Radiographic Comparison of Open and Minimally Invasive Distal Chevron Metatarsal Osteotomy in Patients With Hallux Valgus

This study aimed to compare radiographic outcomes of open and minimally invasive surgery (MIS) in patients with hallux valgus. We reviewed data of patients with hallux valgus who underwent open or minimally invasive distal chevron osteotomy at our institution. Radiographic assessment was completed preoperatively, immediate postoperatively, and one year postoperatively using eight weight bearing parameters . The classic distal chevron osteotomy method was used for open surgery and a modified method that added percutaneous K-wire fixation to the minimal invasive Chevron-Akin (third-generation MIS) was used for correction of the distal metatarsal articular angle (DMAA). A total of 65 feet (33 open surgeries and 32 MIS) were included. The HVA, IMA, and DMAA improved significantly following surgery regardless of surgical method (p<0.001). Other radiographic indicators showed no statistically significant differences after surgery. DMAA improved by 71.0±14.2% after surgery, and the open surgery group showed less significant reduction in DMAA (49.7±25.7%, p<0.001). Other parameters showed no difference between the two groups regarding relative postoperative changes. The MIS group showed shorter operation time (p<0.001) and hospitalization period (p=0.034) than did the open surgery group. Therefore, the MIS group is expected to be cost-effective. Radiographic measurements revealed comparable outcomes of MIS compared with open surgery. Additionally, adding percutaneous K-wire fixation during MIS had an advantage in correcting DMAA compared with open surgery. Furthermore, the correction of DMAA could reduce recurrence of valgus deformity of the hallux.

Frontal Plane Correction of Hallux Valgus Deformity With a Minimally Invasive Third Generation Tecnique: Short-Term Radiographic Outcomes of a Prospective Case Series

A number of minimally invasive osteotomies have been described for the repair of hallux abducto valgus (HAV) deformities. However, there are no known published studies that evaluate the effects of minimally invasive surgery techniques on the reduction of frontal plane rotation in patients with HAV. The purpose of this study was to assess correction in the transverse and frontal planes in patients undergoing surgical repair of HAV deformity utilizing a modified percutaneous technique. One hundred and five feet in 105 patients with HAV deformity were treated with a third generation minimally invasive technique using a first metatarsal osteotomy that allowed for frontal plane correction in conjunction with an Akin osteotomy. The minimum follow-up time was 12 months. Preoperative and postoperative anteroposterior weightbearing x-ray images were assessed and four measurements were evaluated: hallux abductus angle (HAA), intermetatarsal angle (IMA), tibial sesamoid position and frontal plane rotation of the first metatarsal. There were statistically significant differences for each of the assessments between the preoperative and postoperative radiographs (p < .001). There was a mean reduction in the HAA of 23.5° ± 9.6°, in the IMA, 7.0° ± 3.5°, in the tibial sesamoid position, 2.6 ± 1.3, and an improvement in the assessment of first metatarsal pronation (1.4 ± 0.9). The overall complication rate was 18.1%, with 5.7% of the feet requiring reoperation. The minimally invasive procedure employed by the authors demonstrated suitable outcomes in reducing deformity in both the transverse and frontal planes.

Combined Distal Metatarsal and Akin Osteotomies for Concomitant Metatarsophalangeal and Interphalangeal Hallux Valgus: Clinical and Radiological Outcomes

Combined metatarsal and Akin-type proximal phalanx osteotomies represent a surgical solution for concomitant metatarso-phalangeal and inter-phalangeal hallux valgus. This retrospective observational study aimed to evaluate clinical and radiographic outcomes following combined distal linear metatarsal and Akin osteotomies. The study included 42 feet from 37 patients, with a mean follow-up of 27.1 (range 24-37) months. Mean surgical time was 16.54 ± 4.17 minutes. Pre- and postoperative clinical scores and radiological parameters were collected. Positive outcomes with a low recurrence and complications rates were reported. A statistically significant improvement in the Manchester-Oxford foot questionnaire, the EuroQol 5D-5L dimensions instrument, the visual analogue scale, the intermetatarsal angle, the hallux valgus angle, the distal metatarsal articular angle, and the interphalangeal angle correction was observed. Despite the results reported, further prospective studies are needed to identify the most suitable patients for this combined osteotomy approach.

The Triplanar Hallux Abducto Valgus Classification System: Is it Valid?

Historically, 2-dimensional radiographic study techniques have been used to classify deformity and guide treatment of hallux valgus deformities in the transverse plane. Recently, a triplanar hallux abducto valgus classification system was proposed. The key elements of this classification system are the pathologic alignments in 3 anatomic planes. The triplanar hallux abducto valgus classification system is intended to clarify the deformity and apply a triplanar anatomic algorithm for treatment. To our knowledge, this classification system has not been validated. Our objective was to assess reliability of the triplanar hallux valgus classification system. Patients with hallux abducto valgus were identified from a foot and ankle registry. Digital radiographs were assembled in a digital slide presentation. The eligibility criteria required complete radiographic studies and represented varying degrees of hallux abducto valgus. The reviewers included 3 board-certified, fellowship-trained orthopedic foot and ankle surgeons. Each reviewer independently classified the hallux abducto valgus deformity for a total of 75 observations. After an 8-week washout period, the order of the hallux abducto valgus cases was randomized in the digital slide presentation and redistributed to the reviewers. The average kappa value from 3 readers was 0.241 with 95% CI (0.093-0.374), indicating a fair agreement. The inter-reader agreement was 0.046 with 95% CI (-0.041 to 0.112), showing poor agreement between readers. Our results indicate the triplanar hallux abducto valgus is not a reliable classification system. While this is the first known triplanar hallux abducto valgus classification system, it lacks prognostic value and reliability.

First tarsometatarsal arthrodesis for severe hallux valgus using the tension band principle - Technical tip and case series

BACKGROUND

Hallux valgus (HV) is a common foot pathology. Severe HV in the presence of Tarsometatarsal joint (TMTJ) instability is often managed with arthrodesis of the 1st TMTJ. There are concerns regarding non-union and malunion (particularly the early loss of inter-metatarsal angle correction before complete arthrodesis). We report our medium-term results of a small series of patients that underwent an evolved surgical technique utilising orthogonal staples and a transverse suture button fixation to address biomechanical concerns with traditional Lapidus arthrodesis.

METHODS

A retrospective study of a consecutive series of patients who underwent this surgical technique between February 2017 and May 2022. Clinical outcomes were validated through Patient-reported outcomes measures (PROMS); EuroQol-5 Dimension (EQ-5D) and Manchester-Oxford Foot Questionnaires (MOXFQ). Radiographic parameters (hallux valgus (HVA), intermetatarsal (IMA), distal metatarsal articular angle (DMAA)) were assessed. Union of the arthrodesis and complications were recorded.

RESULTS

During the study period, 9 feet underwent the procedure. Radiographic data was available for all nine and PROMS data for seven (77.8%). Significant improvement occurred in all radiographic deformity parameters at mean 6-month follow-up. Mean ± standard deviation correction calculated preoperatively as HVA 40.2°, IMA 19.3° and DMAA 15.8°, corrected to HVA 15.4°, IMA 5.8° and DMAA 5.9° postoperatively. (HVA; P < 0.001, IMA; P < 0.001, DMAA; P < 0.001) Clinical PROMs at mean follow-up of 2 years were MOXFQ 34.4 ± 25.2, EQ-5D-5 L 0.819 ± 0.150 and VAS pain 13.6 ± 13.6. There were no cases of non-union, Tibialis anterior tendon irritation or hallux varus. Complications included first MTPJ stiffness in one case and CRPS and dorsiflexion malunion of the first ray in another patient.

