Comparison of Distal Soft-Tissue Procedures Combined with ...

Comparison of Distal Soft-Tissue ProceduresCombined with a Distal Chevron Osteotomy for

Moderate to Severe Hallux Valgus: First Web-SpaceVersus Transarticular Approach

Yu-Bok Park, MD, Keun-Bae Lee, MD, PhD, Sung-Kyu Kim, MD, Jong-Keun Seon, MD, PhD, and Jun-Young Lee, MD, PhD

Investigation performed at the Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital,Gwangju, Republic of Korea

Background: There are two surgical approaches for distal soft-tissue procedures for the correction of hallux valgus—thedorsal first web-space approach, and the medial transarticular approach. The purpose of this study was to compare theoutcomes achieved after use of either of these approaches combined with a distal chevron osteotomy in patients withmoderate to severe hallux valgus.

Methods: One hundred and twenty-two female patients (122 feet) who underwent a distal chevron osteotomy as part of adistal soft-tissue procedure for the treatment of symptomatic unilateral moderate to severe hallux valgus constituted thestudy cohort. The 122 feet were randomly divided into two groups: namely, a dorsal first web-space approach (group D;sixty feet) and a medial transarticular approach (group M; sixty-two feet). The clinical and radiographic results of the twogroups were compared at a mean follow-up time of thirty-eight months.

Results: The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale hallux metatarsophalangeal-interphalangealscores improved from a mean and standard deviation of 55.5 ± 12.8 points preoperatively to 93.5 ± 6.3 points at the finalfollow-up in group D and from 54.9 ± 12.6 points preoperatively to 93.6 ± 6.2 points at the final follow-up in group M. The meanhallux valgus angle in groups D and M was reduced from 32.2� ± 6.3� and 33.1� ± 8.4� preoperatively to 10.5� ± 5.5� and9.9� ± 5.5�, respectively, at the time of final follow-up. The mean first intermetatarsal angle in groups D and M was reducedfrom 15.0� ± 2.8� and 15.3� ± 2.7� preoperatively to 6.5� ± 2.2� and 6.3� ± 2.4�, respectively, at the final follow-up. Theclinical and radiographic outcomes were not significantly different between the two groups.

Conclusions: The final clinical and radiographic outcomes between the two approaches for distal soft-tissue procedureswere comparable and equally successful. Accordingly, the results of this study suggest that the medial transarticularapproach is an effective and reliable means of lateral soft-tissue release compared with the dorsal first web-spaceapproach.

Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Hallux valgus is a foot deformity commonly seen in med-ical practice, often accompanied by substantial func-tional disability and foot pain1-3. More than 100 different

surgical techniques have been described for correction of halluxvalgus4,5. The main purpose of these procedures is to decrease

toe pain and correct the deformity. Among these procedures,the combination of an osseous procedure (such as a metatarsalosteotomy) with a distal soft-tissue procedure has shown goodoverall results and is widely used as the surgical treatment forpainful hallux valgus4-10.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support ofany aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of thiswork, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, noauthor has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence whatis written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of thearticle.

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The osseous procedure is aimed at correcting the first-second intermetatarsal angle. The distal soft-tissue procedure isaimed at hallux valgus angle correction and sesamoid reduc-tion4. The purpose of the distal soft-tissue procedure is to releasethe contracted lateral structures, reduce the lateral deformingforces, and reestablish congruity of the first metatarsophalan-geal joint. In 1923, Silver10 described a distal soft-tissue proce-dure consisting of a medial eminence resection, lateral capsularrelease, adductor hallucis tendon release, and medial capsularplication with adductor hallucis transposition. Modificationsof this procedure, such as medial capsulotomy, division of theligament between the lateral capsule and the fibular sesamoid,adductor hallucis release, and lateral capsular fenestration, havesince been introduced6,7,9-11.

There are two surgical approaches for distal soft-tissueprocedures for the correction of hallux valgus12,13. One is the dorsalfirst web-space approach, and the other is the medial trans-articular approach. The dorsal first web-space approach allowsfairly easy release of the lateral soft tissue and visual assessment.However, it requires an additional incision and leaves a dorsalscar in the first web space. The benefits of the medial transar-ticular approach are presumed to be decreased morbidity as-sociated with avoidance of an additional incision, improvedcosmesis, and a reduced risk of osteonecrosis of the first meta-tarsal head14. However, because patients with hallux valgus havelateral and dorsal displacement of the lateral sesamoid, the releaseof the lateral soft tissues through a medial incision tends to beincomplete15.

