Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?

First tarsometatarsal arthrodesis for severe hallux valgus using the tension band principle - Technical tip and case series

BACKGROUND

Hallux valgus (HV) is a common foot pathology. Severe HV in the presence of Tarsometatarsal joint (TMTJ) instability is often managed with arthrodesis of the 1st TMTJ. There are concerns regarding non-union and malunion (particularly the early loss of inter-metatarsal angle correction before complete arthrodesis). We report our medium-term results of a small series of patients that underwent an evolved surgical technique utilising orthogonal staples and a transverse suture button fixation to address biomechanical concerns with traditional Lapidus arthrodesis.

METHODS

A retrospective study of a consecutive series of patients who underwent this surgical technique between February 2017 and May 2022. Clinical outcomes were validated through Patient-reported outcomes measures (PROMS); EuroQol-5 Dimension (EQ-5D) and Manchester-Oxford Foot Questionnaires (MOXFQ). Radiographic parameters (hallux valgus (HVA), intermetatarsal (IMA), distal metatarsal articular angle (DMAA)) were assessed. Union of the arthrodesis and complications were recorded.

RESULTS

During the study period, 9 feet underwent the procedure. Radiographic data was available for all nine and PROMS data for seven (77.8%). Significant improvement occurred in all radiographic deformity parameters at mean 6-month follow-up. Mean ± standard deviation correction calculated preoperatively as HVA 40.2°, IMA 19.3° and DMAA 15.8°, corrected to HVA 15.4°, IMA 5.8° and DMAA 5.9° postoperatively. (HVA; P < 0.001, IMA; P < 0.001, DMAA; P < 0.001) Clinical PROMs at mean follow-up of 2 years were MOXFQ 34.4 ± 25.2, EQ-5D-5 L 0.819 ± 0.150 and VAS pain 13.6 ± 13.6. There were no cases of non-union, Tibialis anterior tendon irritation or hallux varus. Complications included first MTPJ stiffness in one case and CRPS and dorsiflexion malunion of the first ray in another patient.

CONCLUSION

This preliminary study of the procedure used in this series confirm this is a safe surgical technique to address severe HV with a low rate of non-union and significant radiographic improvements. A larger patient dataset is needed to evaluate this procedure robustly.

Utility of the modified 5-item frail index to predict complications and reoperations after hallux valgus percutaneous surgery

INTRODUCTION

The modified 5-item frailty index (mFI-5) has been recently proposed as a useful tool for predicting postoperative complications in orthopedic surgery. We aimed to analyze the utility of this score in predicting complications and reoperations after hallux valgus (HV) deformity surgery.

METHODS

551 patients undergoing percutaneous HV corrective surgery were retrospectively reviewed. The mFI-5 was calculated based and patients were categorized in three groups: 1) non-frail: patients without any of the 5 comorbidities, 2) pre-frail: patients with one comorbidity and 3) frail: patients with two or more comorbidities. Complications and surgical reoperations were recorded.

RESULTS

In the study period 772 percutaneous surgeries were performed to correct HV deformity, 551 patients were included with a median age of 60 (IQR 48-70). Three hundred eighty-nine patients were non-frail (70.6%), 132 were pre-frail (23.9%) and 30 were frail (5.4%). 75 patients suffered complications (13.6%). Even though the rate of complications was higher in frailty patients (23.3%) compared with pre-frail (13.6%) and non frail (12.8%), no significant differences were observed among groups. 48 patients required reoperation (8.7%) but the rate of reoperations among frailty groups was not significantly different (P=.11). Frailty patients had worse AOFAS scores at final follow up (P=.011).

CONCLUSION

The mFI-5 was not useful to predict postoperative complications and reoperations after hallux valgus corrective surgery. Therefore, other factors should be considered when analyzing the risk of complications after HV corrective surgery.

Hallux Valgus Bunion Splint: Surgical Dressing Technique

BACKGROUND

Hallux valgus is a common condition with a complex etiology resulting in numerous treatment options. Recurrence of the deformity can occur following correction. Surgical technique and possibly also postoperative care play a role in reducing recurrence rates. This article highlights a postoperative surgical dressing technique which allows for semirigid support during the immediate postoperative period.

METHODS

A wooden tongue depressor placed along the medial border of the hallux comprises the primary support for the dressing. The rigidity of the tongue depressor allows for the hallux to be drawn toward the depressor, encouraging neutral alignment of the hallux. Dressings are removed 2 weeks postoperatively, with new dressings applied in similar fashion and maintained in place until 6 weeks postoperatively.

RESULTS

Based upon our observations, our surgical dressing technique provides sufficient support following hallux valgus correction surgery while being straightforward to replicate without the need for frequent dressing changes. The dressing materials are of negligible cost and are typically readily available. No associated wound complications have been observed.

CONCLUSIONS

We present an easily replicable and affordable option for postoperative hallux valgus correction surgical dressings.

LEVELS OF EVIDENCE

Level V: Expert Opinion.

Minimally Invasive Chevron Akin Osteotomy: Preoperative Planning Using the Radiographic First-Ray Squeeze Test

Background

Recognizing preoperative first-ray hypermobility is important to planning hallux valgus (HV) surgery. A recent study showed the minimally invasive chevron Akin (MICA) osteotomy increased varus displacement of the proximal fragment of the first metatarsal osteotomy. The present study aims to evaluate the ability of the radiographic first-ray squeeze test to predict the varus displacement of the proximal fragment of the first metatarsal osteotomy when performing the MICA procedure.

Methods

A prospective case series of patients with moderate to severe HV who underwent MICA was performed. The HV deformity correction was analyzed by comparing the preoperative and 12-week postoperative hallux valgus angle (HVA) and the intermetatarsal angle between the first and second rays (1-2 IMA). The ability of the radiographic first-ray squeeze test to predict the varus displacement of the first metatarsal was done by comparing the preoperative 1-2 IMA measured in the AP radiographic first-ray squeeze test (IMA-ST) with the intermetatarsal angle between the second metatarsal and the axis of the first metatarsal osteotomy proximal fragment (IAPF) taken 12 weeks postoperatively.

