Unfavorable Outcomes Following Surgical Treatment of Hallux Valgus Deformity: A Systematic Literature Review

Revision of Recurrent Hallux Valgus

Recurrence is a common complication after surgical correction of hallux valgus deformity. The reported incidence of recurrence after hallux valgus surgery has been shown to be as high as 64.7%. It has now received acceptance that a hallux valgus angle of more than 20° and an intermetatarsal angle of more than 10° should be classified as a recurrence. For the adequate correction, a number of different techniques need to be considered. According to the literature for more severe deformities, the arthrodesis of either the tarsometatarsal joint or the metatarsophalangeal joint seems to be the technique of choice.

Augmented Reality in Hallux Valgus Surgery

Augmented reality is a promising technology with potential benefit in simplifying visualization and increased accuracy in orthopedic surgery. In hallux valgus surgery, an in vitro study suggests that augmented reality especially helps unexperienced surgeons to perform the osteotomy correctly. However, in clinical practice, augmented reality has not yet found entry in hallux valgus surgery. The future will show if the rapidly developing technology will overcome technical obstacles to make it beneficial to (unexperienced) surgeons.

Advanced Three-Dimensional Assessment and Planning for Hallux Valgus

The article discusses advanced three-dimensional evaluation of hallux valgus deformity using weightbearing computed tomography. Conventional two-dimensional radiographs fall short in assessing the complexity of hallux valgus deformities, whereas weightbearing computed tomography provides detailed insights into bone alignment and joint stability in a weightbearing state. Recent studies have highlighted the significance of first ray hypermobility and intrinsic metatarsal rotation in hallux valgus, influencing surgical planning and outcomes. The integration of semiautomatic and artificial intelligence-assisted tools with weightbearing computed tomography is enhancing the precision of deformity assessment, leading to more personalized and effective hallux valgus management.

A Multi-Dimensional Systematic Review of Minimally Invasive Bunion Surgery (MIBS)

Background/Objectives: Hallux valgus, or a bunion, is a prevalent foot deformity associated with pain, limited mobility, and reduced quality of life. Surgical treatments include minimally invasive and traditional open techniques, but the optimal approach remains debated. This systematic review evaluates long-term outcomes, patient satisfaction, cost-effectiveness, the influence of patient-specific factors, rehabilitation protocols, and complication rates for these methods. Methods: A comprehensive search of PubMed, Medline, EMBASE, and Cochrane databases identified 22 studies published within the last 15 years, each with a minimum follow-up of 2 years. The systematic review adhered to PRISMA-ScR guidelines. Eligible studies reported on at least one of six key outcomes, and data were extracted on radiographic and clinical results, patient satisfaction, costs, rehabilitation timelines, and adverse events. Results: Minimally invasive bunion surgery (MIBS) showed faster recovery, higher patient satisfaction, and improved quality of life compared to open surgery. Radiographic outcomes, including hallux valgus and intermetatarsal angle correction, were durable, though outcomes were less consistent for severe deformities. MIBS was more cost-effective over time, owing to shorter operating times and faster recovery. Rehabilitation was accelerated, and wound complications were fewer with MIBS. However, open techniques remained preferable for severe deformities due to their reliability in complex corrections. Conclusions: MIBS offers substantial advantages for most patients undergoing bunion surgery, including faster recovery and fewer complications. However, open techniques may be better suited for severe deformities. Further research is needed to refine patient selection criteria and evaluate long-term outcomes in diverse populations.

Short-term results of minimally invasive surgery using a 3D-printed guide for the treatment of hallux valgus

INTRODUCTION

Minimally invasive surgery (MIS) is often used to treat hallux valgus deformities, as it is associated with few wound complications and shorter recovery times. Minimally invasive chevron osteotomy and Akin osteotomy (MICA) is a common minimally invasive treatment for HV. However, effective correction of hallux valgus and precise screw placement during MIS are difficult. The aim of this study was to introduce and evaluate the clinical and radiographic effectiveness of a novel MIS technique involving the use of a 3D-printed guide for hallux valgus.

MATERIALS AND METHODS

We retrospectively studied the results of MIS with a 3D-printed guide plate for symptomatic hallux valgus from May 2022 to December 2023. The preoperative and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal pronation angle (M1PA), tibial sesamoid position (TSP), forefoot width, visual analogue scale (VAS) score, AOFAS Hallux MTP-IP score, and the number of intraoperative fluoroscopy were measured.

RESULTS

A total of 22 feet in 19 patients were included in the study. There were 15 women and 4 men with an average age of 38.0 y (range 16-61). The preoperative HVA, IMA, DMAA and M1PA were 30.3 ± 10.7°, 13.9 ± 2.8°, 8.3 ± 2.9° and 16.3 ± 6.5°, respectively. The postoperative HVA, IMA, DMAA and M1PA were 10.7 ± 4.1°, 5.7 ± 1.8°, 2.3 ± 1.7° and 3.5 ± 2.1°, respectively. The forefoot width decreased from 92.1 ± 5.5 mm to 85.6 ± 5.4 mm on average. The VAS and TSP ranged from 4.4 ± 0.9 and 4.9 ± 0.8 to 0.3 ± 0.6 and 2.0 ± 1.1, respectively. The AOFAS Hallux MTP-IP scores improved from 59.1 ± 10.7 to 94.8 ± 5.7 on average. The average number of fluoroscopy shots during operation were 34 times (range 30 to 38).

CONCLUSIONS

A 3D printed guide technique can be beneficial for precise positioning of the first metatarsal head, enhancing the accuracy of screw placement, and reducing radiation exposure.

Association of Radiologic and Clinical Outcomes After Chevron Osteotomy Treatment of Hallux Valgus: Average 6.5-Year Follow-Up Study in Women

BACKGROUND

Hallux valgus, the most common forefoot deformity, frequently leads to corrective foot surgery. Despite high surgical rates, patient dissatisfaction remains prevalent, and its causes are unclear. Surgeons often focus on radiologic corrections, assuming greater corrections yield higher satisfaction. This study aimed to investigate whether traditional radiologic measurements, rotational parameters associated with first metatarsal pronation (eg, lateral head shape and tibial sesamoid position), and routinely collected demographic variables (eg, age, body mass index [BMI], occupational status) can predict patient-reported outcomes following chevron osteotomy.

METHODS

In this retrospective analysis, we included 89 female patients who underwent chevron osteotomy from 2016 to 2018. Patients were evaluated on average 6.5 years postoperatively (range 5-8 years). Demographic variables, including age at surgery, BMI, occupational status, and activity level, along with radiographic variables, such as the hallux valgus angle (HVA), intermetatarsal angle (IMA), lateral head shape, and tibial sesamoid position, were collected pre- and postoperatively. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOxFQ) pain subscore; secondary outcomes included visual analog scale (VAS) pain scores, and Likert scale satisfaction.

RESULTS

A statistically significant association was observed between greater correction of the HVA and improved MOxFQ pain subscores (P = .014). Higher preoperative HVA values were associated with lower postoperative pain scores, indicating improved outcomes (P = .043), whereas higher postoperative HVA values were associated with increased pain, suggesting worse outcomes (P = .022). Despite these findings, the overall association of both preoperative and postoperative radiologic measurements, as well as demographic factors, for patient-reported outcomes was limited, with a pseudo-R2 value of just 0.0267. VAS pain scores showed no significant associations (all P > .05). Although the Likert satisfaction scale correlated with preoperative HVA (P = .049) and postoperative HVA (P = .026), the predictive strength of these variables remained modest.

CONCLUSION

In this minimum-5-year retrospective study of 89 female patients who underwent chevron osteotomy and had not undergone a later secondary procedure, we found that HVA radiographic correction with a chevron osteotomy was weakly associated with improved pain and satisfaction.

