Results of hallux varus correction using an extensor hallucis brevis tenodesis

A Literature Review of the Morphological Variability in the Intrinsic Muscles of the Foot: Traps Awaiting Clinicians during Ultrasound

Purpose: Like other muscular compartments of the human body, the intrinsic muscles of the foot present considerable morphological variability. The aim of this review was to present variations that can potentially cause problems during surgery but might be detected during an ultrasound examination. Materials and methods: PubMed was searched for relevant articles. The identified papers were listed, and citation tracking was performed. Results: Even though lower limb structure is well studied, the variations associated with the intrinsic muscles of the foot and their related ultrasound examination are not. Conclusions: The muscles and tendons of the foot demonstrate similar degrees of variance as other regions of the human body; however, this subject is not as widely covered in the literature. Further ultrasound studies are needed to build awareness of morphological variability in this region, as the findings could prevent misdiagnosis.

Primary Congenital Hallux Varus: A Step-Cut Surgical Approach

Hallux varus is a rare deformity of the forefoot, which is characterized by medial deviation of the proximal phalanx of the great toe at the metatarsophalangeal joint. It is usually acquired, secondary to failed hallux valgus surgery, trauma, neurologic or rheumatologic disease. Rarely, this deformity may be congenital, either isolated, or in the context of various underlying congenital malformations of the foot, such as poly-syndactyly or longitudinal epiphyseal bracket, or part of generalized skeletal malformations. We present a case of bilateral congenital hallux varus with concomitant short first metatarsal in a three-year-old girl. A step-cut soft-tissue surgical procedure to achieve proper alignment of the medial ray of the foot is described.

Hallux Varus Correction With Extensor Hallucis Longus Tendon Transfer and Reverse Scarf Osteotomy

INTRODUCTION

Hallux varus is the medial deviation of the hallux. Although rare, it can cause discomfort, functional weakness, difficulty with shoe wear, and dissatisfactory cosmesis. This study reports 3 cases of hallux varus treated using extensor hallucis longus (EHL) tendon transfer with or without the use of reverse scarf osteotomy (RSO).

METHODS

This cases series studies the technique of using EHL tendon transfer and the role for RSO in the surgical correction of hallux varus. Indication for RSO included osseous overcorrection in the index hallux valgus surgery or as an adjunct when EHL tendon transfer alone was unable to restore alignment. Patients were followed-up for 24 months and their postoperative outcomes were recorded.

RESULTS

All patients were female between the ages 55 to 67 years. Radiological parameters after surgery improved in all patients. The mean hallux-valgus angle was corrected from -23.7 ± 3.5° to -3.2 ± 2.0° postoperatively (P < .05). Intermetatarsal angle was increased from 5.0 ± 1.9° to 6.7 ± 1.0° (P = .065). Distal metatarsal articular angle improved from -28.9 ± 7.6° to -7.8 ± 3.7° (P < .05). Mean American Orthopaedic Foot and Ankle Society scores improved from 37 ± 24 to 75 ± 9 (P = .064) at 24 months. In addition, visual analogue scale pain scores reduced from 5 ± 1.5 to 1 ± 1 (P < .05). All patients reported being satisfied with the procedure, and no complications were reported at 24 months after surgery.

CONCLUSION

Hallux varus correction using EHL tendon transfer with or without RSO appears to provide satisfactory results at 24 months.

LEVELS OF EVIDENCE

Level V: Expert opinion, Techniques.

Postoperative Hallux Varus Treatment by Reverse Scarf Osteotomy

BACKGROUND

Postoperative hallux varus is often accompanied by an abnormal decrease in the first-second (M1M2) intermetatarsal angle, which we have sought to correct by a reverse scarf-type osteotomy.

METHODS

A series of 36 hallux varus operated on by reverse scarf osteotomy, including 14 with prior osteotomies, was reviewed with an average follow-up of 56 months. The measurements were clinical: American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, subjective satisfaction index, joint mobility, and radiologic angles: M1M2 and first metatarsophalangeal angle.

