Mobility of the First Ray in Patients With or Without Hallux Valgus Deformity: Systematic Review and Meta-Analysis

Relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in patients with hallux valgus

OBJECTIVES

Hallux valgus is associated with tarsometatarsal arthritis; its pathophysiology remains unknown. Therefore, we aimed to elucidate the relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in the sagittal plane.

METHODS

Forty-three patients (64 feet) with hallux valgus who underwent surgery at University Hospital Kyoto Prefectural University of Medicine were included and divided into two groups: control (without second and third tarsometatarsal joint degeneration) and osteoarthritis (with second and third tarsometatarsal joint degeneration). Intergroup comparisons of the incongruity of the first tarsometatarsal joint in the sagittal plane, age, body mass index, hallux valgus angle, first-second intermetatarsal angle, metatarsus adductus angle, Meary's angle, and calcaneal pitch angle were performed.

RESULTS

The proportion of patients with incongruity of the first tarsometatarsal joint was significantly higher in the osteoarthritis group than in the control group. Logistic regression analysis identified incongruity of the first tarsometatarsal joint and metatarsus adductus angle as significant related factors for arthritis of the second and third tarsometatarsal joints.

CONCLUSIONS

Incongruity of the first tarsometatarsal joint in the sagittal plane was involved in the development of arthritis of the second and third tarsometatarsal joints in patients with hallux valgus.

The Lapidus Bunionectomy Revolution: Current Concepts and Considerations

Hallux valgus is a common foot deformity in which many surgical techniques have been introduced. Originally, Paul Lapidus detailed a midfoot arthrodesis technique to address the deformity and medial column instability that served as the foundation for the modified Lapidus bunionectomy. The appreciation of the multiplanar nature of hallux valgus deformity continues to evolve and helps to guide the investigation of the ideal surgical correction to yield more predictable results and reduced complications. Various fixation constructs have been used over the years for the Lapidus bunionectomy without a clear superior fixation technique, and literature supports early weight-bearing with each.

Open vs Minimally Invasive Resection of the First Metatarsocuneiform Joint: An Anatomical Study

BACKGROUND

The modified Lapidus arthrodesis is a standard procedure to correct middle to severe hallux valgus (HV) deformities. Recently, minimally invasive techniques of first metatarsocuneiform joint (MCJ) resection using a Shannon burr were described. The primary goal of this study is to compare the anatomical efficacy and safety of first MCJ resection using a straight 2 × 13-mm Shannon burr and minimally invasive technique (MIS) vs an open technique using an oscillating saw.

METHODS

Ten pairs of fresh frozen cadaveric feet were randomly assigned to open or MIS first MCJ resection with subsequent systematic dissection. For the MIS procedure, a dorsomedial approach was used and for the open procedure a medioplantar approach was used. Cartilage removal was investigated by analyzing standardized scaled photographs of the resected articular surfaces with ImageJ software. Nearby structures at risk were analyzed for iatrogenic violation: tibialis anterior (TA), extensor hallucis longus (EHL) and peroneus longus (PL) tendons, and the Lisfranc ligament complex (LLC).

RESULTS

In the MIS group, the median cartilage resection was 85.9% at the cuneiform and 85.6% at the metatarsal bone compared to 100% cartilage resection in open technique (P < .01). Iatrogenic damage of the LLC, EHL, and TA tendons was not found in any group. The PL tendon was thinned out (<25% of tendon thickness) in 4 cases (40%) in the open group and in 1 case (10%) in the MIS group. A safe zone of 3.0 mm between the articular surface of the cuneiform bone and the LLC was identified, which can be resected without putting the LLC at risk when performing lateral-based wedge resections.

CONCLUSION

In this cadaver study with the procedures performed by an experienced foot and ankle surgeon, and using 2 different surgical approaches, we found general parity between the Shannon burr MIS technique vs oscillating saw open technique techniques with more risk to the PL with our open technique and approximately 15% less cartilage resection with our MIS technique.

LEVEL OF EVIDENCE

Level V, cadaver study.