CONCLUSION

This preliminary study of the procedure used in this series confirm this is a safe surgical technique to address severe HV with a low rate of non-union and significant radiographic improvements. A larger patient dataset is needed to evaluate this procedure robustly.

Outcomes of Joint-Preserving Surgery for Forefoot Deformities in Patients With Rheumatoid Arthritis

BACKGROUND

With the advent of effective disease-modifying medications, the surgical treatment of forefoot deformities in patients with rheumatoid arthritis (RA) has evolved from joint-sacrificing to joint-preserving surgery. However, it is unclear whether joint-preserving surgery is effective for the full range of metatarsophalangeal joint involvement. Hence, this study investigated the postoperative outcomes of joint-preserving surgery for rheumatoid forefoot deformities with a wide range of joint destruction.

METHODS

This retrospective observational study included 68 feet from 68 patients with RA who underwent joint-preserving surgery for forefoot deformities between 2014 and 2020. The Larsen grade classification was used to assess the first metatarsophalangeal joint destruction and classify patients into 4 groups as follows: 0 and 1 (n = 14), 2 (n = 21), 3 (n = 19), and 4 and 5 (n = 14). The Self-Administered Foot and Ankle Evaluation Questionnaire (SAFE-Q) score, hallux valgus angle (HVA), and intermetatarsal angle (IMA) were determined before surgery and at the last follow-up visit.

RESULTS

The median observation duration was 40 (range, 24-78) months. SAFE-Q scores of all groups significantly improved in all subscales at the last observation, with no significant differences among the study groups. Radiographic evaluations of all groups revealed significant improvements in HVA and IMA after surgery, with no significant differences among the groups.

CONCLUSION

In patients using the surgical approaches described in this study, joint-preserving surgery for rheumatoid forefoot deformities led to satisfactory clinical and radiographic improvements, regardless of the severity of joint destruction.

LEVEL OF EVIDENCE

Level III, case-control study.

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.

Does the Presence of Asymptomatic Flatfoot Deformity Impact the Clinical and Radiographic Outcomes of the Minimally Invasive Chevron and Akin Bunionectomy?

BACKGROUND

Flatfoot deformity is believed to play a role in hallux valgus development and recurrence. While symptomatic flatfoot deformity can be treated with separate procedures at the time of hallux valgus correction, the question remains whether the patient undergoing correction of a symptomatic hallux valgus deformity should have their asymptomatic flatfoot concurrently addressed. We aimed to investigate whether the presence of asymptomatic flatfoot influences patient-reported and radiographic outcomes of the minimally invasive chevron and Akin bunionectomy.

METHODS

A total of 104 patients were included in this study. Forty-two asymptomatic patients met the radiographic criteria for flatfoot while 62 had a normal arch. Patient-reported outcomes were evaluated and compared between the two groups using validated PROMIS measures preoperatively and at a minimum one-year postoperatively. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, calcaneal pitch (CP), and talonavicular coverage angle (TNCA) were measured and compared preoperatively and minimum six-months postoperatively.

RESULTS

Both groups demonstrated similar preoperative and postoperative PROMIS scores with significant improvements in physical function, pain interference, pain intensity, and global physical health. Preoperatively, HVA was similar between both groups, however the flatfoot group showed a greater IMA, Meary's angle, TNCA, and lower CP. Postoperatively, HVA and IMA were similar between groups, although patients in the flatfoot group retained a significantly greater Meary's angle, TNCA, and lower CP. Both groups showed significant improvements in HVA, IMA, and TNCA.

CONCLUSION

Our study indicates that the minimally invasive chevron and Akin bunionectomy leads to improved clinical and radiographic hallux valgus outcomes without adversely impacting radiographic flatfoot parameters. Therefore, the MIS bunionectomy may be an effective option for hallux valgus correction in patients with mild, asymptomatic flatfoot.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Radiological Analysis of the Syndesmosis Concept in Metatarsus Primus Varus and Hallux Valgus Deformities Recurrence Prevention

Hallux valgus (HV) is a common deformity of the foot. Its postoperative recurrence is not uncommon and is closely related to the recurrence of its underlying metatarsus primus varus (MPV) deformity. The syndesmosis procedure uses 1 to 2 intermetatarsal cerclage sutures to realign the first metatarsal and then induces a biological bonding between the 2 metatarsals to prevent the MPV deformity from recurring. This radiological study aimed to assess its effectiveness in long-term MPV and HV deformities recurrence prevention. Ninety-two feet of 51 consecutive patients had syndesmosis procedures that were prospectively followed up for more than 1 y and up to 14 y, averaging 100.5 (SD 45.2) months. Patients underwent X-ray examinations regularly at fixed intervals of their feet. We used Hardy's methods in measuring the intermetatarsal angle (IMA), hallux valgus angle (HVA), and medial sesamoid position from standing foot X-rays. More than 450 relevant X-ray and photo images were submitted as Supplementary Material for online viewing and reference. There was a significant final correction of IMA from 14.30° (SD 2.70) to 6.70° (SD 1.75) (p < .0001). There was no significant increase in IMA after the sixth postoperative month to their final follow-up endpoints, regardless of their lengths. There was a significant final correction of HVA from 31.95° (SD 7.45) to 19.1° (SD 7.45) (p < .0001). This study reconfirmed past findings that the MPV deformity could be corrected without osteotomies. Creating a syndesmosis-like intermetatarsal bonding was effective for long-term MPV recurrence prevention. Three feet had postoperative stress fracture of the second metatarsal. However, the HV deformity correction was less satisfactory, and the reasons were explained.

Medial sesamoid position in moderate to severe hallux valgus: Correlation between three radiographic measurements

BACKGROUND

In hallux valgus surgery, it is essential to accurately assess the position of the sesamoids both pre- and postoperatively. Weight-bearing foot anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views are radiographic methods used to assess the medial sesamoid position. This study aimed to measure the medial sesamoid position and evaluate the correlation between these three radiographic methods.

METHODS

This retrospective study comprised 59 feet from 49 patients who underwent hallux valgus surgery. The mean age of patients was 54.6 (range, 22-70) years. We took preoperative and postoperative measurements using the weight-bearing anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views to assess the medial sesamoid position.

RESULTS

The mean grades of the medial sesamoid position preoperatively and 6 months postoperatively were 2.5 and 0.8, 1.6 and 0.4, and 1.3 and 0.3 points based on the anteroposterior, tangential sesamoid, and computed tomography axial views, respectively (P < 0.001). Preoperatively, there was a strong positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.645) and anteroposterior and computed tomography axial views (P < 0.001, r = 0.468). In contrast, the tangential sesamoid and anteroposterior views showed a weak positive correlation (P = 0.03, r = 0.283). Six months postoperatively, there was a positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.473), anteroposterior and computed tomography axial views (P < 0.001, r = 0.470), and tangential sesamoid and anteroposterior views (P < 0.001, r = 0.480).

