We reviewed the records of 53 patients who underwent HV surgery by a single surgeon during the years 2017 to 2019. The patients were operated using one of three surgical techniques. During 2017, an open chevron osteotomy was performed on 170 patients with mild to moderate HV, based on Nyska classification.[15] The last 19 patients who were operated by this method during 2017 constituted "group C" (“C” for chevron). During 2018, a minimally invasive V-shaped osteotomy (MICA) was performed on 18 HV patients, who constituted "group V". In "group M" (for modified), we included 16 HV patients who were operated at the end of 2018 and during 2019 by a modified, "straight" minimally invasive osteotomy (Figures 1,2).
We included patients, both males and females, aged 15-99 years, who had a mature bone structure (closed physis on preoperative X-ray radiographs). They all had available preoperative weightbearing orthogonal foot radiographies. Study exclusion criteria were immature bones, a history of multiple foot surgeries, Charcot foot or other structural foot abnormalities in addition to HV, metatarsus adductus associated with HV, and a recent trauma to the foot. We defined HV as an inter-metatarsal angle (IMA) greater than 8 degrees. The indication for surgery was pain that was associated with a diagnosed HV and that was not alleviated by non-surgical measures.
Pre- and postoperative standing X-ray radiographs were evaluated for every patient. We used radiographs that were obtained at a mean of 12±3 weeks postoperatively. Pre- and postoperative HVA and IMA were measured by a single surgeon (EP) using PACS software (Carestream Vue PACS, Fujifilm Corporation, JAPAN).[15] We used the Hardy and Clapham method[16] to assess the position of the medial sesamoid bone on an anteroposterior radiograph of the foot. Briefly, the position of the medial sesamoid relative to the centerline of the first metatarsal on the dorsoplantar plane was determined. Position I was considered normal. Position IV was defined when the first metatarsal midline crossed the medial sesamoid midline, and a displacement (positions V-VII) was graded according to the medial distance of the sesamoid location (Figure 3).
The original percutaneous chevron osteotomy was described previously.[9] In the modification presented herein, the osteotomy was performed in a straight line, perpendicular to the metatarsal axis on the sagittal view, as shown in Figure 1. Before fragment fixation, we supinated the big toe, pulling the MT1 head along with it, until the sesamoids were shown by fluoroscopy to return to the normal position under the metatarsal head (Figure 4). Then, the K-wires were inserted into the metatarsal head and were followed by cannulated screw fixation (Figure 5). The postoperative regimen included immediate weight bearing with Flat DARCO shoe (MedSurg™, Huntingon WV). During the first follow-up visit, at two weeks, dressings were changed and weightbearing X-rays were taken. At 6 weeks, K-wires were removed when necessary; and at twelve weeks, weightbearing X-rays were taken again.
Statistical analysis
SPSS 25 software (Chicago, IL) was used for the statistical analysis. Descriptive statistics were applied to the data. The Fisher’s exact test and the Student’s t-test were used to compare categorical and continuous variables, respectively. An ANOVA, followed by a post-hoc pairwise analysis when needed, was used to compare the pre- and postoperative IMA, HVA and sesamoid bone position between patients who underwent the three procedures. A paired samples t-test was applied to compare the IMA, HVA and sesamoid bone positions, before and after surgery, between patients who underwent the three procedures. An alpha of 0.05 was considered significant.