SLR - April 2014 - Laura E. Sansosti
Reference: Park YB; Lee KB; Kim SK et al. Comparison of Distal Soft-Tissue Procedures Combined with a Distal Chevron Osteotomy for Moderate to Severe Hallux Valgus: First Web-Space Versus Transarticular Approach. J Bone Joint Surg Am. 2013 Nov 6:95-A (21): e158 (1-8)
Scientific Literature Review
Reviewed By: Laura E. Sansosti, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Hallux Abducto Valgus (HAV) is a common deformity faced in podiatric practice. Distal soft tissue procedures are often used in conjunction with metatarsal osteotomies to aid in reduction of the intermetatarsal angle, sesamoid reduction, and decreasing lateral deforming forces. Both the dorsal first web-space and medial transarticular approach have been employed to achieve distal soft tissue release, each having advantages and disadvantages. This prospective, therapeutic Level II study compares the clinical and radiographic results of both approaches for distal soft tissue release in conjunction with a distal Chevron osteotomy in the correction of moderate to severe HAV. The authors hypothesized that patients with a dorsal web-space approach would have higher AOFAS scores postoperatively.
Methods: One-hundred twenty-two adult females with symptomatic, unilateral moderate to severe HAV defined as a preoperative hallux valgus angle of >20 degrees, intermetatarsal angle >14 degrees and an incongruent first metatarsophalangeal joint were included in the study. Patients were excluded if they had previously failed hallux valgus surgery, posttraumatic hallux valgus, degenerative joint changes, hallux rigidus, or instability at the first metatarsocuneiform joint. Patients were divided equally into Group D (dorsal web-space approach) and Group M (medial transarticular approach). Both groups had similar demographics and length of follow up. Clinical and radiographic evaluations were performed preoperatively and postoperatively at three, six, twelve months, and annually thereafter. All procedures were performed by a single surgeon. All pre- and postoperative evaluations were performed by two other orthopaedic surgeons. Surgical technique for the dorsal web-space approach involved a 3cm incision and transection of the adductor tendon, fibular sesamoidal ligament, and transverse metatarsal ligament with perforation of the lateral capsule. The medial transarticular approach was achieved through the incision for the osteotomy and consisted of release of the lateral capsule and adductor tendon. Distal Chevron osteotomies with a 60-degree cut were then performed and fixated with K-wires in all patients. Clinical assessment was achieved using pre- and postoperative AOFAS scores and a patient satisfaction survey. Postoperative complications were also reviewed.
Results: Pre- and postoperative AOFAS scores for both groups were approximately 55 and 93, respectively. AOFAS scores and patient satisfaction between groups at final follow up did not show a statistically significant difference (p=.635). Both groups showed marked improvement (p<.05) in tibial sesamoid position, hallux valgus and intermetatarsal angles at time of final follow up, with no significant difference between groups (p=.64, p=.79, p=.453, respectively). Complications were equally distributed between the two groups – Group D 10 percent vs. Group M 8.1 percent (p=.71). Complications included stiffness, numbness, infection, and pain.
Conclusions: Soft tissue imbalance contributes to the pathophysiology of the hallux abducto valgus deformity. Failure to adequately address the soft tissue component may result in lack of appropriate correction. Both approaches for soft tissue release presented in this article have advantages and disadvantages. Based on the results of the study, the authors concluded that the medial transarticular approach is comparable to that of the dorsal first web-space in terms of clinical outcome. As the first dorsal metatarsal artery has been found to be the primary source of blood flow to the first metatarsal head, the medial transarticular approach may be advantageous as it limits the risk of osteonecrosis. Great caution should be exercised, however, when attempting this approach due to limited visualization of the lateral structures. Limitations of the study include smaller cohort size and relatively short follow up period.