to moderate hallux valgus, no previous history of foot surgery, no history of inflammatory arthritis, or MTPJ arthritis. All the operations were performed by the senior author. Functional outcome and pain were evaluated using pre and post operative Manchester Oxford Foot and ankle questionnaire (MOXFQ). IMA and HVA, avascular necrosis and union were assessed. Complications and satisfaction were recorded.

Results The MIS group with mean age at operation of 55, showed significant improvement in all the domains of the MOXFQ. Walking (p <0.018), foot pain (p = <0.013), social interaction (p = <0.001). The mean HVA and IMA corrections were 11.8° and 6.3°, (p < 0.001). The open group with mean age at operation of 55 years showed significant improvement in all domains of the MOXFQ, walking (p = <0.0001), foot pain (p = <0.002), social interaction (p = <0.0001). The HVA and IMA corrections were 10.5 and 5.9 degrees respectively (p = <0.001). The improvement in MOXFQ and HVA and IMA corrections were not statistically significant between the MIS and open groups.

Discussion and Conclusion Our results showed that the MIS chevron osteotomy is an effective procedure with minimal complications and satisfactory functional outcome, comparable to the open standard chevron osteotomy. Larger sample size is required to confirm our findings.
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Old 11th January 2013, 12:06 AM
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Default Re: Chevron Osteotomy

Chevron Osteotomy of the First Metatarsal Stabilized With an Absorbable Pin
Our 5-year Experience

Alberto Morandi, Emanuele Ungaro, Andrea Fraccia, Valerio Sansone
Foot & Ankle International January 10, 2013 1071100712464956
Quote:
Background: The potential requirement for hardware removal originally fueled the development of bioabsorbable pins as an alternative to metal screws for fixing osteotomy sites in foot surgery. More recently, the concern regarding the adverse effects of metal implants may provide further grounds for using bioabsorbable rather than metal fixation.

Methods: This is a prospective study of 383 consecutive patients (439 feet) who underwent a chevron osteotomy to correct a hallux valgus deformity performed between 2005 and 2010. In the study group of 251 patients (285 feet), the distal metatarsal osteotomy was fixed with a bioabsorbable pin made of poly-L-lactide and poly-DL-lactide (70:30 ratio). In the control group of 132 patients (154 feet), the osteotomy was fixed with a metal screw. The average follow-up was 27 months for the study group and 31 months for the control group.

Results: We observed statistically significant improvements in the mean intermetatarsal angle of 6.1 ± 2.7 degrees in the study group and 5.2 ± 1.6 degrees in the control group (P < .001) and in the mean hallux valgus angle of 14.8 ± 4.7 degrees and 15.5 ± 3.7 degrees, respectively (P < .001). The mean ± SD improvement on the American Orthopaedic Foot and Ankle Society 100-point scale was 45 ± 11 points for the study group and 49 ± 15 points for the control (P < .001). Our complication rate was 0.7% for the study group.

Conclusion: Our study found that fixation with a bioabsorbable pin was as reliable as fixation with a metal screw and allowed major angular corrections. The bioabsorbable polymer was well tolerated, and the complication rate was low.
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Old 11th January 2013, 03:55 PM
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Default Re: Chevron Osteotomy

Modified chevron osteotomy with lateral release and screw fixation for treatment of severe hallux deformity.
Hofstaetter SG, Schuh R, Trieb K, Trnka HJ.
Z Orthop Unfall. 2012 Dec;150(6):594-600.
Quote:
Background: This prospective study examined the clinical and radiological results of the Chevron osteotomy with screw fixation and distal soft tissue release up to an intermetatarsal angle of 19°. Furthermore, the results are presented for patients over the age of 70 years, and whether or not there is a higher complication rate.

Material and Methods: 86 feet of patients between 23 and 81 years were included in the study. Apart from the overall group, a group with an intermetatarsal angle of 16° to 19° and a group of patients over 70 years old were eavaluated. They were evaluated preoperatively and at follow-up after an average of 3.3 years according to the American Orthopaedic Foot and Ankle Society score.

