The effect of hallux abducto valgus surgery on the sesamoid apparatus position

Are sesamoids and proximal phalanx of metatarsus primus varus deformity of hallux valgus feet displaced? A radiological study

BACKGROUND

The hallux valgus deformity is made up of misaligned first metatarsal, hallux, and sesamoids. Their angular deformities are well-studied, but not their positional displacements. A few available reports claimed the proximal end of the proximal phalanx and sesamoids were not shifted medially along with the first metatarsal head. However, the general observation is otherwise. This study revisits the issue.

METHODS

A radiological study of 189 feet with and without the hallux valgus deformity was carried out to analyze the first metatarsal, hallux, and sesamoid positional changes in relation to the second metatarsal and among themselves. A total of 194 X-ray images with all relevant measurements that formed the raw database for this study were submitted for online viewing and reference.

RESULTS

There was a statistically significant change in the first metatarsal, hallux, and sesamoid positions of feet with hallux valgus deformity compared to normal feet. All have migrated medially but to different degrees. It was contrary to the past findings of no change in sesamoid and hallux positions.

CONCLUSIONS

We agree with past findings that the metatarsus primus varus deformity is directly related to the failed medial metatarsosesamoid ligament. We also believe in the failure of the deep 1-2 transverse metatarsal ligament responsible for the sesamoid migration.

The Effect of Hallux Valgus Surgery on the Transverse Plane Hallux Proximal Phalanx Position

The objective of this investigation was to evaluate the apparent movement of the hallux proximal phalanx in the transverse plane relative to the second metatarsal following hallux valgus surgery. Pre- and postoperative radiographs of a consecutive series of 45 feet undergoing hallux valgus surgery were analyzed. Significant improvements were observed in the first intermetatarsal angle (12.4 vs 7.5 degrees; p < .001), hallux valgus angle (24.3 vs 13.4 degrees; p < .001), tibial sesamoid position (4.6 vs 2.7; p < .001), and second metatarsal-hallux proximal phalanx angle (80.1 vs 84.6 degrees; p < .001). No difference was observed in the distance between the second metatarsal bisection and the medial aspect of the tibial sesamoid (31.7 vs 31.5 mm; p = .756) nor between the second metatarsal bisection and medial aspect of the hallux proximal phalanx base (34.6 vs 34.2 mm; p = .592). Significant differences were observed between the second metatarsal bisection and the central aspect of hallux proximal phalanx base (26.5 vs 23.9 mm; p < .001) and between the second metatarsal bisection and the lateral aspect of the hallux proximal phalanx base (19.3 vs 15.4 mm; p < .001). A statistically significant difference was observed in the change of distance between the second metatarsal bisection and the medial, central, and lateral aspects of the hallux proximal phalanx base (-0.4 vs -2.6 vs -3.9 mm; p = .002). These results indicate that the hallux proximal phalanx does not translocate in the transverse plane following hallux valgus surgery, but instead pivots about the medial aspect of the joint.

The Rotational Effect of Scarf Osteotomy With Transarticular Lateral Release on Hallux Valgus Correction

The purpose of this study was to explore the rotational effect of scarf osteotomy with transarticular lateral release (TALR) on hallux valgus correction. From January 2016 to January 2018, 28 consecutive patients (30 feet) were included in this study. The first intermetatarsal angle (IMA), hallux valgus angle (HVA), and round-shaped lateral edge of the first metatarsal head (R sign), and sesamoid rotation angle (SRA) were recorded prior to and 3 months after the surgery. The rotation of the capital fragment of the first metatarsal was termed the capital rotation angle (CRA) and was measured intraoperatively after the completion of scarf osteotomy. The IMA, HVA, and SRA were significantly reduced from 13.9 ± 4.9°, 34.6 ± 7.4°, and 28.7 ± 9.8° to 2.4 ± 2.3°, 7.3 ± 4.7°, and 13.4 ± 8.8°, respectively (p < .01 for all). The mean CRA was 7.0 ± 3.4° and was not significantly correlated with the reduction of IMA and SRA (p > .05 for all); nor was it significantly correlated with IMA preoperatively and postoperatively (p > .05 for all) or the reduction of SRA and IMA (p > .05). The R sign was positive in 40% (12/30) of the feet preoperatively compared to 13.3% (4/30) postoperatively (p < .001). Scarf osteotomy produced a supination effect on the capital fragment of the first metatarsal and supinated the sesamoids via lateral translation of the first metatarsal head. These changes may contribute to the correction of the pronation component of hallux valgus deformity.