We hypothesized that the dorsal web-space approach wouldproduce better results than the medial transarticular approachwould. Each method has its own advantages and disadvantages,but there has been little comparative study of the results of thetwo approaches. Accordingly, the purpose of the present studywas to compare the clinical and radiographic results between

the two distal soft-tissue procedures when performed in com-bination with a distal chevron osteotomy for the correction ofmoderate to severe hallux valgus deformities.

Materials and Methods

This prospective study was approved by the institutional review board of ChonnamNational University Hospital, and informed consent was obtained from all

patients. Between January 2006 and December 2009, 146 adult female patients(146 feet) underwent a first metatarsal distal chevron osteotomy combined witha distal soft-tissue procedure for the treatment of symptomatic, unilateral, mod-erate to severe hallux valgus deformity. All procedures were performed by a singlesurgeon. Indications for this procedure were painful symptomatic unilateralhallux valgus, difficulty in wearing shoes, a preoperative hallux valgus angle ‡20�,a preoperative first-second intermetatarsal angle ‡14�, and an incongruent firstmetatarsophalangeal joint. All patients had failure of nonoperative treatmentconsisting of shoe-wear modification and nonsteroidal anti-inflammatory med-ications. Sixteen patients (sixteen feet) with previous failed hallux valgus surgery,posttraumatic hallux valgus, preexisting radiographic evidence of substantialdegenerative arthritis of the first metatarsophalangeal joint, and hallux rigidusor instability at the first metatarsocuneiform joint were excluded.

The remaining 130 patients (130 feet) were divided into two groups,namely, those who were treated with a dorsal first web-space approach (group D),and those who were managed with a medial transarticular approach (group M).Patients were randomized into group D or group M according to their positionon the operative registration list (i.e., those whose names were listed next to aneven number were treated with a dorsal first web-space approach, and thosewhose names were listed next to an odd number were managed with a medialtransarticular approach). Eight patients (eight feet) without adequate follow-upfor at least twenty-four months were excluded. In the end, 122 patients (122 feet)were included and constituted the study cohort. Group D was made up of sixtypatients (sixty feet), and group M consisted of sixty-two patients (sixty-two feet)(Fig. 1). Mean patient age at the time of surgery was 46.9 years (range, nineteento seventy-two years) in group D and 46.7 years (range, nineteen to seventy-fiveyears) in group M, and the mean duration of follow-up was 38.2 months (range,twenty-four to sixty-eight months) in group D and 37.8 months (range, twenty-four to sixty-six months) in group M.

Clinical and radiographic evaluations were performed preoperativelyand postoperatively at three, six, and twelve months and then annually thereafter.

Fig. 1

CONSORT (Consolidated Standards of Reporting Trials) flow diagram31 of this study is shown.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 95-A d NU M B E R 21 d N O V E M B E R 6, 2013CO M PA R I S O N O F TWO SU R G I C A L A P P R OAC H E S CO M B I N E D W I T H

A DI S TA L CH E V R O N OS T E O T O M Y F O R HA L LU X VA L G U S


Comparison of the results between the two groups was performed preopera-tively and at the final follow-up by two orthopaedic surgeons (Y.-B.P. and S.-K.K.)who were not directly involved in the surgical procedures.

Surgical TechniquesThe operative technique consisted of a distal soft-tissue procedure and the distalchevron osteotomy. Regional anesthesia was accomplished with use of an ankleblock, and exsanguination of the foot and maintenance of hemostasis were ac-complished with use of an Esmarch tourniquet around the ankle

16. The soft-

tissue procedure was performed prior to the distal chevron osteotomy.

Dorsal First Web-Space ApproachA 3-cm dorsal longitudinal incision was centered on the first intermetatarsalweb space. The dissection was made in the midline to protect the branches ofthe deep peroneal nerve. The adductor hallucis tendon was identified, and thedistal end of the adductor tendon that was released from the base of the proximalphalanx of the great toe was dissected from the lateral aspect of the fibular ses-amoid. The fibular sesamoid-metatarsal ligament and transverse metatarsal liga-ment were transected (Fig. 2). The lateral aspect of the first metatarsophalangealjoint capsule was perforated with several puncture wounds, and varus stress ofabout 20� to 30� was then applied to the first metatarsophalangeal joint so as tocomplete the release of the lateral soft tissues. By using a standard medial approach to

perform the distal chevron osteotomy, a longitudinal midline capsulotomy was ableto be performed in the same plane of the incision. After finishing the distal chevronosteotomy, the hallux was then reduced to a neutral position, and the medial side ofthe joint capsule was closed longitudinally after excising the redundant edges.