Results

Between July 2022 and May 2023, a total of 39 feet in 28 patients underwent MICA. The mean IMA improved from 13.8 (SD = 2.2) to 3.8 degrees (SD = 1.5) (P < .001), and the mean HVA improved from 27.8 (SD = 6.1) to 4.9 degrees (SD = 2.5) (P < .001). A linear regression analysis revealed that IMA-ST is highly associated with the 12 week assessed IAPF (P < .001).

Conclusion

The preoperative radiographic first-ray squeeze test appears to predict with high fidelity the varus displacement of the proximal fragment of the first metatarsal that can occur after the MICA procedure.Level of Evidence: Level III, prospective cohort study.

Utility of the modified 5-item frail index to predict complications and reoperations after hallux valgus surgery

INTRODUCTION

The modified 5-item frailty index (mFI-5) has been recently proposed as a useful tool for predicting postoperative complications in orthopedic surgery. We aimed to analyze the utility of this score in predicting complications and reoperations after hallux valgus (HV) deformity surgery.

METHODS

551 patients undergoing percutaneous HV corrective surgery were retrospectively reviewed. The mFI-5 was calculated based and patients were categorized in three groups: (1) non-frail: patients without any of the 5 comorbidities, (2) pre-frail: patients with one comorbidity and (3) frail: patients with two or more comorbidities. Complications and surgical reoperations were recorded.

RESULTS

In the study period 772 percutaneous surgeries were performed to correct hallux valgus deformity, 551 patients were included with a median age of 60 (IQR 48-70). 389 patients were non-frail (70.6%), 132 were pre-frail (23.9%) and 30 were frail (5.4%). 75 patients suffered complications (13.6%). Even though the rate of complications was higher in frailty patients (23.3%) compared with pre-frail (13.6%) and non frail (12.8%), no significant differences were observed among groups. 48 patients required reoperation (8.7%) but the rate of reoperations among frailty groups was not significantly different (p=0.11). Frailty patients had worse AOFAS scores at final follow up (p=0.011).

CONCLUSION

The mFI-5 was not useful to predict postoperative complications and reoperations after hallux valgus corrective surgery. Therefore, other factors should be considered when analyzing the risk of complications after HV corrective surgery.

Connection between medial dorsal cutaneous nerve and saphenous nerve: case report

PURPOSE

There are no data on the connection of the saphenous nerve (SN), located on the medial side of the foot, with the terminal branches of the superficial fibular nerve. The aim of this study is to reveal the variation that surgeons should pay attention to for anesthesia applied in foot surgeries.

METHODS

In this study, the left foot of a 70-year-old female cadaver fixed with formalin was dissected. The distance to the medial malleolus and the incision line was recorded using digital caliper to determine the reference points in the resulting variation.

RESULTS

It was observed that a branch from the SN, which arose from the SN and proceeded anteriorly to the upper part of the medial malleolus and continued towards the dorsum of the foot, hooked with a branch from the medial dorsal cutaneous nerve (MDCN). The branches arising from this hook were distributed on the medial edge of the foot up to the proximal metatarsophalangeal joint I. The distance of this nerve connection to the medial malleolus is 91.14 mm, and the distance to the incision line is 15.76 mm.

CONCLUSIONS

It is suggested that the case presented as an unusual SN variation, which may affect the success of local anesthesia in invasive procedures to the medial part of the foot and could be considered in the evaluation of sensory loss after anteromedial surgical approach to the ankle, should be included in the classification of the cutaneous innervation pattern of the foot.

Minimally invasive Chevron Akin (MICA) osteotomy for severe hallux valgus

INTRODUCTION

The minimally invasive Chevron Akin (MICA) osteotomy has been widely used to treat hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure and to evaluate the clinical and radiographic outcomes.

MATERIALS AND METHODS

Retrospective study including 60 consecutive feet (52 patients) undergoing MICA for severe HV. The data were collected pre- and post-operatively at the last follow-up. Patients were clinically evaluated by the visual analog pain scale (VAS) and AOFAS hallux MTP-IP score. Radiographic assessments included measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length, distal metatarsal articular angle (DMAA), and plantar translation of MT head. The complications were recorded during the follow-up.

RESULTS

The mean age was 59.9 years, and the mean follow-up was 20.5 months. The average AOFAS increased from 41.2 to 90.9 points, and the VAS from 8.1 to 1.3 at the last follow-up. The average HVA decreased from 41.2º to 11.6º, the IMA from 17.1º to 6.9º, and the DMAA from 17.9º to 7.8º. The average shortening of the first metatarsal and the plantar translation of the MT head was 5.1 mm and 2.8 mm, respectively. The most observed complication was hardware discomfort, observed in 5 feet (8.3%). There were two cases of recurrence (3.3%).

CONCLUSION

MICA technique was demonstrated in this series of cases to be an effective procedure for severe HV, with a low rate of recurrence and an acceptable rate of complications.

LEVEL OF EVIDENCE

IV; case series.

Radiographic and Patient-Reported Outcomes of a Low-Cost Modified Lapidus Bunion Correction Technique

Background

The modified Lapidus (ML) is a powerful procedure for correction of hallux valgus (HV) with emerging techniques. Studies considering patient-reported outcomes, radiographic measures, complications, and implant costs are currently limited.

Methods

Retrospective cohort with prospectively collected Patient Reported Outcome Information System Physical Function (PROMIS-PF) Computerized Adaptive Test (CAT) scores, radiographic parameters (intermetatarsal angle, IMA; hallux valgus angle, HVA; and tibial sesamoid position, TSP), complications, and total operative time and implant costs were reviewed from 2014 to 2019.

Results

Seventy-three feet (68 patients) underwent bunion correction by ML with lag-screw fixation. Median age was 55.8 years (IQR 45.6, 53.9), 4 of 73 (5.5%) were male, 11 of 73 (15.1%) were smokers, and 15 of 73 (20.6%) were diabetic (median HbA1c 6.4% [IQR 6.0, 7.4], none insulin dependent, 5 of 15 with neuropathy). Complications included 6 of 73 (8.2%) wound issues resolved with topical or oral treatment, 9 of 73 (12.3%) painful or broken hardware requiring hardware removal. Two of 73 (2.7%) had persistent pain despite union. One of 73 (1.4%) was overcorrected and required first MTP arthrodesis. Of 3 nonunions (2.7%), 1 resolved with corrected hypothyroidism, 1 was asymptomatic and required no treatment, 1 had a hallux valgus recurrence and sought revision surgery elsewhere. Preoperative radiographic angles were HVA 35 degrees, IMA 14 degrees which improved at final postoperative follow up to HVA 10 degrees, IMA 6 degrees. Tibial sesamoid position improved from 6.05 ± 1.00 to 2.22 ± 1.38. Thirty-two patients had preoperative and 42 had 1-year postoperative outcomes. PROMIS-PF (51% collection rate) was 43 (IQR 37,52) preoperatively, 37 (31, 39) at 6 weeks, 46 (42, 51) at 3 months, and 49 (41, 53) at >360 days postoperatively. The drop in PROMIS-PF between preoperative and 6 weeks and the rise from 6 weeks to 3 months were statistically significant. Pre- and postoperative PROMIS-PF scores were not significantly different. Implant cost averaged US$146.