CONCLUSIONS

We observed that the anteroposterior view exhibited a higher degree of medial sesamoid position displacement than the computed tomography axial and tangential sesamoid views. For the preoperative evaluation of the medial sesamoid position, the correlation between the computed tomography axial and tangential sesamoid views was stronger than that between the tangential sesamoid and anteroposterior views. However, all three views showed strong correlations postoperatively.

Correlation Between Traditional Anteroposterior Radiographic Measurements With Lateral Radiographic Measurements Following Triplanar Correction of Hallux Valgus and With Patient-Reported Outcomes From a Prospective Multicenter Trial

Hallux valgus (HV) is a common condition in which the first ray is deformed, leading to pain and altered joint mechanics. A variety of radiographic measurements are used to evaluate HV. Little is known about measurements used in the assessment of HV on lateral radiographs compared to anteroposterior (AP) radiographs. The primary aim of this study was to correlate lateral measurements with AP measurements pre and postoperatively. The secondary aim was to correlate lateral measurements with patient-reported outcome measures (PROMs) pre and postoperatively. One hundred eighty-three patients were initially enrolled in the study. Two fellowship-trained musculoskeletal radiologists independently performed all measurements. On AP radiographs, hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. On lateral radiographs, sagittal IMA, Meary's angle, and sagittal first ray length were measured. Measurements were recorded at baseline and 6, 12, and 24 months postoperatively. Intraclass correlation coefficients (ICCs) were used for inter-reader analysis. ICCs were moderate to very strong among readers. There were significant but weak correlations between lateral measurements and AP measurements. For at least 1 timepoint, IMA correlated with sagittal IMA, sagittal first ray length, and Meary's angle. HVA only correlated with sagittal first ray length. These correlations were all weak in magnitude. There were a few significant but weak correlations between the measurements in the study and PROMs. This study showed that sagittal IMA, sagittal first ray length, and Meary's angle are not predictive of AP measurements or patient outcomes and are not useful in preoperative assessment of HV.

Relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in patients with hallux valgus

OBJECTIVES

Hallux valgus is associated with tarsometatarsal arthritis; its pathophysiology remains unknown. Therefore, we aimed to elucidate the relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in the sagittal plane.

METHODS

Forty-three patients (64 feet) with hallux valgus who underwent surgery at University Hospital Kyoto Prefectural University of Medicine were included and divided into two groups: control (without second and third tarsometatarsal joint degeneration) and osteoarthritis (with second and third tarsometatarsal joint degeneration). Intergroup comparisons of the incongruity of the first tarsometatarsal joint in the sagittal plane, age, body mass index, hallux valgus angle, first-second intermetatarsal angle, metatarsus adductus angle, Meary's angle, and calcaneal pitch angle were performed.

RESULTS

The proportion of patients with incongruity of the first tarsometatarsal joint was significantly higher in the osteoarthritis group than in the control group. Logistic regression analysis identified incongruity of the first tarsometatarsal joint and metatarsus adductus angle as significant related factors for arthritis of the second and third tarsometatarsal joints.

CONCLUSIONS

Incongruity of the first tarsometatarsal joint in the sagittal plane was involved in the development of arthritis of the second and third tarsometatarsal joints in patients with hallux valgus.

Biomechanical comparison of two surgical methods for Hallux Valgus deformity: Exploring the use of artificial neural networks as a decision-making tool for orthopedists

Hallux Valgus foot deformity affects gait performance. Common treatment options include distal oblique metatarsal osteotomy and chevron osteotomy. Nonetheless, the current process of selecting the appropriate osteotomy method poses potential biases and risks, due to its reliance on subjective human judgment and interpretation. The inherent variability among clinicians, the potential influence of individual clinical experiences, or inherent measurement limitations may contribute to inconsistent evaluations. To address this, incorporating objective tools like neural networks, renowned for effective classification and decision-making support, holds promise in identifying optimal surgical approaches. The objective of this cross-sectional study was twofold. Firstly, it aimed to investigate the feasibility of classifying patients based on the type of surgery. Secondly, it sought to explore the development of a decision-making tool to assist orthopedists in selecting the optimal surgical approach. To achieve this, gait parameters of twenty-three women with moderate to severe Hallux Valgus were analyzed. These patients underwent either distal oblique metatarsal osteotomy or chevron osteotomy. The parameters exhibiting differences in preoperative and postoperative values were identified through various statistical tests such as normalization, Shapiro-Wilk, non-parametric Wilcoxon, Student t, and paired difference tests. Two artificial neural networks were constructed for patient classification based on the type of surgery and to simulate an optimal surgery type considering postoperative walking speed. The results of the analysis demonstrated a strong correlation between surgery type and postoperative gait parameters, with the first neural network achieving a remarkable 100% accuracy in classification. Additionally, cases were identified where there was a mismatch with the surgeon's decision. Our findings highlight the potential of artificial neural networks as a complementary tool for surgeons in making informed decisions. Addressing the study's limitations, future research may investigate a wider range of orthopedic procedures, examine additional gait parameters and use more diverse and extensive datasets to enhance statistical robustness.

Validity and Reliability of a New Radiological Method to Estimate Medial Column Internal Rotation in Hallux Valgus Using Foot Weight-Bearing X-Ray

BACKGROUND

Medial column internal rotation in hallux valgus (HV) can be measured using weight-bearing computed tomography (WBCT). Anteroposterior weight-bearing foot radiographs' (WBXR) ability to estimate medial column internal rotation in HV was evaluated comparing these measurements with those obtained from WBCT.

METHODS

Three observers evaluated WBCT and WBXR of 33 HV feet twice. Medial column internal rotation was measured with WBCT and classified into 3 levels according to WBXR findings. Intra- and interobserver reliability were obtained for WBXR and WBCT, in addition to WBXR-WBCT correlation.

RESULTS

WBXR and WBCT intraobserver agreement was substantial and near perfect, respectively (κ 0.79 and 0.84). Their interobserver agreement was excellent (intraclass correlation 0.85 and 0.9, respectively). The WBXR-WBCT correlation was substantial (κ 0.68). WBXR diagnostic accuracy to predict the WBCT results was 85%.

CONCLUSIONS

The proposed method for medial column internal rotation measurement using WBXR is reliable and has a substantial agreement with WBCT measurements.

LEVELS OF EVIDENCE

Level III.

Proximal Supination Osteotomy for Hallux Valgus: Comparison of Clinical and Radiologic Outcomes for the Most Severe Deformities

BACKGROUND

There is little available information regarding the difference in outcomes between severe hallux valgus (S-HV), defined as 40 degrees ≤ hallux valgus angle (HVA) < 50 degrees, and what we consider to be "super-severe HV" (SS-HV), defined as >50 degrees, following a proximal metatarsal osteotomy. We aimed to retrospectively compare the outcomes of a proximal metatarsal osteotomy in S- and SS-HV.

METHODS

The series consisted of 57 female patients (57 feet) treated with a proximal supination osteotomy for symptomatic S- and SS-HV (33 and 24 feet, respectively). The outcome measures included radiographic parameters and for 45 patients included the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) score, and a visual analog scale pain score (VAS-PS) preoperatively and at a minimum follow-up of 12 months with a median of 26 months. No significant differences were found in age, body mass index, and the duration of follow-up between patients with S-HV and SS-HV (P > .10 for all comparisons) with the numbers available.