A meta-analysis of comparative clinical studies of isolated osteotomy versus osteotomy with lateral soft tissue release in treating hallux valgus

BACKGROUND

Contradictory results have been reported in the literature over the beneficial effect of the lateral soft tissue release (LSTR) when associated to an osteotomy for the treatment of hallux valgus (HV).

MATERIALS AND METHODS

Six comparative studies totalizing 425 patients (549 feet) were computed and comparing two groups: one group of patients having osteotomy alone and the other group having osteotomy with LSTR.

RESULTS

Subgroup analysis in relation to the type of LSTR yielded significant better HVA correction (P<0.0001) in favor of those reporting the release of the lateral sesamoido-metatarsal ligament (LSML). A moderate significance (P=0.03) of the inter-metatarsal angle (IMA) difference was found in favor of LSTR.

CONCLUSIONS

There could be a beneficial effect of transecting LSML in all cases of HV deformity, and a probable efficacy of an added adductor hallucis tendon transection when the deformity is moderate to severe.

Should We Use Intermetatarsal Angle as Primary Determinant to Define the Limits of Distal Chevron Osteotomy?

Classic treatment algorithms limit the use of distal chevron osteotomy (DCO) to cases with an intermetatarsal angle (IMA) <14°. As the IMA increases, it is accepted that the contact between the metatarsal head and shaft will be insufficient. We have investigated the reliability of IMA to predict contact area percentage after DCO. Preoperative radiographs of patients with hallux valgus were subdivided as mild, moderate, and severe using traditional algorithms. After excluding the mild cases, we randomly selected 100 patients (50 moderate and 50 severe) and calculated the estimated bony contact (EBC) with our method and investigated the percentage of patients who could have >50% contact area if we perform a DCO. Thirty of 50 (60%) and 17 of 50 (34%) patients had >50% EBC in moderate and severe groups, respectively. We performed DCO for 24 patients (14 moderate and 10 severe cases). The 100-point American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarso-phalangeal-interphalangeal scale was used to assess the clinical outcome. For the moderate group, we calculated mean IMA 16° (standard deviation [SD] ± 1.4°) and mean EBC 66.9% (SD ± 10.8%). For the severe group, we calculated mean IMA 20.9° (SD ± 0.7°) and mean EBC 63.1% (SD ± 10.4%). Paired t tests showed significant improvement comparing preoperative and postoperative AOFAS scores, IMA, hallux valgus angle, and sesamoid position for all operated patients (p < .001). We did not see any recurrence of hallux valgus or hallux varus and had only 1 minor complication that we managed conservatively. IMA may not always be a reliable parameter to predict the stability of DCO. Because the stability depends on the contact surfaces of osteotomy fragments, metatarsal head diameter and remaining bone contact should be the primary concerns. Two patients with the same IMA can have a different contact surface varying on a broad spectrum.

Lateral Sesamoid Position Relative to the Second Metatarsal in Feet with and without Hallux Valgus

Objective  To determine if the sesamoids migrate laterally in the feet with hallux valgus or if they only appear to move, maintaining their relationship with the other forefoot structures.

Methods  Anteroposterior radiographs of 80 patients (94 feet, all weight-bearing), from the period between 2015 and 2016, were evaluated. Forty-eight had a valgus hallux angle greater than 15° (hallux valgus group) and 46 presented a hallux valgus angle lower than 15° (control group). The distances from the first metatarsus head and the lateral sesamoid bone to the second metatarsus axis were measured. Subsequently, the coefficients of these distances were determined by the length of the second metatarsus to adjust it for different foot sizes.

Results  Both the absolute and the relative measures from the first metatarsus head to the second metatarsus axis were significantly different between the groups, with a positive correlation with hallux valgus and intermetatarsal angles. However, neither the absolute nor the relative distance of the lateral sesamoid bone to the second metatarsus was different between the groups, as they did not correlate with hallux valgus or intermetatarsal angles.