Discussion/Conclusion

We report low complication rates and costs with high patient postoperative functional and radiographic outcomes. PROMIS-PF decreased acutely postoperatively but recovered and maintained high levels by 3 months postoperatively.

Level of Evidence

Level IV, case series.

Outcomes After Chevron Osteotomy with and Without Additional Akin Osteotomy: A Retrospective Comparative Study

Background

Chevron osteotomy is one of the most common approaches to hallux valgus corrective surgery. This procedure is often combined with Akin osteotomy of the proximal phalanx of the hallux. There are no definitive guidelines specifying the indications for a given osteotomy technique nor data on postoperative loss of correction or the effect of the type of first-ray surgery on the development of adjacent-joint arthritis. The aim of this study was to assess radiographic treatment outcomes via chevron osteotomy with and without Akin osteotomy.

Methods

The study evaluated 117 patients treated in the period 2016-2019. Ninety-nine of those patients underwent distal chevron osteotomy alone, and 18 patients underwent a combined chevron-Akin double osteotomy. The analyzed radiograms had been obtained preoperatively, at 6 weeks after surgery, and after a long-term follow-up. The following parameters were assessed: the intermetatarsal angle (IMA), hallux valgus angle (HVA), interphalangeal angle (IPA), postoperative recurrence of valgus deformity, adjacent-joint arthritis, and complications.

Results

Chevron-Akin osteotomy helped maintain lower HVA and IPA values in long-term follow-up in comparison with those in the patients who underwent chevron osteotomy alone. The chevron osteotomy group showed a significant increase in the mean HVA from 18.37° at the first follow-up visit to 20.81° at the last follow-up visit. There were no differences between the groups in terms of the remaining assessed radiographic parameters. Hallux valgus surgery does not increase adjacent-joint arthritis.

Conclusion

The use of combined chevron-Akin osteotomy does not affect HVA or IMA correction. The combination of chevron and Akin osteotomies reduces the risk of increased HVA and IPA in long-term follow-up. The additional Akin osteotomy does not increase the risk of adjacent-joint arthritis. Combining chevron osteotomy with Akin osteotomy is recommended in hallux valgus deformity correction.

Global research trends and hotspots analysis of hallux valgus: A bibliometric analysis from 2004 to 2021

Background

Hallux valgus (HV) is a common foot and ankle surgery disease. The correction of HV deformity relies on a highly challenging surgical treatment. Thus, widely adopted evidence-based clinical guidelines are still needed to guide the selection of the most appropriate interventions. Recently, the study of HV has been growing and scholars are increasingly paying particular attention to this area. However, bibliometric literature remains lacking. Therefore, this study aims to reveal the hotspots and future research trends in HV via bibliometric analysis to fill this knowledge gap.

Methods

Literature related to HV from 2004 to 2021 was retrieved from the Science Citation Index Expanded (SCI-expanded) of the Web of Science Core Collection (WoSCC). Quantitative and qualitative analyses of scientific data are performed using software such as CiteSpace, R-bibliometrix, and VOSviewer.

Results

A total of 1,904 records were identified for analysis. The United States had the most number of published articles and total citations. Thus, the United States has made an essential contribution to the field of HV. Meanwhile, La Trobe University in Australia was the most productive institution. Menz HB and Foot &amp; Ankle International were the most influential authors and the most popular journals among researchers, respectively. In addition, “older people,” “chevron osteotomy,” “Lapidus,” and “hallux rigidus” have always been the hotspots of attention. Changes and developments in the surgery of HV have gained researchers' interest. Future research trends are more focused on “radiographic measurement,” “recurrence,” “outcome,” “rotation,” “pronation,” and “minimally invasive surgery.” Thus, focusing on these subject directions can facilitate academic progress and provide the possibility of better treatments for HV.

Conclusion

This study summarizes the hotspots and trends in the field of HV from 2004 to 2021, which will provide researchers with an updated view of essential information and somehow guide future research.

Recurrence Rates With Longer-Term Follow-up After Hallux Valgus Surgical Treatment With Distal Metatarsal Osteotomies: A Systematic Review and Meta-analysis

BACKGROUND

Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years.

METHODS

This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years.

RESULTS

We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and "others." The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees.

CONCLUSION

At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

Radiographic Outcomes of Hallux Valgus Deformity Correction With Chevron and Scarf Osteotomies

There is no gold standard in the treatment of hallux valgus deformity. The purpose of our study was to compare various aspects of radiographic assessment following scarf and chevron osteotomies and try to determine which technique helps achieve a more pronounced intermetatarsal angle (IMA) and hallux valgus angle (HVA) correction and produces lower rates of complications, including adjacent-joint arthritis. This study included patients who underwent hallux valgus correction with the scarf (n = 32) or chevron (n = 181) method with a follow-up period of over 3 years. We evaluated the following parameters: HVA, IMA, duration of hospital stay, complications, development of adjacent-joint arthritis. The scarf technique helped achieve a mean HVA and IMA correction of 18.3° and 3.6°, respectively, and the chevron technique helped achieve a mean correction of 13.1° and 3.7°, respectively. The achieved deformity correction in terms of both the HVA and IMA was statistically significant in both patient groups. The loss of correction assessed with the HVA was statistically significant only in the chevron group. Neither group showed a statistically significant loss of IMA correction. The duration of hospital stay, reoperation rates, and fixation instability rates were comparable in the 2 groups. Neither of the evaluated methods caused a significant increase in total arthritis scores in the evaluated joints. Our study showed good outcomes of hallux valgus deformity correction in both evaluated groups; however, scarf osteotomy yielded somewhat better radiographic outcomes in HVA correction and no loss of HVA correction at 3.5 years of follow-up.

