Prevalence and Predisposing Factors for Recurrence after Hallux Valgus Surgery: A Systematic Review and Meta-Analysis

Developing Machine Learning-Based Predictive Models for Hallux Valgus Recurrence Based on Measurements From Radiographs

BACKGROUND

Machine learning (ML) is increasingly used to predict the prognosis of numerous diseases. This retrospective analysis aimed to develop a prediction model using ML algorithms and to identify predictors associated with the recurrence of hallux valgus (HV) following surgery.

METHODS

A total of 198 symptomatic feet that underwent chevron osteotomy combined with a distal soft tissue procedure were enrolled and analyzed from 2 independent medical centers. The feet were grouped according to nonrecurrence or recurrence based on 1-year follow-up outcomes. Preoperative weightbearing radiographs and immediate postoperative nonweightbearing radiographs were obtained for each HV foot. Radiographic measurements (eg, HV angle and intermetatarsal angle) were acquired and used for ML model training. A total of 9 commonly used ML models were trained on the data obtained from one institute (108 feet), and tested on the other data set from another independent institute (90 feet) for external validation. Optimal feature sets for each model were identified based on a 2000-resample bootstrap-based internal validation via an exhaustive search. The performance of each model was then tested on the external validation set. The area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model were calculated to evaluate the performance of each model.

RESULTS

The support vector machine (SVM) model showed the highest predictive accuracy compared to other methods, with an AUC of 0.88 and an accuracy of 75.6%. Preoperative hallux valgus angle, tibial sesamoid position, postoperative intermetatarsal angle, and postoperative tibial sesamoid position were identified as the most selected features by several ML models.

CONCLUSION

ML classifiers such as SVM could predict the recurrence of HV (an HVA >20 degrees) at a 1-year follow-up while identifying associated predictors in a multivariate manner. This study holds the potential for foot and ankle surgeons to effectively identify individuals at higher risk of HV recurrence postsurgery.

Preoperative increased pronation angle of the first metatarsus associated with correction loss after hallux valgus surgery: A semi-weight-bearing computed tomography study

BACKGROUND

The effect of preoperative first metatarsal pronation on postoperative prognosis of hallux valgus (HV) surgery is under investigation. Utilizing semi-weight-bearing computed tomography, the preoperative pronation angle was assessed to quantify its impact on postoperative prognosis.

METHODS

In a retrospective analysis of 31 feet, those with re-increased hallux valgus angle postoperatively were classified as the non-maintained group, and the remainder as the maintained group. Preoperative pronation angles were compared to establish a threshold. Subsequently, feet were re-classified into high or low-pronation categories. The relative risk of non-maintenance in high-pronation category was calculated.

RESULTS

The non-maintained group exhibited a significantly higher preoperative pronation angle (p = 0.021), with a 28.4º threshold. The high-pronation category had a relative risk of 2.34 for non-maintenance.

CONCLUSIONS

Increased preoperative first metatarsal pronation angle is associated with correction loss after HV surgery. Utilizing sWBCT to measure the pronation angle provides valuable insights into postoperative prognosis.

LEVEL OF EVIDENCE

III.

A Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity

Various modifications of distal chevron metatarsal osteotomy (DCMO) have been introduced for correcting moderate hallux valgus deformity; however, the amount of correction may be limited, and complications, such as the recurrence of the deformity and avascular necrosis of the metatarsal head, have been a problem. This study aimed to present a modified 90-degree DCMO technique that overcomes the previously reported shortcomings and to report a successful short-term radiographic outcome. Sixty-eight consecutive patients who underwent the operation with our modified DCMO technique and twenty-two consecutive patients with the conventional DCMO technique (control group) were retrospectively analyzed. The radiographic measurements were evaluated preoperatively, at two months post operation, and at the final follow-up. Both groups showed a significant correction of the hallux valgus angle, first-second intermetatarsal angle, distal metatarsal articular angle, and sesamoid position at the final follow-up, while the amount of correction was significantly greater in the modified DCMO group. In both groups, there were no cases of complications such as avascular necrosis of the metatarsal head, nonunion, and surgical site infection appearing throughout the follow-up period. Therefore, the modified 90-degree DCMO technique is effective and safe, which could serve as a favorable option to treat moderate hallux valgus deformity.

Three-dimensional motion of the toes with simulated contraction of individual toe flexors and extensors: A cadaver study

BACKGROUND

The primary motion of the toes is flexion and extension. The motion results from activity of multiple muscles, and toe disorders may result from muscle dysfunction. The relationships of specific muscles related to toe function is underreported. The purpose of this study was to quantitatively evaluate three-dimensional toe motion resulting from specific muscle contraction using cadavers.

METHODS

Three-dimensional joint movements of the 1st, 2nd, and 5th toe were produced by applying traction of individual muscles using six Thiel-embalmed cadaver legs. The traction increments were 3 mm, 6 mm, and 9 mm, during which the angle of the distal bone with respect to the proximal bone of each toe joint was measured using a magnetic tracking system.

