FOOT AND ANKLE

A comparison of proximal and distal chevron

osteotomy for the correction of moderate
hallux valgus deformity
C-H. Park,
J-H. Jang,
S-H. Lee,
W-C. Lee
From Seoul Paik
Hospital, Seoul,
South Korea

C-H. Park, MD, PhD,

Professor
Yeungnam University Hospital,
Department of Orthopedic
Surgery, 317-1, Daemyeongdong, Nam-gu, Daegu 705-717,
Korea.
J-H. Jang, MD, Orthopaedic
Surgeon
Yeson Hospital, Department of
Orthopaedic Surgery, 59, Naedong, Ojeong-gu, Bucheon-si,
Gyeonggi-do 421-805, Korea.
S-H. Lee, MD, PhD, Professor
Ilsan Hospital, Department of
Orthopaedic Surgery, Dongguk
University, 841, Siksa-dong,
Ilsandong-gu, Goyang-si,
Gyeonggi-do 410-773, Korea.
W-C. Lee, MD, PhD, Professor
Seoul Paik Hospital,
Department of Orthopaedic
Surgery, Inje University
College of Medicine, 85 Jeodong 2-ga, Seoul 100-032,
Korea.
Correspondence should be sent
to Professor W-C. Lee; e-mail:
wclee@seoulpaik.ac.kr
2013 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.95B5.
30181 $2.00
Bone Joint J
2013;95-B:64956.
Received 29 May 2012;
Accepted after revision 8
January 2013

VOL. 95-B, No. 5, MAY 2013

The purpose of this study was to compare the results of proximal and distal chevron
osteotomy in patients with moderate hallux valgus.
We retrospectively reviewed 34 proximal chevron osteotomies without lateral release
(PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a
single surgeon. There were no differences between the groups with regard to age, length of
follow-up, demographic or radiological parameters. The clinical results were assessed using
the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the
radiological results were compared between the groups.
At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the
mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100),
respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid
position were the same in both groups. The metatarsal declination angle decreased
significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal
was significantly greater in the DCO group (p < 0.001).
We conclude that the clinical and radiological outcome after a DCO is comparable with
that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis.
Cite this article: Bone Joint J 2013;95-B:64956.

More than 100 different operations to correct

hallux valgus have been described. These can be
broadly categorised into two groups: distal and
proximal metatarsal osteotomy.1 Distal chevron
osteotomy (DCO) is a widely accepted method
for the correction of mild to moderate hallux
valgus because of its simplicity and shorter
rehabilitation period.2-4 It has some disadvantages. Only a relatively small amount of correction of the deformity is possible and there is
some post-operative shortening of the first metatarsal with a risk of avascular necrosis of the
metatarsal head.5-7 However, good results have
been reported in patients with moderate to
severe hallux valgus using a DCO with an
extensive associated lateral soft-tissue release,8
or by modification of the chevron.7,9,10
Proximal metatarsal osteotomy, which is
usually also performed with a lateral softtissue release, has been widely used for the
treatment of moderate to severe hallux valgus.11-13 Because the correction is performed
near the first metatarsocuneiform joint,
where the first metatarsal is deviated from its
normal position, greater correction can be
achieved with minimal shortening.14 However, osteotomy at this site is relatively unstable and takes longer to heal than a distal

metatarsal osteotomy. Proximal metatarsal osteotomy is also more likely to unite in dorsiflexion,
which can cause transfer metatarsalgia.15,16
A Scarf osteotomy has the characteristics of
both distal and proximal osteotomies because of
its method of correction. The classic Scarf osteotomy may be considered to be a type of distal osteotomy because it uses translation to correct the
deformity,17 whereas a Scarf osteotomy incorporating some angulation may be considered to be a
type of proximal osteotomy.18,19
Therefore, distal osteotomy may be used
for the correction of mild deformity and proximal osteotomy for the correction of more
severe deformity. Either method may be used
for the patient with a moderate deformity.
Osteotomy involving the diaphyseal area,
such as the Scarf or Ludloff osteotomy, has
been compared with either distal or proximal
osteotomy.20-22 However, to the best of our
knowledge there have been no previous studies comparing the results of distal and proximal metatarsal osteotomy in patients with
moderate hallux valgus, and this was our aim.
Our hypothesis was that proximal chevron
osteotomy (PCO) could achieve better clinical
and radiological results than DCO. The study
had ethical approval.
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C-H. PARK, J-H. JANG, S-H. LEE, W-C. LEE

