Orthopaedics & Traumatology: Surgery & Research (2010) 96, 407—416

ORIGINAL ARTICLE

Percutaneous hallux valgus correction using the

Reverdin-Isham osteotomy
T. Bauer ∗, D. Biau , A. Lortat-Jacob , P. Hardy

Orthopedic and Traumatologic Surgery Department, Ambroise-Paré Hospital, Paris Area West University, 9, avenue
Charles-de-Gaulle, 92100 Boulogne, France

Accepted: 25 January 2010

KEYWORDS Summary
Hallux valgus Introduction: The present study assessed 2-year clinical and radiological results of percuta-
deformity; neous correction of hallux valgus by Reverdin-Isham osteotomy and sought to clarify indications
Percutaneous for the technique.
surgery; Patient and methods: A continuous prospective single-center series of 104 cases of medium-
Metatarsal to-moderate hallux valgus was managed by the same percutaneous technique, with a median
osteotomy; 2 years’ clinical and radiological follow-up (with no loss to follow-up). Uni- and multivariate
Reverdin-Isham analysis determined predictive factors for the mobility and degree of correction obtained.
osteotomy Results: American Orthopedic Foot and Ankle Society (AOFAS) functional score rose from a
preoperative median of 49/100 to 87.5/100 postoperatively (p < 0.05); 89% of patients were sat-
isfied or very satisfied with their result at end of follow-up. Hallux valgus and distal metatarsal
articular angle (DMAA) were significantly reduced (30 and 15◦ to 15 and 7◦ , respectively;
p < 0.05). Associated lateral ray surgery significantly increased the postoperative risk of MTP1
joint incongruence (p = 0.009).
Discussion: Percutaneous correction by Reverdin-Isham osteotomy seemed effective in isolated
medium-to-moderate hallux valgus, but involves a learning curve and lacks precision in case of
associated lateral metatarsal osteotomy, with a risk of DMAA hypercorrection and increased risk
of MTP1 joint incongruence. Indications for percutaneous Reverdin-Isham osteotomy seem to
be limited to isolated medium-to-moderate hallux valgus (M1M2 angle <15◦ , M1P1 angle around
30◦ ) with elevated DMAA and congruent MTP1 joint.
Level of evidence: Level IV. Therapeutic study.
© 2010 Elsevier Masson SAS. All rights reserved.

Introduction

Hallux valgus is a frequent deformity of the first-ray of

∗ Corresponding author. the forefoot, progressively and to varying degrees associat-
E-mail address: [email protected] (T. Bauer). ing first-phalanx abduction and pronation, first-metatarsal

1877-0568/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2010.01.007
408 T. Bauer et al.