Correlation Analysis Between Clinical Hypermobility Measurement and Radiographic Parameters of the Hallux Valgus Deformity

The finding of "hypermobility" has conventionally been considered as a dichotomous categorical variable in both clinical practice and in the literature. In other words, it is defined as being either "present" or "absent" in patients with hallux valgus. Yet it might be far more likely that this represents a continuous variable described by a bell-shaped distribution. Therefore the objective of this investigation was to consider hypermobility as a continuous variable, and to compare the sagittal plane first ray motion to radiographic parameters commonly used in the evaluation of the hallux valgus deformity by means of correlation analyses. The radiographs and measurements of 86 feet were included and measurement of sagittal plane first ray motion was performed with the validated Klaue device. No statistically significant correlation was observed between the total first ray motion with the first intermetatarsal angle (Pearson correlation coefficient 0.106; p = .333), hallux valgus angle (Pearson correlation coefficient -0.106; p = .330), nor sesamoid position (Pearson correlation coefficient 0.155; p = .157). The results of this investigation uniquely consider measurement of hypermobility as a continuous variable, and find no correlation between first ray sagittal plane motion and radiographic parameters associated with the hallux valgus deformity. These results might indicate that although the concept of hypermobility has traditionally been coupled with presentation of the hallux valgus deformity, this might simply represent the result of a historical confirmation bias.

Short- and long-term results for severe hallux valgus correction using a first metatarsal distal osteotomy

PURPOSE

The purpose of this study is to analyze the short- and long-term results of severe hallux valgus (HV) treated with a L-Reverse osteotomy.

METHODS

Patients treated with L-Reverse osteotomy for severe HV between the years 2006-2015 were included. Patients were evaluated preoperatively, at 3 months and 4 or more years postoperatively. Changes in the HV angle (HVA) and intermetatarsal angle (IMA) were measured. Clinical outcomes were assessed using the AOFAS score.

RESULTS

28 patients were included. Pre-operative IMA changed from 18.1° (18-18.9°) to 7° (6.3-8.5°), and HVA from 38.5° (34.5-41.3°) to 10.0° (8.4-11.8°) at 3 month follow up (p < 0.005). Long term follow up was of 5.6 (4.9-6.4) years. IMA value was 7.5° (6.1°-8.1°) and HVA was 10.1° (6.7°-16.3°), with no statistical difference with initial correction (p = 0.14). Median AOFAS score was 92.7 (89-4-96.1).

CONCLUSION

L-Reverse osteotomy can achieve correction of HV severe deformities with good outcomes in long term follow up.

LEVEL OF EVIDENCE

III.

Quantitative evaluation of the vertical mobility of the first tarsometatarsal joint during stance phase of gait

We determined how the in vivo mobility of the first tarsometatarsal (TMT) joint can be quantified during gait. Twenty-five healthy participants (12 females) with no history of foot disorders were included. Non-invasive ultrasound (US) with a three-dimensional motion analysis (MA) system was used to evaluate the kinematic characteristics of first TMT joint during stance phase of gait. US probe was positioned longitudinally above the first TMT joint and adjusted to its proximal dorsal prominence. Gait analysis was conducted by the MA system starting with the activation of B-mode US video at 80 frames per second and 60-mm depth for simultaneous capture. During stance phase, the first metatarsal was translated dorsally with respect to the medial cuneiform, returning to a neutral level at toe-off in all subjects. During middle stance phase, the medial cuneiform was stable in males but displaced in the plantar direction in females and was the primary contributor to the differences in sagittal mobility observed between groups. Quantitatively measuring sagittal mobility of the first TMT joint could be useful for the early detection of foot abnormalities. The dynamic characteristics of the medial cuneiform during gait in healthy females may be associated with a high prevalence of hallux valgus.

Lapidus Arthrodesis

There has been significant enhancement in surgical management of hallux valgus deformity. Recognition of the role of medial column hypermobility has resulted in better functional outcomes with decreased risk of recurrence. Modern techniques have evolved to include enhanced fixation in a move toward minimal postoperative downtime. Evolution to include true triplane correction, including frontal plane derotation of the first ray, has resulted in optimal functional outcomes. The addition of anatomic triplane restoration, enhanced internal fixation, and early return to weight-bearing activities are combined resulting in lifelong correction with excellent functional outcomes and a high degree of patient satisfaction.

Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study

INTRODUCTION

Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column.

METHODS

In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed.

RESULTS

A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001).

CONCLUSION

In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

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.

Anatomical factors associated with progression of hallux valgus

BACKGROUND

The purpose of this study was to clarify the incidence rate and the risk factors for the progression of the hallux valgus deformity.

METHODS

Patients who had weight-bearing radiographs of the foot taken twice or more, with a ≥2-year interval, were retrospectively analyzed. Progression of the deformity was defined as an increase in the hallux valgus angle of ≥5° during the follow-up. The association of hallux valgus progression with patient characteristics and radiographic measurements at baseline was determined using univariate and multivariate analyses.

