First Metatarsal Head and Medial Eminence Widths with and Without Hallux Valgus

Evaluation of hallux valgus treatment: is classical angular correction approach relevant?

BACKGROUND

Hallux valgus correction is mostly done by metatarsal procedures, and widely accepted strategy is to decide which surgical method should be used is based on radiological severity using intermetatarsal (IMA) and hallux valgus (HVA) angles (classical angular correction approach-CACA). The aim of the study is to compare the postoperative improvement in radiographic parameters and morphologic appearance of the foot between patients operated with and without adhering to CACA strategy based on classical severity classification using angle measurements.

MATERIALS AND METHODS

A retrospective comparative study between two groups (conforming and not conforming to proposed algorithm) was performed. Of 122 feet of 119 patients underwent metatarsal procedures for hallux valgus between October 2022 and November 2023, 92 feet of 92 patients were enrolled in the study (age 43.86 ± 16.1 years, 15.2% male). Patients were classified into two groups as conforming and non-conforming to CACA algorithm based on IMA and HVA angles (mild: IMA ≤ 13°, HVA ≤ 30°; moderate: 13° < IMA < 20°, 30° < HVA < 40°; severe: IMA ≥ 20°, HVA ≥ 40°). Algorithm proposed distal osteotomies for mild cases, shaft osteotomies for moderate cases and proximal osteotomies or tarsometatarsal arthrodeses for severe cases. HVA and IMA corrections after surgery, bony foot width, soft tissue foot width, medial eminence bony distance and medial soft tissue distance alterations, American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal Scale (AOFAS-MTP-IP) scores and improvement of foot appearance according to Manchester scale in postoperative first year follow-up were compared between groups.

RESULTS

58 procedures (group 1) conformed CACA, while 34 (group 2) did not. There was no statistically significant difference in terms of IMA (3.81° ± 4.01°, 2.72° ± 2.25°, p = 0.423), HVA (12.78° ± 7.81°, 10.31° ± 5.4°, p = 0.106) bony forefoot width (4.41 ± 6.66 mm, 1.65 ± 6.67 mm, p = 0.059), soft tissue forefoot width (1.21 ± 6.61 mm, 2.41 ± 7.45 mm, p = 0.423), medial eminence width (5.72 ± 3.17 mm, 6.07 ± 3 mm, p = 0.609) alterations and AOFAS-MTP-IP scores (82.17 ± 5.26, 83.06 ± 5.18, p = 0.435) between groups. Medial soft tissue width increased in both groups (2.74 ± 2.53 mm, 1.48 ± 1.67 mm, p = 0.011). Manchester stages were improved in 45 feet in group 1 (77.6%) and 19 feet in group 2 (55.9%) (p = 0.029).

CONCLUSION

The CACA strategy of treating more severe deformities with more proximal procedures and milder deformities with distal osteotomies did not significantly impact postoperative radiologic parameters. Nonetheless, following CACA strategy is likely to improve the morphologic appearance of the foot.

LEVEL OF EVIDENCE

III, comparative study.

Radiographic and Cadaveric Analysis of Minimally Invasive Bunionectomy Osteotomy Position-"MIS Bunion Sweet Spot"

Minimally invasive surgery (MIS) is a growing technique that favors faster recovery and cosmetic results. We propose a recommended osteotomy position or "MIS Sweet Spot" to make the procedure more reproducible and lessen the learning curve to improve outcomes. A total of 211 patients from 3 surgeons between 2 different study centers were included in a retrospective radiograph measurement analysis and a cadaveric dissection to confirm the safety of nearby anatomical structures. An average distance of 2.2 cm proximal from the first metatarsophalangeal joint was found as the "Sweet Spot" to perform the transverse osteotomy. At this distance, neurovascular and tendinous structures were unharmed and the osteotomy remained extracapsular. Furthermore, an average of 10.7° of intermetatarsal angle reduction and a reduction of tibial sesamoid position of 3 points were achieved. A predictable and measurable distance for osteotomy placement will help to provide more confidence in producing the bunionectomy osteotomy with the specialized tools used in MIS and can help to reduce operative time and improve results.Level of Clinical Evidence (LOCE): 3.