A cross-sectional study on reliability and quality of YouTube® videos related to hallux valgus and evaluation of newly developed hallux valgus-specific survey tool

Objective

Previous studies have reported low quality and reliability on YouTube videos about various medical issues including videos related to hallux valgus (HV) treatment. Therefore, we aimed to evaluate the reliability and quality of YouTube videos on HV and develop a new HV-specific survey tool that physicians, surgeons, and the medical industry can use to create high-quality videos.

Methods

Videos viewed over 10,000 times were included in the study. We used the Journal of the American Medical Association (JAMA) benchmark criteria, global quality score (GQS), DISCERN tool, and new HV-specific survey criteria (HVSSC) developed by us to evaluate the quality, educational utility and reliability of the videos, the popularity of which was assessed using the Video Power Index (VPI) and view ratio (VR).

Results

Fifty-two videos were included in this study. Fifteen videos (28.8%) were posted by medical companies producing surgical implants and orthopedic products, 20 (38.5%) by nonsurgical physicians, and 16 (30.8%) by surgeons. The HVSSC indicated that the quality, educational value, and reliability of only 5 (9.6%) videos were adequate. Videos posted by physicians and surgeons tended to be more popular (p = 0.047 and 0.043). Although no correlation was detected among the DISCERN, JAMA, and GQS scores, or between the VR and VPI, we found correlations of the HVSSC score with the number of views and the VR (p = 0.374 and p = 0.006, respectively). A good correlation was detected among the DISCERN, GQS, and HVSSC classifications (rho = 0.770, 0.853, and 0.831, respectively, p = 0.001).

Conclusions

The reliability of HV-related videos on YouTube is low for professionals and patients. The HVSSC can be used to evaluate the quality, educational value, and reliability of videos.

Causal relationship between thyroid dysfunction and hallux valgus: A two-sample Mendelian randomization study

INTRODUCTION

Previous observational studies have reported that thyroid dysfunction is associated with hallux valgus (HV). However, the causal effect of thyroid dysfunction on hallux valgus is still unknown. To assess whether there is a causal relationship between thyroid dysfunction and hallux valgus, we performed a two-sample Mendelian randomization (MR) study.

METHODS

The data of the two-sample Mendelian randomization study were obtained from public databases. In this study, hypothyroidism, hyperthyroidism, free thyroxine (FT4), and thyrotropin (TSH) were chosen as exposures. The single nucleotide polymorphisms (SNP) of hypothyroidism and hyperthyroidism were from the genome-wide association studies (GWAS) of the IEU database, including 337,159 subjects. Data for FT4 and TSH (72,167 subjects) were extracted from the ThyroidOmics Consortium. HV was used as the outcome. The SNPs associated with HV were selected from a GWAS of 202,617 individuals in the fignngen database. The inverse variance weighted (IVW) method was used as the primary analysis. Four complementary methods were applied, including MR-presso, MR-Egger, and weighted median. In addition, Cochran's Q test, MR-presso, MR-Egger regression, and the leave-one-out test were used as sensitivity analysis, and the MR-pleiotropy test was performed to examine pleiotropy.

RESULTS

According to the results of IVW, we found that there was a causal relationship between hypothyroidism and HV, and hypothyroidism increased the incidence of HV (OR = 2.838 (95% CI: 1.116-7.213); p = 0.028). There were no significant causal effects of hyperthyroidism, FT4, and TSH on HV (p > 0.05). Sensitivity analyses showed that the results were robust and reliable, and no horizontal pleiotropy was detected.

CONCLUSIONS

Our findings provided genetic support that hypothyroidism might increase the risk of HV. It will predict the occurrence of HV in patients with hypothyroidism and provide suggestions for early prevention and intervention.

Development of a preoperative questionnaire to improve satisfaction with hallux valgus repair: A Delphi study

BACKGROUND

Satisfaction with hallux valgus repair is often poor, despite good surgical outcomes. Many tools have been developed to assess the outcome of the procedure; however none evaluate the association between the initial motive for repair and the reasons for post-surgical dissatisfaction. The aim of this study was to develop a new tool to analyse the subjective and objective expectations of individuals during a pre-operative consultation for hallux valgus repair in order to improve post-surgical satisfaction.

METHODS

We first collected the reasons for dissatisfaction with repair from the medical files of dissatisfied individuals. Then, a steering committee of 4 French experts in the management of hallux valgus designed a questionnaire based on the reasons for dissatisfaction. We then used the DELPHI method to validate the questionnaire: we submitted the questionnaire to a panel of 34 francophone experts in hallux valgus repair for rating in 4 rounds.

RESULTS

The medical files of 853 individuals were reviewed and a 52-item questionnaire relating to expectations from hallux valgus surgery was drafted. After the 4 rounds, a final 44 item questionnaire reached consensus. Thirteen items related to clinical and psychological profile, 5 to pain, 9 to physical activity, 4 to aesthetics and 13 to footwear.

CONCLUSION

This tool should facilitate gathering of individuals' expectations from hallux valgus repair to ensure realistic goals and reduce post-surgical dissatisfaction.

Modified Lapidus Procedure and Hallux Valgus: A Systematic Review and Update on Triplanar Correction

This review article examines contemporary methods and assesses radiographic outcomes and postoperative complications following the modified Lapidus procedure. A systematic review demonstrated significant improvements in intermetatarsal angle, hallux valgus angle, and tibial sesamoid position. We are updating a modified Lapidus technique for achieving triplanar correction of hallux valgus. Two cases of hallux valgus, one primary and one recurrent, are presented. As demonstrated in the systematic review, outcomes of Lapidus procedures create future opportunities. Surprisingly, only 78% of the studies assessed for this review reported on the hallux valgus angle and only 33% reported on tibial sesamoid position.