RESULTS

Totally, 268 patients (217 women and 51 men; median age, 64 years) were analyzed. An increase in the hallux valgus angle of ≥5° occurred in 44 (17%) patients in a median follow-up of 49 months. Large hallux valgus angle (odds ratio, 1.07) on the dorsoplantar radiograph at baseline were independent risk factors for the progression of the deformity.

CONCLUSION

Progression of the hallux valgus deformity occurred in one of six patients. Furthermore, large hallux valgus angle was the risk factor for subsequent deformity progression. Patients with large hallux valgus angle should be informed about the possible progression of the deformity.

Descriptive Quantitative Analysis of First Metatarsal Sagittal Plane Motion

Evaluation of the sagittal plane motion of the first ray is a commonly accepted physical examination technique performed during the assessment and treatment of the hallux valgus deformity. Excessive or abnormal motion in this location, termed "hypermobility," has also traditionally been strongly associated with surgical decision-making and serves as a widely accepted indication for performance of the first metatarsal-medial cuneiform arthrodesis procedure. The objective of this investigation was to perform an analysis of first ray sagittal plane motion from a large population in order to determine the descriptive quantitative characteristics of the data set. First metatarsal sagittal plane motion was measured from a group of 149 subjects (298 feet) with a Klaue device. The mean total first metatarsal sagittal plane motion was 9.37 ± 2.39 mm (3.97-18.76). The data set was found to demonstrate many of the characteristics of a normally distributed population based on the histogram distribution, skewness (0.651), and kurtosis (0.761). No difference was observed between measurement of total sagittal plane motion between right and left feet (9.13 ± 2.37 mm vs 9.61 ± 2.40 mm; p = .081), nor between male and female subjects (9.29 ± 2.27 mm vs 9.58 ± 2.70 mm; p = .352). No substantial correlation was observed between total sagittal plane motion and subject age (Pearson correlation -0.053; p = .522). Results indicate that first ray sagittal plane motion might be best considered as a continuous variable as opposed to categorical variable, and might help objectify the difference between "normal" and "abnormal" motion.

Radiographic measurements have limited effect in dynamic plantar pressures in hallux valgus patients

PURPOSE

Radiographic measurements are the gold standard in the management for preoperative surgical planning of hallux valgus deformity. Plantar pressure technology is a tool that is not commonly used to evaluate and manage hallux valgus patients, and few studies have reported the correlation of plantar pressure measurements and radiography.

METHODS

A prospective cohort study was designed to analyze plantar pressure measurements and radiographic variables. The inclusion criteria were age over 18 years old, and diagnosis of hallux valgus requesting surgical correction because of discomfort, pain or difficulty with shoe wear. Plantar pressure measurements were performed using a platform. Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements.

RESULTS

A total of 114 patients met the inclusion criteria. Mean age of the patients was 50 years, and 94 patients (82.5%) were women. We found significant correlations between dynamic plantar pressure measurements and HVA, DMAA, and MDA. Mean pressure under third metatarsal head was the most associated plantar pressure measurement with hallux valgus angle and metatarsal declination angle. However, this association showed signs of weakness.

CONCLUSION

Hallux valgus angle and metatarsal declination angle had a minimal influence on plantar-loading parameters. Pressure values did not discriminate the magnitude of HV deformity. Others factors responsible for the observed plantar pressures pattern should be addressed.

The metatarsaus adductus effect by the syndesmosis procedure for hallux valgus correction

Aims

The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

Methods

We reviewed clinical records of a single surgical practice from its entire 2014 calendar year. In total, 71 patients (121 surgical feet) qualified for the study with a mean follow-up of 20.3 months (SD 6.2). We measured their metatarsus adductus angle with the Sgarlato’s method (SMAA), and the intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA) with Hardy’s mid axial method. We also assessed their American Orthopaedic Foot & Ankle Society (AOFAS) clinical scale score, and photographic and pedobarographic images for clinical function results.

Results

SMAA increased from preoperative 15.9° (SD 4.9°) to 17.2° (5.0°) (p < 0.001). IMA and MPA corrected from 14.6° (SD 3.3°) and 31.9° (SD 8.0°) to 7.2° (SD 2.2°) and 18.8° (SD 6.4°) (p < 0.001), respectively. AOFAS score improved from 66.8 (SD 12.0) to 96.1 (SD 8.0) points (p < 0.001). Overall, 98% (119/121) of feet with preoperative plantar calluses had them disappeared or noticeably subsided, and 93% (113/121) of feet demonstrated pedobarographic medialization of forefoot force in walking. We reported all complications.

