The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 9

Scientific Articles | September 01, 2007

Blood Supply to the First Metatarsal Head and Vessels at Risk with a Chevron Osteotomy

J.J. George Malal, MBBS, DOrtho, MS(Ortho), DNB(Ortho), MRCS¹; J. Shaw-Dunn, BSc, MBChB, PhD, FRCS, AIAS²; C. Senthil Kumar, FRCS(Tr&Orth)³

¹ MRCS 36 Nazareth House Lane, Widnes, Cheshire WA8 8UE, United Kingdom. E-mail address: drjobyjacob@rediffmail.com
² Department of Human Anatomy, University of Glasgow, Glasgow G12 8QQ, United Kingdom
³ Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Human Anatomy, University of Glasgow, Glasgow, United Kingdom

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Sep 01;89(9):2018-2022. doi: 10.2106/JBJS.F.01030

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Abstract

Background: Chevron osteotomy, a commonly performed procedure for the treatment of hallux valgus, results in osteonecrosis of the first metatarsal head in 0% to 20% of cases. The aim of this study was to map out the arrangement of the vascular supply to the first metatarsal head and its relationship to the limbs of the chevron osteotomy.

Methods: Ten cadaveric lower limbs were injected with an India ink-latex mixture, and the feet were dissected to assess the blood supply to the first metatarsal head. The dissection was carried out by tracing the branches of the dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy was mapped, with the limbs of the osteotomy set at an angle of 60° from the geometric center of the first metatarsal head. The relationship of the limbs of the osteotomy to the blood vessels was recorded.

Results: The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal, and medial plantar arteries. The first dorsal metatarsal artery was the dominant vessel among the three arteries in eight specimens. All of the vessels formed a plexus at the plantar-lateral aspect of the metatarsal neck, just proximal to the capsular attachment, with a varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck.

Conclusions: The identification of the plantar-lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long plantar limb exiting well proximal to the capsular attachment may decrease the postoperative prevalence of osteonecrosis of the first metatarsal head.

Figures in this Article

Use of a lateral displacement chevron osteotomy of the first metatarsal head to treat mild-to-moderate hallux valgus deformity was first described by Austin in 1962 and has since been widely adopted and practiced^1-4. A perceived limitation of this procedure has been the risk of osteonecrosis of the metatarsal head fragment, the prevalence of which has been reported as ranging from 0% to 20%, although more recent reports have indicated a very low prevalence^1,4-8. There is also controversy about an increased risk of osteonecrosis from an additional lateral soft-tissue release^5-7,9,10.

The vascular damage to the metatarsal head is caused by the disruption of the intramedullary blood supply by the osteotomy itself and by the limbs of the chevron cut, which may further damage the metaphyseal vessels on the surface¹¹. This risk is aggravated by overpenetration of the saw blades or injury during a lateral soft-tissue release¹².

The blood supply to the first metatarsal head was described in detail by Shereff et al.¹³ and Sarrafian ¹⁴. According to those descriptions, the dorsal aspect of the metatarsal head is penetrated by two large dorsomedial and dorsolateral metaphyseal branches, which supply the dorsal two-thirds of the head. Two smaller metaphyseal arteries penetrate the plantar aspect of the head, supplying its plantar one-third. Smaller capital arteries penetrate the head medially and laterally, supplying the medial and lateral fourths of the head.

These descriptions by Shereff et al.¹³ and Sarrafian¹⁴ suggesting the predominance of dorsal metaphyseal vessels in supplying the first metatarsal head were contrary to our observations during limited exposures of the metatarsal head for routine hallux valgus surgery, as we could not identify any substantial vessels entering the dorsal aspect. The purpose of this study was to review the vascular supply of the first metatarsal head and to establish the position of the supplying vessels in relation to the chevron osteotomy of the distal part of the first metatarsal.

Materials and Methods

Materials and Methods | Results | Discussion | References

Ten cadaveric lower limbs in which the arteries had been injected with an India ink-latex mixture were dissected. The mixture was injected into the femoral or carotid arteries, and only specimens showing complete distal penetration of the dye mass were included in the study. None of the specimens had had any previous surgical interventions or had documented vascular abnormality. Two of the specimens had a frank hallux valgus deformity. The first metatarsal was exposed through a medial longitudinal incision and was carefully dissected, with preservation of all vessels entering the bone. A medial bunionectomy was performed, and the limbs of a standard chevron osteotomy were marked out. The geometric center of the metatarsal head was used as the starting point for osteotomies of equal length placed at an angle of 60° to each other, according to the original description by Austin and Leventen¹. No templates were used for standardization between specimens.