Contribution Ratio of Metatarsal Osteotomy and First Tarsometatarsal Joint Reduction in Moderate to Severe Hallux Valgus Correction

Hallux valgus is a common foot and ankle disease, for which numerous surgical procedures were introduced. So, understanding the mechanism of deformity reduction is important to select the proper method. Intermetatarsal angle (IMA) determines the severity of hallux valgus, which is influenced by the translated metatarsal head and the reduction of the first tarsometatarsal joint. We hypothesized that both of the mechanisms simultaneously contribute to the correction of IMA. Hallux valgus (70 feet) operated with a Scarf osteotomy with the Akin procedure were reviewed. Hallux valgus angle (HVA), IMA (mechanical and anatomical), hallux valgus interphalangeal angle (HVIP), distal metatarsal articular angle (DMAA), and sesamoid position were checked. The ratio of contributions to the IMA changes were calculated and compared. When the individual contributions by metatarsal head translation and first tarsometatarsal joint reduction were compared, metatarsal head translation contributed by 82%, whereas first tarsometatarsal joint reduction contributed by 18%. Both were responsible for mechanical IMA correction. However, IMA change by metatarsal head translation was a major correction mechanism compared to anatomical IMA change by first tarsometatarsal joint reduction.

Feasibility study of hallux valgus measurement with a deep convolutional neural network based on landmark detection

OBJECTIVE

To develop a deep learning algorithm based on automatic detection of landmarks that can be used to automatically calculate forefoot imaging parameters from radiographs and test its performance.

MATERIALS AND METHODS

A total of 1023 weight-bearing dorsoplantar (DP) radiographs were included. A total of 776 radiographs were used for training and verification of the model, and 247 radiographs were used for testing the performance of the model. The radiologists manually marked 18 landmarks on each image. By training our model to automatically label these landmarks, 4 imaging parameters commonly used for the diagnosis of hallux valgus could be measured, including the first-second intermetatarsal angle (IMA), hallux valgus angle (HVA), hallux interphalangeal angle (HIA), and distal metatarsal articular angle (DMAA). The reference standard was determined by the radiologists' measurements. The percentage of correct key points (PCK), intragroup correlation coefficient (ICC), Pearson correlation coefficient (r), root mean square error (RMSE), and mean absolute error (MAE) between the predicted value of the model and the reference standard were calculated. The Bland-Altman plot shows the mean difference and 95% LoA.

RESULTS

The PCK was 84-99% at the 3-mm threshold. The correlation between the observed and predicted values of the four angles was high (ICC: 0.89-0.96, r: 0.81-0.97, RMSE: 3.76-6.77, MAE: 3.22-5.52). However, there was a systematic error between the model predicted value and the reference standard (the mean difference ranged from - 3.00 to - 5.08°, and the standard deviation ranged from 2.25 to 4.47°).

CONCLUSION

Our model can accurately identify landmarks, but there is a certain amount of error in the angle measurement, which needs further improvement.

Outcomes of modified chevron osteotomy for hallux valgus

PURPOSE

This study aimed to detect the effect of a modified chevron osteotomy on hallux valgus (HV) deformity at five-year follow up.

METHODS

Twenty patients with symptomatic HV who underwent modified chevron osteotomy between June 2014 and January 2016 were included in the present study. The minimum follow-up duration was five years. Each patient was evaluated preoperatively, six weeks postoperatively and five years postoperatively using the visual analog scale (VAS) pain score, the American Orthopedic Foot & Ankle Society (AOFAS) score and cosmetic and radiological outcomes.

RESULTS

The AOFAS score improved from 54.40 ( ± 4.58) preoperatively to 94.30 ( ± 2.15) six weeks postoperatively (p < 0.001) and 96.95 ( ± 1.54) five years postoperatively (p < 0.001). The VAS scores decreased from 6.30 ( ± 1.17) preoperatively to 0.15 ( ± 0.37) five years postoperatively (p < 0.001). The mean intermetatarsal angle improved from 16.00° ( ± 2.20°) preoperatively to 4.15° ( ± 1.22°) six weeks postoperatively (p < 0.001) and 4.40° ( ± 1.39°) five years postoperatively (p < 0.001). The mean HV angle also improved, from 32.70° ( ± 5.34°) preoperatively to 4.80° ( ± 1.40°) six weeks postoperatively (p < 0.001) and 5.20° ( ± 1.32°) five years postoperatively (p < 0.001). The cosmetic results were either excellent or good in 19 patients (95%). There was no recurrence in this study during the five postoperative years.

CONCLUSION

A modified chevron osteotomy can achieve successful correction of moderate-to-severe HV, with excellent outcomes at five-year follow up.

Is bilateral hallux valgus chevron osteotomy a safe procedure for ambulatory surgery?

INTRODUCTION

Several osteotomies of the first metatarsal have been described for treatment of hallux valgus but chevron osteotomy is one of the most common and well-established procedure for treating this deformity. Although there is a trend towards considering bilateral surgery there is lack of publications addressing bilateral treatment in ambulatory units. The aim of this study is to analyze results of bilateral and unilateral distal chevron osteotomies associated with lateral soft tissue release as ambulatory procedures.

MATERIALS AND METHODS

A retrospective review was made about the patients treated at our ambulatory unit over a period of five years. Initially, general information as patient's satisfaction's rate and return to normal activity's time and evaluation of standardized follow-up charts and records made by the surgeon were recorded. Secondly, the hallux metatarsophalangeal interphalangeal scale developed by the American Orthopedic Foot & Ankle Society was used.

RESULTS

A total of 194 patients with 230 feet operated were included in this study. We found 29 patients that didn't meet the inclusion criteria and were excluded. The unilateral group was composed by 139 feet and the bilateral group by 52 feet. The improvement between preoperative and discharge clinical and radiographic results was significant independently in both groups. A total of 14% of complications were found in our study, 19% in the unilateral group and 12% at the bilateral group. None of them required revision surgery.

CONCLUSION

Bilateral distal chevron osteotomies, associated with lateral soft tissue release, are safe and effective ambulatory procedures. It was found a satisfactory deformity correction in moderate HV. Both patients that underwent unilateral and bilateral procedures had similar clinical and radiological outcomes with no increase in complications or return to normal activity time. With this study it was demonstrated that bilateral chevron osteotomies can be performed as ambulatory procedures.

Reliability of different smartphones measuring the hallux valgus parameters in a new rapid method: a follow-up study

Objective

This study aimed to further compare the abilities to measure hallux valgus parameters in different smartphones using the intrinsic photograph-editing function.