RESULTS

The M1M2 angle increased on average from 3 to 8 degrees whereas the average M1P1 angle of varus went from -21 to +9 degrees, including 2 patients who had a reoccurring valgus of 20 degrees. The median AOFAS score increased from 47 to 79, the VAS from 6.7 to 2.3, joint mobility lost an average of 9 degrees, and all those operated on were satisfied with the result. All operated bones healed without secondary displacement.

DISCUSSION

The reverse scarf osteotomy is capable of correcting the intermetatarsal angle and at the same time correcting the postoperative hallux varus. Functional scores generally improved, including in patients with a reoccurring valgus and those with reduced mobility.

CONCLUSION

The reverse scarf osteotomy can be performed to treat postoperative hallux varus with a mild intermetatarsal angle with reasonable clinical and radiologic results.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Post-operative hallux varus: a review of treatment methods

PURPOSE

Hallux varus is a classical complication of hallux valgus surgery with a medium rate of 6%.

MATERIAL AND METHODS

Methods of treatment are MTP1 fusion or conservative joint operations. Hallux varus results from imbalance between excessive medial capsule retraction or tensioning and excessive lateral laxity or soft-tissue release but also and mainly from an over displacement of the first metatarsal which reduces the intermetatarsal angle and thus leads to medial displacement of the great toe. A majority are well tolerated, but few need to be re-operated upon.

RESULTS

Factors guiding choice are mainly range of motion and reducibility of the first metatarsophalangeal joint and tendon balance. Joint sparing could be decided for a mobile and well balancesd MTP1 with two options, soft-tissue repairing such as tendon and ligament transfer and reverse osteotomies. The choice depends mainly on the radiological features as an unduly closed intermetarsal angle which leads to a reverse scarf or chevron osteotomy whatever previous surgery was or was not with an osteotomy.

CONCLUSION

Conservative treatment is tricky, and MTP1 fusion is still a reliable procedure which can be used widely.

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.

Surgical treatment of iatrogenic hallux varus

Iatrogenic hallux varus is a dreaded complication of hallux valgus surgery, consisting in 1st-ray deformity in the form of medial malalignment of the 1st phalanx with respect to the metatarsal axis. Such over-correction results from imbalance between excessive medial capsule retraction or tensioning and excessive lateral laxity or soft-tissue release. There may be loss of medial stability of bone origin due to excessive "exostosectomy" or excessive intermetatarsal angle closure. Following excessive lateral release, the imbalance gradually induces a varus deformity of the 1st phalanx due to traction by the medial muscles: abductor hallucis and medial head of flexor hallucis brevis inserting to the medial sesamoid. The deformity comprises 3 components, of varying importance: medial deviation of the hallux at the 1st metatarsophalangeal joint, supination of the phalanx, and interphalangeal flexion (i.e., claw deformity of the hallux). Treatment strategy is determined by the various clinical and radiological data explaining the postoperative hypercorrection. The clinical analysis is decisive, while radiology contributes more technical factors once the treatment option has been decided on. There are two main options for surgical revision to restore 1st ray propulsion: 1) static or dynamic reconstruction of the ligamentous structures, conserving metatarsophalangeal motion; or 2) metatarsophalangeal and/or interphalangeal fusion. Factors guiding choice are mainly range of motion, and reducibility of the metatarsophalangeal and interphalangeal deformity. We describe the procedures in detail, emphasizing the essential points for success. Joint sparing is to be sought in flexible deformities and young patients. Ligament reconstruction can be anatomic or palliative by tenodesis effect, which makes adjustment difficult. Alongside soft-tissue reconstruction, the metatarsal osteotomy should also be revised if the intermetatarsal angle has been unduly closed. Metatarsophalangeal fusion is the most reliable solution and is unavoidable if the joint is stiff or degenerative; it undoubtedly reduces risk of failure. LEVEL OF EVIDENCE: V, expert opinion.