Medial Transarticular ApproachA medial longitudinal incision was made over the first metatarsophalangeal joint,starting at the midportion of the proximal phalanx of the great toe and extending2 cm proximal to the medial eminence. A longitudinal midline capsulotomywas performed in the same plane as that of the incision. The medial eminencewas excised about 2 mm medial to the sagittal sulcus with a sagittal saw. To clearlyvisualize the lateral capsular structures, the first metatarsophalangeal joint wasdistracted distally with use of two vein retractors and manual traction of thegreat toe. A curved mosquito forceps was then inserted into the middle portionof the lateral side of the joint capsule and widened metatarsophalangeal joint.After the lateral side of the joint capsule was released with use of a number-15blade, the adductor hallucis tendon was released completely (Fig. 3). Varus stresswas then applied to the first metatarsophalangeal joint in order to complete therelease of the adductor hallucis tendon from the proximal phalanx of the greattoe. The hallux was reduced to a neutral position after completing the distalchevron osteotomy, and the medial side of the joint capsule was closed longi-tudinally after excising the redundant edges.

Fig. 2

Figs. 2-A through 2-D Anatomical structures to be released through the dorsal first web-space approach. Fig. 2-A The adductor hallucis tendon is identified

with use of a mosquito forceps. Fig. 2-B The adductor hallucis tendon (arrow) has been released from its insertion at the base of proximal phalanx of the

great toe. Fig. 2-C After releasing the fibular sesamoid-metatarsal ligament, the fibular sesamoid (arrow) can be observed. Fig. 2-D The transverse

metatarsal ligament (arrow) has been identified and transected.

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Distal Chevron OsteotomyA standard medial incision was made over the first metatarsophalangeal jointstarting at the midportion of the proximal phalanx and extending 2 cm proximalto the medial eminence. After making a longitudinal midline capsulotomy, a medialeminence resection and chevron osteotomy were performed with use of stan-dard techniques. We created a 60� V-osteotomy centered in the first metatarsalhead, displaced the capital fragment by approximately 5 to 9 mm laterally, andmanually impacted the head fragment onto the shaft to obtain a stable reduction.The osteotomy was then fixed with two medially placed Kirschner wires (1.4-mmin diameter). Any remaining proximal medial osseous prominence at the os-teotomy site after displacement of the metatarsal head was resected.

Clinical AssessmentAn American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score

17and a patient satisfaction score were obtained preoperatively

as well as at the time of final follow-up. The 100-point AOFAS scoring systemcombines subjective and objective data to evaluate clinical parameters: pain (40points), function (45 points), and alignment (15 points). To evaluate subjectivepatient satisfaction with the procedure, we asked the patients for their subjectiveresponses. Responses were graded as ‘‘very satisfied,’’ ‘‘satisfied,’’ ‘‘improved,’’ or ‘‘dis-satisfied.’’ The reliability and validity of this patient satisfaction scale are unknown.

We also evaluated the postoperative complications, including first meta-tarsophalangeal joint stiffness (defined as range of motion of <30�), osteonecrosis(defined radiographically as the presence of crescent-shaped subchondral lucencies,cysts, osseous collapse, fragmentation, and joint-space narrowing), a short halluxdefined as >2.5 mm of metatarsal shortening, delayed union or nonunion (definedas successful healing not occurring within six months), displacement after fixation(defined as movement of the capital fragment from the original site), deep infection

(defined as purulent discharge from the wound and abnormal results on blood tests),or first metatarsophalangeal joint arthritis (defined as joint-space narrowing)

18-20.

Radiographic AssessmentWeight-bearing anteroposterior and lateral radiographs of the foot were madepreoperatively and at each postoperative follow-up visit in order to measure thehallux valgus angle, the first-second intermetatarsal angle, tibial sesamoid position,first metatarsal length, and sagittal alignment of the first metatarsal. All ra-diographic measurements were obtained with use of the Picture Archiving andCommunication System (version 5.4; Marotech, Seoul, Republic of Korea). Thehallux valgus angle was defined as the angle formed by the intersection of thediaphyseal axis of the proximal phalanx of the great toe and the longitudinalaxis of the first metatarsal, which was determined by connecting the center ofthe first metatarsal head and the center of the proximal articular surface

21. The

first-second intermetatarsal angle was obtained by determining the angle formedby a line bisecting the second metatarsal shaft and a line drawn between thecenter of the first metatarsal head and the center of the proximal articular surface(Fig. 4). The sesamoid position was defined by the position of the medial ses-amoid in relation to a longitudinal line bisecting the first metatarsal shaft andwas classified as grade 0, 1, 2, or 3

22. First metatarsal length was measured with

use of the Hardy and Clapham method23

, and the alignment of the head of thefirst metatarsal in the sagittal plane in relation to the shaft of the first metatarsalwas defined as having neutral, dorsal, or plantar angulation.

