Complications after surgery of the hallux

Chevron osteotomy and scarf osteotomy for hallux valgus angle and intermetatarsal angle correction: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis aimed to investigate the differences in hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopedic Foot and Ankle Society (AOFAS) scores, and complication rates between chevron osteotomy and scarf osteotomy for correcting hallux valgus.

METHODS

Two investigators independently searched for randomized controlled trials (RCTs) published from 2007 to 2018 on PubMed, Web of Science, and Cochrane Library databases. Next, chevron and scarf osteotomies were compared for their postoperative outcomes using HVA, IMA, and AOFAS scores and their complication rates. Meta-analysis was performed using Review Manager (version 5.3).

RESULTS

Six RCTs-comprising 507 feet, of which 261 and 246 underwent chevron and scarf osteotomies, respectively-were included. The meta-analysis revealed that chevron osteotomy led to significantly smaller postoperative HVAs than scarf osteotomy (weighted mean difference [WMD] = -1.94, 95% CI = - 2.65 to - 1.29, P < .00001). However, the differences in postoperative IMA (WMD = - 0.44, 95% CI = - 1.10 to 0.22, P = .19), postoperative AOFAS scores (WMD = 0.75; 95% CI = - 5.32 to 6.82; P = .81), and complication rates (risk ratio = 1.22, 95% CI = 0.65-2.27, P = .53) between feet that underwent chevron and scarf osteotomies were nonsignificant.

CONCLUSIONS

Compared with scarf osteotomy, chevron osteotomy had significantly more favorable postoperative outcomes in terms of HVA correction, but not in terms of IMA, AOFAS scores, or complication rates.

LEVEL OF EVIDENCE

Level I, systemic review and meta-analysis.

Correction effects of peroneus longus contraction on hallux valgus radiographic parameters

BACKGROUND

Hypermobility of the first tarsometatarsal joint plays an important role in hallux valgus pathogenesis. The peroneus longus is recognized as a dynamic stabilizer of the first tarsometatarsal joint. However, the association between the peroneus longus function and the hallux valgus deformity remains unknown. This study aimed to determine the effect of peroneus longus contraction induced by electrical muscle stimulation on the correction of hallux valgus radiographic parameters in patients with hallux valgus.

METHODS

Thirty-five patients with hallux valgus (47 feet; 2 men, 33 women; mean age 64.9 years) were included. Non-weight-bearing dorsoplantar radiographs of the foot were obtained with and without electrical muscle stimulation of the peroneus longus. Radiographic parameters of hallux valgus deformities, including the hallux valgus angle, intermetatarsal angle, first metatarsal protrusion distance, and distance between the first and second metatarsal bases, were measured and compared between the two conditions.

RESULTS

All hallux valgus radiographic parameters were significantly improved by contraction of the peroneus longus. The median hallux valgus angle decreased by 13.2°. Fewer changes in the hallux valgus angle were identified in patients with severe deformity and geriatric patients.

CONCLUSIONS

Although the peroneus longus muscle has received little attention in the management of hallux valgus, our findings suggest that it has the potential to be a novel conservative approach for treating mild-to-moderate hallux valgus.

Third-Generation Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus: Three-Year Outcomes

Introduction

Numerous minimally invasive techniques have been developed for Hallux Valgus in recent years. Third-generation Minimally Invasive Chevron Akin (MICA) osteotomy has shown promising early results, but longer-term follow-up is required to assess whether patient clinical and radiological improvement is sustained. This cohort study presents three-year follow-up outcomes for patients of a single surgeon case series.

Methods

Thirty-three patients underwent third-generation MICA surgery between 2017 and 2018. Patient clinical-reported outcome measures included American Orthopaedic Foot & Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ) scores, and Coughlin satisfaction. Radiographic outcomes were evaluated after a period of three years using hallux valgus angle (HVA) and inter-metatarsal angle (IMA), and compared to pre- and early post-operative outcomes.

Results

At 36 months, mean AOFAS scores improved from 48.2 to 95.6, mean MOXFQ scores improved from 57.6 to 6.7. Using the Coughlin scale, 81.8% of patients rated their outcome as 'Excellent' and 18.2% as 'Good'. Radiographic outcomes showed HVA and mean IMA decreased from 34.6 degrees to 16.0 degrees and from 13.1 to 6.1, respectively at 36 months.

Conclusion

Third-generation MICA demonstrates promising patient satisfaction scores post-operatively, and we have shown these improvements are sustained over a minimum three-year follow-up period.

Level of Evidence

Level IV, case series.

Does Minimally Invasive Surgery Provide Better Clinical or Radiographic Outcomes Than Open Surgery in the Treatment of Hallux Valgus Deformity? A Systematic Review and Meta-analysis

BACKGROUND

Hallux valgus is the most common foot deformity and affects 23% to 35% of the general population. More than 150 different techniques have been described for surgical correction. Recently, there has been increasing interest in the use of minimally invasive surgery to correct hallux valgus deformities. A variety of studies have been published with differing outcomes regarding minimally invasive surgery. However, most studies lack sufficient power and are small, making it difficult to draw adequate conclusions. A meta-analysis can therefore be helpful to evaluate and compare minimally invasive and open surgery.

QUESTIONS/PURPOSES

We performed a systematic review and meta-analysis of randomized controlled trials and prospective controlled studies to answer the following question: Compared with open surgery, does minimally invasive surgery for hallux valgus result in (1) improved American Orthopaedic Foot and Ankle Society (AOFAS) scores and VAS scores for pain, (2) improved radiologic outcomes, (3) fewer complications, or (4) a shorter duration of surgery?

METHODS

The systematic review and meta-analysis was conducted according to the guidelines of the Cochrane Handbook for Systematic Reviews of Intervention and the Preferred Reporting Items for Systematic Reviews and Meta-analyses. A search was performed in the PubMed, Embase, Scopus, CINAHL, and CENTRAL databases on May 3, 2022. Studies were eligible if they were randomized controlled or prospective controlled studies that compared minimally invasive surgery and open surgery to treat patients with hallux valgus. We defined minimally invasive surgery as surgery performed through the smallest incision required to perform the procedure accurately, with an incision length of approximately 2 cm at maximum. Open surgery, on the other hand, involves a larger incision and direct visualization of deeper structures. Seven studies (395 feet), consisting of six randomized controlled studies and one prospective comparative study, were included in the qualitative and quantitative data synthesis. There were no differences between the minimally invasive and open surgery groups regarding age, gender, or severity of hallux valgus deformity. Each included study was assessed for the risk of bias using the second version of the Cochrane tool for assessing the risk of bias in randomized trials or by using the Newcastle-Ottawa Scale for comparative studies. Most of the included studies had intermediate quality regarding the risk of bias. We excluded one study from our analysis because of its high risk of bias to avoid serious distortions in the meta-analysis. We performed a sensitivity analysis to confirm that our meta-analysis was robust by including only studies with a low risk of bias. The analyzed endpoints included the AOFAS score (range 0 to 100), where higher scores represent less pain and better function; the minimum clinically important difference on this scale was 29 points. In addition, the VAS score was analyzed, which is based on a pain rating scale (range 0 to 10), with higher scores representing greater pain. Radiologic outcomes included the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle. Complications were qualitatively assessed and evaluated for differences. A random-effects model was used if substantial heterogeneity (I 2 > 50%) was found; otherwise, a fixed-effects model was used.

RESULTS

We found no clinically important difference between minimally invasive and open surgery in terms of the AOFAS score (88 ± 7 versus 85 ± 8, respectively; mean difference 4 points [95% CI 1 to 6]; p < 0.01). There were no differences between the minimally invasive and open surgery groups in terms of VAS scores (0 ± 0 versus 0 ± 1, respectively; standardized mean difference 0 points [95% CI -1 to 0]; p = 0.08). There were no differences between the minimally invasive and open surgery groups in terms of the hallux valgus angle (12° ± 4° versus 12° ± 4°; mean difference 0 points [95% CI -2 to 2]; p = 0.76). Radiographic measurements of the intermetatarsal angle did not differ between the minimally invasive and open surgery groups (7° ± 2° versus 7° ± 2°; mean difference 0 points [95% CI -1 to 1]; p = 0.69). In addition, there were no differences between the minimally invasive and open surgery groups in terms of the distal metatarsal articular angle (7° ± 4° versus 8° ± 4°; mean difference -1 point [95% CI -4 to 2]; p = 0.28). The qualitative analysis revealed no difference in the frequency or severity of complications between the minimally invasive and the open surgery groups. The minimally invasive and open surgery groups did not differ in terms of the duration of surgery (28 ± 8 minutes versus 40 ± 10 minutes; mean difference -12 minutes [95% CI -25 to 1]; p = 0.06).

CONCLUSION

This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery. Methodologic shortcomings of the source studies in this meta-analysis likely inflated the apparent benefits of minimally invasive surgery, such that in reality it may be inferior to the traditional approach. Given the associated learning curves-during which patients may be harmed by surgeons who are gaining familiarity with a new technique-we are unable to recommend the minimally invasive approach over traditional approaches, in light of the absence of any clinically important benefits identified in this meta-analysis. Future research should ensure studies are methodologically robust using validated clinical and radiologic parameters, as well as patient-reported outcome measures, to assess the long-term outcomes of minimally invasive surgery.