adduction, pronation and elevation and lateral capsuloliga-

mentary retraction of the first-ray metatarsophalangeal
(MTP1) joint [1—3]. Surgical correction is indicated for
pain and difficulty with footwear. Many procedures have
been described and notably a variety of first-metatarsal
osteotomy procedures [3—9].
Distal metatarsal osteotomy is recommended to cor-
rect mild-to-moderate deformity with intermetatarsal angle
not exceeding 15◦ or to correct the distal metatarsal
articular angle (DMAA) [10,11]. Minimally invasive or
percutaneous designs have been described for distal first-
metatarsal osteotomy, with or without osteosynthesis
[11—15]. Reverdin’s osteotomy, revised by Isham, is a per-
cutaneous procedure without osteosynthesis, to align the
first-ray by medial rotation of the first-metatarsal head
and DMAA correction [12]. The interest of a percutaneous
technique lies in the reduced morbidity and surgery time,
theoretically shortening recovery time. Its vagaries concern Figure 1 Bone resection by motorized burr, with medial
the quality of correction and long-term stability. approach.
The present study assessed 2-year clinical and radiolog-
ical results of percutaneous correction of hallux valgus by
in the work-space. In the second stage, first-metatarsal
Reverdin-Isham osteotomy and analyzed prognostic factors
Reverdin-Isham osteotomy was performed using a straight
of failure, so as to clarify indications for the technique.
burr with the same medial approach. The medial closed
wedge osteotomy of the first-metatarsal distal metaphysis,
Patient and methods parallel to the joint surface, was carried out from distal
dorsal, just behind the joint space, to proximal plantar,
Description of study behind the sesamoids, with a slope of 45◦ (Fig. 2). The lat-
eral cortex was conserved. The hallux was then put in forced
A continuous prospective single-center, single-surgeon series adduction, enabling compression by osteoclasia, medial clo-
of 104 cases of hallux valgus was managed by the same sure of the Reverdin-Isham osteotomy and DMAA correction
percutaneous technique, in 82 patients, between Septem- (Fig. 3). In the third step, lateral capsuloligamentary release
ber 2004 and June 2006. Surgery was indicated for painful of the metatarsophalangeal joint was associated with trans-
hallux valgus with functional impact and difficulty with verse abductor tenotomy by Beaver® blade with a second
footwear. A percutaneous design was indicated for mild-to- dorsolateral approach facing the metatarsophalangeal joint-
moderate deformity: hallux valgus angle (M1P1 angle) up to line. The final step comprised varization osteotomy of the
40◦ and intermetatarsal angle (M1M2 angle) up to 15◦ . Some first-phalanx, with a third, dorsomedial, approach of 3 mm
patients presenting with M1P1 >40◦ but M1M2 <15◦ were also medially to the extensor hallucis longus tendon. A short
included, as were others with M1M2 >15◦ but M1P1 <40◦ . straight burr was used for proximal metaphyseal osteotomy
Median age was 57 years (range, 23 to 87 years); there were of the phalanx, under fluoroscopy, conserving the lateral
76 women and six men. There were 33 right feet, 27 left, cortex. Correction was obtained by medial closure of the
and 22 one-step bilateral operations. osteotomy with the hallux in forced varus (Fig. 4). No
osteosynthesis was performed. Postoperative dressing in
Surgical technique slight hypercorrection for 10 days maintained the correc-
tion and kept the osteotomies closed, and was then changed
for a dressing with a cohesive bandage with an ortho-
All patients were operated on under locoregional anesthe-
plasty maintaining first-ray alignment for 1 month (Fig. 5).
sia (perimetatarsal conduction block), and 77 in ambulatory
Complete weight-bearing was resumed immediately, with a
surgery. All underwent the same first-ray procedure per-
formed by the same surgeon, following Isham [12] and
De Prado et al. [16]. The patient was installed in supine
position, with a tourniquet above the malleoli, inflated to
250 mmHg. A 3—5 mm incision in the medial and plantar
edge of the first-metatarsal head was followed by cap-
sule detachment to obtain a work-space. First, the medial
and dorsal protrusion of the first-metatarsal head was
resected by conical burr on a drill with torque multipli-
cation, operating at low speed (max.: 5000 rpm) to avoid
burning and bone and skin necrosis (Fig. 1). Bone resec-
tion was pursued under fluoroscopy up to the functional
joint surface of the first-metatarsal head, outside the medial
sagittal groove. Bone fragments were evacuated under man-
ual pressure, with saline lavage and cleansing by rasps Figure 2 Reverdin-Isham osteotomy (AP view).
Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy 409

Figure 3 Reverdin-Isham osteotomy (AP view). Correction is Figure 5 Postoperative orthoplasty (as of day 10).
obtained by medial rotation (closure of metatarsal osteotomy,
distal metatarsal articular angle [DMAA] correction).