Table I. Study inclusion and exclusion criteria (HVA, hallux valgus angle; IMA, intermetatarsal angle)
Inclusion criteria

Exclusion criteria

Symptomatic moderate hallux valgus (HVA of 20 to 40, IMA of 12 to 15)

First metatarsal osteotomies by a single surgeon
Primary hallux valgus surgery
Presence of both sesamoids
Intact sensation
Mobile first metatarsophalangeal joint
No inflammatory arthropathy and diabetic Charcot arthropathy
No deformity outside the first ray
No infection

Mild and severe hallux valgus (HVA < 20 and > 40, IMA < 12 and >15)
Failed previous hallux valgus surgery
Absence of the medial sesamoid
Absent sensation
Hallux rigidus
Inflammatory arthropathy and diabetic Charcot arthropathy
Deformity outside the first ray requiring surgical correction
Infection

Patients and Methods

We retrospectively reviewed 90 consecutive first metatarsal
osteotomies in 76 patients with symptomatic moderate hallux valgus, with a hallux valgus angle of between 20 and
40 and an intermetatarsal angle of between 12 and 15,
performed by a single surgeon (WCL) between September
2007 and January 2010. The first 36 patients (45 feet) were
treated by DCO and the subsequent 40 patients (45 feet) by
PCO. The inclusion and exclusion criteria are shown in
Table I. In all, 13 patients (13 feet) were lost to follow-up
and three patients (five feet) were excluded because of the
absence of a medial sesamoid bone. Two patients (two feet)
with rheumatoid arthritis and three (three feet) with failed
previous surgery for hallux valgus were excluded from the
study. This left 55 patients (67 feet), of whom 25 (33 feet)
were in the DCO group and 30 (34 feet) in the PCO group.
All were women, with a mean age of 41 years (18 to 62) in
the DCO group and 45.4 years (19 to 62) in the PCO
group. The mean follow-up was 14.5 months (14 to 32) in
the DCO group, and 14.7 months (15 to 26) in the PCO
group. There was no difference in age or duration of follow-up between the two groups (p = 0.196 and p = 0.135,
respectively). A lateral soft-tissue release was performed in
the PCO group, but not in the DCO group. A medial closing wedge osteotomy of the proximal phalanx was carried
out in 36 patients (41 feet) who had a residual hallux valgus
deformity after satisfactory correction of the intermetatarsal angle by metatarsal osteotomy.
The clinical outcome was assessed using the Hallux Metatarsophalangeal Interphalangeal Scale, as developed by
the American Orthopaedic Foot and Ankle Society
(AOFAS),23 and a visual analogue scale for pain (VAS). The
VAS ranged from 0 to 10 points (0 denoting no pain and 10
denoting worst pain imaginable). These scores were evaluated pre-operatively and at final follow-up.
The hallux valgus angle, intermetatarsal angle and position of the sesamoids were compared between the two
groups. The hallux valgus angle was taken to be the angle
between a line from the centre of the proximal articular surface of the first metatarsal to the centre of the first metatarsal head and a line joining the midpoints of the proximal
and distal articular surfaces of the proximal phalanx.24 The