The Impact of Social Deprivation on Outcomes in Forefoot Surgery

BACKGROUND

The impact of social deprivation (SD) on health outcomes is a topic of increasing interest in orthopaedics. There are limited studies and no clear consensus, though, on the impact of SD on outcomes in foot and ankle surgery. Area deprivation index (ADI) is a well-studied and validated surrogate metric for SD. We hypothesized that patients with greater SD would have worse patient-reported pain and physical function at baseline and at 6 weeks and 6 months following elective forefoot surgery.

METHODS

We retrospectively analyzed data from 477 forefoot surgeries between January 2015 and December 2022 to determine if SD was associated with patient-reported outcomes (PROs) related to pain and physical function. Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) assessments administered preoperatively and at 6 weeks and 6 months postoperatively. SD was quantified using the ADI. Patients were divided into high- and low-deprivation groups using the national median ADI of 50.

RESULTS

At baseline before surgery, PROMIS-PF and PROMIS-PI scores were similar between high and low social deprivation groups. At 6 weeks and 6 months after surgery, there were no significant differences between high- and low-deprivation groups for either PROMIS-PF or PROMIS-PI. Both groups (high and low social deprivation) demonstrated similar improvements in pain and function at 6 months after surgery. The only variable associated with outcomes was employment status, with disabled and unemployed patients exhibiting greater pain and less function before surgery. Disabled patients also had greater pain after surgery.

CONCLUSION

Based on our data, social deprivation did not appear to be associated with patient-reported pain or physical function prior to forefoot surgery or at 6 weeks or 6 months following surgery.

Comparing the stability of a novel h-shaped bone plate and commercial endosteal plating systems in hallux valgus correction

BACKGROUND

It is common for physicians to opt for surgical correction of hallux valgus deformities using implants, but post-operative complications are frequently reported. A novel h-shaped plate developed by the authors offers both endosteal and lateral fixation, helping to resist displacement in multiple directions. This study aims to assess the mechanical properties and stability of the h-shaped plate in comparison to various commercially available endosteal plating systems in a simulated hallux valgus correction model using finite element analysis.

METHODS

Finite element models of four different endosteal plates were developed and used to simulate a hallux valgus correction. The distal end of the metatarsal in each model was loaded at 87.5 N, which is the maximum load experienced during cyclic testing. The load was applied in various directions to simulate different metatarsal movements, including plantar flexion, dorsiflexion, abduction, and adduction of the first metatarsal bone. The mechanical properties and stability of each model was recorded for comparison.

RESULTS

When placed under dorsal-to-plantar loading, the model with a h-shaped plate was the most stable of all models, with a displacement of 0.278 mm, plate stress of 429.51 MPa, and screw stress of 294.97 MPa. Under medial-to-lateral loading, the model with a h-shaped plate demonstrated the lowest displacement of 0.152 mm, and plate and screw stresses of 254.27 MPa and 195.40 MPa, respectively.

CONCLUSION

For stabilizing distal chevron osteotomies, the h-shaped bone plate showed greater resistance to displacement in the dorsal-to-plantar and medial-to-lateral directions than the commercially available implants evaluated in this study. The h-shaped plate also presented a lower risk of screw pull-out, which helps to maintain bone alignment postoperatively.

Modified minimally invasive chevron osteotomy versus traditional incision chevron osteotomy

PURPOSE

This study aimed to compare modified minimally invasive chevron osteotomy (MIC group) and traditional incision chevron osteotomy (TIC group) for correction of mild to moderate hallux valgus deformity.

METHODS

This retrospective study enrolled 42 patients (60 feet) with mild to moderate hallux valgus deformities who were treated with modified MIC osteotomy or TIC osteotomy between January 2020 and June 2021. The patients were divided into the MIC and TIC groups according to whether the treatment received was minimally invasive. The MIC group included 20 patients (28 feet), comprising 1 male and 19 female patients; aged 37.15 ± 14.60 years, with mild hallux valgus deformity in 12 cases (14 feet) and moderate hallux valgus deformity in 8 cases (14 feet). In the TIC group comprising 22 patients (32 feet), including 1 male and 21 female patients, aged 40.95 ± 11.60 years, mild and moderate hallux valgus deformities were observed in 10 (18 feet) and 12 cases (14 feet), respectively. Preoperatively and at the last follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux, lesser toe score, and visual analog scale (VAS) pain were used to evaluate clinical efficacy. The hallux valgus angle (HVA), 1-2 metatarsal angle (1-2IMA), and distal metatarsal articular angle (DMAA) were measured and compared on the weight-bearing X-ray film of the foot preoperatively and postoperatively. At the last follow-up, recurrence of hallux valgus deformity, hallux adduction deformity, metatarsal head necrosis, metastatic plantar pain, and other complications were recorded.

RESULTS

All 42 patients were followed up, and the follow-up time of the MIC group was 24.70 ± 6.63 months; The follow-up time of the TIC group was 22.82 ± 6.12 months, and there was no significant difference in follow-up time between the two groups (P > 0.05). One patient in the MIC group experienced pain in the dorsal side of the front foot postoperatively; one patient in the TIC group had a superficial infection of the incision postoperatively. There were no significant differences in age, gender, side classification, course of the disease, degree of hallux valgus deformity, and postoperative complications between the two groups (P > 0.05). The AOFAS scores, VAS, HVA, 1-2IMA, and DMAA in the MIC group improved from 54.61 ± 7.60, 4.50 ± 0.79, 28.38° ± 5.02°, 12.88° ± 1.50°, 12.03° ± 1.88°preoperatively to 89.93 ± 4.96, 2.04 ± 1.10, 10.27° ± 1.68°, 7.49° ± 0.95° and 7.83° ± 1.33° at the last follow-up, the difference was statistically significant (P < 0.05); the AOFAS score, VAS, HVA, 1-2IMA, and DMAA of the TIC group improved from 57.31 ± 7.59, 4.34 ± 0.70, 28.45° ± 4.47°, 12.88° ± 1.50°, 12.16° ± 1.81° preoperatively to 87.97 ± 5.96, 2.00 ± 1.11, 10.99° ± 2.25°, 7.49° ± 0.95°, and 8.25° ± 1.12° at the last follow-up, the difference was statistically significant (P < 0.05), but there was no significant difference in AOFAS score, VAS, HVA, 1-2IMA, and DMAA between the two groups (P > 0.05). The incision length of the MIC group was 2.06 ± 0.20 cm, and the incision length of the TIC group was 5.04 ± 0.54 cm, which was statistically significant (P < 0.05).

CONCLUSION

Whether it is modified minimally invasive chevron osteotomy or traditional incision chevron osteotomy, mild and moderate hallux valgus deformity is effectively treated, and the clinical efficacy and imaging results after surgery are significantly improved. Compared with traditional incision chevron osteotomy, the modified minimally invasive chevron osteotomy has a smaller incision and less trauma for mild to moderate hallux valgus.

First metatarsal osteotomy with an intramedullary locking plate is a good alternative for the reintervention of recurrent hallux valgus

This study describes the results of first metatarsal (M1) distal osteotomy with an intramedullary locking plate in persistent/recurrent painful hallux valgus (HV) deformity (without advanced degenerative changes) after primary surgery. Outcomes included postoperative incidences of HV angle (HVA)<16°, intermetatarsal angle (IMA)<9°, proximal articular set angle (PASA)<10°, and the American Orthopedic Foot and Ankle Society (AOFAS) score. Data normality was assessed with the Shapiro-Wilk test, and preoperative vs. postoperative comparisons, as well as postoperative angles vs. preestablished thresholds, were performed with the Wilcoxon signed rank test or the paired Student's t-test, as applicable. Firth's penalized logistic regression analyzed the association between severe complications and undergoing surgery before 2017. Thirty-two patients were included, with a median (range) age of 62.5 (40.0 - 84.0) years; 31 (96.9 %) were females. The minimum follow-up was 24 months. Postoperative incidences (95 %CI) of HVA<16°, IMA<9°, and PASA<10° were, respectively, 75.0 % (57.9 - 86.8 %), 93.8 % (79.9 - 98.3 %), and 56.0 % (33.6 - 66.4 %). Median postoperative HVA, IMA, PASA, and AOFAS score values improved significantly (p < 0.001 for all). Postoperative HVA and IMA were significantly better than preestablished thresholds (p = 0.008 and p < 0.001, respectively), but the PASA was not (p = 0.507). Seven (21.9 %) patients experienced Clavien-Dindo ≥IIIa complications, all in the early implementation period (first 5 years), corresponding to the first 20 surgeries performed (p = 0.046). In conclusion, distal M1 osteotomy plus stabilization with an intramedullary plate offers a viable joint-preserving alternative for recurrent moderate to severe HV deformities in patients without severe arthritic changes or hypermobility of the first TMT joint. LEVEL OF EVIDENCE: IV.

