150
Original article Clin Ter 2016; 167 (6):e150-154.
Reverdin-Isham osteotomy versus Endolog system for
correction of moderate hallux valgus deformity:
a Randomized Controlled Trial
L. Di Giorgio1, L. Sodano2, G. Touloupakis2, D. De Meo2, L. Marcellini2
1
Consultant Physician, Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, University of Rome
“Sapienza,” Rome; 2 MD, Orthopaedic and Traumatology. Department of Anatomical, Histological,Forensic Medicine and Orthope-
dic Science, University of Rome “Sapienza,” Rome, Italy
Abstract
Objectives. Several procedures have been described for the
management of hallux valgus deformity. In this paper we would like
to compare our experiences with two techniques (Endolog system
and Reverdin-Isham osteotomy) with a randomized study. To our
knowledge, this is the first study to be reported in the literature, that
provides a detailed comparison of these two techniques to treat mo-
derate hallux valgus.
Materials and Methods. A total of 40 consecutive patients (40 feet)
with moderate symptomatic hallux valgus were randomly assigned
into two groups, to compare the results of Reverdin-Isham osteotomy
(group A,20 feet) and Endolog system (group B, 20 feet).
Results. The average follow-up was of 23.7 ±7.7months . The
average correction of HVA and IMA achieved in group A was 17.1°
±6.2° and 5.2° ±2.6° respectively, while in group B, it was 14°±6.2°
and 7.7°±2.6° respectively. The mean AOFAS score improved from
a pre-operative of 40.5 ±15.5 points to 90.3 ±5.3 points in group A,
and from 32.4 ±16.8 points to 89.2 ±10.5 in group B.
Conclusions. No statistically significant differences were detected
between the two groups with respect to the AOFAS score, HVA, and
IMA. Both groups showed good to excellent results.Clin Ter 2016;
167(6):e150-154. doi: 10.7417/CT.2016.1960
Key words: Endolog System, Mini-invasive Surgery, Moderate
Hallux Valgus, Percutaneous Surgery, Reverdin-Isham Osteotomy
Introduction
Hallux valgus (HV) is the most common deformity
affecting the first ray of the foot. It is more prevalent in
women and elderly, and is often associated with functional
deterioration and foot pain (1). Although HV has gained sub-
stantial attention in both older and recent literature, several
authors underlined the fact that a true prevalence estimate
for HV is difficult to ascertain (2-3). It has been defined as
deformity with progressive adduction and pronation of the
first metatarsal bone, abduction and pronation of the first
phalanx and lateral capsular retraction of the first metatar-
Correspondence: Luigi Di Giorgio, Largo Somalia 30/C, 00199 Roma, Italia. Tel.: +39.339.4952.650. E-mail: digiorgioluigi@siot.it
Copyright © Società Editrice Universo (SEU)
ISSN 1972-6007
Di Giorgio et al.
doi: 10.7417/CT.2016.1960
sophalangeal joint (4). More than 150 different operative
procedures were described for the treatment of hallux valgus.
Reverdin-isham osteotomy is a minimally invasive surgery
(MIS) performed through 3 to 5 mm long incision by tactile
sense using a mini blade for soft tissue separation and rotary
bur for osseous procedures most commonly under intrao-
perative image intensification. In contrast, Endolog system
is a mini-open surgery performed through 10-15 mm long
incisions with a traditional blade for soft tissue separation
and sagittal saw blade for osseous procedures under direct
visualization of the structures desired with intraoperative
image intensification final control (5). The first technique is
indicated for mild to moderate HV and the second one for
moderate to severe grade (6-7). As we separately performed
both techniques for the treatment of this deformity we
decided to report the results of each of the two procedures
in the correction of moderate HV in order to evaluate the
indications in this range of deformity.
Materials and methods
Between February 2011 to January 2013, 40 consecutive
patients with moderate HV (40 feet) were included in this
comparative randomized study. They were randomly assig-
ned into two groups: Group A (Reverdin-Isham osteotomy)
comprised 20 feet, while Group B (Endolog system) con-
sisted of 20 feet. The randomization was performed by the
same surgeon (DGL), with a 1:1 allocation ratio in blocks of
five patients. Moderate HV is defined by H.V.A. 20°-40°and
I.M.A. 14°-20° (8). Some patients presenting with HVA>40°
but IMA<20° were also included, as well as patients with
IMA>20° but HVA<40°. Exclusion criteria were: alteration
of metatarsal index or fingers pathology, neuromuscular
disorder, severe osteoarthritis of the first MTP joint, HV
reoperations. A minimum follow up of 12 months was hold.
Three patients did not show up for the follow-up ( 1 in group
A; 2 in group B). The 37 patients’ (1 male and 36 female)
average age was 42.4 ±9.9. (Table 1 A-B).
Level IB, randomized controlled trial 151

Table 1 A. Characteristic of the subjects in both groups at 3 months.