RESULTS

Preoperative HVA in patients with S- and SS-HV was significantly improved at the final follow-up (P < .0001 for both comparisons). No significant differences in postoperative HVA and IMA were observed between patients with S- and SS-HV (P = .51 and .50, respectively). All 5 preoperative subscale scores of SAFE-Q in patients with S- and SS-HV significantly improved postoperatively (P < .01 for all comparisons). Preoperative VAS-PS in patients with S- and SS-HV significantly improved postoperatively (P < .0001 and <.009, respectively). There were no significant differences in preoperative and postoperative scores of all the SAFE-Q subscales and VAS-PS between patients with S-HV and SS-HV (P > .10 for all) with the numbers available.

CONCLUSION

We found for this patient group that a proximal supination osteotomy can achieve a large correction for SS-HV as well as S-HV and significantly improve radiologic and clinical outcomes in SS-HV. The outcomes between patients with S- and SS-HV were not different in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison of triplanar chevron osteotomy with chevron osteotomy in hallux valgus treatment for the prevention of transfer metatarsalgia

Hallux valgus (HV) is often accompanied by metatarsalgia. This study compared the radiological and clinical outcomes of new triplanar chevron osteotomy (TCO) and chevron osteotomy (CO) in the treatment of HV, especially for patients with plantar callosities and metatarsalgia. In this retrospective analysis, 90 patients (45 patients per group) with mild to moderate HV and plantar callosities were treated with TCO and CO from July 2020 to January 2022. In both procedures, the apex was located in the center of the head of the first metatarsal bone, and the CO was oriented towards the fourth MTPJ at a 60° angle. Plantar-oblique chevron osteotomy was defined as chevron osteotomy and a 20° plantar tilt; TCO was defined as plantar-oblique chevron osteotomy-based metatarsal osteotomy with a 10° tilt towards the metatarsal head. Primary outcome measures included preoperative and postoperative hallux valgus angle, 1 to 2 intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal length (FML), and second metatarsal head height X-ray images; clinical measurements, including visual analogue scale and American Orthopaedic Foot & Ankle Society (AOFAS) scores; changes in callosity grade and area; and changes in the number of people with metatarsalgia. Secondary outcomes included complications, recurrence rates, and cosmetic appearance. The hallux valgus angle, IMA, and DMAA were significantly lower after surgery (P  < .001) in all patients. In the TCO group, the mean FML and second metatarsal head height increased significantly postoperatively (P < .001). The AOFAS and visual analogue scale scores improved postoperatively in both groups (P < .001). All patients experienced satisfactory pain relief and acceptable cosmesis. The plantar callosity areas were smaller postoperatively in both the TCO and CO groups, but the change in the area (Δarea) in the TCO group significantly differed from that in the CO group (P < .001). The number of postoperative patients with metatarsalgia and the plantar callosity grade were both significantly lower in the TCO group than in the CO group after osteotomy (P < .05). TCO prevents dorsal shift of the metatarsal head and preserves and even increases FML, thereby preventing future metatarsalgia in patients. Therefore, compared with CO, TCO has better orthopedic outcomes and is an effective method for treating mild to moderate HV and preventing transfer metatarsalgia.

Comparative effects of modified rotary scarf osteotomy and traditional scarf osteotomy in treating moderate to severe hallux valgus: a retrospective cohort study

BACKGROUND

Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of TSO, Modified Rotary Scarf osteotomy (MRSO) was introduced in this study, which aimed to compare the clinical and radiological outcome in the patients treated with MRSO or TSO.

METHODS

Of 175 patients (247 feet) with MSHV, 100 patients (138 feet) treated with MRSO and 75 patients (109 feet) treated with TSO were evaluated according to relevant indicators in twenty-four months follow-up. Pre-surgical and post-surgical HVA, IMA, DMAA, MTP-1 ROM, sesamoid grade and AOFAS (American Orthopaedic Foot and Ankle Society) scores and postsurgical complications were evaluated.

RESULTS

Both groups manifested similar baseline characters. The mean follow-up was of 25.9 (range, 22-37) months. Significantly lower IMA, lower Sesamoid grade and higher DMAA at six months, twelve months and twenty-four months post-surgically had been showed in MRSO group compared to TSO group. There was no significant difference in HVA, MTP-1 ROM and AOFAS data at each follow-up time point post-surgically between the two groups. No major complications occurred in either group.

CONCLUSION

MRSO showed comparable results to TSO, and improved IMA and sesamoid grade to a greater extent, with a lower probability of throughing effect. Although DMAA could be increased by MRSO, MRSO could still be a reproducible, non-dangerous and efficacious alternative procedure for treating HV patients which do not have severe DMAA.

The Lapidus Bunionectomy Revolution: Current Concepts and Considerations

Hallux valgus is a common foot deformity in which many surgical techniques have been introduced. Originally, Paul Lapidus detailed a midfoot arthrodesis technique to address the deformity and medial column instability that served as the foundation for the modified Lapidus bunionectomy. The appreciation of the multiplanar nature of hallux valgus deformity continues to evolve and helps to guide the investigation of the ideal surgical correction to yield more predictable results and reduced complications. Various fixation constructs have been used over the years for the Lapidus bunionectomy without a clear superior fixation technique, and literature supports early weight-bearing with each.

Is there a tolerance for extension of the first metatarsal after the Lapidus procedure? A clinical, functional, and hindfoot radiographic analysis

PURPOSE

Based on the tripod concept of load distribution, our study aimed to evaluate whether a slight extension of first metatarsal (M1) that may occur after the Lapidus procedure (LP) could alter the radiographic measurements of the hindfoot and influence clinical and functional outcomes.

METHODS

Twenty-five patients (27 feet) were reviewed. Hindfoot radiographic analysis was based on seven measurements. Clinical and functional outcomes were evaluated with self-reported questionnaires. Transfer metatarsalgia was also assessed. Correlation analysis was performed according to variations of the studied variables.

RESULTS

The average extension of the M1 was 4.26 degrees (p < 0.001). None of the hindfoot radiographic measurements changed significantly (p = 0.13, p = 0.50, p = 0.19, p = 0.70, p = 0.11, p = 0.36, p = 0.83). Patients improved on most questionnaires (p < 0.001). None presented transfer metatarsalgia. No correlation between M1 extension and clinical and functional outcomes was found.

CONCLUSION

Possibly there is a tolerance of M1 extension in which it does not alter the radiographic measurements of the hindfoot, overload the lesser metatarsals, or compromise clinical and functional outcomes.

The Effect of the Lateral First Metatarsal Head Shape on Hallux Valgus in Forced Turnout in Pre-Pointe Female Ballet Dancers: A Pilot Study

BACKGROUND

A rounded lateral first metatarsal head shape is associated with higher rates of hallux abducto valgus recurrence following corrective surgery; however, the effect of the lateral first metatarsal head shape on the hallux abduction angle (HAA) has not yet been explored in a nonpathologic, pre-pointe ballet dancer population. The primary purpose of this study was to investigate the effect of the lateral first metatarsal head shape on the HAA when pre-pointe female dancers force their turnout.

METHODS

Seventeen female, pre-pointe ballet students (mean age, 10.8 ± 0.95 years) participated in this study. Fluoroscopic images of each dancer's dominant foot were taken, and the lateral first metatarsal head shape was classified visually. Each dancer performed three consecutive stances of natural double-leg upright posture: both functional and forced turnout. HAAs were obtained by marking medial bony landmarks on paper and were compared to photographic measurements.