percutaneous surgery was performed in the same step, asso-

rigid flat-soled orthopedic shoe for the first month. Preven- ciating dorsal metatarsophalangeal arthrolysis, extensor and
tive anticoagulants were not prescribed except in case of flexor tenotomy, P1 osteotomy and arthroplastic resection of
history of deep venous thrombosis or risk factors (coagu- the proximal interphalangeal joint, depending on the sever-
lation disorder, thrombopathy). Metatarsophalangeal joint ity and reducibility of the deformity.
mobilization was authorized after the first dressing was
put on.
In 39% of cases (n = 41), osteotomy of the lateral
metatarsals was performed in the same surgical step. These Assessment
were all patients presenting with lateral ray metatarsal-
gia associated with the first-ray deformity. In all cases, Clinical
percutaneous first-, third- and fourth-ray distal metatarsal Pre- and postoperative functional American Orthopedic
osteotomy was performed. In case of associated claw-toe, Foot and Ankle Society (AOFAS) scores (the AOFAS hallux-
metatarso-phalangeal-interphalangeal scale) was calcu-
lated in all cases [17]. Passive MTP1 joint mobility (sum of
dorsi- and plantar flexion) was measured by manual goniom-
etry with the patient in dorsal decubitus, ankle in neutral
position and knee in extension. Other parameters were also
noted: forefoot digital formula (Greek, square or Egyptian),
time to resumption of normal footwear, and presence of
postoperative edema. Patient satisfaction (very satisfied,
satisfied, dissatisfied or disappointed) was also rated at end
of follow-up.

Radiological
Anteroposterior (AP) weight-bearing views were taken pre-
operatively and at end of follow-up, in all cases. Several
manual measurements were made on each image, by a single
observer: hallux valgus angle (M1P1 angle), metatarsus varus
angle (M1M2 angle), first-metatarsal distal joint surface ori-
entation angle (DMAA), first-ray shortening (metatarsus and
phalanx), and metatarsal index (index plus, index plus-
minus, index minus). MTP1 joint congruency was assessed on
Pigott’s criteria (centered congruent joint, deviated or sub-
luxated non-congruent joint) [2]. MTP1 joint arthritis was
Figure 4 Percutaneous first-phalanx varization osteotomy. assessed on Coughlin and Shurnas’s criteria (Table 1) [18].
410 T. Bauer et al.

Table 1 Radiographic signs of first-ray metatarsopha- Table 2 Results for series.

langeal (MTP1) joint arthritis (Coughlin and Shurnas [18]).
Data Preoperative Postoperative
Grade 0 Normal or subnormal joint
AOFAS score
Grade 1 Osteocondensation, joint space Global score 49 (44—52) 87.5 (67—93.5) <0.05
narrowing (<50%), dorsal Pain 20 (20—20) 40 (30—40) <0.05
osteophytosis, slight flattening Function 29 (24—37) 45 (40—45) <0.05
of M1 head Alignment 0 (0—0) 15 (15—15) <0.05
Grade 2 Overall joint space narrowing MTP1 mobility
(>50%), osteocondensation, Global mobility 95 (60—100) 80 (55—100) NS
circumferential osteophytosis, Dorsiflexion 80 (70—90) 70 (60—80) NS
irregular sesamoids aspect Plantar flexion 15 (10—20) 10 (10—20) NS
Grade 3 Abnormalities as in grade 2, Forefoot morphotype
but with almost total joint Greek 26 (25%) 33 (32%) NS
space narrowing and presence Square 31 (30%) 46 (44%) NS
of cysts Egyptian 47 (45%) 25 (24%) NS
Grade 4 Disappearance of MTP1 joint Angles
space M1P1 30 (25—32) 15 (11—18) <0.05
M1M2 14 (12—15) 11 (9—13) NS
DMAA 15 (12—18) 7 (4—10) <0.05
Metatarsal index
Minus 70 (67%) 73 (70%) NS
Statistical analysis Plus-minus 24 (23%) 26 (25%) NS
Plus 10 (10%) 5 (5%) NS
Quantitative variables were expressed as median and MTP1 non-congruent 31 (30%) 34 (33%) NS
interquartile range (IQR), unless stated otherwise. Qualita- Quantitative variables: median with interquartile range (IQR);
tive variables were expressed as numbers and percentages. qualitative variables: absolute value with percentage (%); mobil-
Stepwise descending multiple regression models, based on ity: degrees.
Akaike’s Information Criterion (AIC) [19] were used to pre-
dict: M1P1 angle, M1M2 angle, DMAA, and postoperative
dorsiflexion and joint congruence. The following dependent
variables showing sufficient influence (p < 0.2) on univari-
ate analysis were included in the multivariate model:
preoperative M1P1 angle, preoperative M1M2 angle, preop-
erative DMAA, percutaneous lateral metatarsal osteotomy, Results
and MTO1 arthritis (as seen from MTP1 joint-line pinching
on preoperative AP X-ray). Analysis used R software [20]. All All patients were followed up for at least 12 months, with
tests were bilateral; the significance threshold was set at a mean follow-up (FU) of 24 months (range: 12—40 months).
0.05. None were lost to follow-up (Table 2, Fig. 6a and b).