Conclusion  Despite the medial deviation of the first metatarsus in hallux valgus, the sesamoid bone maintains its relationship with the second metatarsus in the transverse plane. This apparent lateral displacement may lead to misinterpretation of these radiographs. This fact is of paramount importance in the pre-, intra-, and postoperative period of patients with hallux valgus.

Triplanar Quantitative Radiographic Analysis of the First Metatarsal-Phalangeal Joint in the Hallux Abductovalgus Deformity

Although hallux abductovalgus (HAV) is widely considered to be a triplanar deformity involving the transverse, sagittal, and frontal planes, most of the published literature has focused on evaluating the deformity in only the transverse plane, and we are unaware of any investigation objectively evaluating the relationship among the 3 planes in the setting of HAV deformity. The objective of this investigation was to quantitatively evaluate radiographic measurement of the relationship between the transverse, sagittal, and frontal planes in the HAV deformity. Anteroposterior, lateral, and sesamoid axial radiographs from 42 consecutive feet were evaluated with measurement of the first intermetatarsal angle, hallux abductus angle, metatarsal sesamoid position, first metatarsal inclination angle, sesamoid rotation angle, and tibial sesamoid grade. Variables were graphically depicted against each other on frequency scatter plots with calculation of a regression line and Pearson's correlation coefficient. As transverse plane deformity increased, the frontal plane deformity also tended to increase and the first metatarsal inclination angle tended to decrease. And as frontal plane deformity increased, the first metatarsal inclination angle tended to decrease. To our knowledge, these are the first quantitative and objective data in support of a triplanar component to the HAV deformity, and we believe this reinforces the evaluation of this deformity with emphasis on all 3 planes.

Sesamoid Position in Healthy Volunteers Without Deformity: A Computed Tomography Study

We used coronal computed tomography to determine the normal sesamoid position in 20 healthy volunteers. The sample involved 40 feet (20 left [50%] and 20 right [50%]) in 20 volunteers, including 11 females (55%) and 9 males (45%). The relationship between the first metatarsal head and the sesamoid complex was categorized as Yildirim grade 0 in every case (100%). The mean width of the foot was 77.7 ± 5.8 mm, and the ratio of the foot width to the distance from the second metatarsal head to the tibial sesamoid was 39.6% ± 2.02%. Based on our findings, we consider Yildirim grade 0 to be the normal sesamoid alignment.

Lateral Sesamoid Position Relative to the Second Metatarsal in Feet With and Without Hallux Valgus: A Prospective Study

We sought to determine whether hallux valgus displaces the sesamoid bones laterally away from a stationary first metatarsal or whether the first metatarsal head is displaced medially from the stationary sesamoids, which remain in position relative to the rest of the forefoot. We reviewed weightbearing radiographs in the dorsal plantar view of 128 consecutive patients (149 feet) seen over 2 months in 2014. Of these, 82 feet (55%) had a hallux valgus angle of >15° (hallux valgus group) and 67 feet (45%) had an angle of no more than 15° (control group). We measured the absolute distances from the center of the lateral sesamoid and the first metatarsal head to the long axis of the second metatarsal. Next, the relative distances, defined as the ratio of these 2 absolute distances to the length of the second metatarsal, were calculated to adjust for foot size. Both the absolute and the relative distances from the center of the first metatarsal head to the second metatarsal differed significantly between the 2 groups and correlated positively with the hallux valgus angle and first intermetatarsal angle. However, neither the absolute nor the relative distance to the lateral sesamoid bone differed significantly between the groups, nor did they correlate with either of the 2 angles. Thus, despite medial shifting of the first metatarsal in hallux valgus, the lateral sesamoid retains its relationship to the second metatarsal in transverse plane. Its apparent lateral movement is a radiographic misinterpretation. Awareness of this misinterpretation should improve the success of corrective surgery.