The arterial distribution was followed distally from the dorsalis pedis and posterior tibial arteries, exposed through separate incisions. After the arterial supply on the dorsal, plantar, and medial surfaces had been recorded, the metatarsal was dislocated from the first tarsometatarsal joint and rotated forward and medially to expose the vessels on the lateral aspect. The spatial distribution of the vessels in relation to the first metatarsal and the limbs of the chevron osteotomy was recorded, as was the prominence of the vessels in relation to one another.

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Fig. 1: Photograph showing the main arteries supplying the first metatarsal (MT) head and the course of the dorsalis pedis. The first metatarsal has been removed to aid visualization.

Results

Materials and Methods | Results | Discussion | References

The dorsalis pedis artery plunged plantarward in the first web space at the level of the first tarsometatarsal joint and gave off the first dorsal and plantar metatarsal branches at a variable distance along the lateral aspect of the first metatarsal shaft. The first dorsal metatarsal branch continued in a plantar direction and was found below the level of the equator of the metatarsal head, in close relation to the adductor hallucis tendon before it divided into the dorsal digital vessels and entered the hallux. The first plantar metatarsal artery curved around the plantar-lateral corner of the distal part of the metatarsal shaft and was found to anastomose with the superficial branch of the medial plantar artery in five of the specimens.

The nutrient artery to the first metatarsal shaft was found to arise from the first dorsal metatarsal artery in nine of the specimens, whereas it was found to branch directly from the dorsalis pedis artery in one specimen. The location of the nutrient artery was found to be very variable in the middle third of the metatarsal shaft laterally.

The first metatarsal head received its extraosseous blood supply from the first dorsal metatarsal and first plantar metatarsal arteries (both branches of the dorsalis pedis) and from the superficial branch of the medial plantar artery (Fig. 1). The first dorsal metatarsal artery was the direct continuation of the dorsalis pedis artery and was the prominent vessel of the three arteries in eight of the specimens. In the remaining two specimens, the first plantar metatarsal artery was larger. A contribution from the medial plantar artery could not be identified in three of the specimens.

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Fig. 2: Photograph showing the position of the first dorsal and plantar metatarsal arteries in relation to the proposed chevron cuts.

Both the dorsal and the plantar metatarsal branches of the dorsalis pedis artery were found immediately adjacent to the lateral surface of the distal part of the first metatarsal shaft and could easily be damaged from any overpenetration of a saw blade during the creation of a chevron osteotomy or from a scalpel during a lateral release (Fig. 2). All of the three vessels gave off branches to form a plexus at the plantarlateral corner and the adjoining surfaces of the metatarsal neck. From this plantar-lateral plexus, a variable number of perforators entered the metatarsal head just proximal to the capsular attachment on its plantar-lateral aspect (Fig. 3). The plantar limb of the proposed chevronosteotomy emerged through this plexus in all of the specimens. Only a few minor vessels were found entering the metatarsal head on its medial and dorsal surfaces.

Discussion

Materials and Methods | Results | Discussion | References

Our observation that the plantar-lateral corner of the first metatarsal neck is the predominant site for vascular ingress, with only a few minor vessels being identified on the dorsal surface, is contrary to the descriptions by Shereff et al.¹³ and Sarrafian¹⁴. Shereff et al. injected the blood vessels with acrylic and then dissolved the soft tissues with sodium hypochlorite to reveal the extraosseous vascular anatomy. As they observed, this resulted in the digestion of smaller vessels or caused them to be obscured. They used a different set of harvested metatarsals to describe the intraosseous blood supply. We believe that the difference between their technique and our method, which involved dissection of the specimens rather than digestion of the soft tissues, may be the reason for the divergence between our findings with regard to the smaller vessels and their distribution.

Our study, in which specimens were injected with latex and India ink, had its own limitations. Although we had been careful with regard to assessing and confirming distal perfusion of the dye, there could still have been regional variability in the extent of the penetration of the dye, which could have affected our observations. Also, only two of the specimens had a hallux valgus deformity, although there is no indication that this could have affected the vascular anatomy or our observations.

The frequency of osteonecrosis and its complications following a distal chevron osteotomy with or without a lateral soft-tissue release is still being debated, although its true prevalence appears to be very low. However, vascular injuries do occur to a variable extent and need to be avoided¹⁵. Kuhn et al. measured blood flow to the first metatarsal head during twenty chevron osteotomies and documented a 71% decrease in the flow after completion of the procedure, although none of these cases progressed to detectable osteonecrosis¹⁶. It is evident that precautions need to be taken to protect this vascular supply during the chevron procedure.

In a study of the blood supply to the first metatarsal head in relation to chevron osteotomies, both with and without a lateral release, in cadavera, Jones et al. were, to our knowledge, the first to acknowledge the existence of an extensive plantar-lateral network of vessels supplying the capital fragment¹². They suggested that soft-tissue stripping proximal to the capsular attachment should be avoided and recommended releasing the lateral aspect of the capsule through the metatarsophalangeal joint to protect the proximal and lateral perforators.