Statistical MethodsIn the absence of an established minimal clinically important difference for theprimary outcome measure (the AOFAS score), no formal power analysis (two-sided, p = 0.05) was performed. We tested the null hypothesis that the mean

Fig. 3

Figs. 3-A through 3-D Anatomical structures to be released through the medial transarticular approach. Fig. 3-A The first metatarsophalangeal joint is

distracted distally using two vein retractors and manual distraction of the great toe to facilitate visualization of the lateral soft-tissue structures. Fig. 3-B The

lateral side of the joint capsule (arrow) is demonstrated in the metatarsophalangeal joint with use of a mosquito forceps. Fig. 3-C After releasing the lateral

side of the joint capsule with use of a number-15 blade, the adductor hallucis tendon (arrow) can be observed. Fig. 3-D The adductor hallucis tendon has

been released completely.

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AOFAS score of group D would be better than that of group M (i.e., a type-II error).A sample-size calculation determined that forty-seven patients were needed pergroup to ensure 90% power based on a 10-point (standard deviation, 15 points)minimal clinically important difference between groups. A total of 130 patientswere recruited to allow for loss to follow-up. Additionally, a post hoc poweranalysis demonstrated that the sample size was sufficiently powered to compare

outcomes of AOFAS score, hallux valgus angle, first-second intermetatarsal angle,tibial sesamoid position, and complication rates at the time of final follow-up.

The independent t test was used to determine the significance of in-tergroup differences in age and follow-up duration. The Mann-Whitney U testwas used to determine the significance of intergroup differences in AOFAS score,hallux valgus angle, first-second intermetatarsal angle, and tibial sesamoid

Fig. 4

Figs. 4-A and 4-B Radiographic measurements of the hallux valgus angle (a) and the first-second intermetatarsal angle (b) preoperatively (Fig. 4-A) and

postoperatively (Fig. 4-B).

TABLE I Clinical Outcomes of the Two Distal Soft-Tissue Procedures*

Dorsal FirstWeb-Space Approach

Medial TransarticularApproach P Value†

Preoperative AOFAS scoreTotal 55.5 ± 12.8 54.9 ± 12.6 0.805Pain 22.4 ± 5.4 22.3 ± 6.5 0.784Function 31.6 ± 6.4 30.9 ± 5.2 0.315Alignment 1.5 ± 3.1 1.7 ± 3.3 0.460

Final follow-up AOFAS scoreTotal 93.5 ± 6.3 93.6 ± 6.2 0.635Pain 38.2 ± 3.9 37.7 ± 4.3 0.566Function 40.7 ± 3.9 41.6 ± 3.6 0.740Alignment 14.6 ± 1.6 14.3 ± 2.1 0.497

P value‡ 0.000 0.000

*Values are expressed as the mean and the standard deviation. †Mann-Whitney U test. The p values shown are for intergroup comparisons. A pvalue of <0.05 was considered significant. ‡Paired t test. The p values pertain to the comparisons between the preoperative American Or-thopaedic Foot & Ankle Society (AOFAS) total score and the AOFAS total score at the time of the final follow-up. A p value of <0.05 was consideredsignificant.

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position. The paired t test was used to assess the intragroup differencesof clinical and radiographic results before and after surgery. The Pearsonchi-square test was performed to determine the significance of intergroupdifferences in the prevalence of complications. Significance was defined asp < 0.05.

Source of FundingThe authors did not receive any external funding for this study.

Results

Preoperative and postoperative AOFAS scores for both groupsare shown in Table I. The AOFAS scores between group D

and group M at the final follow-up were not significantly dif-ferent (p = 0.635).