Preoperative Planning and Intraoperative Technique for Accurate Translation of a Distal First Metatarsal Osteotomy

We used preoperative radiographic and intraoperative anatomic measurements to predict and achieve, respectively, the precise amount of capital fragment lateral translation required to restore anatomic balance to the first metatarsophalangeal joint. Correlation was used to relate the amount of capital fragment translation and operative reduction of the first intermetatarsal angle (IMA), hallux abductus angle (HAA), tibial sesamoid position (TSP), metatarsus adductus angle, and first metatarsal length. The mean capital fragment lateral translation was 5.54 ± 1.64 mm, and the mean radiographic reductions included a first IMA of 5.04° ± 2.85°, an HAA of 9.39° ± 8.38°, and a TSP of 1.38 ± 0.9. These changes were statistically (p < .001) and clinically (≥32.55%) significant. The mean reduction of the metatarsus adductus angle was 0.66° ± 4.44° and that for the first metatarsal length was 0.33 ± 7.27 mm, and neither of these were statistically (p = .5876 and 0.1247, respectively) or clinically (≤3.5%) significant. Pairwise correlations between the amount of lateral translation of the capital fragment and the first IMA, HAA, and TSP values were moderately positive and statistically significant (r = 0.4412, p = .0166; r = 0.5391, p = .0025; and r = 0.3729, p = .0463; respectively). In contrast, the correlation with metatarsus adductus and the first metatarsal shortening were weak and not statistically significant (r = 0.2296, p = .2308 and r = -0.2394, p = .2109, respectively). The results of our study indicate that predicted preoperative and executed intraoperative lateral translation of the capital fragment correlates with statistically and clinically significant reductions in the first IMA, HAA, and TSP.

The Relationship Between the Sesamoid Complex and the First Metatarsal After Hallux Valgus Surgery Without Lateral Soft-Tissue Release: A Prospective Study

Some investigators have emphasized restoring the relationship between the sesamoid complex and the first metatarsal head to reduce the risk of hallux valgus recurring after surgical reconstruction. In a prospective study, we analyzed whether the first metatarsophalangeal joint could be realigned after scarf-Akin bunionectomy without lateral soft tissue release. A total of 25 feet, in 22 patients, were prospectively enrolled and analyzed using anteroposterior radiographs and coronal computed tomography scans obtained before and 3 months after surgery. The Yildirim sesamoid position decreased from a preoperative of 2 (range 1 to 3) to a postoperative position of 0 (range 0 to 1; p < .001), the mean first intermetatarsal angle decreased from 12.6° ± 2.4° to 5.8° ± 2.1° (p < .001), and the mean distance between the second metatarsal and the tibial sesamoid changed from 25.7 ± 4.6 to 25.9 ± 4.6 (p = .59). Our findings suggest that dislocation of the sesamoid complex is actually caused by displacement of the first metatarsal. In conclusion, the scarf-Akin bunionectomy adequately restores the alignment of the first metatarsophalangeal joint, including restoration of the sesamoid apparatus, without direct plantar-lateral soft tissue release.

Osteodesis for hallux valgus correction: is it effective?

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

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

Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy

Of the >100 procedures that have been proposed to treat hallux valgus or the "bunion" deformity, most have focused on correction through metatarsal osteotomies at various levels combined with soft tissue balancing procedures at the first metatarsophalangeal joint. This paradigm of metatarsal osteotomy and soft tissue balancing has been so commonplace, any argument for a fundamental change to the approach becomes uncomfortable and seems unwarranted to most foot and ankle surgeons. However, the simple fact that so many procedures exist, with so many modifications of these procedures, can be interpreted as a failure of our basic paradigm of metatarsal osteotomy and soft tissue balancing. We have observed that failure to recognize frontal plane rotation of the first metatarsal and our willingness to ignore deformity correction principles and create osteotomies outside the center of rotation of angulation are factors that can result in inconsistent outcomes. Our current multiprocedural mindset drives the search for yet more procedures and modifications in an attempt to reduce the incidence of complications. We present an anatomic analysis of hallux abducto valgus and metatarsus primus adducto valgus and critically analyze some of the shortcomings of currently popular corrective procedures. We also review the available data regarding frontal plane rotation of the first metatarsal and propose a new paradigm that considers frontal plane rotation of the first metatarsal as a priority in choosing the most appropriate procedure for bunion correction.

Physical therapy post-hallux abducto valgus correction

This article discusses physical therapy considerations after hallux valgus correction. Hallux valgus is a fairly common occurrence, and corrective surgery is an option when conservative measures fail. Symptoms such as pain, swelling, and difficulty walking may persist after surgical correction of bunion deformity that addresses soft tissue and bone structure. Physical therapy is helpful after corrective hallux valgus surgery to address impairments and continued dysfunction and to improve overall patient outcome expectations. This article describes the benefits of a multifaceted physical therapy program after hallux valgus correction.