Characteristic of the subjects Group A Reverdin-Isham (n 19) Group B Endolog System(n 18) p- value A-B
Mean SD Mean SD
Age 40.8 ±7.9 44.2 ±11.6 .2
Follow up (months) 22 ±7.3 25.5 ± 7.8 .2
Duration of surgery (minutes) 24.7 ± 6.3 46.8 ± 7.7 <0.05
Radiation exposure (cGy cm2) 6.2 ±1.1 3.8 ±0.6 <0.05
Preoperative 30.2° ±6.6° 27.5° ±7.2° 0.2
HVA Postoperative 13.1° ±4.9° 13.4° ±4.4° 0.8
Difference 17.1°(p value<0.05) ±6.2° 14°(p value<0.05) ±6.2° 0.1
Preoperative 14.1° ±2.2° 15.9° ±3° 0.8
IMA Postoperative 8.9° ±2.4° 8.2° ±1.9° 0.3
Difference 5.2°(p value<0.05) ±2.6° 7.7°(p value<0.05) ±2.6° 0.6
.

Table 1B. Description of the trial. point scale divided into three main categories: pain, function
and alignement (9). At the end of the follow up patients
received an additional questionnaire. They were asked if
they were satisfied with the results of the surgery, if they
were satisfied with reservations and if they would get the
procedure again. All clinical examinations were performed
by one surgeon (DGL).

Radiographical evaluation

The HVA was measured in the anterior-posterior view

as the angle between the line connecting the center of the
proximal and the distal articular surfaces of the proximal
phalanx and the line connecting the center of the proximal
and the distal articular surfaces of the first metatarsal. The
IMA was measured as the angle between the former line and
the line connecting the center of the proximal and the distal
articular surfaces of the second metatarsal (10). The angles
were measured on radiographs using the GraphisoftArchi-
CAD 14 software at 4 weeks of follow-up.

Operative technique

All operations were performed by one orthopedic sur-

geon (DGL). All patients were operated with loco-regional
anesthesia in day surgery.

Group A: Reverdin-Isham osteotomy + Akin osteotomy

Clinical assessment
The evaluations were collected preoperatively and at
1, 3 and 12 months postoperatively. The feet were assessed
using hallux-metatarso-phalangeal-interphalangeal scale
of the American Orthopaedic Foot and Ankle Society (AO-
FAS). This widely used scoring system consist of a 100
(percutaneous)(Fig.1).
The patient was stabilized in supine position without
tourniquet. A 3-5mm incision in the medial and plantar
edge of the first-metatarsal head was followed by capsule
detachment to obtain working space. The medial eminence
was resected using a wedge burr with a high-torque, low-
speed drill to avoid bone or skin burn and necrosis, using
a small back-and-forth sweeping movement. The extent of
bone removal was controlled under fluoroscopy, and all of
the bony fragments were removed by pressure of the me-
tatarsal head after injection of normosaline into the joint.
Reverdin-Isham osteotomy was performed using a straight
burr with the same medial approach. The medial closed
wedge osteotomy of the first-metatarsal distal metaphysis,
parallel to the joint surface, was carried out from distal dor-
sal, just behind the joint space, to proximal plantar, behind
152 Di Giorgio et al.