Comparative Analysis of Structural Differences in Progressive Collapsing Foot Deformity With and Without Hallux Valgus

BACKGROUND

Progressive collapsing foot deformity (PCFD) and hallux valgus (HV) are complex 3-dimensional deformities of the foot. This study aimed to investigate structural and alignment differences between PCFD with and without HV using weightbearing computed tomography.

METHODS

Patients with PCFD aged 18 years or older who underwent weightbearing computed tomography were consecutively enrolled. Standard 2-dimensional PCFD and HV parameters were assessed semiautomatically. Foot and ankle offset, forefoot arch angle, and pronation of the medial column bones in the coronal plane, with the ground as a reference, were manually measured. Additionally, the angles from the inferior aspect of subtalar posterior facet of the talus to the ground (subtalar horizontal angle), from the inferior (posterior facet) to superior facets of the talus (infratalar-supratalar angle), and from the inferior (posterior facet) of the talus to the superior facet of the calcaneus (infratalar-supracalcaneal angle) were examined. HV deformity was defined by an HV angle of ≥15 degrees.

RESULTS

Among 72 feet (58 patients) studied, 33 displayed HV, whereas 39 did not. In the coronal plane, the PCFD with HV group showed a higher infratalar-supratalar angle and greater pronation at the first tarsometatarsal joint, first metatarsal bone, and head. The PCFD with HV group also exhibited greater naviculocuneiform joint supination. Generalized estimating equation logistic regression analysis revealed significant associations of HV deformity with the intrinsic rotation of the first metatarsal bone (P < .001), infratalar-supratalar angle (P = .004), and rotation of the first tarsometatarsal joint (P < .001).

CONCLUSION

This study confirmed significant structural and alignment differences between PCFD with and without HV. Notably, the infratalar-supratalar angle, rotation of the first tarsometatarsal joint, and intrinsic rotation of the first metatarsal bone were associated with HV deformity.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

New Minimally Invasive Bunion Surgery: The End-All Be-All Bunion Repair?

The revival of "new" minimally invasive bunion surgery (MIBS) is made possible as a laparoscopic-like fluoroscopically guided procedure using new instrumentation, advanced osseous realignment techniques and procedure-specific orthopedic hardware. Bunions of all severities can be treated with MIBS with a functional walking recovery in a small surgical shoe. Realignment occurs through a subcapital osteotomy with metatarsal head shifts that are stabilized by a single or dual metatarsal MIBS screw(s) that span a resultant osseous defect. Bone healing occurs by callus deposition, a process of "first metatarsal regeneration," resulting in a new straight realigned first metatarsal segment. New MIBS is rapidly evolving with widespread use and we are currently on the fifth & sixth generational update, highlighting a 1-screw construct. Surgeons are rapidly flocking to learn and incorporate this modern procedure in their daily practice.

Current concepts of fourth-generation minimally invasive and open hallux valgus surgery

Hallux valgus (HV) presents as a common forefoot deformity that causes problems with pain, mobility, footwear, and quality of life. The most common open correction used in the UK is the Scarf and Akin osteotomy, which has good clinical and radiological outcomes and high levels of patient satisfaction when used to treat a varying degrees of deformity. However, there are concerns regarding recurrence rates and long-term outcomes. Minimally invasive or percutaneous surgery (MIS) has gained popularity, offering the potential for similar clinical and radiological outcomes with reduced postoperative pain and smaller scars. Despite this, MIS techniques vary widely, hindering comparison and standardization. This review evaluates the evidence for both open Scarf and Akin osteotomy and newer-generation MIS techniques. Fourth-generation MIS emphasizes multiplanar rotational deformity correction through stable fixation. While MIS techniques show promise, their evidence mainly comprises single-surgeon case series. Comparative studies between open and MIS techniques suggest similar clinical and radiological outcomes, although MIS may offer advantages in scar length and less early postoperative pain. MIS may afford superior correction in severe deformity and lower recurrence rates due to correcting the bony deformity rather than soft-tissue correction. Recurrence remains a challenge in HV surgery, necessitating long-term follow-up and standardized outcome measures for assessment. Any comparison between the techniques requires comparative studies. Surgeons must weigh the advantages and risks of both open and MIS approaches in collaboration with patients to determine the most suitable treatment.

The Unfamiliar Complications of Minimally Invasive Foot Surgery

Over the last 5 years, minimally invasive surgery (MIS) has seen a significant surge, propelled by advancements in surgical equipment, implants, methodologies, and comprehensive education. The introduction of specialized hardware and advanced bone-cutting burrs has contributed to a reduction in complications. Evidence from peer-reviewed studies suggests that the outcomes of MIS are often on par with, and at times surpass, those of traditional surgical methods. In the context of MIS, certain complications are specifically linked to the use of burrs and hardware, the types of deformities being addressed, and the tools utilized. This article aims to discuss these complications associated with MIS.

Radiographic and Patient-Reported Outcomes for First Tarsometatarsal Arthrodesis Using an Intramedullary Nail for Hallux Valgus Deformity A Consecutive Case Series

BACKGROUND

First tarsometatarsal (TMT) arthrodesis is one of the most common procedures performed each year for the correction of hallux valgus deformity, and nonunion rates for first TMT arthrodesis are commonly reported to be between 4% and 15%. The purpose of this study was to evaluate the effectiveness of an intramedullary nail system in patients requiring first TMT arthrodesis.

METHODS

An ambispective, multisurgeon, consecutive case series was conducted, in which retrospective and prospective collection of patient-reported outcome measure (PROM) and radiologic data were conducted. Patients who underwent first TMT arthrodesis from July 2019 to July 2022 for hallux valgus deformity with an intramedullary nail system and had adequate records for a minimum of 3 months postoperation (±4 weeks) were included.

RESULTS

Seventy patients were included in the final analysis, with a median prospective PROM follow-up of 1.6 years. There was an overall union rate of 91.4% (64/70 patients). Nine patients required secondary procedures: 4 hardware removals and 5 nonunion revisions. Collected PROMs and radiologic data showed significant improved from preoperative to prospective follow-up (P < .01).

CONCLUSION

First TMT arthrodesis using an intramedullary nail system result in nonunion rates and PROMs comparable to other techniques currently being used.

LEVELS OF EVIDENCE

Level IV: Retrospective Case Series.

Association Between Postoperative Medial-Middle Intercuneiform Joint Widening and Recurrence Rates in Hallux Valgus Treated With Modified Lapidus Procedure

BACKGROUND

Although an association between intercuneiform (C1-C2) joint instability and the recurrence of hallux valgus (HV) deformity after the modified Lapidus procedure has been suggested, there is currently no radiographic evidence to support it. This study aims to investigate radiographic changes in the C1-C2 joint after the modified Lapidus procedure for HV correction, using weightbearing computed tomography (WBCT).