Correction of frontal plane rotation of sesamoid apparatus during the Lapidus procedure: a novel approach

The Lapidus procedure affords correction of a multitude of first ray pathologic entities. When reconstructing the first ray using the Lapidus procedure, the relocation of the first metatarsal over the sesamoid bones with frontal plane rotation should be considered one of the key components. In the present technical report, we have described a bunion correction with emphasis on sesamoid reduction through indirect frontal plane manipulation. Our technique, borne from applied basic anatomy of the first metatarsophalangeal joint, uses intact soft tissues about the first metatarsophalangeal joint to reduce subluxed or dislocated sesamoids.

Descriptive quantitative analysis of hallux abductovalgus transverse plane radiographic parameters

Although the transverse plane radiographic parameters of the first intermetatarsal angle (IMA), hallux abductus angle (HAA), and the metatarsal-sesamoid position (MSP) form the basis of preoperative procedure selection and postoperative surgical evaluation of the hallux abductovalgus deformity, the so-called normal values of these measurements have not been well established. The objectives of the present study were to (1) evaluate the descriptive statistics of the first IMA, HAA, and MSP from a large patient population and (2) to determine an objective basis for defining "normal" versus "abnormal" measurements. Anteroposterior foot radiographs from 373 consecutive patients without a history of previous foot and ankle surgery and/or trauma were evaluated for the measurements of the first IMA, HAA, and MSP. The results revealed a mean measurement of 9.93°, 17.59°, and position 3.63 for the first IMA, HAA, and MSP, respectively. An advanced descriptive analysis demonstrated data characteristics of both parametric and nonparametric distributions. Furthermore, clear differentiations in deformity progression were appreciated when the variables were graphically depicted against each other. This could represent a quantitative basis for defining "normal" versus "abnormal" values. From the results of the present study, we have concluded that these radiographic parameters can be more conservatively reported and analyzed using nonparametric descriptive and comparative statistics within medical studies and that the combination of a first IMA, HAA, and MSP at or greater than approximately 10°, 18°, and position 4, respectively, appears to be an objective "tipping point" in terms of deformity progression and might represent an upper limit of acceptable in terms of surgical deformity correction.

Lateral release in hallux valgus deformity: from anatomic study to surgical tip

The important part of hallux valgus deformity operations, especially in the case of an incongruent joint, is the release of the soft tissue on the lateral side of the first metatarsophalangeal joint. The purpose of the present anatomic study was, with preparation of the lateral structures of the joint and lateral conjoined tendon, to provide a background for a surgical tip of the release of the joint for an additional metatarsal osteotomy. For the present study, we used 30 specimens (15 left and 15 right) from 19 cadavers at the Institute of Anatomy, First Faculty of Medicine, Charles Faculty (Prague, Czech Republic). Only specimens that met the criteria of hallux valgus were included in the present study. The technique was based on the incision of the lateral sesamoid ligament and partial tenotomy of the lateral conjoined tendon from the first interdigital web space. The release was done gradually with supination and abduction of the big toe to achieve the smallest size of the tenotomy. The median of the tenotomy size of the conjoined tendon was 6.5 (range 5 to 14) mm. The median size of the conjoined tendon in the frontal plane just ventral to the sesamoid bone was 10.6 (range 8 to 14) mm. The technique of the release, in which the big toe was abducted and supinated, can minimize the size of the lateral conjoined tendon release and can minimize the possibility of a postoperative deformity.

Reliability and relationship of radiographic measurements in hallux valgus

BACKGROUND

Although various radiographic measurements have been developed and used for evaluating hallux valgus, not all are universally believed to be necessary and their relationships have not been clearly established. Determining which are related could provide some insight into which might be useful and which would not.

QUESTIONS/PURPOSES

We investigated the reliability of eight radiographic measurements used to evaluate hallux valgus, and determined which were correlated and which predicted the hallux valgus angle.

METHODS

We determined eight radiographic indices for 732 patients (mean age, 51 years; SD, 17 years; 107 males and 625 females) with hallux valgus: hallux valgus angle, intermetatarsal angle, hallux interphalangeal angle, distal metatarsal articular angle, proximal phalangeal articular angle, simplified metatarsus adductus angle, first metatarsal protrusion distance, and sesamoid rotation angle. Intraobserver and interobserver reliabilities of each radiographic measurement were analyzed on 36 feet from 36 randomly selected patients. Correlations among the radiographic measurements were analyzed. Radiographic measurements predicting hallux valgus angle were evaluated using multiple regression analysis.