Treatment of Hallux Varus After Traumatic Adductor Hallucis Tendon Rupture

Hallux varus is a deformity of acquired and less commonly congenital etiologies. It can present secondary to the release of the soft tissues surrounding the first metatarsophalangeal joint surfaces during bunion surgery. If the condition is left untreated, it can be debilitating, with progressive pain and destruction of joint surfaces. Many procedures have been described for the treatment of iatrogenic causes of hallux varus; however, little has been reported regarding the success of procedures when used for less typical traumatic causes. In the present report, a case is presented of surgical repair of a traumatic hallux varus using a suture and button fixation device and 3-year patient follow-up data.

Hallux varus following scarf osteotomy

Hallux varus is an uncommon condition and majority of the cases are iatrogenic. It can occur as a result of any type of hallux valgus correction surgery and in our cases scarf osteotomy is not an exception. Treatment of this complication can be challenging and it is important to understand the factors that cause this deformity before embarking on surgical correction. Four cases of hallux varus following Scarf osteotomy (1% of our total Scarf osteotomy cases) and discuss the salient features of these patients. The authors ascertained the factors that caused iatrogenic hallux varus and formulated a classification of the nature of the deformity. The management of iatrogenic hallux varus based on our experience and proposed classification system has also been outlined and discussed.

Managing Complications of Percutaneous Surgery of the First Metatarsal

The percutaneous osteotomy based on a Hohmanntype first metatarsal subcapital linear osteotomy was introduced into Mainland China in the late 1980s. No internal fixation is used for stabilization of the osteotomy, leading unfortunately to unpredictable results. Despite its high acceptance by patients and enthusiasm by surgeons at present, the clinical outcomes of percutaneous surgery have not been promising. The authors have no experience of performing this osteotomy and report only on their management of the complications of this technique and their recommended treatment algorithm.

Tendon Transfers and Salvaging Options for Hallux Varus Deformities

Hallux varus is an infrequently encountered deformity of the first ray characterized by a medial deviation of the hallux on the first metatarsal head at the first metatarsal phalangeal joint. Iatrogenic flexible hallux varus often requires surgical repair to create a functional, pain-free, shoeable foot. Although arthrodesis remains the mainstay of treatment, many soft tissue transfer procedures have been described in the literature as joint-sparing alternatives to fusion. This article explores in detail the tendon transfer procedures that have been described for repair of flexible hallux varus deformity.

Traumatic Hallux Varus Treated by Minimally Invasive Extensor Hallucis Brevis Tenodesis

A case of traumatic hallux varus due to avulsion fracture of the lateral side of the base of proximal phalanx was reported. The lateral instability of the first metatarsophalangeal joint was believed to be due to the disruption of adductor hallucis function. It was successfully managed by minimally invasive extensor hallucis brevis tenodesis.

Gradual Correction of Traumatic Hallux Varus With Metatarsal Hemicallotasis

Traumatic hallux varus associated with osseous deformity, especially in the case of a decreased distal metatarsal articular angle, is an extremely challenging, but rewarding, deformity to treat. To the best of our knowledge, no previous reports have referred to surgical correction of traumatic hallux varus using first metatarsal hemicallotasis. We report the case of a 54-year-old male with traumatic hallux varus associated with medial subluxation of the second metatarsophalangeal joint and second metatarsocuneiform joint arthrosis. The patient was successfully treated with metatarsal hemicallotasis with medial soft tissue release, a proximal second metatarsal shortening osteotomy, and second metatarsocuneiform joint arthrodesis. After 1 year and 6 months, the correction had been maintained in a suitable position, no discomfort or pain was present, and the patient was completely satisfied with the surgical results. Metatarsal hemicallotasis can safely determine the angle of correction and minimize the risk of avascular necrosis of the metatarsal head even in deformed halluces with previous traumatic injuries and/or surgical treatment. This technique should be indicated only for hallux varus with a decreased distal metatarsal articular angle, an angular-type metatarsal head, and good metatarsophalangeal joint congruence.

