Elsevier

Foot and Ankle Surgery

Volume 24, Issue 5, October 2018, Pages 460-465
Foot and Ankle Surgery

Location and direction of the nutrient artery to the first metatarsal at risk in osteotomy for hallux valgus

https://doi.org/10.1016/j.fas.2017.05.004Get rights and content

Highlights

  • Osteotomy for hallux valgus interrupts intraosseous blood supply to the first metatarsal.

  • We investigated the first metatarsal nutrient artery, arising from the first dorsal metatarsal artery.

  • Enhanced computed tomography scans of 8 feet of 8 fresh cadavers were assessed.

  • Barium was injected through the external iliac artery.

  • Mostly, the nutrient artery entered the first metatarsal at the distal third or junction of the middle and distal thirds.

  • Mostly, the nutrient artery entered the first metatarsal obliquely from a proximal direction coronally.

  • Saw blade overpenetration alone or with extensive capsular stripping might damage the artery.

  • Location and direction of the first metatarsal nutrient artery was established.

Abstract

Background

Osteotomy for hallux valgus interrupts intraosseous blood supply to the first metatarsal, presumably causing non-union, delayed union, or osteonecrosis of the head of the first metatarsal. We investigated the first metatarsal nutrient artery, arising from the first dorsal metatarsal artery, and identified aspects of surgical technique contributing to nutrient artery injury.

Methods

Enhanced computed tomography scans of 8 feet of 8 fresh cadavers were assessed. Barium was injected through the external iliac artery; location and direction of the first metatarsal nutrient artery was recorded.

Results

Mostly, the nutrient artery entered the first metatarsal at the distal third or junction of the middle and distal thirds obliquely from a proximal direction coronally; entry point and direction varied axially. Saw blade overpenetration alone or with extensive capsular stripping might damage the artery.

Conclusions

Location and direction of the first metatarsal nutrient artery was established.

Introduction

Hallux valgus is a common deformity in adults that is characterized by abnormal angulation, rotation, and lateral deviation of the first toe at the first metatarsophalangeal (MTP) joint [1], [2], [3]. The community prevalence of hallux valgus estimated by epidemiological studies varies between 21% and 70% [4], [5], [6], [7]. Surgical correction has been demonstrated to be effective in treating hallux valgus compared with watchful waiting and orthotic therapy [8]. First metatarsal osteotomy has been widely adopted and practiced. Distal first metatarsal osteotomy such as Chevron or Mitchell osteotomy is frequently used to correct mild-to-moderate hallux valgus deformity [9], [10]. For moderate to severe deformity, scarf osteotomy or proximal first metatarsal osteotomy are generally used [10]. However, complications assumed to be associated with some degree of damage to the vascular supply to the first metatarsal have been reported [11], [12], [13], [14].

These complications, which include non-union, delayed union, and osteonecrosis of the first metatarsal head, may be related to disruption of blood supply, and have prompted recommendations to restrict the use of distal first metatarsal osteotomy. Other procedures including scarf osteotomy or a long oblique osteotomy extending to the metatarsal neck can cause necrosis of the metatarsal head. In Chevron osteotomy, the prevalence of osteonecrosis of the first metatarsal head has been reported to range from 0% to 20% [15], [16], [17], [18], [19], [20]. Blum noted that 5 cases of avascular necrosis in a series of 204 Mitchell osteotomies [20]. Wallace et al. reported that 15 cases of avascular necrosis were noted (0.11%) in 13,952 first metatarsal osteotomies, 13 after Chevron, and 2 after scarf osteotomy [21]. There is also an increased risk of osteonecrosis from an additional lateral soft-tissue release [17], [18], [21], [22], [23]. There is a huge range in the reported incidence of avascular necrosis following the first metatarsal osteotomy [24], and the incidence might be rare. However, once avascular necrosis occurs, it causes serious problems.

