CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 376, pp. 183-194 0 2000 Lippincott Williams & Wilkins, Inc. Correction of Hallux Valgus Metatarsal Osteotomy Versus Excision Arthroplasty Alexander Zembsch, MD; Hans-Jorg Trnku, MD; and Peter Ritschl, MD The long-term retrospective results (followup that these techniques should be applied to dif- range, 10-22 years) of an uncontrolled series of ferent patient populations. However, they for- basal metatarsal closing wedge osteotomies merly were used for the same indication. This and Keller’s excision arthroplasties performed long-term analysis shows that the Keller in patients 14 to 40 years of age are analyzed. arthroplasty should be abandoned for the In the osteotomy group, 34 patients (50 feet) treatment of hallux valgus in young and active were available for clinical review and 26 pa- patients. The basal metatarsal closing wedge tients (37 feet) were available for radiologic re- osteotomy is conceptually the correct treat- view. In the Keller group, 24 patients (37 feet) ment for hallux valgus deformity for the were reviewed clinically and 23 patients (34 younger patient; nevertheless, it is technically feet) were reviewed radiologically. Patients demanding and is associated with a higher risk were assessed using the Hallux Metatarsopha- of failure. The long-term results of both proce- langeal Interphalangeal Scale of the American dures are unacceptable for the patient and the Foot and Ankle Society, an additional clinical surgeon. The short and middle-term results of score, weightbearing radiographs, the pa- the newer basal type osteotomies, such as the tient’s record, and clinical investigation. Sta- proximal crescentic osteotomy, the proximal tistical analysis revealed significantly better re- chevron osteotomy, or the proximal oblique os- sults of the clinical and radiologic outcomes teotomy combined with distal soft tissue re- after osteotomy. In the osteotomy group, the leases, suggest a more satisfying long-term out- first metatarsal was elevated dorsally in 14 feet come. (38%).The incidence of varus deformities was higher with basal osteotomy (18% versus 5.4%). Metatarsalgia occurred similarly in Excisional arthroplasty as a treatment for hal- both groups (28% versus 27%). It is known lux valgus, popularized by Keller in 1904,’’ has been a mainstay in bunion surgery for a long time. Advocates of the procedure empha- size its technical simplicity and the excellent From the Orthopaedic Hospital Gersthof, First Depart- results obtained in deformity improvement, ment, Vienna, Austria. pain relief, and functional range of motion Reprint requests to Alexander Zembsch, MD, Or- thopadisches KH Gersthof, I. Abteilung, Wielemans- (ROM) of the metatarsophalangeal j~int.~~,~’ gasse 28, A-1 180 Vienna, Austria. Opponents of the procedure list disadvantages Received: April 22, 1999. such as metatarsalgia, recurrence of defor- Revised: September 27,1999; November 29,1999. mity, limitation of flexion, development of Accepted: December 8, 1999. hammertoe deformity of the second toe, and 183 Clinical Orthopaedics 184 Zembsch et al and Related Research degenerative arthritis in the interphalangeal MATERIALS AND METHODS joint.22 Zadik32 cautioned that the Keller pro- cedure should not be used in the patient with Forty-nine patients (70 feet) underwent a basal severe deformity, whereas Henry et a19 re- metatarsal closing wedge osteotomy with a modi- fied McBride distal soft tissue release for correc- ported that a more severe hallux valgus defor- tion of hallux valgus from 1974 to 1985. For the mity requires excessive resection of the prox- same indication in 5 I patients (77 feet), a Keller ex- imal phalanx. Excellent or good results have cision arthroplasty with a cerclage fibreux2*was been reported in patients older than 50 years of performed between 1980 and 1986. All patients age,6%’6,30,31but a deformity recurrence has who had undergone these procedures were 40 years been observed more frequently in younger pa- of age or younger at the time of surgery. tients after a Keller procedure than after a dis- The indication for surgery was painful hallux val- tal metatarsal o~teotomy.~~Several authors gus that did not respond to conservative treatment suggested that significant metatarsus primus within a minimum of 6 months. Patients were ex- varus is a contraindication for resection amined and treated by a general practitioner and arthroplasty because the deformity may per- were referred to the authors’ clinic for surgery. Both techniques were performed individually by different sist because of an unaltered first inter- orthopaedic surgeons after the indication had been metatarsal confirmed by clinical and radiologic examination. Adequate joint preserving procedures that Exclusion criteria for this study were degenera- reduce the intermetatarsal angle, such as tive arthritis of the first metatarsophalangeal joint, basal or distal metatarsal osteotomies con- prior involvement of the hallux by surgery, rheu- juncted with soft tissue procedures, have matoid arthritis, trauma, neurologic diseases affect- been performed effectively. 