Conclusion

This study, for the first time, reported the previously unknown metatarsus adductus side-effect of the syndesmosis procedure. However, it did not compromise function restoration of the forefoot by evidence of our patients' plantar callus and pedobarographic findings.

Level of Clinical Evidence: III

Cite this article: Bone Jt Open 2021;2(3):174–180.

Finite Element Analysis of Generalized Ligament Laxity on the Deterioration of Hallux Valgus Deformity (Bunion)

Hallux valgus is a common foot problem affecting nearly one in every four adults. Generalized ligament laxity was proposed as the intrinsic cause or risk factor toward the development of the deformity which was difficult to be investigated by cohort clinical trials. Herein, we aimed to evaluate the isolated influence of generalized ligament laxity on the deterioration using computer simulation (finite element analysis). We reconstructed a computational foot model from a mild hallux valgus participant and conducted a gait analysis to drive the simulation of walking. Through parametric analysis, the stiffness of the ligaments was impoverished at different degrees to resemble different levels of generalized ligament laxity. Our simulation study reported that generalized ligament laxity deteriorated hallux valgus by impairing the load-bearing capacity of the first metatarsal, inducing higher deforming force, moment and malalignment at the first metatarsophalangeal joint. Besides, the deforming moment formed a deteriorating vicious cycle between hallux valgus and forefoot abduction and may result in secondary foot problems, such as flatfoot. However, the metatarsocuneiform joint did not show a worsening trend possibly due to the overriding forefoot abduction. Controlling the deforming load shall be prioritized over the correction of angles to mitigate deterioration or recurrence after surgery.

Anatomical study of Lapidus arthrodesis using two different plantar plate systems

BACKGROUND

First tarsometatarsal arthrodesis (modified Lapidus procedure) constitutes a sufficient treatment for moderate to severe hallux valgus deformity and first ray instability. The plantar plate arthrodesis was shown to provide superior mechanical stability and less postoperative complications than screw fixation or dorsal plating. Nevertheless, the in-brought hardware may cause irritation of the tibialis anterior or peroneus longus tendon requiring explantation of the material in some cases. The purpose of this study was to investigate the potential of tendon irritation after plantar first tarsometatarsal joint arthrodesis in a cadaver study.

METHODS

Plantar plate arthrodesis was performed as in real surgery on twelve pairs of fresh frozen cadaveric feet. Two different plate systems were randomly allocated to each pair of feet. After plate fixation careful dissection of the feet followed to analyze potential tendon irritation and to determine a "safe zone" for plantar plate placement.

RESULTS

A "safe zone" between the insertion sties of tibialis anterior and peroneus longus tendon was found and proven to be sufficiently exposed using a standard medio-plantar approach. Both plates were fixed in this zone without compromising central tendon parts. Peripheral tendon parts were irritated in 42% using Darco Plantar Lapidus Plating System® (Wright Medical, Memphis, TN) and in 8% using the Plantar Lapidus Plate® (Arthrex, Naples, FL). Bending of the anatomically preshaped plates is often necessary to ensure optimal fit on the bone surface.

CONCLUSIONS

Modified Lapidus procedure with plantar plating of the first tarsometatarsal joint can be performed safely without compromising central tendon parts via standard medio-plantar approach.

LEVEL OF CLINICAL EVIDENCE

5, Cadaver Study.

Hypermobility of the First Ray: the Cinderella of the measurements conventionally assessed for correction of Hallux Valgus

Background and aim of the work:

hypermobility of the first ray (FRH) began to be considered as a pathological entity from Morton’s studies and was associated as a primary cause of hallux valgus (HV). Currently, this relationship is in discussion, and various authors consider FRH as a consequence of the deformity. The purpose of this narrative review is to summarise the most influential publications relating to First Ray Mobility (FRM) to increase knowledge and promote its conventional assessment during clinical practice.

Methods:

papers of the last century were selected to obtain a homogeneous and up-to-date overview of I-MTCJ mobility and HV, as well as their relationship and management.