The course of the nutrient artery to the first metatarsal has been described in some reports [25], [26], and we believe that this artery is important during surgery for hallux valgus. However, even if the risk of damage to the nutrient artery may be caused by overpenetration of the saw blade during osteotomy or injury during lateral soft-tissue release, which may cause necrosis of the first metatarsal head, nonunion, or delayed union, no study has focused on the nutrient artery in detail during osteotomy for hallux valgus, and no study has described the location and direction of this artery.

The purpose of this study was to assess the location and direction of the nutrient artery to the first metatarsal in fresh cadavers on axial and coronal enhanced computed tomography (CT), and to identify features that can help to prevent damage to the artery during surgery for hallux valgus.

Section snippets

Methods

This study was approved by the research board of our and involved 8 feet of 8 fresh cadavers (6 males and 2 females). The mean age was 80.3 ± 10.0 years. Fresh cadavers with a history or signs of previous ankle trauma or surgery, congenital or developmental deformities, or inflammatory arthritis were excluded. The left first metatarsal of one specimen was dissected for anatomical observation.

The vessels were flushed with warm normal saline solution through a plastic catheter placed in the

Results

A summary of the results is shown in Table 1. The mean distance from the first MTP joint to the entry point of the nutrient artery to the first metatarsal on the coronal plane (1) was 22.6 ± 3.1 mm, and the mean distance from the first TMT joint to the entry point of the nutrient artery to the first metatarsal (2) was 33.2 ± 3.3 mm. In 6 of the 8 feet, the nutrient artery entered the first metatarsal at the distal third or the junction of the middle and distal thirds of the first metatarsal shaft (

Discussion

The nutrient artery originates from the first dorsal metatarsal artery (branch of the dorsalis pedis artery), and after perforating the lateral cortex, courses through the nutrient foramen, enters the medullary canal, and divides into 2 branches, proximal and distal [27]. The proximal branch terminates and anastomoses with metaphyseal branches at the base, and the distal branch proceeds distally to the metatarsal head and gives terminal branches anastomosing with metaphyseal and capital vessels

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

None.

Acknowledgment

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.

References (33)

  • P.J. Elton et al.

    A chiropodial survey of elderly persons over 65 years in the community

    Public Health

    (1986)
  • M. Rothwell et al.

    The chevron osteotomy and avascular necrosis

    Foot (Edinb)

    (2013)
  • F. Oliva et al.

    Minimally invasive hallux valgus correction

    Orthop Clin North Am

    (2009)
  • M.J. Coughlin

    Hallux valgus

    J Bone Joint Surg Am

    (1996)
  • E. Roddy et al.

    Prevalence and associations of hallux valgus in a primary care population

    Arthritis Rheumatol

    (2008)
  • F. Benvenuti et al.

    Foot pain and disability in older persons: an epidemiologic survey

    J Am Geriatr Soc

    (1995)
  • J.E. Dunn et al.

    Prevalence of foot and ankle conditions in a multiethnic community sample of older adults

    Am J Epidemiol

    (2004)
  • E.G. White et al.

    Footcare for very elderly people: a community survey

    Age Ageing

    (1989)
  • S.G. Leveille et al.

    Foot pain and disability in older women

    Am J Epidemiol

    (1998)
  • M. Torkki et al.

    Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial

    JAMA

    (2001)
  • M.J. Coughlin et al.

    Hallux valgus: demographics, etiology, and radiographic assessment

    Foot Ankle Int

    (2007)
  • S. Pinney et al.

    Surgical treatment of mild hallux valgus deformity: the state of practice among academic foot and ankle surgeons

    Foot Ankle Int

    (2006)
  • C. Horne et al.

    Chevron osteotomy for the treatment of hallux valgus

    Clin Orthop

    (1984)
  • M.H. Jahss

    Hallux valgus: further considerations—the first metatarsal head

    Foot Ankle

    (1981)
  • P. Kinnard et al.

    A comparison between Chevron and Mitchell osteotomies for hallux valgus

    Foot Ankle

    (1984)
  • R.A. Mann

    Complications associated with the Chevron osteotomy

    Foot Ankle

    (1982)
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