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.

Identification of copy number variants contributing to hallux valgus

Hallux valgus is a common form of foot deformity, and genetic factors contribute substantially to the pathogenesis of hallux valgus deformity. We conducted a genetic study on the structural variants underlying familial hallux valgus using whole exome sequencing approach. Twenty individuals from five hallux valgus families and two sporadic cases were included in this study. A total of 372 copy number variations were found and passed quality control filtering. Among them, 43 were only present in cases but not in controls or healthy individuals in the database of genomic variants. The genes covered by these copy number variations were enriched in gene sets related to immune signaling pathway, and cytochrome P450 metabolism. The hereditary CNVs demonstrate a dominant inheritance pattern. Two candidate pathogenic CNVs were further validated by quantitative-PCR. This study suggests that hallux valgus is a degenerative joint disease involving the dysregulation of immune and metabolism signaling pathways.

Validation of the Artificial Floor Technique in First Metatarsophalangeal Joint Arthrodesis

BACKGROUND

Patient function after arthrodesis of the first metatarsophalangeal joint (MTPJ) relies on proper positioning of the first MTPJ. To maximize the likelihood of good postoperative function, the dorsiflexion angle, referred to as the fusion sagittal angle, should range between 20° and 30°, corresponding to 10° to 15° of dorsiflexion off the weightbearing axis. However, achieving appropriate sagittal alignment intraoperatively is challenging. The artificial floor technique (AFT) uses a rigid, flat surface to simulate the weightbearing position of the foot intraoperatively to accurately position the first MTPJ without fluoroscopy. This technique has been previously described and is commonly used but, to our knowledge, it has never been validated.

QUESTIONS/PURPOSES

(1) Is the AFT a valid and repeatable technique for positioning the fusion sagittal angle between 20° and 30° of dorsiflexion from the first metatarsal? (2) Does the fusion sagittal angle obtained using the AFT vary with foot size?

METHODS

In this retrospective study, a search was performed using Current Procedural Terminology codes for patients undergoing first MTPJ arthrodesis by one surgeon between June 2012 and June 2020. The surgical technique used during this time did not vary and consisted of the use of a rigid, flat, sterile surface. The entire foot was placed flat on the surface, simulating the weightbearing position and allowing for an evaluation of the fusion sagittal angle of the first MTPJ. The target sagittal alignment was achieved when the soft tissue of the plantar surface at the distal-most aspect of the proximal phalanx was measured (using a sterile ruler) as 1 cm off the artificial floor. The recommended fusion sagittal angle falls within a range of 20° to 30°, which allows for 1-mm to 2-mm variations in measuring the elevation of the proximal phalanx off the artificial floor. Fixation was achieved with two 2.8-mm threaded, double-pointed Steinmann pins placed through the intramedullary canal of the proximal and distal phalanges and into the first metatarsal. Once fixation was achieved, the fusion sagittal angle was confirmed with the AFT without using fluoroscopy. Postoperatively, patients were allowed to bear weight fully on their heels in a postoperative, rigid-soled shoe. During the study period, 117 patients (135 feet) underwent first MTPJ arthrodesis utilizing the AFT for either first MTPJ arthritis/hallux rigidus, hallux valgus, or inflammatory arthropathy. Of those, we considered patients with preoperative AP and lateral weightbearing radiographs and patients with AP and lateral weightbearing radiographs at 3 months postoperatively after the removal of the internal fixation construct as eligible for analysis. Based on these criteria, 84% (113 of 135) of feet were included in the final radiographic analysis. Sixteen percent (22 of 135) of the feet were excluded because postoperative radiographs demonstrating the removal of the internal fixation construct were absent from the Picture Archiving and Communication System (PACS) in these cases. The length of the whole foot, first metatarsal, and proximal phalanx were measured on preoperative weightbearing radiographs. In addition, fusion sagittal angles were measured on weightbearing radiographs after removal of internal fixation construct at a minimum of 3 months postoperatively (mean 3.5 ± 2.2 months). No patients were lost to follow-up before obtaining those radiographs. Two qualified reviewers independently evaluated each radiograph. We ascertained inter- and intraobserver reliability using intraclass correlation coefficients (ICCs). We determined whether the fusion sagittal angle obtained using the AFT varied with foot size by using a multiple linear regression model.

RESULTS

In the entire study group, the mean fusion sagittal angle using the AFT was 27° ± 4°. The interobserver ICC of the fusion sagittal angle measurements was 0.92 (95% confidence interval [CI] 0.56 to 0.97; p < 0.001). The intraobserver ICC for reviewer 1 was 0.95 (95% CI 0.92 to 0.97; p < 0.001) and the intraobserver ICC for reviewer 2 was 0.97 (95% CI 0.88 to 0.98; p < 0.001). Ninety-one percent (103 of 113) of the study group fell within the acceptable range of 20° to 30° ± 2°. The multiple linear regression analyses demonstrated that the preoperative lengths of the whole foot (β =-0.05 [95% CI -0.12 to 0.02]; p = 0.16), proximal phalanx (β =-0.13 [95% CI -0.46 to 0.20]; p = 0.44), and first metatarsal (β = 0.13 [95% CI -0.10 to 0.35]; p = 0.27) were not independently associated with the postoperative fusion sagittal angle.

CONCLUSION

The AFT allows for accurate and reproducible positioning of the first MTPJ within the appropriate functional range of dorsiflexion, regardless of foot size. Additionally, this technique can be performed without fluoroscopy and so avoids radiation exposure to the patient and the surgical team.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Iatrogenic transfer metatarsalgia after hallux valgus surgery: a comprehensive treatment algorithm

Current literature has described many of the complications following hallux valgus surgery and their treatment options.

Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet.

Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique.

We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication.

With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

Percutaneous Chevron Osteotomy: A Prospective Randomized Controlled Trial

Introduction: Minimally invasive surgical techniques for hallux valgus have gained popularity, showing good results characterized by smaller postoperative scars, less pain, lower infection risk, and fewer wound complications. Given the lack of evidence available in our country regarding this subject, especially about this type of surgical technique, our paper aims to compare open and MIS approaches for chevron osteotomy. We evaluated the outcome and complications after 12 months. Materials and Methods: We undertook a prospective, randomized, controlled, single-center study between October 2017 and December 2020. The patients were randomized into two groups: one group that received percutaneous chevron osteotomy (MIS), and the other, open chevron osteotomy (OC). For clinical assessment, we determined the function and the level of pain using the Visual Analogue Scale (VAS) and The American Orthopaedic Foot and Ankle Surgery score (AOFAS). The VAS scale was measured before the surgical procedure, at discharge, and at 3 weeks, 6 weeks, 6 months, and 12 months after surgery. The AOFAS score was calculated preoperatively and after 6 months. The hallux angle (HVA) and intramedullary angle (IMA) were measured preoperatively, and at 6 weeks, 6 months and 12 months. Results: We included 26 cases in the open chevron osteotomy group (24 female, 2 male) and 24 in the MIS group (24 female, 0 male). Both groups demonstrated improvements regarding the IMA and HVA at the last follow-up without any significant differences between the groups at the final assessment. The VAS showed significantly better post-operative results for the MIS group at discharge (p < 0.001) and 3 weeks (p < 0.001), 6 weeks (p < 0.001), and 6 months (p = 0.004) post-surgery. The AOFAS showed no significant differences either before or after surgery. Four cases with screw prominence were reported, three of which belonged to the MIS group. Only one case with metatarsalgia was found in the OC group. Conclusions: This paper demonstrates that minimally invasive chevron osteotomy has comparable results with open chevron osteotomy, even though surgical time and radiological exposure are significantly longer. More studies are required to evaluate the complications and the risk of recurrences.

A qualitative study to understand patients’ experiences of their post-operative outcomes following forefoot surgery

Background

Hallux valgus and hallux rigidus are two common forefoot conditions causing deformity, pain, functional limitations, disability and deteriorating health status resulting in the requirement for surgery. Even when surgery is performed by an experienced surgeon, there remains a potential for patients to experience dissatisfaction and unfavourable outcomes. Adverse results are moderated by psychosocial variables; however, there is a paucity of qualitative research providing insight into how patients perceive their outcomes and the factors affecting their recovery.

Objective

The study aimed to qualitatively explore patients’ experiences of their surgical outcomes following forefoot surgery and factors associated with their recovery. Semi-structured interviews with 15 patients who received surgery for hallux valgus and/or hallux rigidus were conducted.

Results

Thematic analysis generated five themes: physical limitations, the psychosocial impact of surgical recovery, regaining normality, patients’ expectations for physical recovery and an altered body-image. Physical and psychosocial factors were inter-related. Patients experiencing problematic outcomes were functionally limited, had low mood and were unable to return to a normal life post-surgery. The women reported weight related issues and were limited in their footwear and clothing choices, negatively impacting on their self-esteem.