intermetatarsal angle was taken to be the angle between the

line of the first metatarsal and the line bisecting the portion
of the diaphysis of the second metatarsal bone. The position of the medial sesamoid, in relation to the longitudinal
axis of the first metatarsal on the dorsoplantar weightbearing radiograph, was graded from I to VII, as described
by Hardy and Clapham.25
These radiological parameters were measured pre-operatively, immediately post-operatively, and at six weeks, three
months and six months after surgery and at final follow-up.
The metatarsal (MT) declination angle, which is the angle
between the longitudinal axis of the first metatarsal and the
floor on standing lateral views, was used to assess malunion
in dorsiflexion. Because the longitudinal axis of the first
metatarsal did not change after distal chevron osteotomy,
this angle was assessed only in the PCO group. Malunion in
dorsiflexion was defined as a decrease in the MT declination angle by 5. The relative length of the first to the second metatarsal was measured on anteroposterior
radiographs using the methods of Morton26 and Hardy and
Clapham25 pre-operatively and at final follow-up. This was
to assess the shortening of the first metatarsal and changes
in the length of the first metatarsal were compared between
the two groups.
The pre-operative metatarsus adductus angle and the
immediate post-operative distal metatarsal articular angle
(DMAA) were compared between the groups to assess factors affecting the development of recurrent hallux valgus
post-operatively. For the DMAA measurement, two points
were placed at the most medial and most lateral extents of
the articular surface of the metatarsal, and a line was drawn
between these points. Another line was drawn perpendicular to this line. The DMAA was defined as the angle
between the perpendicular line and the longitudinal axis of
the first metatarsal (Fig. 1). The metatarsus adductus angle
measured the angle between the longitudinal axes of the
second metatarsal and the midfoot.27 A line was drawn
between the midpoint of a line joining the most distal
medial point of the first cuneiform and the proximal point
of the navicular and the midpoint of a line drawn between
the proximal and distal lateral points of the cuboid. A further line was drawn perpendicular to this line, and the angle
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651

Fig. 1

Fig. 2

Non-weight-bearing radiograph of a 53-year-old woman after proximal chevron osteotomy. Two points were placed at the most medial
and most lateral extents of the metatarsal articular surface, and a line
(AB) was drawn connecting these two points. Another line (CD) was
drawn perpendicular to this line. The distal metatarsal articular angle
was defined as the angle between the perpendicular line (CD) and the
longitudinal axis of the first metatarsal (EF).

Non-weight-bearing radiograph of a 60-year-old woman after distal

chevron osteotomy. A line (AB) was drawn connecting the midpoint
between the most distal medial point of the first cuneiform and the
proximal point of the navicular and the midpoint between the proximal and distal lateral points of the cuboid. Another line (CD) was
drawn perpendicularly to this line and an angle between the perpendicular line and the longitudinal axis (EF) of the second metatarsal
was defined as metatarsus adductus angle.

between this perpendicular line and the longitudinal axis of

the second metatarsal was defined as the metatarsus adductus angle (Fig. 2).
The pre-operative DMAA was not measured because the
margin of the articular surface often could not be identified
on several radiographs. By contrast, in most cases the distal
articular margins could clearly be identified on postoperative radiographs. The DMAA was therefore measured
on the immediate post-operative radiographs and compared between the two groups.
Recurrent hallux valgus was defined as a hallux valgus
angle of 20, and the rate of recurrence at final follow-up
was compared between the two groups. The relative risk of
recurrence was evaluated and compared between the groups.
An additional study was carried out to determine the
effect of proximal phalangeal osteotomy. The feet were
divided into two groups based on whether or not proximal
phalangeal osteotomy had been performed, and the change
in the hallux valgus angle after surgery was compared
between the two groups. We also evaluated the association
between proximal phalangeal osteotomy and recurrence.
Surgical technique. The procedure was performed under
spinal anaesthesia with the patient supine. The leg was
exsanguinated with an elastic bandage and a tourniquet
applied to the thigh.
For the DCO, lateral soft tissue release was not performed because of the risk of avascular necrosis of the metatarsal head. Before carrying out the osteotomy, a 1.6 mm
Kirschner (K-) wire was placed at the apex of the chevron
to avoid extension of the osteotomy into the distal

fragment. The apex of the chevron was distal and was

located 7 mm proximal to the articular margin. Each arm of
the chevron was made at 30 to the axis of the metatarsal.
The distal fragment was translated laterally as much as possible, which was often by > 50% of the width of the metatarsal head. In the last ten cases the distal fragment was
displaced in a plantar direction by about 1 mm or 2 mm to
avoid transfer metatarsalgia. A 1.6 mm K-wire was then
inserted from proximal to distal towards the metatarsal head
to stabilise the osteotomy and was left protruding.
For the PCO, a lateral soft-tissue release and proximal
metatarsal osteotomy were performed through the same
medial incision. A dorsal flap including skin and subcutaneous tissue was then elevated, and dissection was taken laterally just superficial to the extensor hallucis longus and brevis.
The tendinous parts of the oblique adductor and transversus
were released and the deep transverse metatarsal ligament
was incised. A longitudinal incision was then made in the
capsule along the dorsal margin of the lateral sesamoid.
Before osteotomy, a 1.6 mm K-wire was placed at the apex
of the chevron to avoid extension of the osteotomy. The apex
of the chevron was located 7 mm distal to the first metatarsocuneiform joint. Each arm was made at 30 to the axis
of the metatarsal. After correction of the intermetatarsal
angle by translation and angulation at the osteotomy site,
two or three 1.6 mm diameter K-wires were used to stabilise
the osteotomy and were buried under the skin.
Correction was assessed fluoroscopically. If there was
residual deformity despite satisfactory correction of the
intermetatarsal angle a closing wedge osteotomy