METHODS

This retrospective cohort study included 52 feet (50 patients) with HV who underwent modified Lapidus procedure and had preoperative and postoperative WBCT. Patients who had an additional transfixation screw between the first and second ray were excluded. The preoperative and average 6.5 months postoperative C1-C2 distance, C1-C2 angle, and C1-ground angle were measured on coronal multiplanar reconstructed WBCT images. Radiographic parameters between the recurrence group (n = 9) and nonrecurrence group (n = 43) were compared. Recurrence of HV deformity was characterized by a postoperative hallux valgus angle (HVA) greater than 20 degrees.

RESULTS

Nine of 52 patients (17.3%) had recurrence of their HV deformity. The recurrence group had greater changes in the C1-C2 distance; the median widening in the recurrence group was 0.7 mm (IQR, 0.6-0.8), whereas the nonrecurrence group was 0.3 mm (IQR, 0.1-0.4, P < .001). Regression analysis showed that increase in the C1-C2 distance were significantly associated with recurrence (odds ratio, 1.79; 95% CI, 1.18-3.77; P = .0015). Although no preoperative imaging parameters were associated with a change in the C1-C2 distance, increasing postoperative sesamoid position (r = 0.32, P = .022) and HVA (r = 0.28, P = .046) were correlated with a greater change in the C1-C2 joint gapping.

CONCLUSION

Our study results suggest a possible association between early postoperative widening of the C1-C2 joint and the recurrence of the HV deformity following a modified Lapidus procedure. This raises, but does not answer, the question as to whether the routine stabilization of intercuneiform joint directly or indirectly may help reduce the rate of hallux valgus recurrence when performing the modified Lapidus procedure.

Secondary Surgery Following Lapidus Bunionectomy

While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a 9-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the 3 years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR] = 3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR = 2.33; CI: 1.08, 5.00) and third point of fixation (OR = 2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients.

Recurrence rates with long-term follow-up after hallux valgus surgical treatment using shaft metatarsal osteotomies: a systematic review and meta-analysis

Purpose

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

Methods

This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of shaft osteotomies of the M1 for non-inflammatory and non-degenerative HV having a minimum follow-up of 5 years were included. We found five eligible studies comprising six datasets, all assessed Scarf osteotomies with a mean follow-up that ranged from 8 to 14 years.

Results

The HV recurrence rate was 40%, considering the threshold of >15° hallux valgus angle (HVA), 30% having >20°, and 2% having >25°.

Conclusion

At a minimum follow-up of 8 years following shaft osteotomies of M1, the HVA was 15.9°, the intermetatarsal angle (IMA) was 7.7°, and the DMAA was 8.3°. Furthermore, the recurrence rates considering the various thresholds of HVA were: 40% having >15°, 20% having >20°, and 2% having >25°.

Level of Evidence

Meta-analysis, Level IV.

Hallux Valgus Deformities: Preferred Surgical Repair Techniques and All-Cause Revision Rates

INTRODUCTION

Hallux valgus is a commonly treated condition by foot and ankle surgeons with more than 200 different described correction techniques. Recurrence rates range from 5% to 50%, with increasing support of the theory that arthrodesis procedures may have a lower recurrence rate than osteotomies. Arthrodesis procedures to the first metatarsophalangeal (MTP) joint or tarsometatarsal (TMT) joint for correction of hallux valgus deformity are becoming more commonly utilized. The purpose of this study is to investigate the surgical incidence and revision rates of hallux valgus deformities corrected by arthrodesis compared to osteotomy in the state of South Carolina.

METHODS

The South Carolina Revenue and Fiscal Affairs Office was queried from 2000 to 2017 to identify all surgically treated hallux valgus deformities. Data extraction included patient demographics, ICD-9 diagnoses, CPT procedure codes, and dates of surgery. A logistic regression model was used for statistical inference.

RESULTS

A total of 22 199 feet had surgical treatment for hallux valgus during this time period, with 20 422 (92.0%), 592 (2.7%), and 1185(5.3%) receiving an osteotomy, arthrodesis, or other procedure at initial treatment, respectively. There was an all-cause revision rate of 5.6% in the osteotomy group and 6.4% in the arthrodesis group. Demographic factors such as female sex, white race, and surgery pre-2010 were associated with higher revision rates. Multiple comorbidities were correlated with higher revision rates such as tobacco use, hypothyroidism, osteoarthritis, recurrent dislocations, hallux rigidus, lesser toe deformities, metatarsus varus, and talipes cavus.

CONCLUSION

Despite the recent increase in arthrodesis procedures for the treatment of hallux valgus deformity, our results suggest that osteotomy procedures are more commonly performed and there is no difference in all-cause revision surgery. However, there are multiple patient demographics and comorbidities that are associated with higher rates of revision surgery and should be considered and discussed during the preoperative planning period.

LEVEL OF EVIDENCE

Level IV.

Spontaneous Reduction in the Intermetatarsal Angle in Distal First Metatarsal Osteotomies with No Lateral Head Displacement in Hallux Valgus

BACKGROUND

The outcomes of first metatarsal (M1) distal osteotomies in hallux valgus (HV) can be improved, especially for intermetatarsal angle (IMA) correction, which is mainly based on lateral displacement of the M1 head (i.e., translation) through the osteotomy. Conversely, there is a spontaneous reduction in the IMA in first metatarsophalangeal joint (MTP1) arthrodesis. But we do not know whether this can be applied to distal osteotomies. We propose a distal osteotomy, called 3D chevron, which combines supination and varization of the M1 head. This might realign soft tissues around the MTP1, potentially leading to a spontaneous reduction in the IMA by an analogous mechanism to MTP1 fusion. Therefore, our study aimed to assess whether spontaneous reductions in IMAs exist in distal M1 osteotomies in the absence of lateral translations of M1 heads.

METHODS

A prospective continuous series of 25 3D chevrons was performed. Two groups were formed during surgery. Patients requiring no M1 head lateral displacement were included in the "successful correction without translation" group, and patients requiring M1 head lateral displacement were included in the "failed correction without translation" group. Radiographic analysis was performed preoperatively and at 1 year postoperatively.

RESULTS

Twenty-two women and three men, with a mean age of 44.8 ± 14.2 years and a mean body mass index of 22.6 ± 4.1 kg/m2, underwent follow-up at one year after surgery. The "successful correction without translation" group was composed of HV with milder deformities (13/25 HVs, median preoperative IMA = 13 (IQR 2)) compared to the "failed correction without translation" group (median IMA = 16 (IQR 2.25) p < 0.001). Spontaneous reductions in IMAs were observed in the "successful correction without translation" group, with a median decrease in the IMA of 6 degrees (CI95%[5.5; 8.0]; p < 0.001) between preoperative and 1-year radiographs.

CONCLUSION

Distal osteotomies allow for spontaneous reduction in the IMA in HV. First metatarsal head translation through an osteotomy should not be considered as the only procedure to correct IMAs in distal osteotomies.

Triple osteotomy of first ray for severe hallux valgus surgery: Long-term follow-up

This study aimed to present a retrospective case series of the long-term results of severe hallux valgus treated with triple osteotomy of the first ray. Patients with severe hallux valgus treated with a basal medial opening wedge, distal chevron, and Akin osteotomy from 2008 to 2012 were identified from the electronic medical records. Radiological outcomes such as pre- and postoperative hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle) were collected. Patients were contacted to complete foot and ankle outcome score (FAOS). Nineteen patients underwent 20 triple osteotomies of the first ray. Clinical data and FAOS were collected at a median follow-up of 10.2 years. There was a significant improvement in hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle from pre- to postoperatively, both at initial and final radiographic follow-up (P < .0001). Patient satisfaction was high, with median FAOS of 94.5 (symptoms), 97 (function/activities of daily living), 100 (function/sport and recreation), 85 (foot and ankle-related quality of life), and 100 (pain). Triple first-ray osteotomy is a successful mode of treatment for severe hallux valgus, with high levels of patient satisfaction and excellent improvement in radiological parameters measured over long-term follow-up.

