SLR - June 2015 - Jackie Pyle

A Comparison of Proximal and Distal Chevron Osteotomy, Both with Lateral Soft-Tissue Release, for Moderate to Severe Hallux Valgus in Patients Undergoing Simultaneous Bilateral Correction: A Prospective Randomized Controlled Trial

Reference: Lee KB, Cho NY, Park HW, Seon JK, Lee SH. A comparison of proximal and distal Chevron osteotomy, both with lateral soft-tissue release, for moderate to severe hallux valgus in patients undergoing simultaneous bilateral correction: a prospective randomized controlled trial. Bone Joint J. 2015 Feb;97-B(2):202-7

Scientific Literature Review

Reviewed By: Jackie Pyle, DPM
Residency Program: Southern Arizona VA Health Care System

Podiatric Relevance: Distal metatarsal osteotomies are a common treatment for mild to moderate bunions. They have a lower complication rates and relatively short rehabilitation time compared to proximal osteotomies. It may be beneficial to consider a distal metatarsal osteotomy over a more complicated proximal metatarsal procedure for moderate to severe bunions.
    
Methods: Fifty female patients with 100 feet were randomized into two groups, proximal and distal. Four patients were lost in follow up. The results are based on each group having 92 feet (46 patients). All patients had bilateral symptomatic bunions with HAA > 20 degrees and IMA >14 degrees with incongruent 1st MPJs. All failed conservative treatment. All procedures were performed by one surgeon over 4.5 years. The distal group (D) had Chevron osteotomies performed with a lateral soft tissue release in the standard fashion and fixed with two 1.4mm k-wires. The proximal group (P) had a reverse Chevron osteotomy made 10mm distal to first metatarsal cuneiform joint. This was fixated with two 1.6mm k-wires. A lateral soft tissue release was also performed.. All patients were allowed to heel weight bear in a post op shoe. Sutures were removed at two 2 weeks and k-wires removed in clinic at 6-8 weeks. Radiographs were taken preoperatively and at final follow visit. Subsequent follow up visits were done at three, six, and twelve weeks post operatively then yearly. Patient results were based on AOFAS clinical outcome score. The Mann-Whitney U test was used to determine the significance of the AOFAS scores.

Results: The post-operative AOFAS scores were not statistically different between the P and D groups. In the P group, 25 patients were very satisfied, 18 were satisfied and three were dissatisfied. The in D group, 27 patients were very satisfied, 17 were satisfied and two were dissatisfied. Overall, 93.5 percent of patients in group P and 95.7 percent of group D were happy with the operative results. Significant radiographic improvement of HAA and IMA were noted in both groups post-operatively. There was a 13 percent complication rate in group P and a 10.8 percent complication rate in group D.
 
Conclusions: Though proximal metatarsal osteotomies have been the mainstay treatment for moderate to severe bunions, this study shows that a distal Chevron osteotomy with soft tissue release is as effective and as reliable for moderate to severe bunions as a proximal metatarsal osteotomy with distal soft tissue release.

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