RESULTS

Hallux valgus angle had the highest reliability, whereas the distal metatarsal articular angle and simplified metatarsus adductus angle had the lowest. Distal metatarsal articular angle, intermetatarsal angle, and sesamoid rotation angle had the highest correlations with hallux valgus angle. Distal metatarsal articular angle correlated with sesamoid rotation angle. The intermetatarsal angle, interphalangeal angle, distal metatarsal articular angle, first metatarsal protrusion distance, sesamoid rotation angle, and metatarsus adductus angle predicted the hallux valgus angle.

CONCLUSIONS

We suggest using hallux valgus angle, intermetatarsal angle, interphalangeal angle, sesamoid rotation angle, and first metatarsal protrusion distance considering their reliability and prediction of the deformity.

Arthroscopy of the first metatarsophalangeal joint in 59 consecutive cases

The authors analyzed the results of 59 consecutive cases of the first metatarsophalangeal (MTP-I) joint arthroscopy to verify the efficacy and safety of the procedure. Fifty-nine patients were followed for >18 months after MTP-I joint arthroscopic procedures. The mean duration of follow-up was 25 months. Clinically, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the satisfaction of the patients were evaluated. Hallux valgus angle, the first intermetatarsal angle, and medial sesamoid position were analyzed in cases of hallux valgus. The American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal scale score was increased from 69 points preoperatively to 92 points postoperatively (p < .05). Radiologically, the mean hallux valgus angle was decreased from 29.2° preoperatively to 9.7° postoperatively (p < .05). The mean first intermetatarsal angle was decreased from 14.8° preoperatively to 7.7° postoperatively (p < .05). The medial sesamoid position was improved from 4.8 preoperatively to 2.0 postoperatively (p < .05). Ninety-five percent of the patients were satisfied with the procedures. There was 1 case of a wound problem and 1 case of temporary digital nerve injury as complications. Based on our experience, arthroscopy of MTP-I joint appears to be a safe and reproducible procedure for selected cases of MTP-I joint disorders.

Treatment of hallux valgus by modified McBride procedure: a 6-year follow-up

BACKGROUND

Surgical decision-making was reevaluated by comparison with an algorithm designed to analyze treatment of hallux valgus deformities.

MATERIALS AND METHODS

A modified McBride procedure was performed on 52 feet of 35 patients with hallux valgus deformity. From this series, 36 feet of 21 patients were evaluated preoperatively, early postoperatively, and late postoperatively by means of subjective evaluation and clinical and radiological findings.

RESULTS

The hallux valgus angle preoperatively, early postoperatively, and late postoperatively was 32.7 +/- 8.5 degrees, 10.1 +/- 6.9 degrees, and 20.6 +/- 9.5 degrees, respectively. Hallux valgus recurrence of 72.2% was observed. Subjective results were better and the patients rated their satisfaction with the procedure as excellent or high in 23 cases (63.9%) and moderate, low, or unsatisfactory in 13 cases (36.1%).

CONCLUSIONS

This level of patient satisfaction demonstrates that the McBride procedure is an efficient approach for eliminating pain due to hallux valgus deformity.

The multiplanar effect of first metatarsal osteotomy on sesamoid position

The standard classification system used to measure the sesamoids in the evaluation of hallux abductovalgus is a uniplanar description of a multiplanar deformity. Additionally, it cannot accurately describe a true measure of sesamoid positional change in the perioperative period because the first metatarsal is laterally transposed during corrective surgery. The intended emphasis of this investigation is to evaluate the sesamoid position in multiple planes relative to a stationary anatomical landmark following first metatarsal osteotomy for the surgical correction of hallux abductovalgus deformity. A retrospective radiographic review of 46 feet in 38 patients demonstrated statistically significant (P < .001) differences between preoperative and postoperative values for the first intermetatarsal angle, hallux abductus angle, sesamoid rotation angle, tibial sesamoid position, and tibial sesamoid grade. However, there was no significant difference in the sesamoid position in both the transverse (P = .07) and frontal (P = .29) planes when measured relative to the stationary second metatarsal. Based on the preceding results, the appropriate expected surgical outcome of hallux abductovalgus correction may be to relocate the first metatarsal on top of the relatively immobile sesamoids.