Fig.1. X-ray check: preoperative, postoperative, at 3 months with the percutaneous technique.

the sesamoid bones, with a slope of 45° with conserved
lateral cortex. The hallux was then put in forced adduction,
enabling compression by osteoclasia with lateral cortex
rupture with a snap, medial closure of the Reverdin-Isham
osteotomy and DMAA correction. Lateral capsule ligamen-
tary release of the metatarsophalangeal joint was associated
with transverse adductor tenotomy by a separate incision.
In all patients a percutaneous osteotomy of the base of the
proximal phalanx (Akin) had been performed too: an inci-
sion (often the same of adductor tenotomy) is made over
the dorsolateral aspect of the base of the proximal phalanx,
laterally to the extensor tendon and then, going in subpe-
riosteum way under the tendon, with a straight burr 2-15
, starting from medial cortex, the osteotomy is performed
from medial to lateral, plantar to dorsal, using all soft tissue
(extensor tendon and skin) as the pivot point, leaving only
few millimeters of the lateral cortical bone intact; finally,
by applying pressure to the toe in medial direction, axial
correction is obtained. The osteotomies were stable without
internal fixation and, the correction of deformity had been
kept with a crepe bandage (11).
Group B: Endolog System (Fig.2)
An approximately 10-15mm dorsal medial incision
over the first metatarsophalangeal joint, and a linear cap-
sular incision were made. The bunion was then shaved