RESULTS

No significant difference was found between the round and angular lateral first metatarsal head shape for the change in HAA from natural double-leg upright posture to forced turnout. Hallux abduction angle significantly increased by 4.6° (P < .001) in forced turnout compared to the natural double-leg upright posture for the photographic method, whereas the paper method demonstrated an increase of 2.6° (P = .007). No statistical differences were found between the paper and photographic methods in measuring the HAA for all stances.

CONCLUSIONS

Our findings suggest no association between the HAA and lateral first metatarsal head shape; however, HAA does increase when a dancer assumes forced turnout. The paper method demonstrated similar reliability to the photographic method and shows the potential for future use as a clinical tool in assessing hallux abducto valgus.

Fracturing the Lateral Hinge Improves Radiographic Alignment and Does Not Affect Clinical Outcomes of the Minimally Invasive Akin Osteotomy

BACKGROUND

Intraoperative fracture of the lateral cortex is common during Akin osteotomy. In a recent study, lateral cortex fracture did not impede healing or result in loss of correction in a combined cohort of open and percutaneous osteotomies stabilized by K-wire fixation. We hypothesize that undesired lateral cortex fracture will not affect radiographic correction and patient-reported outcomes in a percutaneous cohort stabilized by permanent, rigid screw fixation.

METHODS

Consecutive patients with hallux valgus who underwent first metatarsal osteotomy and percutaneous Akin osteotomy stabilized by permanent, rigid screw fixation between May 2020 and January 2022 were retrospectively reviewed. Patients were stratified based on fractured lateral cortex (FC) or its absence (nonfractured cortex [NFC]). Visual analog scale (VAS) and Foot Function Index (FFI) were used to assess pain and patient-reported outcomes at 1-year follow-up. Patients were polled for satisfaction at 1-year follow-up by yes/no survey.

RESULTS

Ninety-eight patients (89% female) were reviewed (98 feet; 43 NFC, 55 FC). Mean age was 48.3 years (range, 18-83 years). Mean preoperative VAS score was 7.5 and 7.7 in NFC and FC groups, which significantly decreased to 0.6 (P < .01) and 0.6 (P < .01), respectively. Mean total FFI was 53.9 and 54.2 and decreased to 17.9 (P < .01) and 17.2 (P < .01) in the NFC group and FC group, respectively. Overall, 97.8% of the NFC group and 96.4% of the FC group reported satisfaction.Mean HVA improved from 27.2 (16-42) degrees to 10.7 degrees (4-12) postoperatively in the NFC group. And in the FC group, HVA improved from 29.3 (19-39) degrees to 7.1 (4-12) degrees postoperatively. Postoperative HVA was significantly lower in the FC group (P < .05).

CONCLUSION

In an exclusively percutaneous surgical cohort with correction maintained by rigid screw fixation, fracture of the lateral cortex is associated with improved postoperative radiologic alignment without detriment to patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

Immediate Weightbearing Following First Metatarsal Phalangeal Joint Arthrodesis With 2 Nickel Titanium Alloy Staples

The use of staples has been shown to be a reasonable fixation technique to achieve stability of a first MTPJ arthrodesis. Although it has been shown to be a weaker construct than crossed screws or plate and screw combinations, their ease of insertion, low profile, and stability make them a desirable choice for first MTPJ arthrodesis fixation. However, because of this relative weakness, the question remains whether immediate weightbearing when using staples is advisable. The aim of this study is to determine whether the use of 2 nickel-titanium alloy (NITINOL) staples, placed at 90 degrees to one another is a stable enough construct to support full, immediate weightbearing following first MTPJ arthrodesis. We performed a retrospective chart review of patients undergoing first MTPJ arthrodesis by a single surgeon utilizing 2 NITINOL staples placed at 90 degrees to one another. Patients were allowed to be fully weightbearing immediately postoperatively. Forty-seven of 50 (94%) patients achieved complete radiologic consolidation of fusion at 12 weeks, with only 3 requiring revision surgery for nonunion. All of the patients requiring revision surgery for nonunion, had preoperative diagnosis of hallux abducto valgus. We concluded that the use of 2 NITINOL staples placed at 90 degrees to one another is a viable option for first MTPJ arthrodesis, and immediate weightbearing does not increase rate of nonunion or incidence of revision surgery when compared to other fixation techniques.

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.

Foot Surgery Using Resorbable Magnesium Screws

The use of bioabsorbable magnesium (Mg) screws is new in foot surgery. Their relative merit over conventional titanium screws has not yet been proven. This prospective case series study was conducted to compare the clinical and radiological outcomes of bioabsorbable Mg screws and titanium screws. A consecutive series of patients (n = 60; 11 men and 49 women) underwent corrective hallux valgus surgery. The minimum follow-up period was 1 year. The assessment was based on a patient questionnaire, including the American Orthopedic Foot and Ankle Society (AOFAS) hallux valgus score, visual analog scale, patient's global impression of change (PGIC), and fifth metatarsus circumference (IF5C). The radiographic assessment included the intermetatarsal and hallux valgus angles, as well as time to osteotomy union and hardware failure. At 1 year, similar results were obtained radiographically. The healing of the osteotomies was significantly faster in the Mg group. Hardware failure was common in the Mg group (5/26) than in the TI group (0/34) but hardware removal was more common in the TI group (6/34) versus the MG group (0/26). IF5C increased by 8 ± 2 mm in the Mg group. The AOFAS and PGIC scores at 6 months were similar. Validated foot scores and radiographic analysis indicated that there was no detectable difference between the groups. The fast achievement of osteotomy union compensates for a high rate of hardware failure, resulting in patient satisfaction and avoiding reoperation for hardware removal.

Morphology variations with medial cuneiform in hallux valgus

The hypermobility of the first tarsometatarsal joint has been identified as a key factor in the development of hallux valgus. Previous research found a link between the tarsometatarsal joint obliquity and the hallux valgus angle. Nevertheless, most studies relied on radiographs that lack 3D evidence. This study used 3D analysis to investigate the morphological differences in the medial cuneiform between hallux valgus and normal feet. In this study, twenty-three hallux valgus feet and twenty-three normal feet were scanned with computed tomography and 3D models of medial cuneiforms were reconstructed. Medial cuneonavicular and the first tarsometatarsal joint surfaces of the medial cuneiform were manually extracted. To obtain the obliquity angle of the medial cuneiform and curvature of the medial cuneonavicular joint, the joint surfaces were approximated to planes and spheres. Furthermore, the orientations of two joint surfaces were accessed through a novel positioning method. No significant difference was found in the cuneiform obliquity between hallux valgus and normal feet. Hallux valgus and normal groups did not differ significantly in any of the medial cuneiform joint orientations. The medial cuneiform in hallux valgus had a larger curvature diameter of the medial cuneonavicular joint (P = 0.029), indicating a flatter surface. The results demonstrated that the generally supported atavism (i.e., tarsometatarsal joint obliquity) does not exist in the hallux valgus feet. A flatter medial cuneonavicular joint surface was found in hallux valgus feet. This study contributes to the comprehensive understanding of the etiological factors with hallux valgus.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints

BACKGROUND

Hallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint.

METHODS

Fifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft.

RESULTS

The mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0-3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints).