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C-H. PARK, J-H. JANG, S-H. LEE, W-C. LEE

Table II. Clinical results of the distal (DCO) and proximal chevron osteotomy (PCO) groups (AOFAS, American Orthopaedic
Foot and Ankle Society; VAS, visual analogue scale)
Mean AOFAS score (range)

Mean VAS (range)

Group

Pre-operative

Last follow-up

p-value

Pre-operative

Last follow-up

p-value

DCO
PCO
p-value

49.5 (39 to 65)

47.1 (39 to 57)
0.133

93.9 (82 to 100)

91.8 (77 to 100)
0.176

< 0.001
< 0.001

5.7 (2 to 8)
6.3 (3 to 8)
0.105

1.4 (0 to 4)
1.9 (0 to 4)
0.123

< 0.001
< 0.001

Table III. Pre-operative radiological results and immediate post-operative distal metatarsal articular angles (DMMA) in both groups (D-/PCO, distal/
proximal chevron osteotomy)
Mean pre-operative radiological results (range)
Hallux valgus angle ()

Intermetatarsal angle ()

Sesamoid position

Metatarsus adductus angle ()

Post-operative DMAA ()

27.5 (20 to 37)

25.8 (20 to 37)
0.482

13.2 (12 to 15)

14.3 (12 to 15)
< 0.001

5.2 (3 to 7)
5.5 (4 to 7)
0.241

11.6 (3 to 27)
10.4 (2 to 19)
0.292

11.2 (0 to 24)
13.3 (5 to 26)
0.136

was performed at the base of the proximal phalanx. A

horizontal medial capsular resection of approximately 4 mm
was performed just proximal to the base of the proximal
phalanx, and the capsule of the first metatarsophalangeal
(MTP) joint was repaired using absorbable sutures without
tension. The correction was checked fluoroscopically.
Post-operative care. Post-operatively the foot was placed in
a splint for one week. Weight-bearing on the heel and lateral border of the foot was started the day after surgery; on
the first ray at four to six weeks after distal osteotomy, and
in the seventh week after PCO. The K-wires were removed
at four to six weeks after DCO and at eight to ten weeks
after PCO.
Radiological evaluation. All radiographs were taken at the
same facility using the same technique. Non-weight-bearing
dorsoplantar radiographs were taken immediately postoperatively and at six weeks after surgery. Weight-bearing
radiographs were taken before surgery, at three and six
months after surgery, and at final follow-up. In order to prevent bias, the radiographs were assessed by an independent
observer (CHP) who was not part of the surgical team.
Statistical analysis. Continuous data are expressed with
means and ranges. All dependent variables were tested for
normality of distribution and equality of variances, and
parametric tests were used because the variables showed
normal distribution. The paired t-test was used to compare
the pre- and post-operative clinical findings in the two
groups and the MT declination angle in the PCO group. Students t-test was used to compare age, length of follow-up
and the clinical and radiological results of the two groups,
and to compare the hallux valgus angle between the two
groups with or without proximal phalangeal osteotomy. The
chi-squared test was used to analyse the association between
the method of osteotomy and recurrence, and any association between the method of osteotomy and the occurrence of
transfer metatarsalgia. For all tests, p < 0.05 was considered

30

Hallux valgus angle ()

DCO group
PCO group
p-value

28.3 SD 4.3

DCO

27.5 SD 5.0

PCO

25

20

15
11.1 SD 4.4
9.8 SD 6.1

10

10.8 SD 6.0
9.5 SD 3.9

9.9 SD 4.6

9.0 SD 5.6

5.7 SD 5.5
5.3 SD 5.4

9.6 SD 6.1

8.2 SD 5.7

Pre-operative Immediate

6 weeks

3 months

6 months Last follow-up

Time after operation

Fig. 3
Graph showing the change in the mean hallux valgus angle over time
in the two groups (D-/PCO, distal/proximal chevron osteotomy).

significant. Statistical analysis was performed using SPSS

software (version 12.0; SPSS, Chicago, Illinois).