Fig. 2. X-ray check: preoperative, postoperative, 1month ,3 months. Note callus along the lateral cortex of the metatarsal at 3 months.
Level IB, randomized controlled trial
(exostosectomy). A linear or oblique osteotomy was then
made behind the head of the first metatarsus. An oblique
osteotomy enabled decompression of the articulation. The
mild shortening of the first metatarsal was compensated by
the plantarisation of the metatarsal head and release of the
articular space and of soft tissues. After insertion of a trial
device under fluoroscopic imaging guidance, an appropriate
size Endolog system was press-fitted into the intramedul-
lary bone of the first metatarsal. The angular stability screw
was inserted in the metatarsal head through the hole in the
plate. In all cases the adductor muscle attachment to the
base of the proximal phalanx was percutaneously divided;
a lateral capsulotomy could also be used in combination. A
good translation could be obtained with a mildly oblique
osteotomy of about 10° with respect to the perpendicular
line to the metatarsal axis (7).
Postoperative management
Group A: Postoperative dressing with bandage soaked in
Betadine® for 4 weeks maintained the correction and kept
the osteotomies closed. A clinical check was performed at
15 days with bandage renforcing. Complete weight-bearing
was resumed immediately, with Podalux® postoperative
shoe for the first month.
Group B: Anon rigid bandage and Podalux® postopera-
tive shoe were used for 4 weeks. Full weight-bearing was
immediately allowed. A clinical check was performed 15
days later with stiches removing.
In both groupsX-ray check was performed at 1 and 3
months post-intervention.
Postoperative analgesic pain control
All patients received postoperative as analgesic therapy:
etoricoxib 120 mg/ day for 5 days + oxycodone hydrochlo-
ride/naloxone 5mg × 2/day for 15 days (12).
Statistical Analysis
The two-tailed test with equal variances was used to
compare preoperative and follow-up AOFAS scores, IMA
and HVA angles. A p value of <0.05 was considered statisti-
cally significant.
Results
All patients were followed up for at least 12 months
with an average of 23.7 ±7.7 months (range, 38-12 mon-
ths) (Tab.1.). The average operative time was significantly
Table 3. Patients satisfaction at the end of follow-up.
Patients Satisfection Satisfied Satisfied with reservation
Group A (19pt) 15 (79%) 4 (21%)
Group B (18pt) 14 (77.8%) 3 (16.7%)
Total (37pt) 29 (78.4%) 7 (18.9%)
153
shorter in Group A 24.7 ±6.3 min than group B 46.8 ±7.7
min (p value <0.05) (Tab. 1). X-ray exposition in cGy
cm2 for the surgeon Reverdin-Isham + Akin: average 6.2
±1.1 cGy cm2 (range, 4.6-9.2), Endolog: average 3.8 ±0.6
cGy cm2 (range, 3.1-5.1) (Tab. 1). Both groups achieved
significant improvement of HAV, IMA and AOFAS scores
from the preoperative range (P value <0.05). No significant
radiographic and clinical differences between Reverdin-
Isham and Endolog groups could be detected. The average
correction of HVA and IMA achieved in group A was 17.1
and 5.2, respectively, while in group B, it was 14 and 7.7,
respectively. The mean AOFAS score improved from a
preoperative score of 40.5 points to 90.3 points in group
A and from 32.4 points to 89.1 points in group B. Detailed
postoperative data are shown in Table 1 and Table 2. There
were no complications regarding wound infection, foreign
body reaction, nonunion and secondary metatarsalgia. None
of the patients had postoperative hallux varus deformity and
AVN of first metatarsal’s head. In the percutaneous group,
15 patients declared satisfied, 4 satisfied with reservations
and 0 patients declared unsatisfied. In group B 14 patients
claimed to be satisfied , 3 satisfied with reservations and
1 unsatisfied. The (94,7%) and (94,4%) of group A and B
respectively would have the procedure again (Tab. 3).
Discussion
In the present study, we report for the first time a detailed
comparison of Reverdin-Isham osteotomy + Akin (percuta-
neous) and Endolog System (minincisional) for moderate
HV. There is a large number of papers focused on Reverdin-
Isham osteotomy (6-11-13), but only in one midterm study
reported, 25 patients (33 foot) (with moderate to severe
HV) were treated with Endolog System (7). Both technique
were effective in the correction of moderate HV. The mean
correction of HVA and IMA achieved with percutaneous
procedure was 17, 1° and 5,2° respectively. This angular
correction is comparable and consistent with the reported
radiographic results obtained with other percutaneous first-
ray distal metatarsal osteotomy procedures, with or without
osteosynthesis (6-14-15). Bauer at al obtained a significant
reduction of the IMA angle from 13° preoperatively to 10°
and HVA from 28° to 14° (6). The results obtained with
the Endolog system are similar with radiographic results
obtained by Schneider W and Trnka HJ with other open
metatarsal osteotomies (chevron osteotomy) (16-17). We
did not find significant differences neither in relation to the
AOFAS score nor to the achieved correction’s degree. The
perceived pain was similar in both techniques. The short
follow-up did not allow us to determine whether there may
have been important differences in relation to correction
Unsatisfied Again No more
0 (0%) 18 (94.7%) 1 (5.3%)
1 (5.5%) 17 (94.4%) 1 (5.6%)
1 (2.7%) 35 (94.6%) 2 (5.4%)
154
worsening; it would be interesting to investigate these details
in a long term follow-up. Bauer et al, reported a significantly
elevated risk of postoperative first MTP joint non congruency
of 17% for isolated first-ray surgery, and 47% in case of
associated lateral ray surgery (13). The residual intracap-
sular bony fragments increase other risk of joint stiffness.
In our series we didn’t reported these complications. The
Endolog system allows to modify the hallux’s length causing
a shortening of the first metatarsal ray. We didn’t have in
these series, but in presence of arthrosic more rigid hallux
we prefer to correct the deformity performing an oblique
osteotomy with mild retro-position of the metatarsal head
and a stabilization with Endolog, instead of percutaneous
technique, in order to gain articular decompression. Even
in patients with a pronounced hallux pronation we prefer to
perform a triplanar correction of the deformity with Endolog
System. Percutaneous technique needs less operating time
then open surgery and this could be a valid reason to prefer
it. Postoperative bandage is determinant for the stability of
the osteotomy after percutaneous correction and we the-
refore consider the patient’s compliance of fundamental
importance for the surgical planning. As expected, radiation
amount is significantly lower with the Endolog system. Low-
cost differences were reported between the two techniques
for operating materials but only because of the fact that
monouse burrs are still very expensive in our Institute. If we
consider also occupation of the operating theatre the cost
is surely higher for the correction with Endolog system.
The two techniques used in this study for the correction of
moderate HV were comparable to those of most minimally
invasive or percutaneous procedures, with 97, 3% of patients
satisfied or satisfied with reservation at 1 year of follow-
up. The present study however includes certain limitations,
and notably a minimum follow-up of no longer than 1 year.
Longer-term assessment will be required to confirm the
present findings, both clinically and in terms of angular
correction. Another limit would be the small number of
cases compared, but both groups are well balanced with no
significant differences in the preoperative data. Based on the
results obtained, we report that both techniques are valid and
strongly recommended for the correction of moderate HV.
The learning curve is similar but operation with Endolog sy-
stem is more expensive at least. In our daily clinical practice
we use both techniques but in young compliant patients, who
may also be concerned about aesthetic results, we prefer to
perform percutaneous technique for moderate HV.
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