Methods

We retrospectively reviewed 61 patients (100 feet) of hallux valgus without medical or surgical interventions at our department. The radiographic parameters were assessed and measured via the Picture archiving and communication systems (PACS), iPhone, and Android. The accuracy, reliability, and the time-taken were compared and analyzed between each two methods.

Results

The mean value of measured hallux valgus parameters were as follow: hallux valgus angle (HVA): 33.71 ± 7.25°; the first and second intermetatarsal angle (IMA): 12.84 ± 3.62° in PACS; HVA: 33.59 ± 7.18° and IMA: 12.80 ± 3.65° in Android; HVA: 33.63 ± 7.23° and IMA: 12.87 ± 3.60° in iPhone. No significant difference was found among the average results measured by PACS, Android and iPhone (F = 0.008, P = 0.992 in HVA; F = 0.009, P = 0.991 in IMA). For measurements by PACS, Android smartphone, and iPhone, the variability of HVA (F = 0.061, P = 1.000) and IMA (F = 0.133, P = 1.000) was similar. The intraclass correlation coefficients (ICCs) of the mean results of four times measurements of HVA and IMA as follows: PACS vs Android: 0.995 (0.993–0.997) and 0.982 (0.973–0.988); PACS vs iPhone:0.997 (0.995–0.998) and 0.974 (0.962–0.982); Android vs iPhone:0.997 (0.995–0.998) and 0.981 (0.971–0.987). The interobserver and intraobserver reliability was very good for Android smartphones and iPhone in measuring hallux valgus parameters. The mean time of measurement by PACS, Android smartphone, and iPhone were 25.34 ± 1.18 s, 20.10 ± 0.92 s, and 19.92 ± 0.99 s respectively. The measurement time of smartphones is significantly faster than that of PACS by about 5 seconds (P = 0.000). The measurement time of iPhone was slightly faster than that of Android smartphone, while no significant difference was found (P = 0.24).

Conclusion

It is more convenient and faster to use smartphones when compared with PACS, at the same level of accuracy. Furthermore, the abilities of different smartphone platforms are proven to be of no significant difference.

Minimally Invasive Chevron Akin: Locking The Metatarsal-Cuneiform Joint

INTRODUCTION

Minimally Invasive Chevron Akin (MICA) can be used to treat hallux valgus (HV) associated with a hypermobility of the first metatarsal-cuneiform joint (1MTCJ). The aim of this study was to perform a radiographic analysis of the MICA, focused on evaluating the 1MTCJ.

METHODS

Forty patients (50 feet) with moderate to severe HV underwent a MICA procedure. Radiographic analysis included hallux valgus angle (HVA), intermetatarsal angles between the first and second rays (IMA), the intermetatarsal angle between the proximal fragment of the osteotomy and the second ray (IAPF) and the distance between a point 3 cm distal from the base of the second metatarsal and a point located at the same height for the first metatarsal base (Dist 1-2). The IAPF was compared with the preoperative IMA, and the other parameters were compared preoperatively and postoperatively. The radiographic complications were also recorded.

RESULTS

Most patients were female (92%). The mean age was 50.4 years (SD = 16.1) and the mean follow-up was 16.1 months (SD = 3.5). The average HVA improved from 32.5° to 7.3°, and the average IMA from 14.2° to 4.2°. The IAPF and Dist1-2 values showed an increase of 4.8° and 4.0 mm respectively. There were no radiographic complications. Conclusion. Minimally invasive Chevron Akin promotes a great correction of the moderate to severe HV conventional parameters and increase the transversal stability of the 1MTCJ fixing this joint as medial as possible.

LEVEL OF EVIDENCE

Level IV, case series.

Hallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis

INTRODUCTION

Treatment of hallux valgus deformity associated with mild or moderate osteoarthritis (OA) is still a topic of debate. In the literature, there are few studies concerning the management of patients affected by this condition. This study aims to report the experience at mid- to long-term results of an original joint-preserving surgical technique.

MATERIALS AND METHODS

Patients affected by mild to moderate hallux valgus deformity and associated to grade 1-2 OA and treated with modified Simple-Effective-Rapid-Inexpensive (SERI) technique from 2008 to 2018 were selected. Inclusion criteria were mild or moderate hallux valgus angle (HVA) <40° and an intermetatarsal angle (IMA) <20° and associated grade 1-2 OA of the first metatarso-phalangeal joint (MTPJ).

RESULTS

128 feet in 120 consecutive patients, undergone modified SERI procedure, have been retrospectively reviewed at a mean follow-up of 5.1 ± 3.8 years (range 2-11). American Orthopaedics Foot Ankle Society (AOFAS) score that was significantly improved from 44.2 ± 13.2 to 88.2 ± 9.6. Pre-operative average HVA and IMA values decreased respectively from 31.6° ± 3.9° to 9.1° ± 4.4° and from 16.2° ± 3.8° to 7.2° ± 3.1°. The average distal metatarsal articular angle (DMAA) value improved from 28.2° ± 6.5° to 7.1° ± 6°. OA of the first MTPJ highlighted a grade 1 in 46 feet and a grade 2 in 82 feet pre-operatively and a grade 0 in 30 feet, grade 1 in 82 feet, and grade 2 in 16 feet at the final follow-up.

CONCLUSIONS

The modifications to the SERI technique could extend the indications to patients affected by hallux valgus with mild to moderate OA. The wider case series and the longer follow-up of this study make us believe this technique is very useful for improving the quality of life in these patients.

LEVEL OF EVIDENCE

IV.

Clinical and Radiographic Outcomes of Percutaneous Chevron-Akin Osteotomies for the Correction of Hallux Valgus Deformity

BACKGROUND

Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort.

METHODS

All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded.

RESULTS

A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2.

CONCLUSION

MICA is good method to correct hallux valgus deformity with low postoperative narcotic use.

LEVEL OF EVIDENCE

Level III, restrospective cohort study of a single surgeon practice.

Modified Lapidus vs Scarf Osteotomy Outcomes for Treatment of Hallux Valgus Deformity

BACKGROUND

The Lapidus procedure and scarf osteotomy are indicated for the operative treatment of hallux valgus; however, no prior studies have compared outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with symptomatic hallux valgus treated with the modified Lapidus procedure versus scarf osteotomy.

