[Metatarsal osteotomies for hallux valgus]

Proximal metatarsal osteotomy for hallux valgus: an audit of radiologic outcome after single screw fixation and full postoperative weightbearing

Background

Proximal metatarsal osteotomy combined with a distal soft-tissue procedure is a common treatment for moderate to severe hallux valgus. Secure stabilisation of the metatarsal osteotomy is necessary to avoid complications such as delayed union, nonunion or malunion as well as loss of correction. The aim of this study was to report our results using a single screw for stabilisation of the osteotomy.

Methods

We retrospectively reviewed 151 patients with severe hallux valgus who were treated by the above mentioned way with full postoperative weightbearing in a stiff soled shoe. Mean age of patients at time of surgery was 54 years, 19 patients were male and 132 female. Assessment of clinical and radiographic results was performed after 2 days and 6 weeks. Results were also correlated to the experience of the performing surgeon.

Results

Mean preoperative HVA (hallux valgus angle) was 36.4 degrees, and then 3.5 degrees 2 days and 13.4 degrees 6 weeks after the procedure (p < 0.001). Mean preoperative IMA (intermetarsal angle) was 16.8 degrees, and then 6.4 degrees after 2 days and 9.8 degrees after 6 weeks (p < 0.001). Mean preoperative first metatarsal length of 56.4 mm decreased to 53.6 mm after 6 weeks. Possible non-union of the osteotomy was observed in 4 patients (2.6%) after 6 weeks. Performing residents (n = 40) operated in 65 minutes and attending surgeons (n = 111) in 45 minutes, with no significant differences in radiographic measurements between both groups.

Conclusions

Single screw stabilisation of proximal chevron osteotomy is a reliable method for treating severe hallux valgus deformities with satisfactory results.

The Endolog system for moderate-to-severe hallux valgus

PURPOSE

To report the midterm outcome of the Endolog system for correction of moderate-to-severe hallux valgus.

METHODS

23 women and 2 men (33 feet) aged 35 to 80 (mean, 52) years underwent minimally invasive surgery for moderate (n=25) and severe (n=8) hallux valgus using the Endolog system. The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the proximal articular set angle (PASA) were measured on radiographs. The feet were also assessed based on the American Orthopaedic Foot and Ankle Society (AOFAS) scale.

RESULTS

The mean follow-up duration was 18.2 (range, 12-36) months. The mean HVA, IMA, PASA, and the mean AOFAS score improved significantly after surgery (all p<0.0001). Periosteal reaction was noted by week 4, and callus formation after 3 months. There were no delayed or non-union or other complications.

CONCLUSION

The Endolog system achieved good outcome for moderate-to-severe hallux valgus.

Comparison of outcomes between proximal and distal chevron osteotomy, both with supplementary lateral soft-tissue release, for severe hallux valgus deformity

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity.

Cite this article: Bone Joint J 2013;95-B:510–16.

The treatment of hallux valgus

BACKGROUND

Hallux valgus is the commonest forefoot deformity, with an estimated prevalence of 23% to 35%. It causes symptoms on the medial edge of the foot, the sole, and the small toes. Non-operative treatment may alleviate symptoms but does not correct the deformity of the big toe. Surgery is indicated if the pain persists. The correct operation must be selected from a wide variety of available techniques.

METHODS

In this article, we selectively review the pertinent literature, including the recommendations of medical societies in Germany and abroad, in the light of our own clinical experience.

RESULTS

There have been many clinical trials of various treatments for hallux valgus, but very few of these were randomized, and the case numbers were generally small. Mild deformities are best treated by distal first metatarsal osteotomies, e.g. the Chevron osteotomy. Severe deformities require a soft-tissue procedure at the first metatarsophalangeal joint and a proximal first metatarsal osteotomy. In case of osteoarthritis, and in elderly patients, a resection arthroplasty is preferred; arthrodesis is performed in physically active patients. After correction of hallux valgus, patients can usually bear their full weight on the treated foot while wearing a flat surgical shoe. Proper surgical treatment results in a good or very good outcome in 85% of patients and a satisfactory result in a further 10%.

CONCLUSION

The clinical outcome of present treatments seems to be good in most cases, but large-scale randomized trials are still needed to verify the efficacy of the wide variety of operations and fixation techniques that are currently being offered.

[Failures of hallux valgus surgery]

More than 150 corrective procedures for hallux valgus exist and an incorrect choice of procedure leads to insufficient correction. Distal first metatarsal osteotomy cannot correct large deformities and degenerative changes at the metatarsophalangeal joint impede functional recovery. Incongruence of the joint must be corrected during surgery. Recurrence is most often caused by insufficient correction, especially of the first metatarsal bone. Overcorrection is often due to technical problems with the initial metatarsal osteotomy. This also applies to insufficiency of the first ray due to shortening or dorsal angulation. Partial first metatarsal head necrosis occasionally occurs but complete necrosis is rare. Non-union is mostly caused by incorrect osteosynthesis. During postoperative treatment the hallux must be held in the correct position to avoid failure.

Chevron osteotomy with lateral release and adductor tenotomy for hallux valgus

BACKGROUND

Distal chevron osteotomy is a procedure widely performed for the surgical treatment of painful hallux valgus. The risks and benefits of a lateral capsular release and adductor tenotomy combined with chevron osteotomy are still debated. The aim of our study was to report the clinical and radiographic outcomes of this combined procedure in mild and moderate incongruent bunion deformities, with a hallux valgus angle (HVA) up to 40 degrees and an intermetatarsal angle (IMA) up to 20 degrees.

MATERIALS AND METHODS

Forty-two patients (52 feet) who consecutively underwent chevron osteotomy combined with lateral release and adductor tenotomy were reviewed 24-36 months after surgery. The mean age of the patients was 53.5 (range, 43 to 64) years. All the deformities were mild to moderate, with a mean preoperative value of 28 degrees in the HVA (range, 16 degrees to 40 degrees) and of 13 degrees in the IMA (range, 9 degrees to 20 degrees).

RESULTS

At followup, the AOFAS hallux score improved from an average of 46 to an average of 88. The HVA and IMA had an average postoperative decrease respectively of 12 degrees and 6 degrees; lateral sesamoid displacement decreased by a mean of 15%. In no case did we observe infection or nonunion of the osteotomy. In one case, painless avascular necrosis of the first metatarsal head developed.

CONCLUSION

Our short-term results show that distal chevron osteotomy combined with lateral release and adductor tenotomy is a feasible surgical option to address mild to moderate hallux valgus deformity, even with an IM angle between 15 and 20 degrees. Clinical and radiographic outcomes are generally good and patient satisfaction is generally high.

Arthrodese des MTP-I-Gelenks

Arthrodesis of the first metatarsophalangeal joint is a useful technique for the surgical treatment of hallux rigidus, complicated hallux valgus and rheumatoid forefoot deformity, and for revisions following resection arthroplasty or explantation of a prosthesis combined with interposition of a tricortical bone graft. In primary operations, good or excellent results can be achieved in 80-90% of patients. The articular surface and any exostoses or osteophytes are first resected aiming for a 15-30 degrees extension of the metatarsophalangeal angle and a 5-15 degrees valgus angle. Pseudarthroses occur in 10-13% of arthrodeses stabilized with screws or k-wires. When using a plate for fixation, the rate of pseudarthroses is below 6%. Only a small number of pseudarthroses require revision surgery. Up to 15% of patients develop mostly asymptomatic degeneration of the interphalangeal joint of the hallux.