CONCLUSIONS

The clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A 28-Year-Old Woman with Down Syndrome, Congenital Heart Disease, and a History of Knee Surgery and Plantar Fasciitis, with Hallux Abducto Valgus (Bunion) and Lapiplasty Three-Dimensional Correction Surgery

BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. CASE REPORT Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. CONCLUSIONS The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays.

Interreader reliability assessment of hallux valgus evaluation on dorsoplantar weightbearing radiographs from a prospective multi-center trial and correlation with patient-reported outcome measures

OBJECTIVE

To determine inter-reader reliability (IRR) of hallux valgus (HV) related parameters, i.e. intermetatarsal angle (IMA), hallux valgus angle (HVA), lateral round sign of the first metatarsal, tibial sesamoid position (TSP), metatarsus adductus angle (MAA), transverse osseous foot width, 1st MT length, MTP osteoarthritis (OA), and distal metatarsal articular angle (DMAA). These were correlated with patient-reported outcome measures (PROMs).

MATERIALS AND METHODS

A prospective single-arm Level 3 multicenter clinical trial in which standardized radiographs and PROMs were collected at the time of the initial patient visit for pre-operative assessment. Two musculoskeletal radiologists performed measurements blinded to each other's reads and clinical information. Intraclass coefficient and kappa were obtained for inter-reader analysis. A partial spearman rank order was used to correlate the measurements with PROMs.

RESULTS

The final cohort size of 183 patients had mean age of 40.77 years, mean body mass index was 26.11 kg/m2, with 91.2% females and 8.7% males. There was excellent IRR for HVA (0.96, CI: [0.94,0.97]), IMA (0.92, CI: [0.89,0.94]), transverse osseous foot width (0.99, CI: [0.98,1.00]), and DMAA (0.80, CI: [0.74, 0.85]), good agreement for TSP (0.73, CI:[0.67,0.79]) and MAA (0.67, CI: [0.16, 0.84]), fair agreement for MTP OA (0.48, CI: [0.36,0.59]), and poor agreement for lateral round sign (0.32, CI: [0.11, 0.52]. The negative correlation of increasing transverse osseous foot width with worsening PROMIS physical but better MOxFQ and VAS scores is likely spurious.

CONCLUSION

Good to excellent inter-reader reliability was observed for the most often used measurements for HV assessment without major trends in their correlations with PROMs. Lateral round sign is not a reliable finding in HV deformity.

Trends and age- and sex-stratified analysis of hallux valgus correction surgery from 2014 to 2019: A nationwide population-based cohort study in Japan

BACKGROUND

Epidemiological studies on hallux valgus (HV) are challenging owing to differences in sampling and diagnostic criteria across studies. This study aimed to indirectly clarify HV epidemiology using a national database.

METHODS

The age- and sex-stratified annual number rate of HV correction (RHVC) per 100,000 people in Japan during 2014-2019 were examined.

RESULTS

The average annual RHVC was 3.0. RHVC had unimodal (peak, 65-79 years) and bimodal (peaks, 15-19 and 70-74 years) distributions among males and females, respectively, and increased over time in males aged 50-54 and 75-79 years and females aged 80-84 years.

CONCLUSIONS

RHVC increases with increasing age and occurs commonly in female teens. The recent RHVC in Japan was lower than that reported in Europe and the United States, with an increasing trend among elderly people.

LEVEL OF EVIDENCE

III.

Relationship between medial partite hallux sesamoid and hallux valgus in the general population

BACKGROUND

An association between the medial partite hallux sesamoid (MPHS) and hallux valgus (HV) has been suggested; however, a causal relationship has not been confirmed. This study aimed to determine their causal relationship using a cross-sectional radiographic survey of a large-scale population cohort covering a wide age group.

PATIENTS AND METHODS

The fifth survey of the Research on Osteoarthritis/Osteoporosis against Disability study involved 1997 participants aged 21-95 years who had undergone anteroposterior radiography of bilateral feet. The presence of MPHS, its morphology, and radiographic parameters related to the HV were assessed using radiographs. Changes in the prevalence of MPHS with age were assessed using trend tests. The relationship between the MPHS and HV was assessed based on sex and age.

RESULTS

MPHS was found in 508 out of 3994 feet (12.7 %), with a significant difference in prevalence between men and women (10.0 % vs. 13.7 %, p < 0.001). Trend analysis demonstrated a significant decrease in MPHS occurrence with age in both sexes. HV angle was significantly higher in feet with MPHS than in those without (Men: 17.8 ± 7.0° vs. 14.0 ± 5.9°, p < 0.0001; Women: 19.6 ± 7.7° vs. 17.7 ± 7.9°, p < 0.0001). The prevalence of HV angle ≥ 20° was also significantly higher in feet with MPHS than in those without (Men: 33.3 % vs. 14.6 %, p < 0.0001; Women: 46.5 % vs. 34.6 %, p < 0.0001). This association between MPHS and HV was noticeable in younger adults and became less prominent with age.

CONCLUSIONS

MPHS is associated with HV. The weakening of this relationship and the decreased prevalence of MPHS with age suggest that MPHS is not caused by HV, but is one of the causes of HV, especially in younger adults.

Biomechanical Comparison between Rotational Scarf Osteotomy and Translational Scarf Osteotomy: A Finite Element Analysis

OBJECTIVE

Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis.

METHODS

The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three-point bending test.

RESULTS

Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three-point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm).

CONCLUSION

Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus.

Percutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness

BACKGROUND AND HYPOTHESIS

Although percutaneous hallux valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies.

PATIENTS AND METHODS

Twenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to this neurovascular structures, tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified.

RESULTS

The medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3mm (SD 1.4) and 2.4mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet.

CONCLUSIONS

The structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid lesions to neurovascular and tendinous structures.

LEVEL OF EVIDENCE

V, Cadaveric study.

Application of 3D Printing Navigation Template Technology in Severe Hallux Valgus Surgery

OBJECTIVES

To explore the application of 3D printed navigation template technology in severe Hallux valgus surgery.

METHODS

Forty-eight patients with severe Hallux valgus were selected. There were 24 cases in the control group underwent hallux valgus osteotomy using traditional methods and fixed with fully threaded hollow screws during the surgery. There were 24 cases in the 3D group who underwent personalized osteotomy using 3D printing navigation template technology. Patients were followed up regularly for six months after surgery.

RESULTS

The surgery time of the 3D group was shorter than that of the control group, and the intraoperative bleeding was reduced (P<0.05). Compared with the preoperative data, the HVA and IMA significantly reduced immediately and 1, 3, and 6 months after surgery (P<0.05). The VAS scores decreased significantly, while the AOFAS and SF-36 scores increased (P<0.05). At three months and six months after surgery, the VAS score of the 3D group was lower than that of the control group, while the SF-36 score was higher (P<0.05). During the follow-up period, both groups had no recurrent cases or complications.

CONCLUSIONS

The 3D printing navigation template technology improves patients' prognosis, functional recovery, and quality of life.

Multiple factors contributing to the metatarsal head eversion in hallux valgus deformity. A prospective study using weight-bearing CT

PURPOSE

Recently first tarsometatarsal arthrodesis for hallux abducto valgus (HAV) has been advocated as the sole procedure to correct the multiplanar components of the deformity. However, recent debate suggests other factors such as rearfoot pronation and metatarsal torsion affect frontal plane metatarsal eversion and sesamoid positioning. Using weight-bearing CT, 12 feet (12 subjects) with HAV deformities were placed in positions of maximum rearfoot pronation and supination in order to study the effects on metatarsal eversion, sesamoid rotation/displacement, and secondarily the influence of first metatarsal torsion. Sesamoid displacement was quantified by the novel use of the sesamoid displacement angle.

