CHEVRON

FOR

OR

HALLUX

K.

From

RANDOMISED

KLOSOK,

the Royal

METATARSAL

DAVID

J. PRING,

Postgraduate

Medical

TRIAL

JULIAN
School,

H.

JESSOP,

Hammersmith

and 38 months after operation.

The patients in the chevron

group
returned
to work
and mobilised
faster, but, at the later review, those
in the Wilson group had better functional
results and were
more satisfied
with the appearance
of the foot. Correction
ofthe
hallux valgus angle was better maintained
in patients
in the Wilson group and they had a better range of motion
at the metatarsophalangeal
joint; fewer complained
of
metatarsalgia.

earlier

Joint

Received

Surg

[Br]

29 October

1993 ; 75-B
1992;

:825-9.

Acceptedafter

revisions

25 March

1993

More than 130 operations

have been described
for hallux
valgus (Kelikian
1965). The chevron
osteotomy
uses a
horizontal
V division
of the fIrst metatarsal
head to
correct
the deformity
(Johnson,
Cofield
and Morrey
1979 ; Austin and Leventen
1981 ; Lewis and Feffer 1981),
and has been
reported
to give good
results
with few
complications
(1982)
has
cations

(Home,
Tanzer
warned,
however,

include

metatarsal
and

avascular

head,

malalignment

shortening

England

causeslittle
soft-tissue
damage(Helal
1974, 1981). Double
obliquity
of the cut, in both longitudinal
and coronal
planes, improves
the bony stability
and reduces
the need
for internal
fixation
(Helal,
Gupta
and Gojaseni
1974;
Helal 1981).
We report a prospective
randomised
trial of the
chevron
and Wilson
osteotomies
for the correction
of
hallux valgus.

PATIENTS
Fifty-one

AND

METHODS

consecutive

patients

(44

women

and

7 men)

with unilateral
or bilateral
hallux
valgus
gave their
informed
consent
before entering
the trial. The type of
osteotomy
for each patient
was randomised
by the use of
a computer-generated
list. In bilateral
cases, both feet
had
the same
selected
operation
during
the same
operating
session.
The Wilson group included
42 feet in
26 patients

(3 with

rheumatoid

arthritis)

with

an average

angle

(x,

of the

of the metatarsal,

Wilson

osteotomy

is a simple

procedure

J. K. Klosok, FRCS, Consultant

Orthopaedic
Surgeon
Newham
General
Hospital,
Glen Road, Plaistow,
London
UK.
D. J. Pring,
Guernsey

FRCS,
Hospital

Consultant
Group,

Orthopaedic
Guernsey,

MD,

Department

of Orthopaedic

Polwarth

Correspondence
l993
British
0301-620X/93/5637

75-B,

PhD,
Surgery

MIBiol,

N. Maffulli,
in Orthopaedic

Surgery,

Building,

should

Senior

Foresterhill,

No. 5, SEPTEMBER

ofBone

El3

8SL,

Islands.

Hertfordshire

Registrar

and Clinical

University

of Aberdeen

Aberdeen

AB9

be sent to Dr N. Maffulli.

Editorial
Society
$2.00

which

Surgeon

Channel

J. H. Jessop, FRCS, Consultant

Orthopaedic
Surgeon
Watford
General
Hospital,
Vicarage
Road, Watford,
WD1 8HB, UK.

VOL.

London,

overcorrection.

The

School,

MAFFULLI

and Ford
1984).
Mann
that the potential
compli-

necrosis,

excessive

NICOLA
Hospital,

We compared
the chevron
and the Wilson
metatarsal
osteotomy
for hallux
valgus in a prospective
randomised
trial on 87 feet in 51 patients, reviewed
at averages of 5.5

J Bone

OSTEOTOMY

VALGUS

A PROSPECTIVE

JAN

WILSON

and

Joint

Surgery

2ZD,

Lecturer
Fig.

Medical
UK.

Methods
used
intermetatarsal
from standard

centage
operation,

1993

to

measure

the

hallux

valgus

left),

the

angle (x, riht),

and shortening
of the fIrst metatarsal
weight-beanng
anteroposterior
radiographs.
The pershortening
of the first metatarsal
is expressed
as a/b before
divided
by a/b at review,
x 100.

825

J. K. KLOSOK,

826

age of 45 years
comprised
arthritis)

11.4 SD

to 77). The

(20

D. J. PRING,

chevron

group

45 feet in 25 patients
(4 with
rheumatoid
with an average
age of 45 years
8.6 SD (23

to

72).