Results
The mean AOFAS and VAS scores improved significantly in
all patients with no significant differences between the
groups at final follow-up (Table II).
The mean pre-operative hallux valgus angle and sesamoid position did not differ between the groups. The mean
pre-operative intermetatarsal angle was 13.2 (12 to 15)
in the DCO group and 14.3 (12 to 15) in the PCO group,
giving a mean difference in pre-operative intermetatarsal
angles of 1.1 (p < 0.001). No significant differences were
seen in the mean pre-operative metatarsus adductus angle
and the immediate post-operative mean DMAA (Table III).
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A COMPARISON OF PROXIMAL AND DISTAL CHEVRON OSTEOTOMY FOR THE CORRECTION OF MODERATE HALLUX VALGUS DEFORMITY

5.5 SD 0.8

DCO

Intermetatarsal angle ()

14.3 SD 1.3

PCO

13.2 SD 1.2

12.5

10

7.5
5.9 SD 1.8

6.1 SD 2.2

4.8 SD 2.0

**

6.1 SD 3.1

4.9 SD 2.4

6.2 SD 2.3

6.2 SD 3.0

5.2 SD 3.0
3.9 SD 2.3

2.9 SD 2.4

2.5
Pre-operative Immediate

6 weeks

3 months

Position of medial sesamoid (grade)

15

653

6 months Last follow-up

DCO
5.2 SD 1.0

PCO

4
3.4 SD 1.0
3.1 SD 1.0

3.0 SD 1.0

2.6 SD 0.9

2.8 SD 0.9
3.1 SD 0.8
3.0 SD 0.7

2.4 SD 1.0

2.6 SD 0.7
2.5 SD 0.9

2
Pre-operative Immediate

Time after operation

6 weeks

3 months

6 months Last follow-up

Time after operation

Fig. 4

Fig. 5

Graph showing the change in the intermetatarsal angle over time in the
both groups. There was a statistically significant difference between the
groups pre-operatively (* p = 0.001) and immediately post-operatively
(** p = 0.001) (D-/PCO, distal/proximal chevron osteotomy).

Graph showing the change in the medial sesamoid position over time
in the distal (DCO) and proximal chevron osteotomy (PCO) groups.
There was a statistically significant difference between the groups
immediately after operation (* p = 0.03).

Table IV. Relative length of the first metatarsal to the second metatarsal
Method of Hardy and
Clapham25

Mortons method26

DCO group
PCO group
p-value

Pre-operative (mm)

Post-operative (mm)

Post-operative
shortening (mm)

Pre-operative (mm)

Post-operative (mm)

Post-operative
shortening (mm)

3.3 (-5 to 9)
3.0 (-6 to 5)
0.693

-0.9 (-10 to 7)
0.7 (-9 to 3)
0.05

4.2 (0 to 8)
2.3 (-2 to 5)
< 0.001

-0.9 (-3 to 14)

-1.3 (-1 to 9)
0.532

-3.8 (-8 to 11)

-2.3 (-5 to 7)
0.07

2.9 (1 to 10)
1.0 (-1 to 6)
< 0.001

Changes in the hallux valgus angle, intermetatarsal angle

and sesamoid position with respect to time after surgery in
the two groups are shown in Figures 3 to 5. The mean intermetatarsal angle and sesamoid position were significantly
greater in the DCO group than in the PCO group immediately post-operatively, but did not differ between the
groups from six weeks after surgery. The mean MT declination angle decreased significantly from 24.4 (19 to 29)
pre-operatively to 21.0 (7 to 32) at final follow-up in the
PCO group (p = 0.005). The mean shortening of the first
metatarsal after surgery was significantly greater in the
DCO group than in the PCO group (Table IV).
At the final follow-up one foot (3.0%) in each group had
recurrent hallux valgus, with hallux valgus angles of 21
and 25, respectively. There was no significant difference in
the risk of recurrence between the two groups (p = 0.983).
A total of 20 feet (60.6%) in the DCO group and
21 (61.8%) in the PCO group underwent proximal phalangeal osteotomy. There was no difference in the outcome
between these two groups (p = 0.922) and no significant
difference in the mean post-operative hallux valgus angle
VOL. 95-B, No. 5, MAY 2013

between those with or without proximal phalangeal osteotomy (Fig. 6).