At the final follow-up, the results of the survey of patientsatisfaction revealed good results (‘‘satisfied’’ and ‘‘very satisfied’’)in fifty-eight (96.7%) of sixty patients in group D (see Fig. E-1 inthe Appendix) and in sixty (96.8%) of sixty-two patients in group M(see Fig. E-2 in the Appendix). Patient satisfaction was as follows:in group D, twenty-five patients (41.7%) were ‘‘very satisfied,’’thirty-three patients (55.0%) were ‘‘satisfied,’’ and two patients(3.3%) were ‘‘improved’’; in group M, twenty-eight patients (45.2%)were ‘‘very satisfied,’’ thirty-two patients (51.6%) were ‘‘satisfied,’’and two patients (3.2%) were ‘‘improved.’’ Patient satisfactionwas not significantly different between the two groups with useof the Fisher exact test (p = 0.993).

Of the two patients in group D who showed an ‘‘improved’’response, one patient had symptomatic thickening in the dorsalfirst web-space scar and the other patient had persistent bunionpain; of the two patients in group M who showed an ‘‘improved’’response, one patient had symptomatic first metatarsophalan-geal joint stiffness and the other patient had persistent bunionpain. All four patients refused additional surgery. No patient marked‘‘dissatisfied’’ on the questionnaire.

Preoperative and postoperative radiographic results forboth groups are shown in Table II. There were significant im-provements in the hallux valgus angle and the first-second inter-metatarsal angle at the time of final follow-up in each group (p <0.05). Also, no significant intergroup difference was observed inthe hallux valgus angle (p = 0.64) or the intermetatarsal angle(p = 0.79) at the final follow-up.

The tibial sesamoid position showed significant improve-ment at the final follow-up compared with the preoperativeposition in each group (p < 0.05). The tibial sesamoid positionshowed no significant difference between groups at the time offinal follow-up (p = 0.453). Mean first metatarsal shortening was2.3 ± 1.2 mm (range, 0 to 4 mm) in group D and 2.2 ± 1.6 mm(range, 0 to 3.4 mm) in group M at the time of final follow-up.However, no patient complained of having a short hallux.At the time of final follow-up in group D, a neutral position ofthe first metatarsal head in the sagittal plane was observedin fifty-five (91.7%) of the sixty feet, dorsal angulation of thefirst metatarsal head was observed in two feet (3.3%), andplantar flexion of the first metatarsal head was observed inthree feet (5.0%). At the time of final follow-up in group M, aneutral position of the first metatarsal head was observed infifty-eight (93.5%) of the sixty-two feet, dorsal angulation of thefirst metatarsal head was observed in two feet (3.2%), and plantarflexion of the first metatarsal head was observed in two feet (3.2%).No patient complained of a dorsal or plantar angulation.

A total of eleven complications occurred in both groups(six in group D and five in group M). In group D, complica-tions included first metatarsophalangeal joint stiffness in twopatients, numbness along the medial side of the great toe in onepatient, superficial wound infection in one patient, persistentbunion pain in one patient, and thickening of the dorsal first web-space scar in one patient. In group M, complications included

TABLE II Radiographic Outcomes of the Two Distal Soft-Tissue Procedures*

Dorsal First Web Space Medial Transarticular P Value†

Hallux valgus angle (deg)

Preoperative 32.2 ± 6.3 33.1 ± 8.4 0.348Final follow-up 10.5 ± 5.5 9.9 ± 5.5 0.640P value‡ 0.000 0.000

Intermetatarsal angle (deg)


Tibial sesamoid position(grade 0 to 3)


*Values are expressed as the mean and the standard deviation. †Mann-Whitney U test. The p values shown are for intergroup comparisons. A pvalue of <0.05 was considered significant. ‡Paired t test. The p values pertain to the comparisons between the preoperative and final follow-upexaminations. A p value of <0.05 was considered significant.

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first metatarsophalangeal joint stiffness in one patient, numbnessalong the medial side of the great toe in two patients, superficialwound infection in one patient, and persistent bunion pain inone patient. In both groups, there were no cases of recurrence,osteonecrosis, nonunion or malunion, displacement after fixa-tion, deep infection, or first metatarsophalangeal joint arthritis atthe time of final follow-up. Complication rates in group D andgroup M were 10% and 8.1%, respectively. There was no sig-nificant difference in terms of postoperative complication ratesbetween the two groups (p = 0.71).

Discussion

The anatomy about the first metatarsophalangeal joint andits importance in the development of hallux valgus have

been well described1. Soft-tissue imbalance combined with thelack of an antagonistic force on the medial side and overpullof the adductor conjoined tendon on the base of the proximalphalanx plays an important role in the pathophysiology of halluxvalgus4,9,24,25. Failure to correct this pathomechanism has beenconsidered to be one of the causes of inadequate correction ofthe hallux valgus angle24. Therefore, the distal soft-tissue pro-cedures are aimed at hallux valgus angle correction and sesamoidreduction mainly by releasing the contracted lateral structures inorder to decrease the lateral deforming forces and realign thefirst metatarsophalangeal joint4,13,26.