12,17,21,26,29 Meta- ing the lower extremities, and additional simultane- tarsalgia probably is the complication re- ous surgery (except the Hohmann procedure for ported most frequently in association with hammertoe deformity). Fifteen patients (20 feet) in the Keller pr~cedure.~,~,’~Undesirable side the osteotomy group and 27 patients (40 feet) in the effects after basal metatarsal osteotomies in- Keller group were not available for followup. This left 50 feet (34 patients: 32 women and two clude shortening of the first ray and dorsal men, 16 bilateral) for clinical followup and 37 feet malangulation of the first metatarsal, which for radiologic evaluation in the osteotomy group in may lead to metatarsalgia. 17,23,29 Younger this study. Thirty-seven feet (24 patients: 19 patients require pain relief and surgical meth- women and five men, 13 bilateral) were available ods that are capable of obtaining satisfying for clinical followup, and 34 feet were available for functional and cosmetic long-term results. radiologic analysis in the Keller group. The mini- Long-term followup studies with a mini- mum followup was 12 years in the osteotomy mum of 10 years that directly compare the re- group and 10 years in the Keller group. sults of different operative procedures are rare The age at the time of surgery ranged between in the literature?,31 However, little attention 14 and 40 years. The average weight was 73 kg has been paid to the younger patient with hal- (range, 52-98 kg) for the patients in the osteotomy group. In the Keller group, the average weight for lux valgus. The objective of this study was to the patients was 75 kg (range, 54-101 kg). All pa- evaluate the long-term retrospective results tients in both groups were active in their jobs or with a minimum followup of 10 years after (1) managing their households. No patient had dis- basal metatarsal closing wedge osteotomy eases causing immobility or functional impair- combined with a modified McBride procedure ment. The preoperative characteristics of both and (2) a Keller’s excision arthroplasty with a groups are listed in Table 1. cerclage fibreux2* performed for the same in- dication. This long-term followup evaluation Operative Technique allows for an analysis of the effectiveness of All of the operations were performed using periph- these two methods in young and active pa- eral nerve blockade and supramalleolar Esmarch tients with hallux valgus. tourniquet after exsanguination. Number 376 July, 2000 Correction of Hallux Valaus 185 TABLE 1. Preoperative Characteristics Keller Group of Study Groups A dorsomedial incision was made and a medial exostosectomy was performed after generating a Osteotomy Group Keller Group distal capsular flap. The base of the proximal pha- Characteristics n = 50 feet n = 37 feet lanx was exposed subperiostally and '13 to '12 of the phalanx was excised. The capsular flap was inter- Followup (years) 18 rt 2.8 13 t 1.6 positioned into the neoarticulation gap. A cer- Mean ? standard clage fibreuxZ8was added before skin closure. The deviation sesamoids were released from adhesions to the Age at surgery 26 ? 6.8 34 rt 5.2 first metatarsal head, and a lateral longitudinal in- (years) Mean t standard cision of the joint capsule was made. With the deviation forefoot under compression, the medial surplus Patients 34 24 capsule strip was excised and a medial capsulor- Male 2 5 rhaphy was performed with strong sutures. Female 32 19 Average weight 73 kg (range, 75 kg (range, Postoperative Care 52-98) 54-101) Hallux valgus with 100% 100% Osteotomy Group painful bunions After surgery, the foot was placed in a plaster boot, Duration of mean, 2.8 mean, 2.5 and the patient was not allowed to bear weight un- symptoms til complete wound healing was achieved. After re- (years) moval of the sutures, between the tenth and twelfth postoperative days, patients were allowed to be fully weightbearing with a short leg plaster cast. At 6 weeks, the cast was removed and radiographs Osteotomy Group were taken to confirm union. After approximately The first web space was incised dorsally, and the 3 months, the screw was removed. adductor tendon was released from its insertion into the lateral aspect of the capsule, the sesamoid, Keller Group and the proximal phalanx. Two sutures were passed After surgery, a plaster cast with a device to extend through the tendon and the lateral capsule of the the hallux