Preoperative Degenerative Changes at the Tibial Sesamoid-Metatarsal Joint in Hallux Valgus: Association With Postoperative Patient-Reported Outcomes After Modified Lapidus Procedure

Background

Degenerative changes at the sesamoid-metatarsal joints (SMJs) may be a source of pain following hallux valgus surgery. The aims of this study were to describe degenerative changes at the SMJs on weightbearing computed tomography (WBCT) scans and, secondarily, investigate their association with 1-year patient-reported outcome scores following a modified Lapidus procedure for hallux valgus. We hypothesized that reduced joint space in the SMJs would correlate with worse patient-reported outcomes.

Methods

Fifty-seven hallux valgus patients who underwent a modified Lapidus procedure had preoperative and minimum 5-month postoperative WBCT scans, and preoperative and at least 1-year postoperative PROMIS physical function (PF), pain interference, and pain intensity scores were included. Degenerative changes at the SMJs were measured using distance mapping between the sesamoids and first metatarsal head on preoperative and postoperative WBCT scans. The minimum and average distances between the first metatarsal head and tibial sesamoid (tibial-SMJ) for each patient preoperatively and postoperatively were measured. Sesamoid station was measured on WBCT scans using a 0 to 3 grading system. Linear regression was used to investigate the correlations between minimum preoperative and postoperative tibial-SMJ distances and 1-year postoperative PROMIS scores.

Results

The median minimum and average tibial-SMJ distances increased from 0.82 mm (interquartile range [IQR] 0.40-1.03 mm) and 1.62 mm (IQR 1.37-1.75 mm) preoperative to 1.09 mm (IQR 0.96-1.23 mm) and 1.73 mm (IQR 1.60-1.91 mm) postoperative (P < .001 and P < .001), respectively. In a subset of patients with complete sesamoid reduction, we found an association between preoperative minimum tibial-SMJ distance and 1-year postoperative PROMIS PF scores (coefficient 7.2, P = .02).

Conclusion

Following the modified Lapidus procedure, there was a statistically significant increase in the tibial-SMJ distance. Additionally, in patients with reduced sesamoids postoperatively, reduced preoperative tibial-SMJ distance correlated with worse PROMIS PF scores.

Level of Evidence

Level IV, case series.

Midfoot width changes after first metatarsal osteotomy in hallux valgus surgery: A biomechanical effect?

Hallux valgus is a challenging pathology characterized by a valgus deformity in the metatarsophalangeal area of the first ray. The aim of this study was to analyze the influence of first metatarsal osteotomy on the relationship between midfoot bones in patients with hallux valgus. The sample consisted of patients from the orthopedics and traumatology outpatient clinic who underwent surgical treatment for hallux valgus. Preoperative and postoperative X-rays were compared regarding the width of the midfoot and the tarsometatarsal joint. The sample consisted of 17 women, with 22 feet assessed in each group. The distance from the medial cuneiform to the cuboid, the distance from the intermediate cuneiform to the cuboid, the distance between the first and fifth metatarsals, and the distance between the second and fifth metatarsals reduced significantly between pre- and postoperative assessments. Hallux valgus correction through osteotomy of the first metatarsal leads to a structural change in the midfoot. Further studies should determine whether these changes persist over time.

A Cadaveric Study Verifying the Potential of a Rotational Biplanar Chevron Osteotomy to Correct the 3-Dimensional Hallux Valgus Deformity

INTRODUCTION

Metatarsal pronation is present in 87% of patients with hallux valgus (HV) deformity. The chevron osteotomy is commonly used worldwide to correct mild to moderate HV deformities. Many modifications have been described, but few address the rotational deformity of the first metatarsal. The rotational biplanar chevron osteotomy (RBCO), described by M. Prado et al, presents a variation of a biplanar chevron osteotomy that can be used to address first metatarsal rotation. The objective of this study is to investigate and verify the technique of the RBCO.

METHODS

We conducted our study performing an RBCO on 9 cadaveric limbs. The technique uses a medial-based wedge parallel to the plantar limb of the osteotomy to make the distal fragment free to correct rotation. A goniometer was used by 2 individual surgeons to control the rotational correction achieved.

RESULTS

The osteotomy was considered simple to perform and we experienced no complications, such as fractures or instability. The result was satisfactory alignment and adequate stability. On average, a 2 mm wedge resulted in 11° of rotational correction.

CONCLUSION

We predict that RBCO can safely be used for correcting the metatarsal rotation when necessary in mild to moderate HV deformity foot.

LEVELS OF EVIDENCE

Level IV.

Weightbearing Imaging Assessment of Midfoot Instability in Patients with Confirmed Hallux Valgus Deformity: A Systematic Review of the Literature

Hallux valgus deformity (HVD) involves subluxation of the first metatarsophalangeal joint. While HVD is primarily considered a forefoot condition, midfoot instability may play a significant role in its development and severity. However, very few studies have placed a heavy emphasis on studying this phenomenon. Therefore, this review had a particular focus on understanding midfoot instability based on weightbearing imaging assessments of the TMT joint. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched five databases for studies on midfoot instability in HVD patients. The severity of HVD was defined by hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA). Data was extracted, and articles were graded using the Methodological Index for Non-Randomized Studies (MINORS). Of 547 initially retrieved articles, 23 met the inclusion criteria. Patients with HVD showed higher HVA and DMAA on weightbearing radiographs (WBRG) and weightbearing computed tomography (WBCT) compared to healthy individuals. Midfoot instability was assessed through intermetatarsal angle (IMA) and tarsometatarsal angle (TMT angle). Patients with HVD exhibited greater IMA and TMT angles on both WBRG and WBCT. This review highlights the importance of weightbearing imaging assessments for midfoot instability in HVD. IMA and TMT angles can differentiate between healthy individuals and HVD patients, emphasizing the significance of midfoot assessment in understanding HVD pathology. These findings validate the limited evidence thus far in the literature pertaining to consistent midfoot instability in HVD patients and are able to provide ample reasoning for physicians to place a larger emphasis on midfoot imaging when assessing HVD in its entirety.

A Radiologic Triangle Sign for Percutaneous Adductor Tendon Release (PATR): Cadaveric Study and Case Series

Background

Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations.

Methods

A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR.

Results

Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the "triangle sign."

Conclusion

The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique.

Level of Evidence

Level II, development of diagnostic criteria.

Radiological outcome of hallux valgus deformity correction with metatarsal osteotomy from a single-center cohort - Best results achieved by foot and ankle surgeons

BACKGROUND

To evaluate the radiological outcome, especially undercorrection of hallux valgus deformity correction with first metatarsal osteotomy.

PATIENTS AND METHODS

439 1st metatarsal osteotomies including 241 distal (55 %), 175 midshaft (40 %), and 23 proximal (5 %) were available for analysis with median follow-up time was 48 days (range 27-990 days).

RESULTS

The postoperative HVA was normal in 237 (54 %), mild in 110 (25 %), moderate in 87 (20 %), and severe in 5 (1 %) of the cases. BMI (p = 0.0127), sex (p = 0.0004), preoperative HVA (p = 0.0028), and surgeons experience (p < 0.0001) were associated with radiological outcome, whereas age, hospital, and type of osteotomy had no effect. Foot and ankle surgeons achieved normal postoperative HVA in 76 %, general orthopedic surgeons in 41 %, and residents in 47 % of the operations.

CONCLUSION

Radiological undercorrection was common. As foot and ankle surgeons achieved best radiological correction, hallux valgus deformity should be operated by specialists.

Imaging of the post-operative hallux valgus: what do radiologists need to know?