METHODS

This retrospective cohort study included patients treated by 1 of 7 fellowship-trained foot and ankle surgeons. Inclusion criteria were age older than 18 years, primary modified Lapidus procedure or scarf osteotomy for hallux valgus, minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using 6 PROMIS domains. Pre- and postoperative radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders.

RESULTS

A total of 136 patients (73 Lapidus, 63 scarf) with an average of 17.8 months of follow-up were included in this study. There was significant improvement in PROMIS physical function scores in the modified Lapidus (mean change, 5.25; P < .01) and scarf osteotomy (mean change, 5.50; P < .01) cohorts, with no significant differences between the 2 groups (P = .85). After controlling for bunion severity, the probability of having a normal postoperative intermetatarsal angle (IMA; <9 degrees) was 25% lower (P = .04) with the scarf osteotomy compared with the Lapidus procedure.

CONCLUSION

Although the modified Lapidus procedure led to a higher probability of achieving a normal IMA, both procedures yielded similar improvements in 1-year patient-reported outcome measures.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Multiplanar instability of the first tarsometatarsal joint in hallux valgus and hallux rigidus patients: a case-control study

BACKGROUND

Hypermobility of the first ray has been considered associated with various forefoot diseases including hallux valgus (HV) and hallux rigidus (HR). Weightbearing CT scan can be a reliable method for analysis of the first tarsometatarsal (TMT) joint in axial, sagittal, and coronal planes. Our objective was to comparatively investigate signs of instability of the first TMT joint on weightbearing CT between three groups (control, HV, and HR).

METHODS

In this single-centre, retrospective, case-control study, 27 HV patients (30 feet; mean age 54.2 years), 26 HR patients (30 feet; mean age 56.6 years), and 30 controls (30 feet; mean age; 43 years) were enrolled. Measurements of signs of instability were performed in multiplanes including first TMT angle, dorsal translation of the first metatarsal (M1) at the first TMT joint, plantar distance between the medial cuneiform (C1) and M1 in sagittal plane, hallux valgus angle (HVA), intermetatarsal angle (IMA) in axial plane, rotational profiles of C1 and M1 in coronal plane. Analysis of variance (ANOVA) test and chi-square test were performed to compare each parameter between the three groups. Interobserver reliabilities were assessed using interclass correlation coefficients (ICCs).

RESULTS

The HV group had significantly increased first TMT angle (0.23° in controls, 1.15° in HV, 0.19° in HR, p < 0.001), HVA (7.52°, 33.50°, 11.21°, p < 0.001), IMA (9.46°, 16.98°, 11.87°, p < 0.001), C1-M1 angle (22.44°, 29.46°, 23.74°, p < 0.001), and rotational profile of the distal M1 (7.06°, 17.88°, 9.85°, p < 0.001) compared with the control and HR groups. Dorsal translation of M1 (23% in controls, 63% in HV, 70% in HR, p < 0.001) was frequently found in the HV and HR groups with significantly increased plantar distance (0.37 mm, 1.14 mm, 1.46 mm, p < 0.001) compared with controls.

CONCLUSIONS

Multiplanar instability of the first TMT joint was confirmed using weightbearing CT in HV and HR groups compared with controls. HV group demonstrated instability mainly in sagittal and axial planes; HR group had sagittal instability predominantly. Our measurement of rotational instability at the first TMT joint was not able to detect differences between groups. A surgical correction of the instability at the first TMT joint can be an option to address HV and HR.

CLINICAL RELEVANCE

First ray hypermobility at the first TMT joint is an important consideration when addressing HV and HR, a surgical correction of the instability at the first TMT joint should be taken in consideration as an option.

A novel rapid measurement of hallux valgus parameters using the built-in photo edit function of smartphones

Objective

The objective of this study was to assess the accuracy and reliability of and time taken by a novel method using the built-in photo-edit function of smartphones compared with PACS in measuring hallux valgus parameters.

Methods

Seventy patients (124 ft) admitted to our hospital with a diagnosis of hallux valgus without previous surgical procedures were retrospectively reviewed. The foot radiographs of all the patients were extracted from PACS. The hallux valgus angle (HVA) and the first and second intermetatarsal angles (IMAs) were measured by PACS and by this novel method using the built-in photo-edit function of a smartphone. The results of these two methods were compared, and the accuracy and reliability were assessed between these two methods.

Results

The average parameters measured by PACS were as follows: HVA average: 37.43 ± 9.61°; IMA average: 13.37 ± 4.01°. The average parameters measured by smartphones were as follows: HVA average: 37.09 ± 9.52° and IMA average: 13.49 ± 3.91°. When compared by the independent-samples T test, the average parameters between PACS and smartphones were not significantly different (HVA PACS vs HVA smartphones: P = 0.776; IMA PACS vs IMA smartphones: P = 0.816). The variability of the HVA (F = 0.166, P = 0.992) and IMA (F = 0.215, P = 0.982) measurements was similar for the PACS and smartphones. The ICCs of the average parameters of four measurements of HVA and IMA between PACS and smartphones were 0.995 (0.991–0.997) and 0.970 (0.958–0.979), indicating that the two methods were highly correlated. For the smartphone measurement, the interobserver and intraobserver reliability was very good for HVA and IMA. The average measurement time of PACS was 25.41 ± 0.86 s, and the average measurement time of smartphones was 20.29 ± 1.22 s. The smartphone time was significantly faster than that of PACS by approximately 5 s (P<0.001).

Conclusion

This novel method using the built-in photo-edit function of smartphones is accurate, reliable, convenient and time-saving in measuring the angles of hallux valgus.

Overview of randomised controlled trials in hallux valgus surgery (2,184 patients)

BACKGROUND

The aim of this study is to provide an overview of randomised controlled trials (RCTs) in hallux valgus correction surgery summarising the available high-quality evidence.

METHODS

Following PRISMA guidelines, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE (1946 to 1 February 2020) and Embase (1980 to 1 February 2020). We excluded non-randomised trials, systematic reviews and case-series. We also excluded trials of MTPJ arthrodesis. Trials that met our inclusion criteria were assessed by two authors using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to intervention groups.

RESULTS

32 RCTs met the inclusion criteria and were included. The total number of patients in those trials was 2,184. Only 4 RCTs (12.5%) reported significant differences between the intervention and the control groups. The remaining trials evaluated scarf or chevron osteotomies in 18 RCTs, and 10 RCTs compared other osteotomies or technical aspects of hallux valgus surgery using functional and radiological outcome measures with none reporting significant differences.