Since lateral soft-tissue release through a dorsal first web-space approach has been established as an important adjunctfor the correction of hallux valgus, modified methods of ex-posure and release have been described, particularly the medialtransarticular release approach through a single medial incisionat the metatarsophalangeal joint6,14,15,27-29. The dorsal first web-space approach is more widely used by foot surgeons; however,complications can occur with use of this approach, includingosteonecrosis of the first metatarsal head when this procedureis performed in combination with a distal metatarsal osteot-omy, thickness of the incision scar, contracture of the soft tissuereleased from the dorsal first web space, and decreased cosmesisdue to dorsal first web-space scarring30. While the medial trans-articular release method has the benefits of decreased morbidityassociated with the avoidance of an additional incision, im-proved cosmesis due to less scarring in the dorsal first webspace, and a reduced risk of osteonecrosis of the first metatarsalhead, it is associated with complications such as intra-articularcartilage injury and flexor hallucis brevis tendon injury14. Thereis also the possibility of performing an inadequate lateral soft-tissue release because of less clear visualization15. In this series,we did not experience any instance of intra-articular cartilageinjury or flexor hallucis brevis tendon injury intraoperatively ingroup M, and we believe that these injuries can be avoided byusing two vein retractors and a curved mosquito forceps to guidethe number-15 blade during the release. Brand and Smith26 de-scribed the intra-articular adductor release technique in con-junction with the metatarsal chevron osteotomy, and they statedthat this combination facilitated the correction of hallux valguswhile minimizing the recurrence. Chen et al.4 reported on theuse of a distal chevron osteotomy and an intra-articular lateral

soft-tissue procedure for the treatment of moderate to severehallux valgus. They concluded that this combination providesan effective means of correcting hallux valgus with a high levelof patient satisfaction and a low incidence of osteonecrosis, evenin patients with severe hallux valgus. Moreover, Waldecker13 com-pared the outcomes of the two approaches and both demon-strated equally good clinical and radiographic results.

In the present study, the clinical and radiographic out-comes associated with the two distal soft-tissue procedures werecomparable at the time of final follow-up. On the basis of ourresults, we believe that a medial transarticular approach is ade-quate for the correction of hallux valgus. However, caution shouldbe exercised intraoperatively so as to avoid over-release of thelateral side of the joint capsule since, with this technique, theentire capsule has to be incised instead of perforated several timesas in the dorsal first web-space approach.

Osteonecrosis of the metatarsal head is a well-documentedcomplication associated with extensive distal soft-tissue releaseprocedures12,18. An anatomical study of the blood supply to thefirst metatarsal head has suggested that the first dorsal metatarsalartery is the primary source20, and this blood supply should bemeticulously preserved11. In this respect, theoretically, a benefitof the medial transarticular approach, as compared with the dorsalfirst web-space approach, is a reduced risk of osteonecrosis of thefirst metatarsal head. In this study, however, there was no oc-currence of osteonecrosis in either group D or group M.

There are some limitations to this study. First, the follow-up period was relatively short. Second, we used a subjective scaleto evaluate patient satisfaction and the cosmetic result of theprocedure, and this scale may not be valid and reliable.

In conclusion, the clinical and radiographic outcomes ofthe two distal soft-tissue procedures combined with distal chevronosteotomy for hallux valgus correction were comparable and suc-cessful. The results of this study suggest that the medial transarticularapproach is an effective and reliable means of lateral soft-tissuerelease when compared with the dorsal first web-space approach.

AppendixFigures showing preoperative and postoperative clinicalphotographs and radiographs of feet that were treated

with a distal chevron osteotomy and a distal soft-tissue releasethrough either a dorsal first web-space approach or a medialtransarticular approach are available with the online version ofthis article as a data supplement at jbjs.org. n

Yu-Bok Park, MDKeun-Bae Lee, MD, PhDSung-Kyu Kim, MDJong-Keun Seon, MD, PhDDepartment of Orthopaedic Surgery,Chonnam National University Medical School and Hospital,42 Jebongro, Dong-gu, Gwangju,501-757, Republic of Korea.E-mail address for K.-B. Lee: [email protected]

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Jun-Young Lee, MD, PhDDepartment of Orthopaedic Surgery,College of Medicine,

Chosun University, 365 Pilmun-daero,Dong-gu, Gwangju,501-717, Republic of Korea

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