Hallux valgus surgery concerns many patients and various techniques are performed. The assessment of the first toe deformity correction is mainly visual and imaging is required to analyze the intermetatarsal angle and depict complications. However, it is often difficult for the radiologist to distinguish normal and pathological conditions, especially in case of osteotomies which may show various aspects of bone mineralization and healing. In this review, the most relevant imaging features of the post-operative hallux valgus are summarized.

Preoperative degree of deformity and underlying disease affect the postoperative deformity of joint-preserving hallux valgus surgery

BACKGROUND

The combination of distal osteotomy with lateral dissection in joint-preserving surgery for severe hallux valgus deformity has recently begun to yield encouraging results. We examined the frequency of complications and risk factors of those for joint-preserving surgery in patients with and without rheumatoid arthritis (RA).

METHODS

A retrospective, observational study of 72 feet (27 patients with RA) was performed. The inclusion criteria were patients who underwent joint-preserving surgery for hallux valgus deformity at our hospital between January 2008 and March 2016 who could be followed up with for longer than 12 months.

RESULTS

The mean preoperative and immediate postoperative hallux valgus angles (HVA) were 41.8 and 4.4, respectively. The mean preoperative and immediate postoperative intermetatarsal angles between the first and second metatarsal bones (M1-M2A) were 14.6 and 5.8, respectively. At the final postoperative evaluation, the mean HVA was 8.8 and the mean M1-M2A was 6.4.Data were compared among the patients with complications (recurrent valgus deformity, varus deformity), and those without complications (normal HVA) at the final postoperative evaluation. The rate of RA in the varus deformity group was 71.4%, which tended to be higher than in other groups (p = .058). The mean preoperative HVA were 48.2 and 52.6 in the group of recurrent valgus deformity and varus deformity, which was higher than the normal HVA group (p = .001).

CONCLUSIONS

High preoperative HVA was a risk factor for the recurrence of valgus deformity. Most of the varus deformities were observed in the RA group with high preoperative HVA; therefore, caution should be exercised in operating on patients with severe deformity or those with RA.

LEVEL OF EVIDENCE

III.

Severe hallux valgus can be treated using a distal metatarsal osteotomy: Results of 144 cases treated with the SERI technique

PURPOSE

Aim of this study is to analyze the clinical and radiographic results of the simple, effective, rapid and inexpensive (SERI) technique, a linear distal metatarsal osteotomy, for treating severe hallux valgus (HV).

METHODS

Clinical outcomes were assessed pre- and postoperatively using the AOFAS, MOxFQ and VAS score. Pre and postoperative HV angle (HVA) and intermetatarsal angle (IMA) were measured.

RESULTS

117 consecutive patients for a total of 144 feet were included. Pre and postoperatively, mean AOFAS changed from 44.8 ± 16.7 to 89 ± 10.3 (p < .001), mean MOxFQ changed from 76.2 ± 15.8 to 23.4 ± 7.9 (p < .001) and mean VAS score improved from 6.7 ± 2.1 to 1.5 ± 1.5 (p < .001). HVA diminished from 40.6° ± 6.9 preoperatively to 16.0° ± 7.3 postoperatively (p < .001). IMA decreased from 15.1° ± 2.8 preoperatively to 6.5° ± 2.4 postoperatively (p < .001). The main complication reported was stiffness (10.4 %).

CONCLUSION

SERI technique applied to severe HV showed positive clinical and radiological outcomes. A careful patient selection and a low grade first MTPJ arthritis are essential to obtain favorable results.

LEVEL OF EVIDENCE

IV.

Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain

Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.

Insights Into Patients Questions Over Bunion Treatments: A Google Study

Background

Approximately 1 in 4 adults will develop hallux valgus (HV). Up to 80% of adult Internet users reference online sources for health-related information. Overall, with the high prevalence of HV combined with the numerous treatment options, we believe patients are likely turning to Internet search engines for questions relevant to HV. Using Google's people also ask (PAA) or frequently asked questions (FAQs) feature, we sought to classify these questions, categorize the sources, as well as assess their levels of quality and transparency.

Methods

On October 9, 2022, we searched Google using these 4 phrases: "hallux valgus treatment," "hallux valgus surgery," "bunion treatment," and "bunion surgery." The FAQs were classified in accordance with the Rothwell Classification schema and each source was categorized. Lastly, transparency and quality of the sources' information were evaluated with the Journal of the American Medical Association's (JAMA) Benchmark tool and Brief DISCERN, respectively.

Results

Once duplicates and FAQs unrelated to HV were removed, our search returned 299 unique FAQs. The most common question in our sample was related to the evaluation of treatment options (79/299, 26.4%). The most common source type was medical practices (158/299, 52.8%). Nearly two-thirds of the answer sources (184/299; 61.5%) were lacking in transparency. One-way analysis of variance revealed a significant difference in mean Brief DISCERN scores among the 5 source types, F(4) = 54.49 (P < .001), with medical practices averaging the worst score (12.1/30).

Conclusion

Patients seeking online information concerning treatment options for HV search for questions pertaining to the evaluation of treatment options. The source type encountered most by patients is medical practices; these were found to have both poor transparency and poor quality. Publishing basic information such as the date of publication, authors or reviewers, and references would greatly improve the transparency and quality of online information regarding HV treatment.

Level of Evidence

Level V, mechanism-based reasoning.

Bösch osteotomy for hallux valgus correction: results at a mean 10-year follow-up

INTRODUCTION

Bösch osteotomy (BO), which is a first metatarsal subcapital osteotomy stabilised with a K-wire, is a surgical option to correct hallux valgus (HV). The aim of this study was to assess the long-term clinical and radiographic results in a cohort of patients treated at our institution with such osteotomy.

METHODS

In this retrospective monocentric single-surgeon cohort study, we included 58 HVs (46 patients) who underwent HV correction by BO and were followed at a minimum of 7 years. The range of motion (ROM), the American Orthopaedic Foot and Ankle Society's Forefoot scale (AOFAS-FS) and the Visual Analogic Scale (VAS) for pain were recorded. On weightbearing radiographs, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), the Distal Metatarsal Articular Angle (DMAA), and the Lateral Sesamoid Position (LSP) were measured and compared with pre-operative values. The complication rate and first metatarsophalangeal joint stiffness were also assessed.

RESULTS

At a mean follow-up of 10 ± 2 (7-17) years, mean ± standard deviation AOFAS-FS and VAS were 89 ± 11 (67-93) and 2.1 ± 2.8 (0-7) points, respectively. In 42 (72%) cases there was no limitation in the choice of footwears. Radiographically, we found a significant improvement in the HVA (from 33.9° ± 6.7 to 18.8° ± 5.6, p < 0.001), in the IMA (14.2° ± 3.1 to 9.4° ± 2.7, p < 0.001), in the DMAA (from 30.3° ± 6.8 to 11.5° ± 5.1, p < 0.001) and in LSP (median value from 3 to 1, p < 0.001). In 36 (62%) cases the ROM was greater than 75° while in 22 (38%) it ranged between 30° and 75°. Minor complications occurred in six (10%) cases, which did not require any further surgery at the longest follow-up.

CONCLUSION

Bösch technique provided satisfactory clinical and radiographic outcomes in the treatment of hallux valgus which persisted at a mean 10-year follow-up. The complication rate did not differ from more recent techniques described in literature.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Surgical outcome of avulsion fractures of the distal fibula: a systematic literature review

PURPOSE

To provide a systematic overview of clinical and radiographic outcomes in patients who underwent surgical treatment of a painful avulsion fragment of the distal fibula also known as posttraumatic os subfibulare.

METHODS

A systematic literature search across two major sources (PubMed and Scopus) was performed. Twenty-seven studies were included and analyzed using the modified Coleman score to assess the methodologic quality.

RESULTS

The surgical treatment of symptomatic os subfibulare, with or without concomitant ankle instability, generally results in substantial improvement in clinical and radiographic outcomes with relative low complication rates. Clinical outcome measures may not be affected by the presence of ankle instability or by the fragment size. The methodological quality of analyzed studies was satisfactory.