RESULTS

As tendon traction distance increased, the angular measure of the distal bone with respect to the proximal bone at each toe joint increased linearly and three-dimensionally. The flexor hallucis brevis significantly pronated and abducted the 1st toe compared to the extensor hallucis longus and brevis. The flexor digitorum brevis significantly supinated and adducted the 2nd toe compared to the flexor digitorum longus and quadratus plantae, while the extensor digitorum brevis demonstrated significant pronation and abduction compared to the extensor digitorum longus.

CONCLUSIONS

Three intrinsic muscles produced significant toe motion in frontal and horizontal planes. Our results revealed that there was a proportional relationship between tendon excursion and joint angle, and an antagonistic relationship of muscles acting on the toes. These results can be considered regarding pathogenesis of toe disorders or deformity and regarding treatment such as exercise therapy or tendon transfer.

LEVEL OF EVIDENCE

V, cadaveric study.

Effects of Foot-Toe Orthoses on Moment and Range of Motion of Knee Joint in Individuals with Hallux Valgus

Although various types of hallux valgus (HV) orthoses have been used to manage hallux valgus deformity, few previous studies have determined the biomechanical effects of applying a foot-toe orthosis as a therapeutic intervention for HV deformity on the kinetics and kinematics of the knee joint. Biomechanical variables were collected from 24 patients with HV. A three-dimensional motion capture system and force platforms were used to analyze the kinetic and kinematic variables in HV orthosis conditions during gait. To determine the biomechanical effect of each orthosis for HV on knee kinetic and kinematic values, repeated-measures ANOVA was used. The knee adduction moment was significantly decreased under a hard plastic orthosis (HPO) condition compared to that under a without foot-toe orthosis (WTO) condition (p = 0.004). There was a significant decrease in maximal external rotation of the knee joint in HPO than in WTO at the stance phase during gait (p = 0.021). All of the kinetic and kinematic data showed no significant differences between WTO and soft silicone orthosis conditions (p > 0.05). This study indicates that a stronger foot-toe orthosis, such as HPO, to correct HV deformity has a positive effect on the moment and joint motion occurring in the knee joint during walking. In particular, the application of this type of HV orthosis can reduce knee adduction moments associated with the development and progression of knee OA.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

What Proportion of Active-duty Servicemembers Functionally Improve at 1 Year Post Hallux Valgus Correction?

BACKGROUND

When the symptoms of hallux valgus persist despite nonoperative management, surgical intervention may be considered to improve pain and restore function. Although most patients return to full or near-full activity after surgery, this is not always the case in higher-demand populations. In fact, little is known about the likelihood of a military servicemember returning to running or military duty, which is analogous to a recreationally active adult, after hallux valgus correction.

QUESTIONS/PURPOSES

(1) What percentage of military servicemembers are able to return to full duty, including the ability to run 1.5 to 2 miles, 1 year after hallux valgus surgery? (2) What demographic, radiographic, and surgical variables are associated with an increased likelihood of return to full duty?

METHODS

This was a retrospective study of all military servicemembers who underwent surgical correction of hallux valgus deformities at a single tertiary institution from January 2005 to December 2016. We considered military servicemembers who were treated by four fellowship-trained foot and ankle orthopaedic surgeons and who had at least 1 year time-in-service remaining as potentially eligible. A total of 229 people underwent hallux valgus correction during this timeframe, but only 28% (64 of 229) of patients remained eligible: 41% (93 of 229) were excluded because they were not military members, 28% (64 of 229) were ineligible because they had less than 1 year remaining in service, 2% (4 of 229) were excluded because of prior surgery on the ipsilateral extremity, and 2% (4 of 2292) had an incomplete dataset. Interventions included a modified McBride procedure (9% [6 of 64]), distal metatarsal osteotomies (51% [33 of 64]), proximal metatarsal osteotomies (13% [8 of 64]), and Lapidus procedures (27% [17 of 64]). No bilateral procedures were performed. The mean age of our patients was 40 ± 10 years, and the mean BMI was 28 ± 9 kg/m 2 . In addition, 23% (15 of 64) of patients were nicotine users, 38% (24 of 64) were officers, and 45% (29 of 64) were women. The indication for surgery was functionally limiting pain that persisted despite 4 to 6 months of activity modifications, accommodative footwear, and orthotics. Cosmesis was not an indication for surgery. Before surgery, all patients were unable to complete a 1.5- to 2-mile timed run due to pain. The primary outcome measure was the proportion of patients who returned to full duty, which was defined as the ability to complete a 1.5-mile to 2-mile run for a military fitness test in a fixed time allotment, which varies by age and gender, and the ability to perform military-specific physical tasks at 1 year postoperatively. A secondary analysis according to demographic, radiographic, and surgical variables sought to determine any differences between those who did and did not return to full duty; this was assessed using univariable statistical comparisons at a p value of less than 0.01.

RESULTS

A total of 28% (18 of 64) of patients who underwent surgery returned to full duty by 1 year after surgery as determined by the ability to complete a time-allotted 1.5- to 2-mile fitness test run. Of the factors we explored, we did not identify any variables associated with return to full duty. We note that our analysis may have been underpowered to detect differences among factors that could be clinically important, like BMI, age, and comparisons of officers versus enlisted servicemembers.