Results: The AOFAS score showed a significant improvement from 55 points preoperatively to 90 points at follow-up. The preoperative hallux valgus angle decreased significantly from 32° to 5° and the preoperative intermetatarsal angle decreased from 14° to 6°. Patient satisfaction in the overall group was rated in 92 % as excellent or good. Also, the patient group with 16° to 19° angles and the patients over 70 years showed a significant improvement of clinical and radiological parameters. The complication rate was very low in all groups.

Conclusion: The results show that the Chevron osteotomy is a very good surgical technique with few complications for the correction of splay foot with hallux valgus deformity. We showed that by using the modified technique with a long plantar arm, an excessive soft tissue release and screw fixation, the indication can be extended up to an intermetatarsal angle of 19° when using screw fixation. Furthermore the patients over 70 years of age showed a significant improvement of clinical and radiological parameters without serious complications such as avascular necrosis or dislocation of the metatarsal head.
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Old 15th January 2013, 12:40 AM
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Default Re: Chevron Osteotomy

Chevron Osteotomy of the First Metatarsal Stabilized With an Absorbable Pin
Our 5-year Experience

Alberto Morandi, Emanuele Ungaro, Andrea Fraccia, Valerio Sansone,
Foot & Ankle International January 10, 2013 1071100712464956
Quote:
Background: The potential requirement for hardware removal originally fueled the development of bioabsorbable pins as an alternative to metal screws for fixing osteotomy sites in foot surgery. More recently, the concern regarding the adverse effects of metal implants may provide further grounds for using bioabsorbable rather than metal fixation.

Methods: This is a prospective study of 383 consecutive patients (439 feet) who underwent a chevron osteotomy to correct a hallux valgus deformity performed between 2005 and 2010. In the study group of 251 patients (285 feet), the distal metatarsal osteotomy was fixed with a bioabsorbable pin made of poly-L-lactide and poly-DL-lactide (70:30 ratio). In the control group of 132 patients (154 feet), the osteotomy was fixed with a metal screw. The average follow-up was 27 months for the study group and 31 months for the control group.

Results: We observed statistically significant improvements in the mean intermetatarsal angle of 6.1 ± 2.7 degrees in the study group and 5.2 ± 1.6 degrees in the control group (P < .001) and in the mean hallux valgus angle of 14.8 ± 4.7 degrees and 15.5 ± 3.7 degrees, respectively (P < .001). The mean ± SD improvement on the American Orthopaedic Foot and Ankle Society 100-point scale was 45 ± 11 points for the study group and 49 ± 15 points for the control (P < .001). Our complication rate was 0.7% for the study group.

Conclusion: Our study found that fixation with a bioabsorbable pin was as reliable as fixation with a metal screw and allowed major angular corrections. The bioabsorbable polymer was well tolerated, and the complication rate was low.
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Old 5th February 2013, 11:03 AM
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Default Re: Chevron Osteotomy

Treatment for Hallux Valgus with Chevron Metatarsal Osteotomy in Patients over 60 Years Old.
Jeong BO, Lee SH.
J Korean Foot Ankle Soc. 2012 Dec;16(4):223-228. Korean.
Quote:
PURPOSE: To treat hallux valgus in old age patients with chevron metatarsal osteotomy and to see the subsequent clinical and radiological outcomes.

MATERIALS AND METHODS: 23 cases of 18 hallux valgus patients of age 60 years or older who received proximal or distal corrective osteotomy from April 2007 to August 2009 and were followed up for at least 1 year were included in the study. The mean age at operation was 65 years (range, 60~81 years), and the mean follow-up period was 2 years and 6 months (range, 1 year~3 years 6 months). Clinical outcome was assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) score, complications, satisfaction rate, as well as measurements and comparison of pre- and postoperative hallux valgus angles, the 1st~2nd intermetatarsal angle, and the position of hallucal medial sesamoid bone.

RESULTS: The AOFAS score was improved from preoperative average of 35.1 (range, 13-47) to average 85.1 at last follow-up (range, 75-100). Patients were satisfied about the operation in 21 cases (91.3%). Preoperative hallux valgus angle was 31.7degrees on average (range, 19.1degrees-48.9degrees), and 4.9degrees on average at last follow-up (range, 0.3degrees-21.2degrees). The 1st~2nd intermetatarsal angle was 14.4degrees on average (range, 8.7degrees-25.7degrees) and 3.1degrees on average at last follow-up (range, 0.6degrees-7.5degrees). The hallucal medial sesamoid bone position was improved from preoperative average 3.5 (range, 3-4) to postoperative average 1.0 (range, 0-2).