CONCLUSION

Posttraumatic os subfibulare may result in chronic pain and ankle instability. If surgery is indicated, ankle instability should be concomitantly addressed when present. Based on available literature, satisfactory postoperative outcomes can be reliably expected following surgical treatment.

LEVEL OF EVIDENCE

Systematic Review of Level III and Level IV Studies, Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, meta-analysis.

First Metatarsophalangeal Arthrodesis for Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes

Few prior studies have compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. A retrospective review of 98 patients who a received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including nonunion were collected. Patient Reported Outcomes Measurement Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and the foot function index (FFI) revised short form scores were obtained via telephone. Patients were grouped based on review of preoperative radiographs of the foot and this grouping 37 hallux rigidus and 61 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. No differences in the rate of wound complications, radiographic union, and revision surgery were found between the 2 subgroups. At a median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. The postoperative first MTP dorsiflexion angle in the hallux rigidus group was correlated with decreased FFI Pain, FFI Total, and PROMIS Pain Interference domain scores (|r| ≥ 0.40, p < .05 for all). When performing MTP arthrodesis in patients with hallux rigidus, increasing the first MTP dorsiflexion angle may correlate with improved intermediate term patient reported outcomes. However, further studies will need to be done to confirm this theoretical relationship.

Minimally Invasive Surgery Using a Shannon Burr for the Treatment of Hallux Valgus Deformity: A Systematic Review

Background

Recently there has been an increase in minimally invasive surgery (MIS) for the correction of hallux valgus deformity. This systematic review aims to evaluate and present the current literature on MIS hallux valgus correction in studies reporting the use of the Shannon burr with distal metatarsal osteotomies to help establish evidence-based guidelines for surgeons using this technique.

Methods

Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2008 to 2022 and included the use of the Shannon burr during distal metatarsal osteotomies MIS for hallux valgus and at least 12-month follow-up. The MINORS score criteria was used to evaluate the strength and quality of 17 studies by 3 authors. Statistical analysis and meta-analysis were not performed because of the heterogeneity of the included studies and the data being descriptive.

Results

A total of 17 studies were reviewed. A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 (12-59.1) months. American Orthopaedic Foot & Ankle Society scale and visual analog scale scores improved from 52.1 (41-62.5) to 90.3 (83.3-97.1) and 4.9 (3-8.2) to 0.8 (0-1.9). Satisfaction rates were very high among the studies that reported it. The hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle improved from 31.4 (23.5-44.1) to 11.1 (7-17.2), 13.4 (8.1-18.6) to 7.3 (4.2-10.3), and 12.3 (9-16.3) to 4.1 (1-6.7), respectively. The complication rate was 16.6%, and recurrence was 2.2%. Nonunion comprised 0.4%, infections 1.1%, nerve injury 2.2%, avascular necrosis 0%, hallux varus 0.09%, transfer metatarsalgia 0.1%, and hardware removal 6.2%.

Conclusion

MIS for the treatment of hallux valgus using the Shannon burr appears to be a safe and effective therapy, with appropriate correction of the hallux valgus deformity, improvement in functional outcomes, high patient satisfaction, low recurrence, and acceptable complication rates.

Level of Evidence

Level II, systematic review.

Are Radiographs Associated With Patient Satisfaction After Scarf Bunionectomy?

There are over 350,000 bunion surgeries performed in the USA annually, making it one of the most common elective forefoot surgeries. Studies have suggested that as many as 10% of patients remain dissatisfied after bunion surgery. The purpose of this study is to evaluate if radiographic variables are associated with patient satisfaction at 1 year postoperatively. We performed a secondary analysis of prospectively collected data on 69 consecutive adult patients (mean age 45 ± 14 years, 91% female [63/69]) who underwent isolated hallux valgus surgery from January 2016 to January 2017. Subjects completed a standardized 4-item survey inquiring about their satisfaction with regards to pain relief, overall operative result, cosmetic appearance, and ability to wear desired shoe gear. Conventional radiographic indices for hallux valgus were examined preoperatively and 3 months postoperatively. An association model using backward stepwise logistic regression was utilized to determine which variables, if any, are most important in explaining patient satisfaction after surgery. Sixty-nine subjects completed the 4-item satisfaction survey with 53.6% (37/69) of subjects answering they were fully satisfied on all aspects of the survey at 12 months postoperatively. In the final regression model, no radiographic or demographic variables were associated with patient satisfaction including shoe gear, cosmetic appearance, pain relief, and overall operative result. Radiographic variables did not appear to be associated with patient satisfaction at one year postoperatively in our study. Factors such as quality of life, anxiety levels, fear of surgery, and/or preoperative expectations may offer more insight into satisfaction; however, further research should be performed to examine this further.

A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy

Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used.

Clinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus

BACKGROUND

The treatment for severe hallux valgus deformity presents a challenge with high risk of complications. Third generation MIS techniques have increased their publications in recent years. The aim was to compare clinical and radiologic outcomes in moderate and severe cases and report minor and major complications.

METHODS

Retrospective series of cases with prospective data collection of 156 consecutive feet that underwent percutaneous double first metatarsal osteotomy (PEDO) and first phalanx osteotomy between 2008 and 2019 for moderate (hallux valgus angle [HVA] between ≥20 and <40 degrees and/or intermetatarsal angle [IMA] <16 degrees) and severe (HVA ≥40 degrees and/or IMA ≥16 degrees) hallux valgus deformities. Primary outcomes included radiographic and clinical parameters. Secondary outcomes included minor and major complications.

RESULTS

A total of 156 procedures were performed in 128 patients. Mean age was 54.3 years (SD 14.3) (range, 19-82 years), median follow-up was 22.6 months (range, 12-96 months). Radiographic changes pre- to postoperation were as follows: HVA changed from 38.2 (SD 10.1) degrees to 11.2 (SD 8.3) degrees (P < .001), IMA from 14.7 (SD 3.2) degrees to 7.9 (SD 3.7) degrees (P < .001), and distal articular metatarsal angle from 19.7 (SD 6.3) degrees to 8.8 (SD 5.7) degrees (P < .001) after PEDO technique. Clinical changes pre- to postoperation were as follows: American Orthopaedic Foot & Ankle Society ankle-hindfoot scale scores improved from 47.3 (SD 16.5) to 87 (SD 11.6) (P < .001) and visual analog scale scores from 5 (2.7) to 0.9 (1.3) (P < .001). The satisfaction rate was 97% in the total sample. Recurrence rate (HVA ≥20 degrees) was 7.7%. Hallux varus (HVA <0 degrees) occurred in 5.8%, acute osteomyelitis in 1.3%, partial avascular necrosis in 0.6%, screw removal in 0.6%, and reoperation in 1.9%. No nonunion was observed.

CONCLUSION

Clinical and radiographic parameters improved significantly, with a minimum of 12 months of follow-up in moderate and severe hallux valgus. Long experience in percutaneous surgery and specific instruments are needed for this technique. Recurrence was linked to preoperative HVA ≥40 degrees and postoperative tibial sesamoid position; Hallux varus was linked to lateral soft tissue release.

LEVEL OF EVIDENCE

Level IV, case series.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Do Patient Personality Traits and Self-Reported Physical and Psychosocial Symptoms Help to Predict Hallux Valgus Surgery Outcomes?