The effect of sesamoid position on outcome following scarf osteotomy for hallux abducto valgus

BACKGROUND

Hallux valgus is a common forefoot condition, with numerous operations described to correct the deformity. Debate remains as to the relative importance of correcting the position of the sesamoid apparatus.

METHODS

Forty-six cases were reviewed. Preoperative and post-operative X-rays were used to measure forefoot width, inter-metatarsal angle (IM), hallux valgus (HV) angle and sesamoid position (Reynolds stations). Satisfaction was assessed via questionnaire.

RESULTS

Significant improvements were seen in all radiological parameters. 37/43 patients were satisfied with the result. Comparison between the satisfied and non-satisfied group revealed significant differences in the IM angle (p<0.05) and HV angle (p<0.05). However, patient satisfaction was not associated with post-op sesamoid position or change in sesamoid position (p>0.05).

CONCLUSIONS

This study showed that scarf osteotomy, can successfully correct hallux valgus, with high levels of satisfaction. Satisfaction is associated with a greater correction of deformity. Improvement in sesamoid position was not associated with patient satisfaction.

Radiographic investigation of angular and linear measurements including first metatarsophalangeal joint dorsiflexion and rearfoot to forefoot axis angle

This study investigated intra- and inter-rater reliability of several radiographic angular and linear parameters using 6 subjects. Using standard weight-bearing radiographs, the following measurements were performed: first metatarsal protrusion distance, hallux abductus, first intermetatarsal, calcaneal inclination and lateral intermetatarsal angles. Measurement of lateral stressed dorsiflexion of the first metatarsophalangeal joint and the rearfoot-to-forefoot-axis angle taken using a composite view were also obtained. All parameters were measured independently by 2 raters, and measurements were repeated on 3 separate occasions at weekly intervals. Intrarater reliability of radiographic measurements ranged between R = 0.65-1.00 for lateral stressed dorsiflexion, and between R = 0.91 and 0.99 for the rearfoot to forefoot axis angle. Inter-rater reliability of radiographic measurements ranged from R = 0.82-0.99. Specifically, lateral stressed dorsiflexion showed R = 0.87 with a mean difference of -1.47 (confidence interval [CI]: -3.42, 0.47), indicating no significant difference ( t = 1.54, P = 0.13). The rearfoot-to-forefoot-axis angle showed R = 0.92 with a mean difference of -0.15 (CI: -1.05, 0.74), indicating no significant difference ( t = 0.35, P = 0.73). The 7 angular and linear measurements chosen demonstrated high inter- and intrarater reliability. These results indicate that weight-bearing radiographic first metatarsophalangeal joint dorsiflexion using the lateral stressed dorsiflexion view, and measurement of the rearfoot-to-forefoot-axis angle using a composite view could be measured reliably within and between raters.

New radiographic analysis of sesamoid rotation in hallux valgus: comparison with conventional evaluation methods

The position of the hallucal sesamoids needs to be included in evaluation of hallux valgus. In order to quantify the rotational position of the hallucal sesamoids, a new weightbearing tangential radiograph was established by means of a specially designed tangential positioning device. This device has a depression, and a tangential radiograph is taken with the metatarsophalangeal joint at 45 degrees dorsiflexion. A lead marker plate is placed on the depression to show the horizontal plane, and the sesamoid rotation angle (SRA) is measured. The SRA is the angle between the tangential line of the most inferior aspect of the medial-lateral sesamoids and the lead marker line. The SRA was compared with values of the four-grade scale and seven-position scale which were measured from the antero-posterior view, with respect to the hallux valgus angle (HVA), by means of conventional methods. Measurements were made of 58 feet in 29 patients with hallux valgus and 64 feet in 32 normal subjects. The SRA showed the highest correlation among the three parameters (r=0.817). Some cases had a disparity regarding the position of the sesamoids between the tangential view and the AP view due to misclassification on the AP view. We conclude that the scale of position of the sesamoid on the AP view is not valid in some cases, whereas the SRA is useful for assessing quantitatively the rotational position of the hallucal sesamoids in cases of hallux valgus.