Preoperative
assessments
included
the site of pain,
the degree
of discomfort
from the exostosis,
and the
presence
ofp!antar
callosities
and metatarsalgia.
We also
recorded
the major indications
for surgery
according
to
the patients
; better
appearance
was a major concern
of
five

patients,

easier,

37 wanted

better

relief

of pain,

and

31 wanted

shoe-fitting.

J. H. JESSOP,

N. MAFFULLI

position.
tolerated.
surgeon

After 48 hours,
weight-bearing
Dressings
were
changed
after two weeks
and discarded

Review.
months

Patients
and again

later

review,

were
reviewed
at 38 months

50 patients

not been
involved
patient,
a 20-year-old

were

in

was allowed
by the operating
at four weeks.

at an average
after operation.
assessed

of 5.5
At the

by JKK,

the initial
treatment.
woman,
refused
to be

as

who

had

Only
one
reviewed.

She had had bilateral

chevron
osteotomies
and a poor
result at the early review.
Because
some
patients
were
not willing
to attend

Radiography.
Radiographs
were taken preoperatively,
at
6, 12 and 24 months
and at final review.
Standard
weightbearing
anteroposterior
views were studied
to measure
the hallux valgus angle, the intermetatarsal
angle and the
shortening
of the first metatarsal
(Fig. 1). A 60#{176}
internal
oblique
view, giving true laterals
of the first metatarsals,

hospital,
they were examined
at home,
and radiographs
were not taken.
Of the 42 feet in the Wilson
group,
31
radiographs
of 23 patients
were available.
Of the 45 feet

was

(Leland
1988).
When
a patient
had
bilateral
hallux
valgus,
we used the average
of the hal!ux
valgus
angle,
the metatarsal
shortening
value and range
of motion
on

used

distal

to

assess

postoperative

displacement

of

the

fragment.

Harris

Footprints.
changes

in the

and

Beath

distribution

mats

were

of weight

used

(Harris

to record
and

Beath

in the chevron

group,

the

analysis.

two

sides.

(ANOVA)

Operative
techniques.
All the operations
were performed
with a thigh tourniquet,
through
a 5 to 8 cm dorsomedial

the two groups.

centred

(MTPJ).

over

Wilson

exposed.

A double

using
an
displaced

oscillating
laterally.

roof

over

osteotomy
After
below-knee

oblique

and

to reduce

necessary,

the

in its corrected
48 hours
and

used

capsule
and the

to mark

of the
exostosis

the

the lateral

One-

was then

or

analysed

two-way

analysis

used to evaluate

ANOVA

using

of

differences

for repeated

measures

Systat

variance

between
was

used

Ethilon.
was not
performed
was then
provided
a

spike

of

the

Anteroposterior

A walking
heel
was discharged

The
based

plaster

Fig.

2a

was

V-shaped

MTPJ
was raised,
the
excised
with a saw. A

centre

of the

cortex

to facilitate

metatarsal

head

completion

osteotomy.

Soft-tissue
stripping
was minimised,
being
preserved
to protect
the blood
supply
of the metatarsal
head.
An oscillating
saw was
used
to cut a horizontal
V-shaped
osteotomy
in the
metatarsal
head,
taking
great
care not to split it. The

the lateral

head

were

was not routine.

of dressings,
a
an extension
to

position.
the patient

the following
day.
later.
(Fig. 2b). A distally

osteotomy

The data

the risk of dorsal

bony

was trimmed,
but exostectomy
skin closure
and application
plaster
was applied,
with

to penetrate

of the

was

fragment

of the medial
was opened
was

45#{176}
osteotomy

were

joint

interrupted
first MTPJ

saw. The distal

fragment
The obliquity
of the cut

from hospital
on
removed
six weeks
Chevron

metatarsophalangeal

with
The

Where

hold the hallux

was added
after

drill

first

the distal

angulation.

flap
joint

the

The skin was closed

osteotomy
(Fig. 2a).

in 22 patients

available.

Statistical

1947).

incision

36 radiographs

was

capsule

then

displaced

laterally,

rotated

to the

required

position,
and impacted
on to the metatarsal
shaft.
The
prominent
media!
shaft
was
excised
flush
with
the
metatarsal
head, and the medial
capsular
flap was sutured
to the periosteum
of the metatarsal
shaft
only along
its
superior
margin
in order
not to limit
MTPJ
extension.