CONCLUSION: Proximal and distal metatarsal osteotomy treatment yielded good clinical and radiological outcomes in old age hallux valgus patients.
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Old 21st February 2013, 12:38 PM
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Default Re: Chevron Osteotomy

Plate fixation for proximal chevron osteotomy has greater risk for hallux valgus recurrence than Kirschner wire fixation.
Park CH, Ahn JY, Kim YM, Lee WC.
Int Orthop. 2013 Feb 20
Quote:
PURPOSE:
The purpose of this study was to compare the results of hallux valgus surgery between feet fixed with Kirschner wires and those fixed with a plate and screws.

METHODS:
Between December 2008 and November 2009, 53 patients (62 feet) were treated with proximal chevron osteotomy and distal soft tissue procedure for symptomatic moderate to severe hallux valgus deformity. Thirty-four patients (41 feet) were stabilised with Kirschner wires (K-wire group) and 19 patients (21 feet) were stabilised with a locking plate (plate group). Clinical results were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographic parameters were compared between these groups. Recurrence rate at the last follow-up was compared between the K-wire and plate groups.

RESULTS:
Mean AOFAS score was lower in the plate group, however, the difference between the groups was not statistically significant in AOFAS score at the last follow-up. Hallux valgus angle and intermetatarsal angle were significantly larger in the plate group at the last follow-up. Mean 1-2 metatarsal (MT) distance on immediately postoperative radiographs was significant larger in the plate group. Four (9.8 %) of the 41 feet in the K-wire group and 7 (33.3 %) of the 21 feet in the plate group showed hallux valgus recurrence at the last follow-up. The plate group had a significantly higher risk of recurrence than the K-wire group.

CONCLUSIONS:
Fixation of proximal chevron osteotomy using a plate and screws has a greater risk of hallux valgus recurrence than fixation using Kirschner wires.
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Old 18th March 2013, 12:07 PM
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Default Re: Chevron Osteotomy

The chevron osteotomy and avascular necrosis
Matthew Rothwell, James Pickard
The Foot Volume 23, Issue 1 , Pages 34-38, March 2013
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Avascular necrosis (AVN) of the first metatarsal head following the chevron procedure for hallux valgus correction, has been reported widely in the literature; however, in practice it is rarely encountered and may be an over reported myth associated with the chevron technique. Although an infrequent complication, the consequences for those who develop post-operative AVN can be severe. This paper presents an overview of the pathogenesis and classification of AVN. It reviews the vascular anatomy of the first metatarsal with reference to the surgical technique of chevron osteotomy with lateral release. Imaging techniques are described and the management of AVN and revision surgery are also discussed.
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Old 28th March 2013, 05:56 PM
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Default Re: Chevron Osteotomy

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

H-W. Park et al
Bone Joint J April 2013 vol. 95-B no. 4 510-516
Quote:
Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity.
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Old 8th April 2013, 06:43 PM
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Default Re: Chevron Osteotomy

Percutaneous Chevron; the union of classic stable fixed approach and percutaneous technique
Joel Vernois, David Redfern
Fuß & Sprunggelenk; Available online 4 April 2013
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A multitude of different surgical techniques have been described for the treatment of hallux valgus. Since more than 15 years, percutaneous technique has been introduced in Europe by Mariano de Prado. The authors report the result of a mini invasive technique: the percutaneous chevron, the union of the classic stable fixed approach and the less invasive principle of the percutaneous technique.

100 feet has been analyzed radiologically. The mean intermetatarsal angle was 14.5° preoperatively and 5.5° at the last follow-up. The mean correction was 9°. The mean hallux valgus angle was 33.7° preoperatively and 7.3° at the last follow-up. The patient reported satisfaction rate was 95% good / excellent results.

The percutaneous chevron seems to offer a stable, effective and reproducible correction of hallux valgus deformity with the advantages of a minimally-invasive technique.
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