The treatment of iatrogenic hallux varus

Though uncommon, iatrogenic hallux varus is most often the result of overresection of the medial eminence, overtranslation of an osteotomy, overrelease of the lateral soft tissues, or overtightening of the medial tissues. It is not always symptomatic, as the degree of deformity can be well tolerated. For soft-tissue reconstructions, releases have little role to play unless minor deformity is detected early on and the longevity of tendon transfer and tenodesis remains unknown. For bony reconstruction, arthrodesis is the recommended salvage technique.

Post-traumatic dynamic hallux varus instability

Acquired hallux varus secondary to traumatic disruption of the lateral joint structures of the 1st MTPJ is uncommon and has only been reported in the literature once previously.(4) We present a case of traumatic hallux varus that is unique since the deformity is dynamic in nature. In our patient the hallux remained reduced on standing weight bearing films, and luxated only during fluoroscopic stress testing. We also describe our surgical correction where a soft tissue anchor alone was utilized to stabilize the joint through repair of the lateral capsule and collateral ligament. One year following the described repair the patient reports no limitations in performing activities of daily living, and complains of only mild pain with recreational activities.

Forefoot tendon transfers

Flexible forefoot deformities, such as hallux varus, clawed hallux, hammer toes, and angular lesser toe deformities, can be treated effectively with tendon transfers. Based on the presentation of the flexible forefoot deformities, tendon transfers can be used as the primary treatment or as adjuncts to bony procedures when there are components of fixed deformities.

Failure after soft-tissue release with tendon transfer for flexible iatrogenic hallux varus: a systematic review

Hallux valgus is a common forefoot pathology often requiring surgical intervention for symptomatic relief. One complication of hallux valgus correction is flexible hallux varus. Iatrogenic flexible hallux varus often requires surgical repair; however, the most advantageous surgical procedure for repair of iatrogenic flexible hallux varus and their sustainability remains unclear. Therefore, we performed a systematic review to determine the sustainability of soft-tissue release with tendon transfer for the correction of iatrogenic flexible hallux varus. Studies were eligible for inclusion only if they involved failure of soft-tissue release with tendon transfer for flexible iatrogenic hallux varus. Eight studies met our inclusion criteria, seven of which were evidence-based medicine level IV studies and one was level V. A total of 52 patients, all female, involving 68 feet, were included. All studies included soft-tissue release of the first metatarsal-phalangeal joint capsule and 1 of the following procedures: Johnson transfer of the extensor hallucis longus tendon with arthrodesis of the hallux interphalangeal joint (41 feet); Hawkins transfer of the abductor hallucis tendon (9 feet); reverse Hawkins transfer (7 feet); Valtin transfer of the first dorsal interosseous tendon (7 feet); and Myerson transfer of the extensor hallucis brevis tendon (4 feet). The weighted mean age of the patients was 50.4 years, and the weighted mean follow-up was 30.2 months. A total of 11 complications (16.2%) occurred. Of note, only 3 cases (4.4%) of recurrent hallux varus deformity developed, all of which occurred after Johnson transfer of the extensor hallucis longus tendon, with arthrodesis of the hallux interphalangeal joint. Our results support that sustainable correction of iatrogenic flexible hallux varus can be achieved with soft-tissue release of the first metatarsal-phalangeal joint combined with a variety of tendon transfer procedures. However, given the limited data available, potential areas for additional prospective investigation remain.

Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus

Level of Evidence: V, Expert Opinion

Hallux varus: classification and treatment

Appropriate treatment for hallux varus requires comprehensive radiographic and systematic clinical assessment to identify the involved factors. A classification scheme must incorporate many variables in order to determine the best approach to correcting the deformity. This article focuses on iatrogenic hallux varus following bunion surgery, but the same principles apply to other causes of acquired hallux varus.