After

soft-tissue

crepe

bandage

closure,
was

used

a carefully
to hold

the

applied
toe

wool

in its corrected

and

Fig.
Diagrams
chevron

showing
osteotomy

(a) the double

(right
foot).

2b

oblique

Wilson

osteotomy

and

(b) the

for overall
differences
between
preoperative,
early and
late postoperative
findings.
A post hoc Students
t-test
for paired

For

measures

patients

was

with
THE

used

bilateral
JOURNAL

to assess

hallux
OF BONE

differences.

valgus,
AND

JOINT

the

pres-

SURGERY

CHEVRON

ence

of

when

callosities

at least

test

was

used

the 0.05

level.

one

OR

and

of

foot

was

affected,

the

data.

to analyse

WILSON

metatarsalgia

METATARSAL

was
and

OSTEOTOMY

recorded

(five

a chi-squared

Significance

was

Postoperative

follow-up.

Twenty-six
patients

(43

examined

Thirty-seven

Wilson

feet)

was

(42 feet) in the

in the chevron

respectively

Wilson
group

at an average

827

osteotomy

statistically

increased

central

a chevron

osteotomy

ray

group.

None

of these

significant.

loading

compared

(16%)

(Fig.

with

seven

after

3).

osteotomies

4.

group
and 24
were
also re-

of 37 months

45) and 38 months (9 to 45) postoperatively.

Radiography.
The average
preoperative

VALGUS

Footprints.
Using the Harris
and Beath
footprint
method,
12 feet of the Wilson
group (29%) showed
evidence
of

set at

41 chevron
osteotomies
in 23 patients
at an average
of 22 weeks
(1 1 to 40).

patients
feet)

HALLUX

in the chevron

differences

RESULTS

in 23 patients
and
were re-examined,

FOR

,*

(10 to

hallux

valgus

angle
was 29#{176}
7.9#{176}
SD (26 to 41) in the Wilson
group
and 30#{176}
8.8#{176}
(27 to 40) in the chevron
group.
At early
review,

the

corrected

hallux

angle

in the

Wilson

group

to 26) in the chevron

group.
the Wilson
group
had
maintained
an average
of 13.3#{176}
8. 1#{176}
(9 to 22)

with
chevron
to 27).

group the angle

The
difference

statistically
review

significant

at both

At

the later
correction
while
in the

to 25.7#{176}
10#{176}
(20
two
groups
was

(p = 0.004)

early

2 1.2#{176}

and

late

(p = 0.0005).
The Wilson
of 10 mm

ening

had increased
between
the

been

with

8.3#{176}(1 5

review,

had

to 14.5#{176}
6.9#{176}
(9 to 21) compared

6 mm

osteotomy
produced
(6 to 20) compared

(0 to 1 1) after

the

chevron

an average
shortwith an average
of
procedure

(p = 0.02).

No patient
complained
ofhaving
a short hallux.
Elevation
of the metatarsal
head was only appreciable
on the early
review
radiographs,
and was seen in six feet (14% of
those
in the
Wilson
group).
By the
later
review,
remodelling
had obscured
the original
position
of the
distal
fragment.
Depression
of the metatarsal
head was

Preoperative

(a) and 35-month

seen

in a patient

who

in five patients

after

Wilson

after

osteotomy

and

assessment.

of motion

of the first

6#{176}
SD

(51 to 72) and

to

62).

At

evidence

Before
MTPJ

operation
in the

in the chevron
review,
the mean

early
different,

the passive

Wilson

group

patient

to 42) after
the
after
a unilateral

range
of less than
chevron
procedure.
weight-bearing
Metatarsalgia
ening,
only

chevron
Wilson

30#{176}
compared
with
In both
groups

in 86%
five

patients

Only
one
had a final

11 (17 feet) in the

the great
toe was

of feet.

and callosities.
in the

Despite
Wilson

ten in the chevron

group
complained
salgia.
New
central
callosities
had

the greater
group
of central
developed

short-

as against
metatarin seven

patients
(nine
feet) in the Wilson
group
and in five feet
(three
patients)
in the chevron
group.
One
foot in a
patient
with bilateral
hallux
valgus
lost central
callosities
after
a Wilson
osteotomy
compared
with four patients
VOL.

75-B, No. 5, SEPTEMBER

1993

had

of increased

review

a double

central

(b) Harris

oblique

3b

and Beath

Wilson

footprints

osteotomy.