Figure 6 a: isolated hallux valgus: preoperative clinical and radiologic aspect; b: clinical and radiologic control at 18 months.
Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy 411

Complications

Complications included four M1 and five P1 lateral cor-

tex fractures, not requiring revision. There were six cases
of DMAA hypercorrection (DMAA <0◦ ). Two patients showed
severe painful MTP1 joint stiffness (global mobility <30◦ ),
and two others showed complex regional pain syndrome.
Three patients (3%) showed recurrence of deformity (M1P1
angle >20◦ ); there were no cases of hallux varus. Two
patients showed transfer metatarsalgia 18 months after per-
cutaneous correction of isolated hallux valgus.

Subjective and functional results

AOFAS functional score improved significantly, from a pre-

operative median of 49/100 (IQR: 44—52) to 87.5/100
postoperatively (IQR: 67—93.5) (p < 0.05). All items in the
global AOFAS score (pain, function, alignment) showed sig-
nificant improvement. Eighty-nine percent of patients were
satisfied or very satisfied with their result at end of follow-
Figure 7 a: hallux valgus and metatarsalgia: preoperative
up. Normal footwear was resumed at a mean 5 weeks
radiologic aspect; b: radiologic control at 1 year: consolida-
(range: 10 days to 3 months) after percutaneous correc-
tion of lateral ray distal metatarsal osteotomies, resolution
tion of isolated hallux valgus, and a mean 8 weeks (range:
of metatarsalgia. Recurrence of deformity, distal metatarsal
3 weeks to 6 months) in case of associated lateral metatarsal
articular angle (DMAA) hypercorrection, non-congruent first-ray
osteotomy.
metatarsophalangeal (MTP1) joint.