Conclusion

A forefoot condition is multifaceted, with patients experiencing a range of physical and psychological factors that may influence their outcomes and recovery from surgery. Patients need to be supported holistically with the use of a biopsychosocial model. A multidisciplinary approach to care and treatment within the forefoot surgical pathway with the inclusion of allied health professionals will enable to better support patients to enhance their outcomes.

Intrasubject Radiographic Progression of Hallux Valgus Deformity in Patients With and Without Metatarsus Adductus: Bilateral Asymmetric Hallux Valgus Deformity

This study was to analyze intrasubject radiographic progression of the hallux valgus deformity by comparing the mildly and severely affected sides in patients with bilateral asymmetric hallux valgus in the whole group as well as the metatarsus adductus and the nonmetatarsus adductus subgroups. A total of 186 patients with bilateral asymmetrical hallux valgus deformity with a difference of 5° or greater in the hallux valgus angle were included, and 11 radiographic measurements were analyzed. The radiographic differences between the mildly and severely affected sides were compared. Correlation between the changes in the hallux valgus angle and those in other measurements was analyzed, and multiple regression analyses were performed. The anteroposterior talo-second metatarsal angle showed no significant difference between the mildly and severely affected sides. Changes in the intermetatarsal angle and sesamoid rotation angle were significantly associated with the progression of hallux valgus angle in the whole group as well as the nonmetatarsus adductus subgroup. Change in the intermetatarsal angle (p = .006) was the significant factor associated with the progression of hallux valgus angle in the metatarsus adductus subgroup. The anteroposterior talo-second metatarsal angle might be useful in evaluating the overall foot shape in the hallux valgus deformity. Progression of the hallux valgus deformity might be pathophysiologically different between those with and without metatarsus adductus.

Hallux valgus orthosis characteristics and effectiveness: a systematic review with meta-analysis

OBJECTIVE

The treatment effect of orthoses for hallux valgus (HV) is unclear with little interventional studies, the design involves multiple complex factors, and therefore a systematic analysis with meta-analysis is necessary. The objective of this systematic review and meta-analysis is to determine whether current foot orthoses are effective in treating HV.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Electronic databases (PubMed, Scopus, Cinahl and Medline) are searched up to February 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Interventional studies with content focus on HV orthosis design and any of the outcomes related to effectiveness for treating HV are included. The standardised mean differences are calculated. The risk of bias in included studies is assessed using the Cochrane Collaboration's risk of bias tools.

RESULTS

In total, 2066 articles are identified. Among them, nine are selected and quality rated, and data are extracted and closely examined. A meta-analysis is conducted, where appropriate. The main causes of potential bias are missing outcome data and outcome measurement error. The results show that orthosis with a toe separator has the best effect of correcting the HV angle (standardised mean difference: 0.50, 95% CI: 0.189 to 0.803).

CONCLUSION

The orthoses design with a toe separator or an element that allows for the foot anatomic alignment is critical for reducing the HV angle and relieving foot pain. The results contribute to a better selection of treatment for patients.

PROSPERO REGISTRATION NUMBER

CRD42021260403.

Correction of Hallux Abducto Valgus Deformity Using Closing Base Wedge Osteotomy: A Study of 101 Patients

Hallux abducto valgus is a functionally disabling deformity with lateral deviation of the hallux and medial prominence of the first metatarsal head. Various surgical techniques have been used in the treatment of this deformity. In this retrospective review, we assess the outcomes of proximal closing base wedge osteotomy (CBWO). A single-surgeon database was reviewed for patients who underwent proximal CBWO between January 1, 2012, and December 31, 2017. A total of 101 patients were identified with a mean age of 49 years (range 13 to 80) and mean body mass index of 29 kg/m² (range 19 to 53). The medical records were reviewed for smoking status, time to heal, rates of nonunion, shortening of the first metatarsal, intermetatarsal angle, hallux valgus angle, elevatus, mean loss of correction, complication rates, and pain scores. Pre- and postoperative variables were compared using Student's t test for continuous variables. The mean pre- and postoperative intermetatarsal angles were 15.46° (range 10° to 21°) and 3.77° (range 0° to 10°; p < .05). The mean pre- and postoperative hallux abductus valgus angles were 34.57° (range 12° to 60°) and 9.24° (range, 0° to 30°;p < .05). The mean metatarsal length shortening was 3.72 mm, and the mean postoperative elevatus was 2.73 mm. We have demonstrated excellent outcomes of CBWO with correction of intermetatarsal and hallux valgus angles. This procedure allows for superior reduction of moderate to severe intermetatarsal angles in rigid first rays. The mean postoperative elevatus of 2.73 did not result in any adverse sequelae.

Revision surgeries for failed hallux valgus correction: A systematic review

BACKGROUND

Failure of hallux valgus (HV) correction is not uncommon, and its management can be challenging. The available literature is not exhaustive. Therefore, we conducted a systematic review to investigate the current evidence on the role of revision surgery for failed HV correction, including clinical presentation, indications, surgical strategies and outcomes.

MATERIAL AND METHODS

The present systematic review was performed according to the PRISMA guidelines. Pubmed, EMBASE, Google Scholar and Scopus online databases were accessed in November 2020. All the clinical studies on revision for failed HV correction were analysed, and only studies reporting quantitative data under the outcomes of interest were considered for inclusion.

RESULTS

Data from 20 studies (586 procedures) were retrieved. The HV angle, the intermetatarsal angle and the distal metatarsal articular angle were reduced of 17.8° (P < 0.001), 3.3° (P = 0.05) and 7.3° (P < 0.001) respectively. The American Orthopaedic Foot & Ankle Society score improved of 24.7% (P < 0.001). The visual analogue scale improved by 40.8% (P < 0.001). Dorsiflexion and plantar flexion of the first metatarso-phalangeal joint remained similar to their preoperative values (P = 0.2 and P = 0.4, respectively). After revision surgery the following complications were further detected: recurrences 5.1% (30 of 586 patients), non-unions 4.1% (24/586), additional surgical procedures 8.7% (51 of 586 patients).

CONCLUSION

Revision surgery for failed primary HV correction can yield satisfying results. Accurate preoperative planning is necessary to try and identify the causes of failure, and address them appropriately.

First ray alignment in Lapidus arthrodesis - Effect on plantar pressure distribution and the occurrence of metatarsalgia

BACKGROUND

Lapidus arthrodesis is an established treatment option for severe hallux valgus deformity especially in patients suffering from instability of the first tarsometatarsal joint. Surgery related metatarsalgia is known to be associated with persistent elevation of the first ray after realignment surgery. Nevertheless, detailed information on ideal positioning of the first ray in Lapidus surgery is missing so far. This study was designed to determine any correlations between radiographic and pedobarographic outcome following the Lapidus procedure with regard to clinical outcome and the occurrence of metatarsalgia.

METHODS

Thirty feet (28 patients) after Lapidus surgery were available for follow-up at 42.5±21.0 months. All subjects had radiographic and pedobarographic evaluation of the operated foot and patient satisfaction was recorded using questionnaires.

RESULTS

Metatarsalgia was associated with a poorer outcome in FADI and AOFAS scores (p<0.005). A lateral shift of plantar pressure distribution to the third metatarsal head in these cases could be observed. Although Lapidus surgery resulted in significant shortening of the first metatarsal, no correlation to the occurrence of metatarsalgia was detectable. Likewise, axial plane malalignment showed no influence, whereas elevation of the first ray was highly correlated to surgery related metatarsalgia (p=0.007). Subjects suffering from metatarsalgia had a higher BMI (body mass index), but its effect on metatarsalgia turned out not to be significant (p=0.090).

CONCLUSION

In Lapidus surgery realignment of the first metatarsal in the sagittal plane seems to be decisive for good clinical outcome. Failing to plantarflex the arthrodesis resulted in a lateral shift of plantar loading with overload of the lesser metatarsals and the occurrence of metatarsalgia.

The Modified Subcapital Metatarsal Osteotomy in the Treatment of Hallux Valgus Recurrence

The purpose of the present study is to illustrate the use of a modified subcapital metatarsal osteotomy (MSMO) in the treatment of hallux valgus (HV) recurrence. The article reports the clinical and radiological outcomes of a cohort of 52 consecutive patients presenting with recurrent HV, treated with MSMO. A total of 52 patients (54 feet) underwent operations between May 2010 and November 2015. The mean time of follow-up was 2.5 years (range 5.5-1.0 years), and the mean age was 49 years (range 22-76 years). The patient cohort comprised 46 female and 6 male patients. The results of this research show that MSMO is a reliable technique for the correction of HV recurrence. The postoperative radiographic assessments show a statistically significant postoperative improvement of the HV angle (P < .05) and the intermetatarsal angle (P < .05). The postoperative position of the tibial sesamoid was significantly improved (P < .1). The distal metatarsal articular angle was improved (P < .001), though assessment may be affected by the previous operations performed on the first metatarsophalangeal joint. The statistical analysis shows that the postoperative American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale parameters were significantly improved (P < 0.001). Results of this study indicate that the minimally invasive MSMO is effective in restoring anatomical alignment and improving patient outcomes in recurrent cases of HV.Levels of Evidence: Level III: Case-control study.

