Overview of Distal First Metatarsal Osteotomies

In 1881, Reverdin described a closing wedge osteotomy of the first metatarsal head with the apex laterally that also included excision of the medial eminence (Fig. 11-1A). His purpose was to realign the abducted hallux and remove the prominent bump. The procedure effectively reduces an abnormal proximal articular set angle but does not directly address the intermetatarsal angle. Since the time when Reverdin first described his osteotomy, there have been a number of modifications. Roux, in 1920, described an osteotomy of the first metatarsal in which the capital fragment has a long lateral beak (see Fig. 11-1B). There are three cuts to this osteotomy. The first or distal cut is dorsal to plantar, through and through, made in the metaphyseal region of the first metatarsal head. The second or proximal cut transects the entire first metatarsal, thereby mobilizing the capital fragment. After the capital fragment is mobilized, the third osteotomy is made perpendicular to the first cut and completes a trapezoidal section of bone, which is resected. The distal capital fragment is then transposed laterally and tilted medially, closing the trapezoidal space. Similar in design to the Mitchell osteotomy, the Roux osteotomy addressed both transverse plane deformity of the metatarsal head and the intermetatarsal angle. Peabody, in 1931, reported an operation almost identical in location and purpose to that of Reverdin. Peabody performed this osteotomy more proximal than did Reverdin in the anatomic neck (see Fig. 111C). The osteotomy does not quite transverse the entire width of the bone, but leaves the articular or capital fragment attached by a thin segment from the lateral side of the neck and shaft area; at this site, there is undisturbed continuity of capsule and periosteum. Another modification of the Reverdin is the distal L osteotomy, referred to at times as the Reverdin-Green procedure (see Fig. 11-1D). The first cut constructed is transverse, proximal, and parallel to the joint surface. The second dorsal cut is then perpendicular to the shaft of the metatarsal, in the frontal body plane. This creates a wedge that will enable the joint surface to be realigned, properly adjusting the proximal articular set angle. The plantar osteotomy is then made parallel as a shelf protecting the sesamoid articulation surface of the first metatarsal. Transposition of the capital fragment is achieved by completion of the osteotomy laterally. The Reverdin corrects for abnormality of the proximal articular set angle, but the modifications also address the intermetatarsal angle.