As many as 10% of patients remain unsatisfied after hallux valgus surgery. We explored the effects of patient personality traits and other preoperative patient characteristics on patient-reported outcomes following surgery. Eighty consecutive adult patients (mean age 45 ± 14 years, 91% female [73/80]) undergoing scarf bunionectomy at our practice were prospectively enrolled from January 2016 to January 2017 and followed for 12 months. Predictor variables included preoperative physical and psychosocial complaints (determined via Brief Battery for Health Improvement-2 questionnaire), patient aggression level, and personality traits (extraversion, agreeableness, conscientiousness, emotional stability and openness). Primary outcome measures included the Foot and Ankle Outcome Score (FAOS) with its 5 subscales, and patient satisfaction. Multiple multivariable regression models were used to determine preoperative patient characteristics associated with FAOS outcome and satisfaction at 12 months. Seventy subjects (70/80, 87.5%) completed the study. All patients experienced technically successful surgery. In the multivariable regression analyses, none of the combinations of potentially important predictor variables explained more than 19.8% of the variance in any of the 5 FAOS subscales at 12 months (range: 6.1%-19.8%). Furthermore, no predictor was associated with patient satisfaction in either the univariate or multivariable analyses. We conclude that patient personality traits, aggression level, and self-reported physical and psychological symptoms do very little to predict outcomes in hallux valgus surgery. As healthcare delivery in the United States has increasingly prioritized patient satisfaction, we will need to broaden the quest for predictors associated with our best (and worst) patient-reported outcomes after hallux valgus surgery.

[Clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux]

Objective: To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods: A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results: A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S3 in 2 cases, grade S2 in 9 cases, and grade S1 in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions: The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.

Comparison of outcomes of different osteotomy sites for hallux valgus: A systematic review and meta-analysis

BACKGROUND

Hallux valgus (HV) is a common foot deformity for which several corrective surgical procedures, with different osteotomy sites, have been reported. The purpose of the present study was to systematically review randomized (RCTs) or controlled (CCTs) clinical trials and perform meta-analysis on outcomes of different osteotomy sites of the first metatarsal.

METHODS

An extensive literature search was conducted in PubMed and the Cochrane Library from January 1983 to July 2020. Studies were identified using the terms "hallux valgus" and "osteotomy". We included RCTs or CCTs comparing different locations of osteotomy for the first metatarsal bone (distal vs. mid-shaft, distal vs. proximal, and mid-shaft vs. proximal). The surgical outcomes included postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, perioperative complications and recurrence of deformity. We enrolled 10 studies with a total of 793 feet in the qualitative synthesis following full-text screening.

RESULTS

A majority of patients included in the enrolled trials showed mild to moderate deformity, with mean HVA <40°. Out of the 10 enrolled studies; six compared distal osteotomies with mid-shaft osteotomies and showed no significant differences in the surgical outcomes between the scarf and chevron groups; three RCTs compared distal osteotomies with proximal osteotomies with conflicting results, one RCT showed the superiority of proximal osteotomy while the other two RCTs showed equivalent outcomes; one study that compared between mid-shaft and proximal osteotomies showed equivalent outcomes between the groups.

CONCLUSION

For the management of mild to moderate HV deformity, we found no significant clinical and radiological differences between patients treated with scarf and chevron osteotomies. Further controlled trials comparing different sites of osteotomies for moderate to severe HV deformity are needed.

Effectiveness of hallux valgus surgery on improving health-related quality of life: A follow up study

BACKGROUND

Hallux valgus (HV) negatively impacts health-related quality of life (HRQoL). Patientreported outcome measures (PROMs) are increasingly used in clinical studies of the foot and ankle. We aimed to evaluate the effect of HV surgery on PROMs (i.e., pain scales, general HRQoL, and region-specific scales) and radiological angles. Additionally, we aimed to determine whether the effect on these outcomes depends on the type of surgery (including open and percutaneous techniques) and if it is influenced by potential confounding factors (i.e., age, HVA, 1-2 IMA, body mass index (BMI), and distal metatarsal articular angle (DMAA).

METHODS

This was a longitudinal prospective study. We collected the clinical data of all patients who underwent surgery for symptomatic HV deformity in the orthopedic department of the Virgen de la Luz Hospital of Cuenca (Spain).The clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) Hallux metatarsophalangeal-interphalangeal (HMI) scale, visual analogue scale (VAS), Manchester Oxford foot questionnaire (MOXFQ), short form health survey (SF-12) and European Quality of Life-5 Dimensions (EQ-5D).

RESULTS

A total of 72 patients (70 women, 97.2%) were included in the study 72 (72 feet).The AOFAS pre-post-surgery score changed from 42.16 (SD: 10.11) to 83.31 (SD: 6.23). Considering AOFAS domains, the pre-post change was from 14.17 (SD: 9.15) to 33.19 (SD: 4.69) for pain, from 27.22 (SD: 3.90) to 37.94 (SD: 2.78) for function, and from 0.78 (SD: 2.38) to 12.18 (SD: 3.45) for alignment. For other clinical outcomes was VAS score from 5.01(SD: 1.26) to 1.26 (SD: 0.96) and MOXFQ score from 61.44 (SD: 7.09) to 12.35 (SD: 4.85). SF-12 (physical) changed from 36.26 (SD: 5.32) to 47.06 (SD: 4.82), SF-12 (mental) from 38.23 (SD: 8.04) to 46.49 (SD: 4.16), and EQ5-D from 0.64 (SD: 0.008) to 0.90 (SD: 0.10).

CONCLUSIONS

Our data confirmed the improvements in the clinical and radiological outcomes after HV surgery, and provided some evidence of these improvements not depending on the type of surgery or on some potential confounding factors such as BMI, HVA, 1-2 IMA, and DMAA.

Managing Complications of Foot and Ankle Surgery: Hallux Valgus

Hallux valgus deformity is nowadays one of the most common and symptomatic disorders affecting the foot. Surgical corrections of hallux valgus deformity are among the most common orthopedic procedures. Despite the general high success rate complications can occur. The treatment of complications start before the first incision has been performed by thorough preoperative planning and choice of the right procedure. Once the complication is evident, thorough planning is necessary to address the patient's individual needs. In this paper the treatment of recurrent hallux valgus, hallux varus, malunion, and avascular necrosis are discussed.

Imaging Findings and First Metatarsal Rotation in Hallux Valgus

BACKGROUND

Failure to identify and correct malrotation of the first metatarsal may lead to recurrent hallux valgus deformity. We aimed to identify the proportion of hallux valgus patients with increased first metatarsal pronation using weightbearing computed tomography (WBCT) and to identify the relationship with conventional radiographic measurements.

METHODS

WBCT scans were analyzed for 102 feet with a hallux valgus angle (HVA) and intermetatarsal angle (IMA) greater than or equal to 16 and 9 degrees, respectively. Metatarsal pronation angle (MPA), alpha angle, sesamoid rotation angle (SRA), and sesamoid position were measured on standardized coronal WBCT slices. Pronation was recorded as positive. Hindfoot alignment angle (HAA) was assessed using dedicated software. Pearson correlation and multiple regression analyses were used to assess differences between groups.

RESULTS

Mean HVA was 29.8±9.4 degrees and mean IMA was 14.1±3.7 degrees. Mean MPA was 11.9±5.8 (range 0-26) degrees and mean alpha angle was 11.9±6.8 (range -3 to 29) degrees. In a previous study, we demonstrated the upper limit of normal MPA as 16 degrees and alpha angle as 18 degrees. Based on these criteria, we identified abnormal metatarsal pronation in 32 feet (31.4%). We found a strong positive correlation between SRA and HVA/IMA (R = 0.67/0.60, respectively, P < .001). IMA and HAA weakly correlated with MPA and alpha angle (IMA: R = 0.26/0.27, respectively, P < .01; HAA: R = 0.26/0.27, respectively, P < .01). Regression analyses suggested that increasing IMA was the most significant radiographic predictor of increased pronation. In this cohort, there was no correlation between HVA or sesamoid position and MPA / alpha angle (HVA: P = .36/.12, respectively, sesamoid position, P = .86/.77, respectively).

CONCLUSION

In this cohort of 102 feet that met plain radiographic criteria for hallux valgus deformity, first metatarsal pronation was found abnormal in 31.4% of patients. We found a weak association between the IMA and hindfoot valgus, but not the HVA.