Analysis of Shortening and Elevation of the First Ray With Instrumented Triplane First Tarsometatarsal Arthrodesis

BACKGROUND

The Lapidus procedure using planar saw resection has often been criticized for complications related to excessive shortening and elevation of the first ray. The goal of this study was to assess the amount of shortening that occurs when using a cutting guide for controlled saw resection of the first tarsometatarsal (TMT) joint surfaces, along with assessment of deformity correction in all 3 anatomic planes.

METHODS

A prospective multicenter study with IRB approval included 35 hallux valgus subjects evaluated at baseline and 6 months following instrumented triplane first TMT arthrodesis without lesser metatarsal osteotomies.

RESULTS

The average first ray bone segment length loss was 3.1 mm (95% confidence interval [CI] 2.4-3.7) in the anteroposterior (AP) radiographic assessment and 2.4 mm (95% CI 1.7-3.1) in the sagittal plane. The mean preoperative radiographic measurements were 1.7 degrees (dorsiflexion) for sagittal plane angle, 13.8 degrees for intermetatarsal angle (IMA), and 5.1 for tibial sesamoid position (TSP). Improvements were seen postoperatively for all measures with a mean difference of -0.2 degrees (95% CI -1.0 to 0.6) for sagittal plane angle, -9.2 degrees (95% CI -10.1 to -8.3 degrees) for IMA, and -3.5 (95% CI -4.0 to -3.1) for TSP. Five of the patients reported lesser metatarsal pain preoperatively, and no patients complained of lesser metatarsalgia at 6-month follow-up.

CONCLUSIONS

Minimal length loss of the first ray can be expected following instrumented triplane TMT arthrodesis while achieving full 3-dimensional deformity correction and reducing the risk of lesser metatarsalgia.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

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.

Revision of Malaligned Lapidus and Nonunited Lapidus

"Lapidus arthrodesis is becoming more of a common procedure for treatment of hallux valgus deformities. Like other procedures, complications are possible. The common complications associated with Lapidus arthrodesis procedures include nonunion and malunion. Malunion is typically broken down into recurrence, elevated first ray, shortened first ray, or plantarflexed first ray. This article discusses these common complications after Lapidus arthrodesis.

Scarf osteotomy for the treatment of moderate to severe hallux valgus: Analysis of predictors for midterm outcomes and recurrence

BACKGROUND

Controversies remain regarding the predictors for outcomes and recurrence after scarf osteotomy for hallux valgus deformity.

METHODS

Sixty-two patients (70 feet) underwent scarf osteotomy for hallux valgus deformity. The radiological angles, tibial sesamoid position, articular congruence, demographics, comorbidities, AOFAS, VAS and SF-12 scores, and the postoperative compliance were tested as predictors for outcomes and recurrence.

RESULTS

After a mean 38±15.4 months follow-up, all of the radiological angles, the total AOFAS, PCS-12 and VAS scores significantly improved (all P<0.001). Preoperative MCS-12 was directly related to the total postoperative AOFAS score (P=0.003). A higher number of cardiovascular risk factors negatively affected the postoperative total AOFAS score, VAS and PCS-12 (β=-3.42, P=0.030; β=0.262, P=0.022; β=-0.181, P=0.025, respectively). The BMI influenced postoperative PCS-12 (β=-0.244, P=0.002). Preoperative HVA was directly related to postoperative DMAA (P=0.002) and tibial sesamoid position (P=0.005). Preoperative joint incongruence and postoperative noncompliance were associated with recurrence (P=0.043 and P=0.035, respectively).

CONCLUSIONS

Satisfactory results can be expected after scarf osteotomy. Higher BMI and number of cardiovascular risk factors, and low mental status should be carefully considered when counselling patients for this procedure. Adherence to postoperative care instructions influences deformity recurrence.

Management of Complications After Hallux Valgus Reconstruction

Complications following hallux valgus (HV) reconstruction will have an expected incidence of between 10% and 55% of cases. The more commonly reported complications include undercorrection/recurrence, overcorrection (hallux varus), transfer metatarsalgia, nonunion, malunion, avascular necrosis, arthritis, hardware removal, nerve injury, and ultimately patient dissatisfaction. The presence of arthritis will be an indication for fusion, whereas osteotomies will be the procedure of choice if the first metatarsophalangeal joint is healthy. Wide experience in primary HV surgery is advised before dealing with complex cases of failed HV surgery.

Introduction the revolving scarf osteotomy for treating severe hallux valgus with an increased distal metatarsal articular angle: a retrospective cohort study

BACKGROUND

Hallux valgus(HV) with an increased distal metatarsal articular angle (DMAA) is one of the most common foot deformities among adults. Double metatarsal osteotomy (DMO) is effective in treating severe HV deformity with an increased DMAA. However, this technique presents the risk of avascular necrosis (AVN) of the metatarsal head and transfer metatarsalgia due to shortening of the first metatarsal. The aim of this study was to introduce a surgical procedure defined as revolving scarf osteotomy (RSO) and compare the clinical and radiological results of RSO and DMO performed for treating severe HV with an increased DMAA.

METHODS

First metatarsal osteotomies and Akin osteotomy were performed in 56 patients (62 ft) with severe HV with an increased DMAA in Honghui Hospital from January 2015 to December 2017. RSO was performed in 32 ft and DMO was performed in 30 ft. The Akin osteotomy was performed in both groups. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, the hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, and first metatarsal length (FML) and the rates of complications were compared preoperatively and postoperatively in the two groups.

RESULTS

The mean AOFAS score, VAS score, HVA, IMA, and DMAA showed significant improvements in both groups after surgery, but with no significant differences between the two groups. The postoperative FML was significantly larger in the RSO group than in the DMO group (p < 0.001). One of the 30 ft (3.3%) in the DMO group exhibited transfer metatarsalgia at 12 months postoperatively, while another foot (3.3%) in same group had avascular necrosis of the metatarsal head. One of the 30 ft (3.1%) in the RSO group had hallux varus.

CONCLUSIONS

No differences in the clinical and radiographic results were observed between the two groups with severe HV and an increased DMAA. However, RSO does not cause shortening of the metatarsal and AVN of the metatarsal head. A long-term, randomized, controlled prospective study with a larger sample would provide higher-level evidence for confirming the clinical efficacy and safety of RSO.

Reliability of a new dynamic ultrasound test for quantifying first-ray mobility

BACKGROUND

First-ray hypermobility (FRHM) is a documented abnormality whose pathogenic role is controversial. FRHM has been suggested to participate in many common disorders such as paediatric hallux valgus and recurrence after hallux valgus surgery. The controversy is due to lack of functional data on the first tarso-metatarsal joint (TMT1) in real-life situations, to its major anatomical variability, and to the absence of simple investigation methods. The objective of this study was to assess the feasibility and the inter- and intra-observer reproducibility of a new dynamic ultrasound test that quantifies TMT1 mobility and is simple to use provided a good-quality ultrasound machine is available.

HYPOTHESIS

The new ultrasound TMT1 mobility test is reproducible.

MATERIAL AND METHODS

The 32 feet of 16 consecutive patients whose first ray was considered normal were included. Ultrasonography was performed at rest and during a stress test consisting in causing TMT1 gaping by applying a distal dorsal drawer movement to the first metatarsal. The two plantar bony prominences on either side of the TMT1 were identified, and the distance between them was measured at rest and during the stress test. The stress/rest ratio was computed. Each foot was tested twice by two different examiners, for a total of 128 tests.

RESULTS

Mean TMT1 gaping distance was 1.38mm (range, 1.01-2.02mm) at rest and 1.67mm (range, 1.12-2.95mm). The mean stress/rest ratio was 1.21 (range, 1.02-1.62). Both inter- and intra-observer reliability was strong for all measured parameters.

DISCUSSION

A simple and reproducible ultrasound test for measuring TMT1 mobility is described for the first time. The good reproducibility confirms the working hypothesis. This preliminary study was designed to validate the new test. The measured values need to be assessed in various disorders including FRHM, for which the test was designed. Should the results prove conclusive, the TMT1 gaping test may become a pivotal diagnostic tool.

LEVEL OF EVIDENCE

IV, diagnostic study.

Importance of postoperative sesamoid reduction on the outcomes of proximal chevron osteotomy for moderate to severe hallux valgus deformity

BACKGROUND

The purpose of this study was to compare the clinical and radiographic outcomes between feet with or without postoperative sesamoid reduction of proximal metatarsal chevron osteotomy for moderate to severe hallux valgus deformity.

METHODS

All of 110 feet were allocated into two groups (reduction group; 66 feet, non-reduction group; 44 feet) according to the reduction status of sesamoid at 6 months after surgery. The clinical and radiographic results of the two groups were compared preoperatively, 6 months follow-up, and at last follow-up.