Statistical analysis
Clinical results
Multivariate analysis identified preoperative MTP1 joint
At 1 month postoperatively, edema was observed in 10% mobility (p < 10−4 ; estimate = 0.64; 95% confidence interval
of patients in case of correction of isolated hallux val- [CI], 0.48—0.81) and radiographic signs of MTP1 arthri-
gus and in 82% in case of associated lateral metatarsal tis (p = 0.02) as independent predictors of postoperative
osteotomy (p < 0.01). Median MTP1 joint mobility was 95◦ MTP1 joint mobility. Preoperative MTP1 arthritis was
(IQR: 60—100) preoperatively (median = 80◦ [IQR: 70—90] in associated with a significant loss of dorsiflexion of 10%
dorsiflexion and 15◦ [IQR: 10—20] in plantar flexion) and 80◦ compared to arthritis-free patients (p = 0.02). Preopera-
(IQR: 55—100) postoperatively (median = 70◦ [IQR: 60—80] in tive M1P1 angle was the sole predictor of postoperative
dorsiflexion and 10◦ [IQR: 10—20] in plantar flexion) (NS). M1P1 angle (estimate = 0.29; 95% CI: 0.18—0.41; p < 10−4 ).
Mean metatarsophalangeal valgus correction was 50% of
the preoperative deformity. Multivariate analysis found that
associated lateral ray surgery significantly impacted postop-
Radiographic results
erative DMAA: in case of lateral ray metatarsal osteotomy,
mean postoperative DMAA was 4◦ less than in case of isolated
Radiographic analysis found a significant reduction in hallux
first-ray surgery (p < 0.001). Multivariate analysis identified
valgus, with a median MTP1 angle of 30◦ (IQR: 25—32) preop-
lateral metatarsal surgery as a predictor of postoperative
eratively and of 15◦ (IQR: 11—18) postoperatively (p < 0.05).
MTP1 congruency, with a 17% risk of postoperative incon-
The median intermetatarsal M1M2 angle decreased from 14◦
gruency in case of isolated first-ray surgery and a 47% risk in
(IQR: 12—15) preoperatively to 11◦ (IQR: 9—13) postoper-
case of associated lateral metatarsal osteotomy (p = 0.009;
atively (NS). The DMAA decreased from 15◦ (IQR: 12—18)
odds ratio: 0.24) (Fig. 7a and b).
preoperatively to 7◦ (IQR: 4—10) postoperatively (p < 0.05).
DMAA values (on weight-bearing AP view) showed great
variation, with a preoperative range from 8◦ to 25◦ (i.e., Discussion
17◦ ) and a postoperative range from −5 to 15◦ (i.e., 20◦ ).
The MTP1 joint was non-congruent in 31 cases (30%) pre- In the present series, percutaneous correction of mild-
operatively and in 34 (33%) postoperatively (NS). Mean to-moderate hallux valgus by Reverdin-Isham osteotomy
first-metatarsal shortening was 4 mm (range: 0—9 mm) and provided significant functional improvement, comparable to
mean first-phalanx shortening was 3 mm (range: 0—6 mm). results from other percutaneous first-ray distal metatarsal
No failures of metatarsal or phalangeal osteotomy consoli- osteotomy procedures, with or without osteosynthesis
dation were observed. No radiologic progression of arthritis [6,11,12,14,21—23]. Clinical results for percutaneous cor-
was observed at end of follow-up. rection of hallux valgus are comparable to those of the main
412 T. Bauer et al.

Table 3 Comparison of techniques: clinical results.

Author (ref) Date Technique Number of FU (months) Satisfaction (%) Preoperative Postoperative
patients AOFAS score AOFAS score

Veri et al. [34] 2001 Proximal 37 12.2 years 90 37 92

Plaweski et al. [46] 1998 Scarf 120 3 years 85
Bonnel et al. [54] 1999 Scarf 79 7
Jardé et al. [43] 1999 Scarf 50 3.7 years 86
Crevoisier et al. [42] 2001 Scarf 84 22 89.3 82
Salmeron et al. [52] 2001 Scarf 19 15
Kristen et al. [28] 2002 Scarf 111 3 years 50.1 91
Freslon et al. [35] 2005 Scarf 123 4.8 years 84.6
Aminian et al. [24] 2006 Scarf 27 16.1 54.5 86.5
Skotak and Behounek [49] 2006 Scarf 62 18
Chou et al. [25] 1998 Chevron 17 33 91
Trnka et al. [33] 2000 Chevron 57 5 years 87 59.2 91
Teli et al. [52] 2001 Chevron 60 25 83.2
Strienstra et al. [32] 2002 Chevron 38 31 93.5
Schneider et al. [31] 2004 Chevron 112 12.7 years 46.5 88.8
Weinberger et al. [48] 1991 Distal 301 8.3 87.55
Magnan et al. [11] 2005 Distal 118 3 years 91 88.2
Bauer et al. [23] 2009 Distal 189 12 87 52 93
Present series 2009 Distal 104 2 years 89 49 87.5