There

is

ray loading.

63#{176}

had regained
with 36#{176}

procedure.
osteotomy

Fig.

Functional
chevron

results.
osteotomy

Rehabilitation
because

of

was more
the absence

rapid
after
of plaster

3 1 #{176}
9#{176}immobilisation.
These
patients
returned
to work at 7
1 .2 weeks
SD (5 to 9) after
surgery,
compared
with 10

at 29#{176}
7#{176}
(2 1 to 45) and

45). At later review,

the Wilson
group
an average
of42#{176} 1 1#{176}
(3! to 55) compared

3a

arc

was

group
57#{176}
9#{176}
(50
ranges
were
not

(25 to

8#{176}
(26

in three

osteotomy.

Functional

significantly

chevron

Fig.

weeks
At

to 14) for the Wilson

early
review,
22 of

(7

unlimited
Wilson

walking
group
had

Wilson

group

limited
chevron

walking
group.

had

distances
no limitation.
improved

groups

one

Thirty-one
patients
of the indications

patients
Of

were

chevron

: only

four

procedure

had
the
the

complained

of

with
five of
of the patients

the
in

able to run.
gave
improved
shoe-fitting
for surgery.
Preoperatively,

in the Wilson group had needed

three still needed
them

shoes ; only
the 1 5 patients

group

while
only
seven
of
By the later review,

distance
compared
About
three-quarters

both

fitting

group.
the chevron

requiring
eight

broad

still required

special
broadat late review.

shoes
them

as
12

before

the

at late review.

828

J. K. KLOSOK,

Complications.
patient

Table

had

I gives

radiological

or

total avascular
necrosis
Wilson
osteotomy
failed
dures

in eight

five

Wilson

patients

were

probably

signs

failures,

in three

Two ofthe

were

complications.

clinical

of

after chevron
to unite. Nine

osteotomies

Chevronprocedure.

group

the

due

D. J. PRING,

J. H. JESSOP,

No
partial

or

osteotomy.
No
chevron
proce-

as compared

with

patients.

nine failures

to poor

selection.

good
correction,
The second
was

had

minimal

hallux

metatarsal.
The MTPJ

the
also

drifted

One

back

in a 34-year-old

valgus

Surgery
became

hallux

with

shortened
stiff with

woman

a relatively

the
only

short

procedure.

group

(in

year-old

One

patients)

woman

hallux

valgus

with

bilateral

bilateral

to poor
arthritis

subluxed

minor

MTPJ

failure

bilateral

toes and painful

the

in this

group

failure
stiffness

after

an

the
by

hallux

was

early

second
Helal

metatarsal
hallux
led

shortening
to secondary

metatarsal

head.

with loss of plantar

flexion
metatarsalgia
under
the

varus
healing

fracture

frequent

after

angle

greater

than

by Cetti

and

Christensen

20#{176}
in a series

of 34 osteotomies.

the Wilson

Stiffness

et a! (1979)

of 18#{176}
at ten

of the first MTPJ

of a poor
result
in our series.
bearing
on the hallux
and led

found

that

MTPJ.
joint

26 had

lateral metatarsal
heads
Hughes
and Klenerman

less

It is clear
causes

stiffness

a! 1974).
Shortening
our average

than

that

and

is inevitable

incidence
osteotomy.
years,
and

30#{176}
of motion

soft-tissue

at

dissection

in proportion

of 10 mm

a high

for the chevron

76 feet for three

the

first

around

the

to its extent

with

is similar

the

to that

(Helal

et

Wilson

osteotomy;

reported

previously

related

caused

that

metatarsalgia

depression

prolong

was

of the

toe-contact

of the
second

helps
to maintain
support
Mitchells
compensate
modification,

(1983).

only one
a valgus
The

cause

This
prevented
weightto transfer
of load to the

(Henry and Waugh

1975 ; Grace,
1988). Such stiffness
was less

less
with

first

directly

metatarsal

head

obliquity

radiographically

have

caused

chevron

to

this,

more

stiffness.

joint

has

demanding

stability,

and

than
no need

osteotomy

and our results

also
helps
to
Despite
metatarsal

in 20% ofthe

prevented

osteotomy

technically

tended

in the Wilson

plantar
displacement
concept
that
this

have

The

to

of the first metatarsal

et a! (1988) have shown

for metatarsal
shortening.
however,
elevation
of the

may

more

more

time.