PRINCIPLE RESULTS

Although first metatarsal eversion was nearly double in the pronated versus supinated foot, the difference was not statistically significant. Therefore, the bulk of first metatarsal eversion was not secondary to rearfoot eversion. Conversely, a significant positive correlation was found between metatarsal torsion and metatarsal head eversion angles in both supinated and pronated foot positions, with the strongest correlation with rearfoot pronation. Finally, significant increases in sesamoid displacement angles were noted with pronation.

MAJOR CONCLUSIONS

The findings of the present study support the contention that multiple factors are associated with frontal plane first metatarsal eversion and sesamoid displacement. Weight-bearing CT scanning can be used to effectively evaluate the frontal plane components in HAV deformities. The sesamoid displacement angle appears to be a useful adjunct to evaluating the hallucal sesamoids. For surgical correction of the deformity, consideration should be given to pre-operative weight-bearing CT evaluation of the foot. This can illuminate the effects of rearfoot/medial column pronation and the potential influence of metatarsal torsion on the frontal plane components of this triplane deformity. In this way the potential for post-operative HAV recurrence can be minimized.

Outcomes of First Metatarsophalangeal Joint Fusion Using a Precontoured Plate

BACKGROUND

The purpose of this study was to determine the results of an arthrodesis technique of the first metatarsophalangeal joint (MTPJ) using a precontoured dorsal plate to correct the hallux valgus deformity.

METHODS

This was a retrospective analysis of outcomes for first MTPJ arthrodesis performed using 2 precontoured dorsal plates. Radiographic outcomes (intermetatarsal angle [IMA] and hallux valgus angle [HVA]) and patient-reported functional outcome measures (Short-Form 12 and Foot and Ankle Outcome Score) were recorded and compared.

RESULTS

Fifty-five patients underwent 77 first MTPJ arthrodeses for severe hallux valgus deformity with associated degenerative changes at the first MTPJ. The mean reduction of the IMA was 5.67° (P < .05) and the mean reduction of the HVA was 33° (P < .05). The Short-Form 12 assessment of global health demonstrated a significant improvement in both the physical and mental health composite scores by 16.4 points and 10.4 points (P < .05), respectively. The Foot and Ankle Outcome Score demonstrated a cumulative decrease of 35% (59.28; P < .05) in all domains.

CONCLUSIONS

First MTPJ arthrodesis using a precontoured dorsal plate is a successful procedure with a high union rate, low complication rate, and a high level of patient-reported satisfaction.

LEVELS OF EVIDENCE

Level III.

Finite Element Parametric Design of Hallux Valgus Orthosis Based on Orthogonal Analysis

OBJECTIVE

To design appropriate orthosis for hallux valgus, a difficult foot condition that affects a quarter of the body's bones, we need to clarify the numerical biomechanical features, which have not been established in previous biomechanical studies. Therefore, we constructed a finite element model of the bunion foot to investigate the orthopaedic force compensation mechanism.

METHODS

A patient with moderate hallux valgus was recruited. CT imaging data in DICOM format were extracted for three-dimensional foot model reconstruction. In conjunction with the need for rapid design of bunion orthosis, a metatarsal force application sizing method based on an orthogonal test design was investigated. The orthogonal test design was used to obtain the hallux valgus angle (HVA) and the inter metatarsal angle (IMA) data for different force combinations. Based on the extreme difference analysis and analysis of variance of the test results, the influence of different force combinations on the bunion angle was quickly determined.

RESULTS

The results showed that the stress concentration occurred mainly in the first metatarsal bone. The distribution trend was in the medial and lateral middle of the bone and gradually decreased to the dorsal base of the bone body. The greatest stress occurs in the cartilage between the phalanges and metatarsals. In 25 groups of simulation experiments, HVA was reduced from 27.7° to 13°, and IMA was reduced from 12.5° to 7.3°.

CONCLUSION

Applying detailed orthopaedic force collocation to the first metatarsal column can effectively restore the mechanics and kinematics of hallux valgus, and provide a reference for the treatment of bunion valgus and the design of orthopaedic devices.

Validity and reliability of hallux valgus angle measurement on smartphone digital photographs

BACKGROUND

This prospective study aimed to test the reliability and validity of hallux valgus angle (HVA) measurement on smartphone digital photographs compared with the standard radiographic evaluation.

METHODS

Twenty Seven female patients (45 feet) with forefoot deformity were evaluated with weight-bearing anteroposterior foot radiographs and smartphone photographs. Radiographic hallux valgus angle (rHVA) was measured on digital radiographs. Two different photographic HVA measurement methods were used. In the first, the longitudinal axes of the first metatarsal and proximal phalanx were determined, and the angle between these axes was measured (pHVA), similar to the radiographic method. In the other method, the angle of the margo medialis pedis was measured on the photograph (pMMP). Two independent observers performed all measurements twice on two different occasions. Reliability analysis was performed using the interclass correlation coefficient. Agreement between the measurements was tested using Bland-Altman analysis.

RESULTS

The repeated rHVA, pHVA and pMMP measurements showed excellent intra and inter-observer reliability, with ICC values above 0.900. The mean rHVA, pHVA, and pMMP were statistically similar (p:0.929, 27.03°±8.7°, 27.11°±8.8° and 26.5°±9.0° respectively). The mean difference between the rHVA and pHVA was - 0.07°±5.1° (range, --9.67 to 9.56°), and the mean difference between the rHVA and pMMP was 0.53°±4.4° (range, -9.76° to 8.22°). There was a strong positive correlation between both photographic methods and radiographic measurements (rho = 0.809, p = 0.001 and rho = 0.872, p = 0.001). In the Bland Altman plot, the upper and lower LOAs (95%CI) ranged from - 10.11° to 9.93° for rHVA and pHVA, and from - 8.26° to 9.33° for rHVA and pMMP. Linear regression analysis showed a proportional bias for pHVA but not for the pMMP (p:0.010 versus p:0.633, respectively). The range of the mean difference (prediction interval) between the pMMP and rHVA was 17.59° and 20° for pHVA and rHVA. Simple linear regression showed that the rHVA was predicted by the following equation: rHVA = 4.73 + 0.84 × pMMP (r2 = 0.761, p < 0.001).

CONCLUSIONS

Although measuring HVA through smartphone photographs is reliable, it is not a valid prediction method.

LEVEL OF EVIDENCE

Level II, diagnostic assessment.

Minimally Invasive Transverse Distal Metatarsal Osteotomy (MITO) for Hallux Valgus Correction: Early Outcomes of Mild to Moderate vs Severe Deformities

BACKGROUND

We compared the radiological and clinical outcomes of mild to moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon.

METHODS

Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) >40 degrees or preoperative first-to-second intermetatarsal angle (1-2 IMA) >16 degrees; the mild to moderate group was defined as having an HVA <40 degrees and a 1-2 IMA <16 degrees. Pre- and postoperative measurements of the HVA, 1-2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The visual analog scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 physical component summary were used to assess clinical outcomes.