conventional open surgery procedures, such as chevron, impairing dorsiflexion [50]. Severe MTP1 joint stiffening with
Scarf or proximal metatarsal osteotomy, where postoper- significant functional impact is relatively rare, and often the
ative AOFAS scores range from 82 to 93.5, depending on result of complications such as infection, delayed conso-
the reports (Table 3) [24—34]. Patient expectations focus lidation or complex regional pain syndrome [11,33,35,47].
on pain, footwear tolerance and walking [35—40]. Percu- Fibrosis and MTP1 joint capsuloligamentary retraction fol-
taneous Reverdin-Isham osteotomy would thus seem to be lowing extensive resection are considered to be the main
as effective as the main conventional procedures, providing causes of stiffness secondary to open correction. Percuta-
both significant functional improvement on all criteria (pain, neous techniques theoretically reduce the risk of stiffness,
function, alignment) and a high-level of patient satisfaction due to the limited approach, and in case of extra-articular
[10—13,21,25,26,33—35,41—48]. metatarsal osteotomy [6,11,48]. Percutaneous Reverdin-
Unlike Kadakia et al., who reported unacceptable Isham osteotomy may, however, induce stiffness, due to
rates of early complication following percutaneous distal the extensive medial resection of the metatarsal head, the
metatarsal osteotomy, the present series showed no non- release of bone debris in the joint space and capsule and
union, osteonecrosis or early recurrence [15]. It should the intracapsular osteotomy involved [12,13]. With a median
nevertheless be stressed that the percutaneous tech- 15◦ loss of MTP1 joint mobility, stiffness secondary to per-
nique involves a non-negligible learning curve to achieve cutaneous Reverdin-Isham osteotomy is comparable to that
reproductibility, avoiding soft-tissue trauma, and that the induced by other percutaneous or open surgery techniques
postoperative dressing protocol and rigorous follow-up over [31,33,49]. The need for abundant lavage of the work-space,
the first months are mandatory. however, should be stressed, to clear bone debris liable to
cause an inflammatory reaction, with fibrosis and stiffening.

MTP1 joint stiffness

Radiographic results
MTP1 joint stiffness is one of the most feared complications
of hallux valgus correction surgery. Moderate stiffness with This percutaneous procedure proved effective in cor-
about 10—20% loss of mobility is generally reported for open recting mild-to-moderate deformity, achieving a median
hallux valgus surgery [10,31,33,41,49]. Medial MTP1 cap- postoperative MTP1 angle of 15◦ . Such a 50% angular
sule plasty induces immediate joint amplitude loss, first correction is comparable to that reported with other per-
 Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy
Table 4 Comparison of techniques: radiologic results.

Author (ref) Year Technique Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
M1P1 angle M1P1 angle M1M2 angle M1M2 angle DMAA DMAA

Veri et al. [34] 2001 Proximal 37 13 16 6

Plaweski et al. [46] 1998 Scarf 28 18 14 10
Bonnel et al. [54] 1999 Scarf 31.3 9 11.4 6.2 14.6 12.6
Jardé et al. [43] 1999 Scarf 39.8 22.7 15 10.4
Crevoisier et al. [42] 2001 Scarf 32 17 16 10 13 10
Salmeron et al. [52] 2001 Scarf 28 17 11.5 8.2 13 11
Kristen et al. [28] 2002 Scarf 19.1 6.6
Freslon et al. [35] 2005 Scarf 31.2 17.5 12.1 7.5
Aminian et al. [24] 2006 Scarf 34.5 16.9 15.4 10.1
Skotak and Behounek [49] 2006 Scarf 37 18 16 9
Chou et al. [25] 1998 Chevron 22 18 11 9 16 9
Trnka et al. [33] 2000 Chevron 29 18 13 9
Teli et al. [52] 2001 Chevron 31.7 16.9 15.4 8.6 11.3 7.1
Strienstra et al. [32] 2002 Chevron 29.4 11.4 15 4.8
Schneider et al. [31] 2004 Chevron 27.6 14 13.8 8.7
Weinberger et al. [48] 1991 Distal 26 7.5 12.6 6.6
Magnan et al. [11] 2005 Distal 31.5 13.7 12.3 7.3 14.2 6.7
Bauer et al. [23] 2009 Distal 28 14 13 10 15 8
Present series 2009 Distal 30 15 14 11 15 7