CONCLUSION

Although this study analyzed the functional outcomes of a group of military servicemembers after hallux valgus correction, we believe our findings may also apply to recreationally active adults in the general population. Only a minority of military servicemembers (28% [18 of 64]) returned to duty 1 year after hallux valgus correction, as determined by the ability to complete a timed 1.5- to 2-mile run. We believe surgeons can use the findings of this study to set realistic expectations for recreationally active adults, particularly runners, after hallux valgus correction.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Selected hallmarks of hallux valgus in older women with symptomatic hallux valgus compared to middle-aged women with and without deformation of the forefoot

The aim of the study was to compare the shape of the feet, the mobility of the metatarsophalangeal and interphalangeal joints and the flexibility of the calf muscles in older women with hallux valgus versus middle-aged women with and without this deformation to identify the presence of features which correlate particularly strongly with hallux valgus, and on which prophylaxis and conservative treatment should focus. The study involved 201 women: 92 aged 60-84 years with hallux valgus of both toes, 78 aged 38-59 with hallux valgus of both toes, and 31 aged 38-57 years with correctly shaped feet. The intensity of pain in the foot, the valgus angle of the big toe and fifth toe, the longitudinal and transverse arches of the foot, the symmetry of foot load with body weight, toe joint mobility and muscle flexibility were analysed. Both groups of women with hallux valgus differed from women with normal feet in the height of the transverse arch, the extent of dorsal extension in the first metatarsophalangeal joint and plantar flexion in the first interphalangeal joint. Older women were additionally characterised by reduced plantar flexion in the metatarsophalangeal joint of the big toe, limited flexibility of the soleus and gastrocnemius muscles as well as less pain in the toe area than in the foot itself. The most characteristic changes which were observed in older women with hallux valgus are a limited range of motion in the MTP and IP joints of the big toe, a reduced transverse arch and increased restriction of calf muscle flexibility.

Pain Management of Hallux Valgus Surgery Is Achieved by Cocktail Therapy

Background. Hallux valgus is a relatively common forefoot disease in clinical practice. The aim of our study was to assess the role of local cocktail drugs and postoperative pain after hallux valgus surgery. Methods. A retrospective case-control study was conducted to analyze 75 moderate to severe hallux valgus patients from June 1, 2018 to December 1, 2019. All patients were divided into cocktail and control groups according to whether the cocktail therapy was used or not after the operation. The anesthesiologist did not provide analgesic treatment other than nerve block anesthesia and intravenous anesthesia, such as analgesic pumps. The operative region of the cocktail group received a mixture of 10 ml of 0.75% ropivacaine, 10 ml of flurbiprofen axetil injection, and 1 ml of compound betamethasone injection, whereas the control group received nothing in the surgical spot. We recorded patients’ VAS scores preoperatively and at 6, 24 hours postoperatively; the length of hospital stay and the number of hospitalization expenses; the scores of Kolcaba comfort level; and the scores of Pittsburgh sleep quality. Result. There was no significant difference in age or sex between the two groups. The VAS scores at 6 and 24 hours postoperatively were significantly lower in the cocktail group. The average length of hospital stay was 8.24 days in the control group and 3.73 days in the cocktail group. The average total hospitalization cost of the control group was ¥28285.16, and that of the cocktail group was ¥22366.31. In expenses of total hospitalization costs, the cocktail group was lower than the control group. Kolcaba’s comfort various scores and the total score of the cocktail group were higher than the control group. The total score of PSQI and all dimensions in the experimental group were lower than those in the control group. Conclusion. We found a significant difference in the results of postoperative pain management except for age, sex, and hospitalization expenses. After hallux valgus surgery, inject cocktail drugs around the first metatarsophalangeal joint did reduce postoperative pain level. Level of Evidence. Level III, case-control study.

Pre- and Post-Operative Relationship between Radiological Measures and Clinical Outcomes in Women with Hallux Valgus

The surgical correction of a hallux valgus (HV) deformity improves radiological parameters and clinical outcomes. However, it is not known how these improvements are related between themselves. In this retrospective study, 73 women were assessed preoperatively and 60 months after HV surgical correction. Several radiological parameters were measured: the hallux valgus angle (HVA), I−II intermetatarsal angle (IMA) and sesamoid position. The functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal (HMI) scale, and patient-reported outcomes (PROMs) were recorded with the Manchester−Oxford Foot Questionnaire (MOXFQ). A pre−post-surgery comparison of radiological and clinical values was performed, the correlation among them was studied and the differences pre−post-surgery in the radiological measurements compared with those for the clinical outcomes were studied. The results show that all the radiological parameters, functional outcomes and PROMs improved significantly from their pre-operative values to the follow-up values. Multivariate regression analysis showed a significant relationship (p < 0.001) between the differential pre−post-surgery AOFAS scoring only with two sesamoid position differential pre−post-surgery measures: position of medial sesamoid (PMS) and translation of the first metatarsal head (TMH). However, no significant association was observed between the pre−post-surgery radiological differences and the pre−post-surgery MOXFQ scoring.