RESULTS

The overall improvement in clinical outcomes was similar in both groups at average 4-year follow-up. However, the radiographic outcomes and recurrence rate were significantly worse in the sesamoid non-reduction group.

CONCLUSIONS

Our results suggested that postoperative incomplete reduction of sesamoid may increase a risk for the recurrence of hallux valgus deformity.

Rigid Internal Fixation of Proximal Crescentic Metatarsal Osteotomy in Hallux Valgus Correction

BACKGROUND

The purpose of this study was to evaluate outcomes utilizing a low-profile titanium plate and screw construct for rigid fixation of first ray proximal crescentic osteotomies in the treatment of hallux valgus.

METHODS

Forty-eight patients (53 feet) with mild to severe hallux valgus were prospectively enrolled and completed 12-month follow-up. All were treated with a proximal crescentic osteotomy, fixed with a low-profile titanium plate, distal soft tissue correction, with or without an Akin osteotomy. Recorded outcomes included change in first ray dorsiflexion angles, need for hardware removal, radiographic and clinical evaluation, pain, and American Orthopaedic Foot & Ankle Society (AOFAS) scores.

RESULTS

All patients achieved radiographic union of their osteotomy. An Akin osteotomy was performed in 83% of patients. Seventeen feet (32%) had hardware removed. First ray dorsiflexion angles increased from a mean of 1.6 degrees preoperatively to 5.0 degrees postoperatively (P < .001). Dorsal malunion, defined as change in dorsiflexion angle greater than 1 standard deviation above the mean, occurred in 7 feet. The mean hallux valgus angle improved from 29 to 9 degrees (P < .001). The mean 1-2 intermetatarsal angle decreased from 14 to 6 degrees (P < .001). The first metatarsophalangeal joint range of motion decreased from 77 to 59 degrees (P < .001). The mean visual analog scale score improved from 4 to 0.7 (P < .0001). The mean AOFAS score improved from 55 to 89 points (P < .001).

CONCLUSION

Proximal crescentic metatarsal osteotomy, fixed with a low-profile titanium plate and screw construct, with distal soft tissue repair, and Akin osteotomy as indicated, was a safe and reliable method for operative treatment of hallux valgus.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Flexion location of the first metatarsophalangeal joint and the location of forefoot bend in general purpose women's footwear

BACKGROUND

General purpose footwear could have a built-in flexion location which may not match the anatomical fulcrum location for an individual's foot. Mismatched fulcra impact on joint function, and may delay healing of an injured first metatarsophalangeal joint (first MP joint). This study compared the location of the first MP joint in an asymptomatic sample of the South African female population to the bend location set within the lasts (used by footwear manufacturers) to find whether mismatches of the flexion locations of the joint to the bending location of the footwear were likely.

METHODS

The study used a three dimensional foot measurement database of 453 female participants to find the fulcrum location of the first MP joint. The distance between the heel and the first MP joint was expressed as a percentage of the overall length of the unshod foot. Similar measures for sandals and closed shoes were derived, and all were compared to manufacturer last data.

RESULTS

The location of first MP joint ranged from 70% to 79% of total foot length, significantly different from last design specifications of 63% or 66% (p<0.0001). The range of first MP joint fulcrum locations in the same size feet occurred in a wide 24mm mediolateral band under the forefoot, termed a flexion zone.

CONCLUSIONS

The first MP joint cannot properly function as a fulcrum unless footwear has a matching flexion location. Footwear designs should incorporate a wide flexion zone located under the forefoot to permit the range of first MP joint flexion locations. Recommendations to patients are to select appropriate flexible footwear to prevent shear forces, reduce strain, prevent injury and enable range of motion function and healing of injury.

Is generalized ligamentous laxity a prognostic factor for recurred hallux valgus deformity?

BACKGROUND

This study was performed to evaluate the intermediate-term clinical outcomes after proximal chevron osteotomy for hallux valgus in patients with generalized ligamentous laxity, and to determine the effect on postoperative recurrence of deformity.

METHODS

There were 23 cases in laxity group (Beighton score ≥5 points) and 175 in non-laxity group with a mean followup of 46.3 months. Clinical evaluation consisted of the AOFAS score, Foot and Ankle Ability Measure (FAAM), and radiographic measurement of hallux alignment. Risk factors associated with postoperative recurrence were evaluated using univariate analysis.

RESULTS

Recurrence rates were 21.7% in the laxity group and 17.1% in non-laxity group (P=.218). There were no significant differences in clinical and radiographic measurements at final followup between the 2 groups. Preoperative HVA and IMA were found to be predictive factors of recurrence (OR=6.3, 4.2; P=.001, .018, respectively).

CONCLUSION

There were no statistical differences in the clinical and radiographic outcomes between hallux valgus with and without generalized ligamentous laxity. Generalized ligamentous laxity demonstrated no definitive effects on postoperative recurrence of hallux valgus deformity.

Feasibility of open and percutaneous corrective osteotomies of the second phalanx of the great toe: An approach on a cadaveric model

BACKGROUND

Having had a previous experience of 4 open F2 osteotomies to correct interphalangeal hallux valgus, the aim of this study was to test the efficacy of a percutaneous approach for this correction.

METHODS

3 open and 12 percutaneous F2 osteotomies in 15 cadaver feet were performed. Interphalangeal (IPH), F2 asymmetry (AF2) and joint deviation (JD) angles were measured on radiographs. The operated great toes were anatomically analyzed looking for possible lesions to surrounding tissues.

RESULTS

Mean IPH decreased from 10.7° to 2.9°, AF2 from 7.8° to 1°, and JD from 1.4° to 0.5°. Damage to the hallux extensor tendon was detected in 1 foot and a nail bed lesion was detected in 1 case, both operated percutaneously.

CONCLUSIONS

F2 Valgus deformity can be corrected using open or percutaneous osteotomy. The authors consider the open correction worthwhile because percutaneous techniques may damage surrounding tissues and the incision length difference is minor.

LEVEL OF CLINICAL EVIDENCE

3.

Foot Mobilization and Exercise Program Combined with Toe Separator Improves Outcomes in Women with Moderate Hallux Valgus at 1-Year Follow-up A Randomized Clinical Trial

BACKGROUND:

Few studies have documented the outcome of conservative treatment of hallux valgus deformities on pain and muscle strength. We sought to determine the effects of foot mobilization and exercise, combined with a toe separator, on symptomatic moderate hallux valgus in female patients.

METHODS:

As part of the randomized clinical trial, 56 women with moderate hallux valgus were randomly assigned to receive 36 sessions for 3 months or no intervention (waiting list). All patients in the treatment group had been treated with foot joint mobilization, strengthening exercises for hallux plantarflexion and abduction, toe grip strength, stretching for ankle dorsiflexion, plus use of a toe separator. Outcome measures were pain and American Orthopedic Foot and Ankle Society (AOFAS) scores. Objective measurements included ankle range of motion, plantarflexion and abduction strength, toe grip strength, and radiographic angular measurements. Outcome measures were assessed by comparing pretreatment, posttreatment, and 1-year follow-up after the intervention. Mixed-model analyses of variance were used for statistical assessment.

RESULTS:

Patients who were treated with 3 months of foot mobilization and exercise combined with a toe separator experienced greater improvement in pain, AOFAS scores, ankle range of motion, hallux plantarflexion and abduction strength, toe grip strength, and radiographic angular measurements than those who did not receive an intervention 3 months and 1 year postintervention ( P < .001 for all comparisons).

CONCLUSIONS:

These results support the use of a multifaceted conservative intervention to treat moderate hallux valgus, although more research is needed to study which aspects of the intervention were most effective.

Proximal Supination Osteotomy of the First Metatarsal for Hallux Valgus

Postoperative recurrence of hallux valgus is a relatively common complication and is associated with unsatisfactory surgical outcomes. Risk factors for postoperative recurrence include a round lateral edge of the first metatarsal head (a positive round sign) and incomplete reduction of the sesamoids. These risk factors may relate to residual pronation of the first metatarsal following surgery. A novel technique of a proximal supination osteotomy, in which varus and pronation of the first metatarsal can be corrected simultaneously, can achieve significant correction in moderate or severe hallux valgus deformity and a low rate of hallux valgus recurrence.

Hallux Valgus Correction Comparing Percutaneous Chevron/Akin (PECA) and Open Scarf/Akin Osteotomies

BACKGROUND

Minimally invasive surgery is being used increasingly, including for hallux valgus surgery. Despite the growing interest in minimally invasive procedures, there have been few publications on percutaneous chevron/akin (PECA) procedures, and no studies have been published comparing PECA to open scarf/akin osteotomies (SA).

METHODS

This was a prospective, randomized study of 50 patients undergoing operative correction of hallux valgus using one of 2 techniques (PECA vs open SA). Data were collected preoperatively and on 1 day, 2 weeks, 6 weeks, and 6 months postoperatively. Outcome measures include the American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal (AOFAS-HMI) Score, visual analog pain score, hallux valgus angle (HVA), and 1-2 intermetatarsal angle (IMA). Twenty-five patients underwent PECA procedures and 25 patients received SA procedures.