413
414 T. Bauer et al.

cutaneous or open distal metatarsal osteotomy techniques clinically and in terms of angular correction. Bias may also
[6,11,13,23,31—33,51,52] or with Scarf osteotomy (Table 4) have been induced by the fact that the clinical and radi-
[24,27,28,30,35,42,49,53—55]. Weinberger et al. reported ological measurements were not made by an independent
better angular correction with a different percutaneous assessor.
metatarsal osteotomy, with M1P1 angle reduced from 26 to
7.5◦ [48]. With a mean 50% M1P1 angle correction and slight Conclusion
impact on the M1M2 angle, percutaneous Reverdin-Isham
osteotomy is adapted and effective for the correction of
Percutaneous correction of mild-to-moderate hallux valgus
mild-to-moderate deformities (M1M2 angle ≤15◦ , and M1P1
by Reverdin-Isham osteotomy provided clinical results that
angle about 30◦ ).
were comparable to those of most minimally invasive or con-
One of the aims of Reverdin-Isham osteotomy is to reduce
ventional procedures, with 89% of patients satisfied or very
the DMAA by medial rotation of the first-metatarsal head. In
satisfied at 2 years’ follow-up. The technique does, however,
the present series, the mean reduction in DMAA was 50%
involve a steep and long learning curve, and lacks preci-
(median DMAA = 15◦ preoperatively vs. 7◦ postoperatively).
sion in case of associated lateral metatarsal osteotomies,
Comparable DMAA correction was reported by Magnan et
with a risk of DMAA hypercorrection and an elevated risk
al. for the same type of percutaneous procedure [23], with
of MTP1 joint non-congruency. The optimal indications for
percutaneous distal metatarsal osteotomy [11,14] and by
correction of hallux valgus by percutaneous Reverdin-Isham
Chou et al. [25] for chevron osteotomy. Coughlin and Carl-
osteotomy thus seem to be restricted to isolated (with-
son reported better DMAA correction (from 23 to 9◦ ) with
out lateral metatarsal procedure) mild-to-moderate hallux
double metatarsal osteotomy [26]. With Scarf osteotomy,
valgus (M1M2 angle ≤15◦ , and M1P1 angle about 30◦ ), with
medial rotation of the plantar metatarsal fragment seems
elevated DMAA and good MTP1 congruency. In case of asso-
more limited, but still possible using certain tricks to obtain
ciated lateral metatarsal procedure (percutaneous distal
several degrees of DMAA correction [28,35,42,53,54]. The
osteotomy), another first-ray technique should be used:
present series featured wide variation in DMAA, with a range
conventional (Scarf, chevron), or minimally invasive or per-
of 17◦ preoperatively and a range of 20◦ postoperatively.
cutaneous chevron osteotomy, with or without fixation.
This confirms that DMAA measurements lack precision and
Further studies of percutaneous hallux valgus correction
reproductibility, due both to the X-ray views (X-ray orien-
techniques are needed, to refine indications and assess long-
tation) and to first-metatarsal rotation in case of severe
term stability and patient benefit in terms of resumption of
metatarsus varus [41,56—60]. In moderate first-ray defor-
footwear and activity.
mity, there is less first-metatarsal rotation, making DMAA
measurement theoretically more reliable. The wide vari-
ation in postoperative DMAA values, however, shows that Conflict of interest
this percutaneous correction technique fails to ensure reli-
ably precise and foreseeable DMAA reduction [48]. This None.
imprecise adjustment of first-metatarsal head medial rota-
tion, which may be due to technical error or to bone References
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