CONCLUSION

Evidence from RCTs of hallux valgus surgery suggest that scarf and chevron osteotomies are the most popular techniques and lead to similar clinical outcomes.

Biomechanical Comparison of 2 Common Techniques of Minimally Invasive Hallux Valgus Correction

BACKGROUND

Hallux valgus is one of the most common surgically corrected forefoot deformities. Compared to open procedures, minimally invasive (MIS) treatment of hallux valgus has resulted in decreased operative time, reduced complication rates, and greater patient satisfaction. Historically, distal chevron osteotomies are the standard for moderate hallux valgus correction. To our knowledge, no studies have evaluated biomechanical strength of transverse and chevron distal first metatarsal osteotomy (DMO) constructs. The purpose of this study was to evaluate the biomechanical strength of these techniques.

METHODS

Eighteen cadaveric specimens (9 matched pairs) were randomized to transverse or chevron DMO. Each technique was performed by a separate fellowship-trained orthopedic foot and ankle surgeon. Radiographic images were analyzed. Biomechanical testing was performed using Instron Mechanical System. Ultimate load to failure, yield load, and stiffness were assessed. A 10-N preload was applied to the sesamoid bones for stability. A coaxial compression rate (10 mm/min) was applied until failure was observed. Mean and standard deviations were compared. All cadaveric specimens were male.

RESULTS

There was no significant difference in percent metadiaphyseal shift between osteotomies (P = .453). The most common mode of failure was fracture at screw insertion site (55.6%), followed by failure at osteotomy site (44.4%). A trend toward increased ultimate load to failure (P = .480), yield load (P = .054), and stiffness (P = .438) among transverse compared to chevron osteotomy was observed, but this difference was not statistically significant.

CONCLUSION

Biomechanical testing demonstrated no significant difference in ultimate load, yield load, and stiffness between MIS transverse and chevron osteotomy constructs; a trend toward increased strength in the transverse osteotomy cohort was observed. Chevron osteotomies may result in early failure by relative ease of cutout through cancellous bone compared to transverse osteotomies in which failure requires cortical cutout.

CLINICAL RELEVANCE

Use of MIS techniques for hallux valgus correction is gaining clinical traction. Although various clinical studies have evaluated outcomes of these MIS techniques, biomechanical studies have been minimal. Specifically, the potential biomechanical benefits of various MIS hallux valgus osteotomy techniques have not been delineated to date. The content of this manuscript is quite timely, given the rise in use of these MIS techniques.

Pes Planus Deformity and Its Association With Hallux Valgus Recurrence Following Scarf Osteotomy

BACKGROUND

Hallux valgus recurrence is an unsatisfactory complication, with many causes postulated. This study investigated the effect of pes planus on recurrence after scarf osteotomy.

METHODS

A total of 183 feet were retrospectively reviewed. All patients were treated with a scarf osteotomy and if required Akin osteotomy. We measured preoperative lateral talus first metatarsal angle (T1MA) to study pes planus; an angle of under -4 degrees was considered pes planus. We measured pre and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), and sesamoid location. In total 164 feet were suitable for inclusion, with follow-up of at least 6 months (10 males and 154 females, mean age: 52 years).

RESULTS

Recurrence frequency (HVA greater than 15 degrees) was 27 feet (16%). Hallux valgus recurrence was not influenced by gender (P value = .66) or preoperative IMA (P value = .48). Preoperative HVA greater than 35 degrees was associated with increased frequency of recurrence (P value = .004). Those with T1MA less than -10 degrees demonstrated progression in HVA and deterioration in sesamoid location up to 6 months postoperatively (P value = .038). HVA did not progress beyond 6 months. The prevalence of recurrent hallux valgus with normal T1MA was 1%, in T1MA -4 to -10 degrees it was 29% and in T1MA less than -10 degrees it was 47% (P value <.001). Breaks in T1MA less than -4 degrees were found at the naviculocuneiform joint in 68% of feet in this series.

CONCLUSION

The prevalence of hallux valgus recurrence correlated with the severity of pes planus.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization

The first metatarsophalangeal joint (MTPJ) is vital to the biomechanics of the foot and supports a weight up to eight times heavier than the body during athletic activities. The first MTPJ comprises osseous and cartilaginous surfaces along with a complex of supporting structures, including the dorsal extensor tendons, collateral ligaments, and a plantar plate complex. In contradistinction to the lesser MTPJ plantar plates, a single dominant fibrocartilaginous capsular thickening does not exist at the first MTPJ. Instead, the plantar plate complex comprises a fibrocartilaginous pad that invests the hallux sesamoids and is inseparable from the plantar capsule, the intersesamoid ligament, paired metatarsosesamoid and sesamoid phalangeal ligaments (SPLs), and the musculotendinous structures. Acute injury at the first MTPJ is typically secondary to forced hyperextension-turf toe-and can involve multiple structures. During hyperextension, the resulting forces primarily load the distal SPLs, making these structures more susceptible to injury. SPL injuries are best seen in the sagittal plane at MRI. Radiography can also aid in diagnosis of full-thickness SPL tears, demonstrating reduced sesamoid excursion at lateral dorsiflexed (stress) views. Hallux valgus is another common condition, resulting in progressive disabling deformity at the first MTPJ. Without appropriate treatment, first MTPJ injuries may progress to degenerative hallux rigidus. The authors detail the anatomy of the first MTPJ in cadaveric forefeet by using high-resolution 3-T and 11.7-T MRI and anatomic-pathologic correlation. Injuries to the plantar plate complex, collateral ligaments, and extensor mechanism are discussed using clinical case examples. Online supplemental material is available for this article. ^©RSNA, 2020.

Hypermobility in Hallux Valgus

The interaction between hypermobility and hallux valgus remains both contemporary and incendiary. The difficulty in setting clinical and radiological parameters to diagnose and the complexity of questions that circumnutate the philosophy among etiology and denouement, fires up the debate regarding these conditions. Outcomes among procedures that address or neglect ray instability are still used as argument for any group of believers or nonbelievers. Through proving the true existence of hypermobility and its relationship with bunions, our colleges and professors have produced an incredible amount of excellent data that helped us better comprehend the hallux valgus syndrome in a general manner.