RESULTS

Both groups showed significantly improved AOFAS-HMI scores after surgery (PECA group: 61.8 to 88.9, SA group: 57.3 to 84.1, P = .560) with comparable final scores. HVA and IMA also presented similar outcomes at final follow-up ( P = .520 and P = .270, respectively). However, the PECA group showed significantly lower pain level (VAS) in the early postoperative phase (postoperative day 1 to postoperative week 6, P < .001 and P = .004, respectively). No serious complications were observed in either group.

CONCLUSION

Both groups showed comparable good to excellent clinical and radiologic outcomes at final follow-up. However, the PECA group had significantly less pain in the first 6 weeks following surgery. Level of Evidence Level II, prospective comparative study.

Correction of Recurred Hallux Valgus Deformity by Endoscopic Distal Soft Tissue Procedure

The underlying reason for recurrence of hallux valgus deformity after bunion surgery is multifactorial and includes surgeon-based and patient-based factors as well as original components of deformity initially unaddressed at the index procedure. Surgical treatment of a recurred hallux valgus deformity should be undertaken using the same guidelines for correction of a primary hallux valgus deformity. It requires correction of bony alignment, restoration of joint congruity, and achievement of soft tissue balance. The purpose of this Technical Note is to describe the details of endoscopic soft tissue procedure to correct a recurred hallux valgus deformity. To successfully complete this procedure, adequate lateral release to achieve soft tissue balance around the first metatarsophalangeal joint with reduction of the sesamoid bones is mandatory.

Comparison between Simple Radiographic and Computed Tomographic Three-Dimensional Reconstruction for Evaluation of the Distal Metatarsal Articular Angle

The hallux valgus is a pathologic condition in the forefoot that often causes pain and functional limitations. Assessing all deformity components, such as the distal metatarsal articular angle (DMAA) is essential to hallux valgus treatment. Nevertheless, interobserver agreement of DMAA is poor on plain radiographs. The present study compared computed tomographic (CT) 3-dimensional (3D) reconstruction with plain radiographic measurements for measuring the DMAA. We included 43 consecutive patients (77 feet), diagnosed with hallux valgus at the orthopedic outpatient clinic at Hospital de Clínicas de Porto Alegre (Porto Alegre, Brazil) from April 2014 to June 2015 in our prospective study. The DMAAs were measured by 2 observers using CT 3D reconstruction. The results were compared between observers and with the plain radiographic measurements using the concordance correlation coefficient and the Bland-Altman plot to determine the agreement between the 2 methods. The interobserver agreement of the CT 3D measurements was high (concordance correlation coefficient 0.90; p < .001). Significant agreement was found between the plain radiographic and CT measurements (concordance correlation coefficient 0.667; p < .001). The Bland-Altman plot showed that the difference between the plain radiographic and CT measurements increased when greater DMAA values were associated with the presence of metatarsal rotation. The interobserver agreement of DMAA measurements was greater on CT 3D reconstruction than on plain radiography. The poor interobserver agreement of the radiographic DMAA might have resulted from metatarsal rotation.

Weight-bearing recommendations after first metatarsophalangeal joint arthrodesis fixation: a biomechanical comparison

Background

This study sought to determine whether several metatarsophalangeal (MTP) fusion techniques require complete immobilization or if some level of weight-bearing could be recommended after surgery. A comparison of synthetic composite to actual bone was included in order to examine the validity of the testing conditions.

Methods

Four MTP fusion modalities were tested in synthetic composite bone models: unlocked plating, locked plating, crossed lag screws, and an unlocked plate with a single lag screw. Stiffness was calculated and then used to find the two most rigid constructs; the load to failure was recorded. Stiffness and load to failure testing for the two more rigid constructs in paired cadaveric bones were followed.

Results

The unlocked plate plus screw and crossed screw constructs were stiffest (p < 0.008). Loads to failure of the unlocked plate plus screw and crossed screws in synthetic bone were 131 and 101 N, respectively and in cadaveric bone were 154 and 94 N, respectively, which are less than the estimated 25% body weight required at the MTP joint. The plate plus screws were statistically more stiff than crossed screws (p = 0.008), but there was no statistical difference between synthetic and cadaveric bone in load to failure (p = 0.296).

Conclusions

The plate plus screw offered the greatest stiffness; the failure test showed that no construct could withstand weight-bearing as tolerated; and, synthetic composite models of the MTP joint did not provide the consistent results in stiffness and failure.

Three-dimensional analysis of tarsal bone response to axial loading in patients with hallux valgus and normal feet

BACKGROUND

Patients with hallux valgus present a variety of symptoms that may be related to the type of deformity. Weightbearing affects the deformities, and the evaluation of the load response of tarsal bones has been mainly performed using two-dimensional plane radiography. The purpose of this study was to investigate and compare structural changes in the medial foot arch between patients with hallux valgus and normal controls using a computer image analysis technique and weightbearing computed tomography data.

METHODS

Eleven patients with hallux valgus and eleven normal controls were included. Computed tomograms were obtained with and without simulated weightbearing using a compression device. Computed tomography data were transferred into a personal computer, and a three-dimensional bone model was created using image analysis software. The load responses of each tarsal bone in the medial foot arch were measured three-dimensionally and statistically compared between the two groups.

FINDINGS

Displacement of each tarsal bone under two weightbearing conditions was visually observed by creating three-dimensional bone models. At the first metatarsophalangeal joint, the proximal phalanges of the hallux valgus group showed significantly different displacements in multiple directions. Moreover, opposite responses to axial loading were also observed in both translation and rotation between the two groups.

INTERPRETATION

Weightbearing caused deterioration of the hallux valgus deformity three-dimensionally at the first metatarsophalangeal joint. Information from the computer image analysis was useful for understanding details of the pathology of foot disorders related to the deformities or instability and may contribute to the development of effective conservative and surgical treatments.

Percutaneous Triple and Double Osteotomies for the Treatment of Hallux Valgus

BACKGROUND

Percutaneous surgery to correct deformities of the forefoot presents the advantages of using a minimal incision, which involves less soft tissue damage and less risk of wound complications. For severe deformities, percutaneous techniques have not been proven as effective. We propose a technique for the treatment of severe hallux valgus.

METHODS

In a sample of 52 feet operated on 48 patients, we performed a double percutaneous osteotomy (closure proximal osteotomy and a distal Akin) or triple when a Reverdin-Isham osteotomy was added. We measured preoperatively the American Orthopaedic Foot & Ankle Society (AOFAS) score at the 1-year and 2-year follow-up, as well as the values of hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular ankle (DMAA), and shortening and elevation of the first metatarsal. The presence of metatarsalgia was recorded before and after the surgery.

RESULTS

HVA, IMA, and DMAA improved from 39.3 ± 7.1, 17.0 ± 2.0, and 16 ± 8.7 to 11.2 ± 6.2, 8.4 ± 3.4, and 8.3 ± 6.2, respectively. In 5 cases (10%), there was an elevation of the distal metatarsal bone, but only in 2 cases did a transfer metatarsalgia develop. There were no significant correlations between the amount of shortening and the presence of postoperative metatarsalgia. Scores on the AOFAS scale improved from 47.6 ± 5.6 to 89.7 ± 10.1 points.

CONCLUSION

The results are comparable to those reported with other more established techniques. Transfer metatarsalgia did not correlate with lifting or shortening of the metatarsal. We indicate the percutaneous technique for IMA above 15 degrees and increased DMAA or congruent joints.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Cheilectomy as a First-Line Surgical Treatment Option Yields Good Functional Results in Grade III Hallux Rigidus

BACKGROUND

This study aimed to analyze the functional results of cheilectomy in the surgical treatment of grade III hallux rigidus and to evaluate whether cheilectomy is a preferable first-line treatment over other surgical methods.

METHODS

Of 29 patients with moderate daily physical activity who underwent cheilectomy between 2009 and 2012 on being diagnosed as having grade III hallux rigidus according to the Coughlin-Shurnas grading system, 21 patients (14 women and 7 men; mean age, 59.2 years; age range, 52-67 years) (22 feet) with regular follow-up and complete medical records were included in the study. The patients were evaluated in the preoperative and postoperative periods using a visual analog scale for pain and the American Orthopaedic Foot and Ankle Society metatarsophalangeal assessment forms.

RESULTS

The preoperative mean American Orthopaedic Foot and Ankle Society score of 53 (range, 29-67) improved to 78 (range, 57-92) postoperatively (Wilcoxon test P = .001). The preoperative mean visual analog scale score of 89 (range, 60-100) improved to 29 (range, 0-70) in the postoperative period (Wilcoxon test P = .001).

CONCLUSIONS

As a simple and repeatable procedure that allows for further joint-sacrificing surgical procedures when required, cheilectomy is a preferable method to be applied as a first-line option for the surgical treatment of grade III hallux rigidus.