Three patients (three feet, 9.1%) in the DCO group had
transfer metatarsalgia due to shortening of the first metatarsal, and one in the PCO group had transfer metatarsalgia
due to malunion in severe dorsiflexion. There was no significant difference in the risk of transfer metatarsalgia
between the groups (p = 0.153). Orthoses were used to minimise their symptoms. One patient in the PCO group had a
painful callosity under the first metatarsal head due to plantar malunion, but this resolved after a dorsal closing wedge
osteotomy of the first metatarsal. There were no cases of
nonunion, avascular necrosis or complex regional pain syndrome in either group.

Discussion
This study was performed to compare the results of DCO
and PCO in patients with moderate hallux valgus. The clinical results and rates of recurrence were similar between the
two groups. The mean hallux valgus angle, intermetatarsal
angle and sesamoid position did not differ between the

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C-H. PARK, J-H. JANG, S-H. LEE, W-C. LEE

Hallux valgus angle ()

30

29.8 SD 4.1

25

25.0 SD 3.9

Proximal phalangeal
osteotomy
No proximal phalangeal
osteotomy

20

15
11.3 SD 5.7
9.2 SD 6.2

10
6.2 SD 5.7

9.7 SD 5.4

10.0 SD 5.9

9.5 SD 4.7

9.4 SD 4.5

10.4 SD 4.5

7.7 SD 4.5

5.1 SD 5.2

Pre-operative Immediate

6 weeks

3 months

6 months Last follow-up

Time after operation

Fig. 6
Graph showing the change in the hallux valgus angle according to
the performance of the proximal phalangeal osteotomy. There was a
statistically significant difference between the groups pre-operatively
(* p < 0.001).

groups; however, the DCO group had more shortening of

the first metatarsal and the PCO group had a higher risk of
malunion in dorsiflexion.
DCO is technically simple and requires a relatively
shorter period of non-weight-bearing because of its inherent stability.2-4 However, it has a limited ability to correct
the intermetatarsal angle, as the deformity is corrected only
by lateral translation of the metatarsal head. Although lateral soft tissue release may improve the correction,8,28 it
may also jeopardise the blood supply to the metatarsal
head. Therefore, it is usually indicated for patients with
mild to moderate hallux valgus. There are, however, various definitions of moderate hallux valgus deformity.3,28-30
In this study, a moderate deformity was defined as one with
a hallux valgus angle of between 20 and 40 and an intermetatarsal angle of between 12 and 15.31
PCO is more versatile because correction is achieved by
lateral translation, angulation and supination at the osteotomy. Thus, a PCO is usually indicated in patients with
moderate to severe hallux valgus.16,32-35 It is, however, less
stable than a DCO because of its longer lever arm and the
geometry of the osteotomy, which has less contact surface
owing to the medial gap left after lateral angulation and
supination.8,22 Although either a DCO or a PCO can be
used for patients with moderate hallux valgus, no study
has compared the results of the two osteotomies.
A Scarf osteotomy is similar to a distal osteotomy in its
method of correction, as the correction is achieved by lateral
translation. Recently, however, rotation of the distal fragment
has been added to correct greater deformity,18,19 and some
authors have recommended its use for patients with a moderate deformity.17,36 In this study we focused on a comparison of