Results:

in recent years, FRH was studied from a biomechanical and pathophysiologic point of view. There is still not enough data regarding the aetiology of FRM. The higher rate of instability found in HV lacks an explanation of which is the cause and which is the effect. However, the Lapidus arthrodesis is still a valid method in cases of FRH and HV, even if is not rigorously indicated to treat both. When approaching FRH, radiographic or clinical findings are mandatory for the right diagnosis.

Conclusions:

FRM is an important factor that must be considered in routine clinical practice and prior and post HV surgery, as much as the conventional parameters assessed. Surgeons should consider performing I-MTCJ arthrodesis only if strictly necessary, also paying attention to soft tissue balancing. Improving the measurement of FRH could be useful to determine if it is a cause or effect of the HV deformity. (www.actabiomedica.it)

The Validity and Reliability of a New Simple Instrument for the Measurement of First Ray Mobility

Several methods have been described to quantify the first ray mobility. They all have certain disadvantages (great size, sophistication, or lack of validation). The objective of this work was to study the validity and reliability of a new instrument for the measurement of first ray mobility. Anterior-posterior radiographs were obtained from 25 normal feet and 24 hallux valgus feet, with the first ray in a neutral position, maximally dorsiflexed and maximally plantarflexed. The first ray mobility was radiographicaly measured in both groups, and was also manually examined with the new device. A cluster analysis determined whether normal and hallux valgus feet were correctly classified, and a graphic analysis of Bland-Altman was performed to compare the radiographic and manual measurement techniques. Based on the radiographs, the first ray mobility only showed significant differences in dorsiflexion between both groups (P = 0.015). First ray dorsiflexion, plantarflexion and total range of motion measured with the new device were different between both groups (P = 0.040, P = 0.011 and P = 0.006, respectively). The silhouette measure of the cohesion and separation coefficients from the cluster analysis was greater than 0.50 for the dorsiflexion, plantarflexion and total range of motion obtained from the radiographs and from the new device. The Bland-Altman graph suggested that 96% of the data presented agreement between both measurement methods. These results suggested that the new instrument was valid and reliable.

Intraoperative and Postoperative Evaluation of Hallux Valgus Correction: What Is Important?

The hallux valgus is one of the most challenging foot and ankle deformities to correct. The current concept is to consider the hallux valgus as a triplane deformity, and the parameters in transverse, sagittal, and frontal planes must be considered. The hallux valgus angle, intermetatarsal angle, tibial sesamoid position, and lateral edge of the first metatarsal head are valuable parameters to evaluate to understand the magnitude of the deformity. Diaphyseal corrections, such as scarf, and proximal interventions, such as crescentic osteotomy and Lapidus arthrodesis, are the most powerful techniques to address triplane deformity, because they are able to correct all misalignments.

Radiological Evaluation of a Preoperative First Metatarsal Realignment Test for Metatarsus Primus Varus and Hallux Valgus Correction by the Syndesmosis Procedure

BACKGROUND

Metatarsus primus varus correction is one of the primary surgical objectives for hallux valgus correction. Some soft tissue procedures have shown that the first metatarsal can be adequately realigned without osteotomy. The hypothesis of this study was that this correctability should also be demonstrable preoperatively. The purpose of this study was to assess whether a simple forefoot taping technique could do so and whether it could also be correlated with operative results after the syndesmosis procedure.

METHODS

Between May 2014 and December 2015, 147 feet with hallux valgus from 85 patients with an average age of 46.2 years underwent the syndesmosis procedure. All were followed prospectively with standing radiographic assessment of their first intermetatarsal angle, metatarsophalangeal angle, and medial sesamoid position preoperatively without and with a forefoot wrapping technique and postoperatively at 10 days, 6 months, and 1 year.

RESULTS

Their average preoperative intermetatarsal angle was reduced from 14.4 to 8.4 degrees by the wrapping technique, and their average metatarsophalangeal angle was spontaneously reduced from 31.8 to 21.8 degrees. After a minimum 1-year follow-up, they stabilized at 7.4 and 18.6 degrees, respectively. There was significant correlation between hallux valgus and metatarsus primus varus corrections by both forefoot wrapping and surgical methods with Spearman's rank correlation of metatarsophalangeal angle and intermetatarsal angle corrections (r = 0.6077, P < .0001 due to the wrapping method; r = 0.7157, P < .0001 due to the syndesmosis procedure). All raw working radiographic images for this study can be viewed in the Supplemental Material section.