Surgical correction of hallux valgus complicated with adult-type pes plano-valgus

PURPOSE

To investigate the efficiency of simultaneous correction of moderate to severe hallux valgus deformity and adult-type pes planus.

METHODS

Twenty cases of moderate to severe hallux valgus complicated with adult-type pes planus in 19 consecutive patients (15 (79%) women, 4 (11%) men; mean age: 44.50 ± 17.13 years, mean follow-up duration: 31.30 ± 17.02 months) were included. Medial calcaneal sliding osteotomy was performed to correct hindfoot valgus, whereas treatments of hallux valgus were case dependent.

RESULTS

The mean postoperative hallux valgus angle, intermetatarsal angle, hindfoot alignment angle, and hindfoot alignment ratio were 8.40 ± 5.29°, 4.20 ± 2.54°, 3.09 ± 2.92º and 0.41 ± 0.17, respectively. Although a hallux varus deformity occurred as a postoperative complication in one case (5%), there were no cases of postoperative recurrence.

CONCLUSION

Simultaneous correction of hallux valgus and pes plano-valgus using medial calcaneal sliding osteotomy is an effective technique that reduces recurrence of hallux valgus and increases satisfaction in patients with moderate to severe hallux valgus deformity complicated with adult-type pes planus accompanying hindfoot valgus.

Turf Toe and Disorders of the Sesamoid Complex

A turf toe injury encompasses a wide spectrum of traumatic problems that occur to the first metatarsophalangeal joint. Most of these injuries are mild and respond well to nonoperative management. However, more severe injuries may require surgical management, including presence of diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, loose body, and failed conservative treatment.

Consequences of Avulsion Fracture of the Proximal Phalanx Caused by a Technical Failure of Hallux Valgus Surgery

Several cases of avulsion fracture of the proximal phalanx of the big toe during the lateral capsular release procedure were observed. However, these fractures have not been reported as a complication of hallux valgus surgery. The purpose of the present study was to report the proximal phalanx base fracture as an unrecognized complication and to evaluate the clinical and radiographic consequences of this complication. We retrospectively reviewed 225 feet that had undergone hallux valgus surgery involving proximal chevron osteotomy and distal soft tissue release from May 2009 to December 2012. Of these 225 feet (198 patients), 12 (5.3%) developed proximal phalanx base fracture postoperatively. These patients were assigned to the fracture group. The remaining patients were assigned to the nonfracture group. Patients were followed to observe whether the fractures united and whether degenerative changes developed at the first metatarsophalangeal joint because of this fracture. The mean follow-up period was 36 (range 12 to 72) months. All the subjects in the fracture and nonfracture groups underwent weightbearing anteroposterior and lateral radiographs of the foot at the initial presentation and final follow-up point. The 2 groups were compared with respect to the hallux valgus angle, intermetatarsal angle, range of motion, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes. No significant differences were found in age, follow-up period, hallux valgus angle, intermetatarsal angle, range of motion of the first metatarsophalangeal joint, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes between the 2 groups. Ten (83.3%) of the 12 fractures healed, 2 (16.7% of the fractures, 0.89% of the operated feet) progressed to asymptomatic nonunion, and 3 (1.33%) developed first metatarsophalangeal joint degeneration. Avulsion fracture of the proximal phalanx of the big toe is an uncommon complication of hallux valgus surgery. It seems to be caused by excessive tension placed on the lateral soft tissues that attach to the base of the proximal phalanx at the time of plantarlateral soft tissue release. However, this fracture does not seem to cause significant clinical problems.

Does arthrodesis of the first metatarsophalangeal joint correct the intermetatarsal M1M2 angle? Analysis of a continuous series of 208 arthrodeses fixed with plates

INTRODUCTION

First-ray metatarsophalangeal arthrodesis is a classic surgical procedure in the treatment of severe hallux valgus, hallux rigidus, revision surgery, and inflammatory arthritis. The objective of this study was to verify if metatarsophalangeal plate arthrodesis could correct the M1M2 intermetatarsal angle.

MATERIAL AND METHODS

This prospective and continuous series (June 2007 to March 2011) included 208 patients (48% severe and/or arthritic hallux valgus, 18% hallux rigidus, 16% rheumatoid forefoot, 13% surgical revision of the first ray, 5% hallux varus), with a mean age of 62.4±9.9 years (range, 19-87 years). All the patients were operated on by a senior surgeon with the same technique: spherical avivement of the joint surfaces using reamers, osteosynthesis with an anatomic plate (Fyxis-Biotech™) in Ti.6Al.4 V alloy prebent to 5° with a phalangeal arm to receive an oblique metatarsophalangeal screw in compression, in addition to four 2.7-mm nonlocking dorsal screws. The full-scale preoperative and intraoperative angle measurements were taken on AP and lateral X-rays of the weightbearing foot, as related to the etiology and the severity of the preoperative metatarsus varus (M1M2<15°, M1M2 15-19°, M1M2≥20°). The statistical analysis was done using the StatView software.

RESULTS

The mean follow-up was 18.6±12.4 months (range, 2-76 months). Nearly all of the arthrodesis patients (97%) achieved bone union, and 5% of the plates were removed. The M1P1 angle decreased from 33.8±19.7° (range, -45° to -67°) preoperatively to 13.3±5.3° (range, 0-32°) at the last follow-up, and the M1M2 angle from 14.2±5.4°(range, 0-26°) to 6.5±2.3° (range, 0-12°). The preoperative M1M2 angle was <15° in 97 patients, 15-19° for 78 patients, and ≥20° for the 33 others; at the last follow-up it was 5.8±2.1° (range, 0-10°), 6.7±2.2° (0-10°), and 8.1±2.4° (3-12°), respectively. No correction of the metatarsus varus was demonstrated in relation to etiology. The M1M2 angle was >10° in only two patients (one case of rheumatoid arthritis and one case of severe hallux valgus): 0.9%.

DISCUSSION

These results show that isolated metatarsophalangeal arthrodesis of the first ray can correct metatarsus varus even in substantial deformations in any etiology.

LEVEL OF PROOF

Level II cohort study.

Restoring Sesamoid Position in Scarf Osteotomy: A Learning Curve

Incomplete reduction of the sesamoid is a known risk factor for recurrence of the deformity after scarf osteotomy for correction of hallux valgus. The purpose of the present study was to determine whether a learning curve exists for successfully restoring the sesamoid position in scarf osteotomy. We reviewed 71 consecutive cases (71 feet) of scarf osteotomy performed on female patients during a 2.5-year period by the same surgeon. The cases were divided into 3 groups according to the date of surgery, with the first 24 cases assigned to group 1, the next 24 to group 2, and the last 23 to group 3. We compared the median sesamoid position of the 3 groups at 6 weeks postoperatively and patient reported satisfaction at 6 months postoperatively. The sesamoid position ranged from 1 to 7, using the Hardy and Clapham classification system. The median sesamoid position for all patients had improved from 7 preoperatively to 2 postoperatively. The postoperative sesamoid position was significantly better for the second and third groups than for the first (p < .05), and 92% of the patients were satisfied with the procedure. We have concluded that a learning curve to optimally restoring the position of the sesamoid in scarf osteotomy is present and that this has a direct effect on reducing the risk of recurrence of the deformity.

Proximal supination osteotomy of the first metatarsal for hallux valgus

BACKGROUND

Risk factors for hallux valgus recurrence include postoperative round-shaped lateral edge of the first metatarsal head and postoperative incomplete reduction of the sesamoids. To prevent the occurrence of such conditions, we developed a proximal supination osteotomy of the first metatarsal. Our aim was to describe this novel technique and report the outcomes in this report.

METHODS

Sixty-six patients (83 feet) underwent a distal soft tissue procedure combined with a proximal supination osteotomy. After the proximal crescentic osteotomy, the proximal fragment was pushed medially, and the distal fragment was abducted, and then the distal fragment of the first metatarsal was manually supinated. Outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiographic examinations. The average follow-up duration was 34 (range, 25 to 52) months.

RESULTS

The mean AOFAS score improved significantly from 58.0 points preoperatively to 93.8 points postoperatively (P < .0001). The mean hallux valgus and intermetatarsal angle decreased significantly from 38.6 and 18.0 degrees preoperatively to 11.0 and 7.9 degrees postoperatively, respectively (both, P < .0001). Sixty-nine feet (69/83, 83%) had a positive round sign preoperatively, and 66 feet (66/83, 80%) had a negative round sign postoperatively. According to the Hardy's classification of position of the sesamoids, all feet were classified as grade V or greater preoperatively, and 49 feet (49/83, 59%) were classified as grade IV or less postoperatively. Three feet (3/83, 4%) had recurrence of hallux valgus, defined as a hallux valgus angle ≥ 25 degrees.