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Fig. 3: Photograph showing the plexus of vessels entering the plantar-lateral corner of the metatarsal neck.

The prospect of routine chevron osteotomy cutting off this vital blood supply is disconcerting and merits attention. We agree with Jones et al.¹² that technical errors during the osteotomy, along with extensive pericapsular stripping, have the greatest potential to cause osteonecrosis. On the basis of the results of our study, we suggest that performance of a chevron osteotomy with a long plantar limb exiting well proximal to the plantar capsule might decrease the risk of injury to the vessels and therefore may lessen the prevalence of osteonecrosis. A large case-control study is required to further validate this concept.

In conclusion, we identified the plantar-lateral corner of the distal part of the first metatarsal as the primary area for entry of metaphyseal vessels supplying the capital fragment. Performance of the distal chevron osteotomy with a long plantar limb may therefore decrease the risk of osteonecrosis. ?

References

Materials and Methods | Results | Discussion | References

Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally directed "V" displacement osteotomy of the metatarsal head for hallux valgus and primus varus. Clin Orthop Relat Res. 1981;157: 25-30.15725 1981 [PubMed]

Miller S, Croce WA. The Austin procedure for surgical correction of hallux abducto valgus deformity. J Am Podiatry Assoc. 1979;69: 110-8.69110 1979

Leventen EO. The Chevron procedure. Orthopedics. 1990;13: 973-6.13973 1990 [PubMed]

Johnson KA, Cofield RH, Morrey BF. Chevron osteotomy for hallux valgus. Clin Orthop Relat Res. 1979;142: 44-7.14244 1979 [PubMed]

Trnka HJ, Zembsch A, Wiesauer H, Hungerford M, Salzer M, Ritschl P. Modified Austin procedure for correction of hallux valgus. Foot Ankle Int. 1997;18: 119-27.18119 1997 [PubMed]

Resch S, Stenstrom A, Gustafson T. Circulatory disturbance of the first metatarsal head after Chevron osteotomy as shown by bone scintigraphy. Foot Ankle. 1992;13: 137-42.13137 1992 [PubMed]

Meier PJ, Kenzora JE. The risks and benefits of distal first metatarsal osteotomies. Foot Ankle. 1985;6: 7-17.67 1985 [PubMed]

Wilkinson SV, Jones RO, Sisk LE, Sunshein KF, Van Manen JW. Austin bunionectomy: postoperative MRI evaluation for avascular necrosis. J Foot Surg. 1992;31: 469-77.31469 1992 [PubMed]

Peterson DA, Zilberfarb JL, Greene MA, Colgrove RC. Avascular necrosis of the first metatarsal head: incidence in distal osteotomy combined with lateral soft tissue release. Foot Ankle Int. 1994;15: 59-63.1559 1994

Neary MT, Jones RO, Sunshein K, Van Manen W, Youngberg R. Avascular necrosis of the first metatarsal head following Austin osteotomy: a follow up-study. J Foot Ankle Surg. 1993;32: 530-5.32530 1993

Weinraub GM, Meberg R, Steinberg JS. Vascular perfusion of the long dorsal arm versus chevron osteotomy: a cadaveric injection study. J Foot Ankle Surg. 2004;43: 221-4.43221 2004 [PubMed][CrossRef]

Jones KJ, Feiwell LA, Freedman EL, Cracchiolo A 3rd. The effect of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head. J Bone Joint Surg Am. 1995;77: 197-204.77197 1995

Shereff MJ, Yang QM, Kummer FJ. Extraosseous and intraosseous arterial supply to the first metatarsal and metatarsophalangeal joint. Foot Ankle. 1987;8: 81-93.881 1987 [PubMed]

Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographic, functional. 2nd ed. Philadelphia: Lippincott; 1993. p 294-312,319-21,342-5.294 1993

Easley ME, Kelly IP. Avascular necrosis of the hallux metatarsal head. Foot Ankle Clin. 2000;5: 591-608.5591 2000 [PubMed]

Kuhn MA, Lippert FG 3rd, Phipps MJ, Williams C. Blood flow to the metatarsal head after chevron bunionectomy. Foot Ankle Int. 2005;26: 526-9.26526 2005 [PubMed]

Topics

metatarsal bone ; osteotomy ; blood supply, arterial ; first metatarsal

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J.J. George Malal, J. Shaw-Dunn, C. Senthil Kumar; Blood Supply to the First Metatarsal Head and Vessels at Risk with a Chevron Osteotomy. The Journal of Bone & Joint Surgery. 2007 Sep;89(9):2018-2022.

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