Our use of double

First

months.

was the commonest

osteotomy,

insufficient
plantar
displacement
head (Mitchell
et a! 1958). Grace

smaller
correction
achieved
by the chevron
method
has
been reported
by Lewis and Feffer (1981) and Grill et al
(1986) with average
corrections
of 19#{176}
at three years and
by Johnson

or hypoaesthesia

has previously
been reported
Horne
et a! (1984)
followed

may

Wilson
(1963) reported
and two patients
with

metatarsal

operative

Few
comparative
or prospective
studies
have
been
reported
for the many surgical
techniques
used for this
common
condition.
Our average
correction
of ha!lux
valgus
angle is
reported

of third

valgus

DISCUSSION

to that

osteotomy

Dysaesthesia

fixation

In his original
paper,
complete
recurrence,

of bunion

spike

was apparent

similar

of wound

with
the
that
post-

metatarsal
osteotomies.

case.

(Dooley
1968).
It did not correlate,
however,
development
of metatarsa!gia.
We found

low-grade

was on one side in a bilateral

swelling

Stress

A 50-

had

stiff and
recurred.

infection.
Metatarsalgia
under
heads
was treated
satisfactorily

The third

selection.

Early

who

Hela!
metatarsal
osteotomies
of the
combined
with
Wilson
osteotomies.
slow to heal and there
was forefoot

All MTPJs
became
and metatarsalgia

Another
by

due

rheumatoid

of 50#{176}
with

plantar
callosities.
central
rays were
The wounds
were
oedema.
deformity

was

Chevron
(a =45)

Comminuted

in the Wilson

for hallux

Wilson
(n=42)

Dorsal

first

of 87 osteotomies

Complication

Recurrence

metatarsal
further.
20#{176}
movement,
the

of the five failures

in 51 patients

into

hallux
no longer
bore
weight,
and
painful
central
callosities
developed.
The
other
seven
failures
were
multifactorial,
due to five stiff MTPJs
in four patients,
metatarsalgia
in four and recurrence
of deformity
in six.
Wilson

I. Complications

valgus

Slow

was a 34-year-old
woman
with rheumatoid
arthritis
and
valgus
deviation
of the lesser toes, in addition
to hallux
valgus.
The other
toes were not corrected,
and after an
initially
valgus.

Table

Hallux

in the chevron

clinical

N. MAFFULLI

feet.

but increased

been

our
head
Internal

dissection

considered

a Mitchell
for cast

to be

osteotomy,

immobilisation

(Austin
and Leventen
1981). Other
authors
consider
that
it is less stable,
and requires
additional
fixation
by a bone
peg (Johnson

et a! 1979),

or by a modification

of its shape

(Lewis
and Feffer
1981). In our series,
the main cause of
poor
correction
was probably
stretching
of the medial
capsuloplasty.
Use
of a cast
mould
reduces
loss of
correction,
but may well have increased
stiffness.
Excessive
capsular
dissection
may lead to avascular
necrosis
of part or all ofthe
metatarsal
head (Mann
1982;

Horne

et

remaining

a!

1984)

blood

since,

supply

after
is from

1973).
We took care to preserve
saw no signs of avascular
necrosis.

Both

procedures
THE

showed
JOURNAL

osteotomy,
the
the

lateral

a significant
OF BONE

the

capsule

AND

only

(Jaworek
capsule

and

incidence
JOINT

SURGERY

of

CHEVRON

complications.
patients
relief,

Most

were

valgus

trivial,

dissatisfied

shoe-fitting,

impression
operation,

were

with

Patients

before operation,
for the correction

METATARSAL

about

result

or appearance.

is normal.

WILSON

but

the

that the hallux

not appreciating

successful

OR

20%

of our

in terms

Many

had

the

be

and be made aware

of hallux
valgus

better

that
can

No benefits

in any form
party

and

Harris

have

related

been

directly

received

to the

subject

Surg

1986;

B. Surgery

adolescent

Helal

an investigation
Research
Council
1947.

for adolescent

B, Gupta

SK, Gojaseni

Acta Orthop

hallux

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Scam!

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Cetti

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H.

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VOL.

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No. 5, SEPTEMBER

1993

valgus.

supply

Ha//ux

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Systat

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Lewis RJ, Feffer HL. Modified

Mann

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Chevron

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chevron

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Home

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of pain

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after
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to 25#{176}
of hal!ux
should

We thank
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FRCS
allowing
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OSTEOTOMY

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