Iatrogenic medial dislocation of hallucal sesamoids with hallux varus in an adolescent

BACKGROUND

Iatrogenic hallux varus is a rare deformity linked to bunion surgery at late adult age. Here reported is the first adolescent case of acquired hallux varus and medial dislocation of both sesamoid bones.

CASE REPORT

The patient had had a surgical intervention under his first metatarsophalangeal joint when he was 10 years old. Correction of the deformity with a tendon transfer and medial capsular release alone-as was recommended for adults-was impossible in this adolescent, 8 years after the index surgery. Excision of the contracted medial structures and repair of the lateral retinaculum of the fibular sesamoid obtained a perfect correction of the dislocated sesamoid bones.

Salvage of complications of hallux valgus surgery

Complications following hallux valgus surgery can occur and are a frequent source of patient dissatisfaction. The treatment of these complications begins with careful preoperative planning to ensure that the chosen procedure is appropriate for the specific patient. When complications occur, treatment must also be individualized to address the symptoms of the patient. This article presented an overview of the more common complications that are seen following hallux valgus surgery. Nonsurgical and surgical options for treatment were outlined to assist in the management of these complications.

Complications after surgery of the hallux

The great toe is affected by many congenital and acquired conditions including arthritis, hallux valgus, and hallux rigidus and disease of the hallucal sesamoids. Many surgical procedures have been described for the treatment of these conditions. With the increased popularity of forefoot surgery comes the potential for complications even when the surgery is done meticulously by an experienced surgeon under well-planned conditions. When a complication occurs, it can present difficult and challenging problems. It is, therefore, important to recognize a complication early so it may be analyzed and treated successfully. When recognized, a plan should be developed to identify, quantify, control, and resolve the problem. The current review defines some common complications and treatment options. Several problems may exist at the same time. A solution addressing all aspects of the problem must be designed so as not to augment the presenting complications. Salvage operations and long-term treatment are included to provide a perspective on treatment of residual deformity. It is important to realize that there often are several solutions to a difficult problem. Many factors influence the surgeon's choice and implementation of a solution, but the ultimate outcome always depends on a well thought out plan.

Post-burn hallux varus: a case report and management of a rare deformity

Post-burn hallux varus is an extremely rare condition. A 22-year-old male, with a history of campfire burns in childhood, presented with secondary hallux varus of the left great toe. Surgical correction included medial soft tissue release, metatarsophalangeal joint arthrodesis, two-pin fixation of bones, metatarsophalangeal joint capsulorrhaphy, and coverage of the skin defect with a "Z" plasty of the skin and split thickness skin grafting. Follow up 20 months later showed satisfactory results.

Acquired hallux varus

Acquired hallux varus most commonly occurs after hallux valgus surgery. Sagittal plane, coronal plane, and varus deformities are present at the metatarsophalangeal joint. Evaluation of both the metatarsophalangeal and interphalangeal joints for mobility is necessary in surgical decision making. Not all patients require surgery. The anatomy, incidence, pathogenesis, evaluation, classification, and treatment of acquired hallux varus are discussed in this review.

Acquired hallux varus and clinical tolerability

This retrospective study was undertaken to determine the long-term clinical problems, residual disability, and need for further surgery in patients with iatrogenic hallux varus. Between 1975 and 1985, in 16 (19 feet) of 83 patients who underwent foot surgery for hallux valgus or metatarsus primus varus, hallux varus deformity was noted at 1-year follow-up on dorsoplantar roentgenograms obtained with the patients bearing weight. Thirteen of those patients (16 feet) were reexamined at an average of 18.3 years (220 months) after surgery. The average hallux varus deformity in this group was 10.1 degrees. Eleven patients (12 feet) rated their results as excellent. The average hallux metatarsophalangeal interphalangeal score for all patients was 91.5 points. Only those with extreme hallux varus deformity were dissatisfied or required further surgery.