DCO and PCO because these two procedures have been

widely used and we have greater experience of them.
No significant differences in hallux valgus angle, intermetatarsal angle or sesamoid position were identified
between the two groups at final follow-up. We believe that
the inherent stability of the osteotomy site, lax lateral soft
tissues after lateral translation of the metatarsal head and
shortening at the osteotomy site are the reasons why correction is maintained after DCO. In contrast, less stability
at the osteotomy site may lead to a slight increase in the
intermetatarsal angle during the healing period after a
PCO. Various methods of improving the stability of a
PCO have been described including using supplementary
transverse K-wire fixation37 and lashing the distal first
and second metatarsals.12-14,38 However, in our study the
mean intermetatarsal angle (6.2) at final follow-up
remained satisfactory, thereby obviating the need for an
additional procedure.
The relative lengths of the first and second metatarsals
were assessed using Mortons method26 and that of Hardy
and Clapham.25 Mortons method is influenced by the
angular deformity, such as metatarsus primus varus or
metatarsus adductus, unlike that of Hardy and
Clapham.39 In this study the degree of shortening of the
first metatarsal was significantly greater in the DCO
group than in the PCO group, regardless of the method of
measurement.
Shortening of the first metatarsal after DCO can cause
transfer metatarsalgia,5,40 and consequently plantar displacement of the distal fragment has been recommended.5,7
In our study the metatarsal heads of the last ten cases in the
DCO group were displaced in the plantar direction. At final
follow-up, transfer metatarsalgia was worsened or had
developed in two (8.7%) feet after DCO without plantar
displacement, and one (10%) after DCO with plantar displacement. Thus, in this study plantar displacement of the
metatarsal head did not prevent transfer metatarsalgia. A
further study with a larger number of cases may be needed
to assess the ideal amount of plantar displacement relative
to the amount of metatarsal shortening.
The relationship between transfer metatarsalgia and dorsiflexion malunion of the first metatarsal has been previously described,15,36,41 but without defining the criteria for
dorsiflexion malunion. In this study, dorsiflexion malunion
was arbitrarily defined as a decrease in the MT declination
angle by 5, on the basis of a previous paper that observed
the inter-observer difference when measuring the intermetatarsal angle to be 5.42
Dorsiflexion malunion of 5 was seen in ten feet (29.4%)
after PCO; only one patient developed transfer metatarsalgia. Borton and Stephens38 described placing a bone wedge
into the dorsal limb of a PCO to distract, supinate and plantarflex the distal fragment, and reported good radiological
results and an increase in total foot contact area. However,
intentional plantar flexion was not performed in our study to
avoid pain under the first metatarsal head. The low incidence
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A COMPARISON OF PROXIMAL AND DISTAL CHEVRON OSTEOTOMY FOR THE CORRECTION OF MODERATE HALLUX VALGUS DEFORMITY

of transfer metatarsalgia may be attributed to the restoration

of normal weight-bearing function of the first ray after correction of the hallux valgus, or to less dorsal movement of
the first metatarsal at the tarsometatarsal joint owing to
post-operative stiffness.43 One of the causes of dorsiflexion
malunion was slight intentional dorsiflexion in some patients
with a high longitudinal arch, to prevent excessive loading
under the first metatarsal head owing to post-operative stiffness of the tarsometatarsal joint after PCO. The other cause
was dorsal elevation of the distal fragment after removal of
the K-wires at a mean of nine weeks after surgery. We therefore suggest that the K-wires be removed more than nine
weeks post-operatively in patients with osteoporosis or a
small contact surface at the osteotomy site owing to greater
angulation or translation.
One of the limitations of this study is that the follow-up
was short. It has previously been reported that the radiological results do not change with follow-up of more than
year.35,44 A small sample size and loss to follow-up are also
limitations of this study. A power analysis with a non-inferiority test revealed that a minimum sample size of 350 in
each group was needed to achieve 80% power at a 5% significance level. Although this study did not have a large
enough sample size, our findings suggest that there are no
differences in the post-operative clinical and radiological
outcome of DCO and PCO in patients with moderate
hallux valgus. A further limitation of this study is its
retrospective nature. However, the operations were performed consecutively and the surgical methods were changed
between the two study periods to minimise selection bias.
The baseline characteristics were similar between the groups
except for the intermetatarsal angle. However, we think that
an absolute difference of 1.1 may be within the range of
interobserver error.42 Although we did not consider other
factors that can affect the results, such as laxity of the soft tissues and hypermobility of the first metatarsocuneiform joint,
it is difficult to assess these factors objectively.
In summary, DCO is comparable with PCO in its clinical
and radiological results and it may be appropriate for
patients with moderate hallux valgus, given the simplicity
of the technique and its relatively shorter healing time.
However, meticulous attention must be paid to the achievement of appropriate correction and stable fixation.

655

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No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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