Specific Complications

This section is more technical and is intented for foot surgeons; unless you are very curious...

* Post-Chevron Osteotomy

1. Avoiding an osteotomy whose axis is aiming too much distal from medial to lateral

Not only is it difficult to reduce the osteotomy, since it tends to lengthen the first metatarsal, but the bone is likely to displace itself back to its initial site. So the osteomoty need to be parallel with the foot’s transverse axis, but not at right angle with the first metatarsal. If it is slightly oriented proximally, from medial to lateral, the reduction will be minimal and the translation easier, with less chance of that bone moving back to where it was.

In this picture, the course of the osteotomy was too distal and it moved again after surgery. The axis must be perpendicular to the foot’s axis as opposed to the 1st metatarsal’s axis. If that 1st metatarsal is long, one can even guide it through a few caudal degrees. Then, a good translation of the head gets even easier, and is more stable, even I recommend bony fixation. Do not rely on a cast to maintain the osteotomy in place.

2. Avascular Necrosis of the metatarsal head (AVN)

(This means a lack of arterial blood flow to the metatarsal head, which can cause its partial destruction.) This is a very rare complication of a distal metatarsal osteotomy associated with a simultaneous lateral soft tissue release (STR). It is a known classical complication found when both procedures are done at the same time, it was deemed heretical to perform such a double operation. Since then, in the last fifteen years, several studies have shown that AVN is rare ( less than 1 %) after a distal osteotomy combined with a lateral soft tissue release. Extensive tissue release seems to be the major factor. ( see later STR).
But when it happens it might be catastrophic, and a salvage surgery is often needed ( First MTP fusion or arthroplasty). So if possible do not push your chance; and if you really need STR after a distal osteotomy, a proximal osteotomy is probably a better choice!

Following these optimistic studies, in the late 90's I did a STR to my distal chevron osteotomies. This way, my indications for distal osteotomy were progressively less strict. And I did slightly less proximal osteotimies. I did not see any particular complication during the first 3 years, except that when looking at X-rays early after surgery, I would notice some transitory and speckled osteopenia in some patients. All which would anyway disappear in time. This was actually corroborated by several recent studies. ( re. Transient AVNthat healed in almost all ). However, after about 300 Chevron operations associated with this lateral tissue release, one obvious case of symptomatic AVN of the metatarsal head occurred about one year after surgery. ( Re. X-ray at left).
Therefore I have gone back to stricter criterias since year 2000. Even though this consequence is exceptional, broad indications are not worth the risks. If a distal osteotomy (without STR- Soft Tissue Release) might not completely correct the Hallux Valgus, one might as well move on to a proximal osteotomy (crescent, Ludloff , Scarf, etc.) which will allow the added bonus of a secure lateral release without AVN risk..

* Post-Mitchell Osteotomy

Post-Mitchell osteotomy is the riskiest procedure if all criteria are not present. It is much better to perform a proximal osteotomy if the surgeon does not yet master all the finer points of this procedure.

1. Mal-Union: Displacement in Dorsal Flexion

Notice that both 1st toes do not touch the ground.

In this picture, the young patient had undergone Mitchell’s procedure elsewhere. Both osteotomies resulted in mal-union in dorsi-flexion, with chronic pain and trouble to get shod properly. I had to perform a new dorsal open-bevel osteotomy, with bone transplant on both feet. It is therefore better to prevent and correct those Mitchell osteotomies to avoid such complications.

2. Mal-Union : Plantar Flexion Displacement

In this instance, the displacement occurred the other way. This causes an MTP hyper-extension with a inter-phalangial secondary flexion.

3. Median Displacement

4. Healing Delay

In some uncommon cases when no fixation is put in, the osteotomy may take more time to heal. In this case seen several years back, it healed spontaneously after 11 weeks. I have so far no case of non-uion.
5. Metatarsalgia

Metatarsalgia is a particularly frequent result, especially when the surgeon performs this kind of surgery ( Mitchell, with first metatarsal shortening) no matter how long the other metatarsals are!

So such (shortening) osteotomy must not be performed on a metatarsal which would already be short compared to the next ones, since, as is the case here, the patient will have severe pain out of the 2nd metatarsal head. In fact all the weight is transferred on that relatively too long 2nd métatarsal after surgery.
In this example, what is needed is not just to raise and shorten the 2nd metatarsal, but to do the same to the 3rd one (which in turn is also long, compared to the 4th ...one and would in turn bear the weight). It is absolutely necessary to respect the harmony of the metatarsal lengths. So plan ahead.

* Mann’s Crescent Post-Osteotomy

        Roger Mann’s crescent post-osteotomy is difficult to get right. It certainly can lead to a good improvement, but also to post-surgery displacement in some patients.

        In this instance, the angle between metatarsals 1 and 2 was 20º before surgery. An angle of about 10º was achieved at surgery time, but the angle shifted back to 14º before consolidation.

        This is why I now prefer to perform Ludloff-Myerson osteotomies because they give the best results and promote a more solid setting.

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