CONCLUSION

The rates of occurrence of a positive round sign and incomplete reduction of the sesamoids significantly decreased postoperatively, which may have contributed to the low hallux valgus recurrence rates. We conclude that a proximal supination osteotomy was an effective procedure for correction of hallux valgus and can achieve a low rate of hallux valgus recurrence.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Radiographic results after hallux metatarsophalangeal joint arthrodesis for hallux varus

BACKGROUND

Hallux metatarsophalangeal (MP) joint arthrodesis for hallux varus is generally reserved for severe deformity, failed surgery or the development of osteoarthritis. The purpose of this study was to determine the radiologic results of arthrodesis of the hallux MP joint following treatment for hallux varus. Our hypothesis was that in the process of correcting the hallux valgus angle, the 1-2 intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) will be improved due to correction of the deforming forces.

METHODS

A retrospective review was performed on 26 patients with 29 feet that had symptomatic hallux varus deformities treated with arthrodesis of the hallux MP joint between September 1, 2002, and December 31, 2012. The 1-2 IMA and HVA were measured on the preoperative and most recent postoperative films and compared. Twenty-nine patients were followed with postoperative weight-bearing radiographs. Two were men and 24 were women. Twelve were performed on the right foot, 17 on the left, including 3 bilateral cases. Fourteen patients had concomitant procedures on the ipsilateral forefoot.

RESULTS

The average 1-2 IMA changed from 4.8 degrees to 8.4 degrees, a difference of 3.6 degrees (P < .05), and the average HVA changed from -20.7 degrees to 8.1 degrees (P < .05).

CONCLUSION

Our study showed that a hallux MP joint arthrodesis in patients with hallux varus resulted in a predictable increase in the 1-2 IMA.

LEVEL OF EVIDENCE

Level IV, case series.

Osteodesis for hallux valgus correction: is it effective?

BACKGROUND

Although the etiology of hallux valgus is contested, in some patients it may be failure of the stabilizing soft tissue structures around the first ray of the foot. Because there is lack of effective soft tissue techniques, osteotomies have become the mainstream surgical approach to compensate for the underlying soft tissue deficiency; osteodesis, a soft tissue nonosteotomy technique, may be a third alternative, but its efficacy is unknown.

QUESTIONS/PURPOSES

We asked: (1) Can an osteodesis, a distal soft tissue technique, correct hallux valgus satisfactorily in terms of deformity correction and improvement in American Orthopaedic Foot and Ankle Society (AOFAS) score? (2) Is the effectiveness of an osteodesis affected by the patient's age or deformity severity? (3) What complications are associated with this procedure?

METHODS

Between February and October 2010, we performed 126 operations to correct hallux valgus, of which 126 (100%) were osteodeses. Sixty-one patients (110 procedures) (87% of the total number of hallux valgus procedures) were available for followup at a minimum of 12 months (mean, 23 months; range, 12-38 months). This group formed our study cohort. During the study period, the general indications for this approach included failed conservative measures for pain relief and metatarsophalangeal angle greater than 20° or intermetatarsal angle greater than 9°. Intermetatarsal cerclage sutures were used to realign the first metatarsal and postoperative fibrosis was induced surgically between the first and second metatarsals to maintain its alignment. The radiologic first intermetatarsal angle, metatarsophalangeal angle, and medial sesamoid position were measured by Hardy and Clapham's methods for deformity and correction evaluation. Clinical results were assessed by the AOFAS score.

RESULTS

The intermetatarsal angle was improved from a preoperative mean of 14° to 7° (p<0.001; Cohen's d=1.8) at followup, the metatarsophalangeal angle from 31° to 18° (p<0.001; Cohen's d=3.1), the medial sesamoid position from position 6 to 3 (p<0.001; Cohen's d=2.4), and AOFAS hallux score from 68 to 96 points (p<0.001). Neither patient age nor deformity severity affected the effectiveness of the osteodesis in correcting all three radiologic parameters; however, the deformities treated in this series generally were mild to moderate (mean intermetatarsal angle, 14°; range, 9°-22°). There were six stress fractures of the second metatarsal (5%), five temporary metatarsophalangeal joint medial subluxations all resolved in one month by the taping-reduction method without surgery, and six metatarsophalangeal joints with reduced dorsiflexion less than 60°.

CONCLUSIONS

The osteodesis is a soft tissue nonosteotomy technique, and provided adequate deformity correction and improvement in AOFAS scores for patients with mild to moderate hallux valgus deformities, although a small number of the patients had postoperative stress fractures of the second ray develop. Future prospective studies should compare this technique with osteotomy techniques in terms of effectiveness of the correction, restoration of hallux function, complications, and long-term recurrence.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Preoperative radiological factors correlated to long-term recurrence of hallux valgus following distal chevron osteotomy

BACKGROUND

The purpose of this article was to analyze the long-term radiologic results after distal chevron osteotomy for hallux valgus treatment and to determine the preoperative radiographic factors correlating with radiological recurrence of the deformity.

METHODS

The study included 100 consecutive patients who received distal chevron osteotomy for hallux valgus. The osteotomy included fixation with an absorbable pin in 50 cases, and no fixation in the other 50. For 6 weeks postoperatively, half of each group used a soft cast and half had a traditional elastic bandage. Weight-bearing radiographs were evaluated at 6 weeks, 6 months, 1 year, and a mean of 7.9 (range, 5.8-9.4) years postoperatively.

RESULTS

At the final follow-up, radiological recurrence of hallux valgus deformity (HVA > 15 degrees) was observed in 56 feet (73%). Eleven feet (14%) had mild recurrence (HVA < 20 degrees), 44 (57%) moderate (20 degrees ≥ HVA < 40 degrees), and 1 (1%) severe (HVA ≥ 40 degrees). All recurrences were painless, and thus no revision surgery was required. Long-term hallux valgus recurrence was significantly affected by preoperative congruence, DMAA, sesamoid position, HVA, and I/II IMA.

CONCLUSIONS

Radiological recurrence of hallux valgus deformity of 15 degrees or more was very common at long-term follow-up after distal chevron osteotomy. Preoperative congruence, DMAA, sesamoid position (LaPorta), HVA, and I/II IMA significantly affected recurrence.

LEVEL OF EVIDENCE

Level III, comparative case series.

A retrospective study of 63 hallux valgus corrections using the osteodesis procedure

Osteotomy procedures have been the most popular approach to hallux valgus deformity correction. Soft tissue approaches have, in general, been regarded as ineffective for moderate and severe hallux valgus deformities. Osteodesis is a soft tissue technique that has been shown to be effective in the past but is still seldom practiced. In the present report, we describe a retrospective study of 63 hallux valgus feet in 36 patients who had undergone the osteodesis procedure. Their mean age was 46 ± 12 years, and the mean follow-up period was 25.4 ± 9.6 months. The surgical technique consisted of metatarsus primus varus deformity correction by intermetatarsal cerclage sutures and hallux valgus deformity correction by rebalancing the ligaments. The first metatarsophalangeal angle improved from a mean of 32.5° ± 7.6° preoperatively to 18.4° ± 7° postoperatively, the first intermetatarsal angle improved from 14.6° ± 2.6° to 6.8° ± 1.8°, and the American Orthopaedic Foot and Ankle Society score improved from 59 ± 14 to 93 ± 8 points. The rate of patient satisfaction after surgery was 92% (33 of 36 patients, 59 of 63 feet). The complications included a second metatarsal stress fracture in 3 feet (5%), metatarsophalangeal joint medial subluxation in 3 feet (5%), and metatarsophalangeal joint stiffness in 5 feet (8%). This soft tissue, nonosteotomy procedure was a safe technique that effectively corrected hallux valgus and metatarsus primus varus deformities of various severities without osteotomy or fusion.

Autogenous capsular interpositional arthroplasty surgery for painful hallux rigidus: assessing changes in range of motion and postoperative foot health

The autogenous capsular interpositional arthroplasty procedure can be a motion-sparing alternative to arthrodesis for the treatment of recalcitrant hallux rigidus deformity. Previous studies have reported positive results; however, many had small samples or lacked comparable preoperative measures. The present study used a prospective cohort study to assess the benefit of this technique for increasing range of motion, and comparative data to assess the reduction of pain and improvements in perceived foot health status for a consecutively drawn sample of patients. Thirty-four patients (44 feet) reviewed using a long-arm goniometer at a mean of 3.75 years after surgery experienced a significant increase in dorsiflexion (preoperative mean 11.09° ± 10.13°; postoperative mean 26.64° ± 10.07°; p < .001); plantar flexion remained unchanged. Additionally, 15 of 17 patients for whom the hallux abductus angle was initially greater than the normal range was within the normal range postoperatively. The postoperative patient perceptions of foot pain were significantly better than those from a comparable sample of patients presenting for a surgical opinion (t[69] = 6.80), just as were the perceptions of foot function, foot health, and footwear comfort (p < .001 for all). The postoperative perceptions of foot pain were comparable with the postoperative results from a range of previously published studies. These results have shown, with improvements in range of motion and reduction in pain, that autogenous capsular interpositional arthroplasty is a useful, motion-sparing technique in the treatment of painful hallux rigidus and should be considered for classification as a clinical practice guideline.