CONCLUSION

This study found that a simple forefoot tape-wrapping technique could be used preoperatively to verify first metatarsal mobility for metatarsus primus varus correction by the soft tissue syndesmosis procedure without osteotomies.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Evolution of Thinking of the Lapidus Procedure and Fixation

The evolution of Lapidus fixation has been strongly associated with the understanding of the anatomy and function of the first tarsometatarsal joint, the mechanism of hypermobility of the first tarsometatarsal joint, and cause of the hallux valgus deformity in 3 dimensions. Some methods, such as plantar plating, nitinol staples, and intramedullary fixation, have proven to be stronger biomechanically in cadaveric testing. Theoretically, stable fixation will reduce the rate of complications, in particular, that of nonunion and allow for early postoperative weight-bearing. Further clinical studies are needed to examine whether current biomechanical studies will translate to relevant clinical outcomes.

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.

Dynamic First Tarsometatarsal Instability During Gait Evaluated by Pedobarographic Examination in Patients With Hallux Valgus

BACKGROUND

This study aimed to investigate the pedobarographic characteristics of tarsometatarsal instability and to identify factors associated with pedobarographic first tarsometatarsal instability in patients with hallux valgus.

METHODS

Fifty-seven patients (mean age, 59.7 years; standard deviation, 11.4 years; 6 men and 51 women) with a hallux valgus angle (HVA) greater than 15 degrees were included. All patients underwent a pedobarographic examination along with weightbearing anteroposterior (AP) and lateral foot radiography. Radiographic measurements were compared between the 2 groups with and without pedobarographic first tarsometatarsal instability. The association between the radiographic and pedobarographic parameters of the first tarsometatarsal instability was analyzed using the chi-square test. Binary logistic regression analysis was performed to identify significant factors affecting pedobarographic first tarsometatarsal instability.

RESULTS

The HVA (P < .001), intermetatarsal angle (P = .001), and AP talo-first metatarsal angle were significantly different between the pedobarographically stable and unstable tarsometatarsal groups. There was no significant association between radiographic and pedobarographic instability of the first tarsometatarsal joint (P = .924). The HVA was found to be the only significant factor affecting pedobarographic tarsometatarsal joint instability (P = .001).

CONCLUSION

The pedobarographic examination has possible clinical utility in evaluating first tarsometatarsal joint instability in patients with hallux valgus. Patients with a greater HVA should be assessed for the presence of first tarsometatarsal instability, and the necessity of the Lapidus procedure should be considered.

LEVEL OF EVIDENCE

Level III, comparative study.

Static Range of Motion of the First Metatarsal in the Sagittal and Frontal Planes

The first metatarsal and medial cuneiform form an important functional unit in the foot, called “first ray”. The first ray normal range of motion (ROM) is difficult to quantify due to the number of joints that are involved. Several methods have previously been proposed. Controversy exists related to normal movement of the first ray frontal plane accompanying that in the sagittal plane. The objective of this study was to investigate the ROM of the first ray in the sagittal and frontal planes in normal feet. Anterior-posterior radiographs were done of the feet of 40 healthy participants with the first ray in a neutral position, maximally dorsiflexed and maximally plantarflexed. They were digitalized and the distance between the tibial malleolus and the intersesamoid crest in the three positions mentioned was measured. The rotation of the first ray in these three positions was measured. A polynomic function that fits a curve describing the movement observed in the first ray was obtained using the least squares method. ROM of the first ray in the sagittal plane was 6.47 (SD 2.59) mm of dorsiflexion and 6.12 (SD 2.55) mm of plantarflexion. ROM in the frontal plane was 2.69 (SD 4.03) degrees of inversion during the dorsiflexion and 2.97 (SD 2.72) degrees during the plantarflexion. A second-degree equation was obtained, which represents the movement of the first ray. Passive dorsiflexion and plantarflexion of the first ray were accompanied by movements in the frontal plane: 0.45 degrees of movement were produced in the frontal plane for each millimeter of displacement in the sagittal plane. These findings might be useful for the future design of instruments for clinically quantifying first ray mobility.

Hallux Valgus/Medial Column Instability and Their Relationship with Posterior Tibial Tendon Dysfunction

Historically, bunions have focused on the coronal plane; however, there is tension and compression failure in the sagittal plane of the midfoot during arch collapse. Correction of all 3 planes of deformity, coronal, sagittal, and rotational, can be achieved in several ways. Taking a big picture of global foot mechanics by recognizing the common types of conditions associated with arch collapse, including hallux valgus deformities, can serve as a useful roadmap for navigating more complicated deformities where hallux valgus exists.