RESULTS

A total of 116 feet were included in this study and median follow-up period of 29.0 months (range, 24-52 months). Both groups showed significant improvements in all radiologic parameters postoperatively, with the degrees of correction greater in the severe group than in the mild to moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups.

CONCLUSION

This study showed that short-term radiographic results for patients with either mild to moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. In this series, we found MITO with screw fixation to be a satisfactory surgical option for patients with mild to severe HV deformities.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A modified minimally invasive osteotomy for hallux valgus enables reduction of malpositioned sesamoid bones

BACKGROUND

The current minimally invasive distal metatarsal osteotomy for hallux valgus (HV) is V-shaped, which prevents the correction of the rotational metatarsal head deformity and reduction of the sesamoid bones. We sought to determine the optimal method for sesamoid bone reduction during HV surgery.

METHODS

We reviewed the medical records of 53 patients who underwent HV surgery between 2017 and 2019 using one of three techniques: open chevron osteotomy (n = 19), minimally invasive V-shaped osteotomy (n = 18), and a modified straight minimally invasive osteotomy (n = 16). The sesamoid position was graded using the Hardy and Clapham method on weight-bearing radiographs.

RESULTS

When compared to open chevron and V-shaped osteotomies, the modified osteotomy resulted in significantly lower postoperative sesamoid position scores (3.74 ± 1.48, 4.61 ± 1.09, and 1.44 ± 0.81, respectively, P < 0.001). Furthermore, the mean change in postoperative sesamoid position score was greater (P < 0.001).

CONCLUSION

The modified minimally invasive osteotomy was superior to the other two techniques in correcting HV deformity in all planes, including sesamoid reduction.

First Metatarsal Hemiepiphysiodesis for the Treatment of Juvenile Hallux Valgus: A Systematic Review

INTRODUCTION

Juvenile hallux valgus (JHV) is a pediatric deformity characterized by the varus deviation of the first metatarsal and valgus deviation of the proximal phalanx. Among the several surgical techniques available, hemiepiphysiodesis consists of the unilateral growth arrest of the first metatarsal physis. Despite this technique has been proposed over 70 years ago, only a few studies including clinical and radiological outcomes have been published, making the procedure unclear in terms of results. This systematic review aimed to evaluate the outcomes of hemiepiphysiodesis of the first metatarsal in the treatment of JHV.

METHODS

Google Scholar, Embase, PubMed, and Cochrane databases were searched for all the articles reporting on clinical and radiological results of hemiepiphysiodesis of the first metatarsal in the treatment of JHV. The selected articles were reviewed to extract demographic data, surgical techniques, complications, clinical outcomes, and radiological parameters.

RESULTS

Six articles were included in the qualitative analysis. A total of 85 patients with 144 halluces valgus were treated through hemiepiphysiodesis of the first metatarsal. The mean age at surgery was 10.7 years (range 5 to 15). The mean follow-up was 2.7 years (range 1 to 7.5). Hemiepiphysiodesis was performed through 2 different techniques. Eighteen (12.5%) complications occurred. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score increased from 70.6 (range 49 to 93) preoperatively to 89.4 (range 72 to 100) postoperatively. The mean HVA improved from 28.3 (range 14 to 46) to 24.03 degrees (range 0 to 54), and the mean IMA improved from 13 (range 8 to 33) to 10.9 degrees (range 8 to 33).

CONCLUSIONS

This review showed that hemiepiphysiodesis of the first metatarsal is a safe treatment for JHV. Improvement in both clinical and radiological results has been observed in all the studies, sometimes being statistically significant. Despite the improvement, mean postoperative radiological angles remained altered and consistent with mild-moderate hallux valgus. This suggests that hemiepiphysiodesis plays a bigger role in preventing the worsening of the deformity rather than correcting it. Randomized controlled trials with longer follow-up and a larger number of patients are needed to further investigate the efficacy and safety of this treatment.

Impact of forefoot width variation on clinical and functional outcomes following the Lapidus procedure

PURPOSE

This study aimed to evaluate the effect of variations in bony and soft tissue foot widths on clinical and functional outcomes after hallux valgus correction with the Lapidus procedure.

METHODS

Forty-three feet in 35 patients with a mean follow-up of 18.5 months undergoing the LP were reviewed. Clinical and functional data were assessed with the VAS for pain, AOFAS Scale, LEFS and SF-12 health survey, which is divided into physical and mental health composite scales (PCS-12 and MCS-12). Radiographic analysis of forefoot width was based on bony and soft tissue limits. Intermetatarsal-angle and HV-angle were also assessed.

RESULTS

Bony width changed significantly from 95.5 mm to 84.2 mm (11.8%) and soft tissue width from 107.12 mm to 100.84 mm (5.86%) (p < 0.001). IMA and HVA improved significantly. Significant clinical and functional improvements were observed, except in MCS-12. In simple linear regression, correlation was found between variations of bony width with Δ-AOFAS and Δ-PCS-12, meaning that as the forefoot narrows, their values increase (p = 0.02 and p = 0.005, respectively). It was also related to Δ-IMA, meaning that the forefoot narrows as these parameters improve (p < 0.001 and p < 0.001). Soft tissue width was related to Δ-PCS-12 and Δ-AIM. In multiple linear regression, the strongest correlation was between bony width variation and Δ-IMA (p = 0.029, r2 = 0.22).

CONCLUSION

Forefoot narrowing was correlated with improved clinical and functional outcomes, as measured by AOFAS and PCS-12. In addition, correction of the radiographic parameters, mainly IMA, reflected on a significant decrease in the forefoot width.

Characteristics of hindfoot morphology and ankle range of motion in young women with hallux valgus

BACKGROUND

Hallux valgus occurs more frequently in women as they age; therefore, it is beneficial to prevent hallux valgus in younger women. The purpose of this study was to clarify the characteristics of hindfoot morphology and the range of motion of the ankle joint with hallux valgus in young women.

METHODS

The participants were 140 young women (mean age 18.8 ± 0.6 years). A three-dimensional footprint automatic measurement apparatus was used to measure the hallux valgus angle in the standing position and the arch-height ratio and heel-floor angle (HFA) in the standing and chair-sitting positions. The amount of change in foot morphology owing to differences in posture was calculated. The range of motion of the ankle joint dorsiflexion, plantarflexion, inversion, and eversion was measured. Participants were classified into two groups according to the presence of hallux valgus. Statistical analysis was used to compare hindfoot morphology and range of motion between the two groups, and the correlation between foot morphology and range of motion was investigated depending on the presence of hallux valgus.

RESULTS

With hallux valgus, the HFA tilted inwards (p = 0.010), and the change in the arch-height ratio due to the difference in posture was large (p = 0.021). There was no difference in the range of motion of the ankle joints with or without hallux valgus. In women with hallux valgus, the amount of change in arch height and HFA was correlated with the range of motion of eversion (r = 0.391, p = 0.027; r = -0.362, p = 0.042).

CONCLUSIONS

With hallux valgus, the hindfoot pronated, and the arch height decreased from sitting to standing. Furthermore, the amount of change in the hindfoot and midfoot due to posture was related to the range of motion of eversion.

What Do Patients Report Regarding Their Real-World Function Following Triplane Metatarsophalangeal Joint Arthrodesis for Hallux Valgus?

First metatarsal phalangeal (MTP) joint arthrodesis has been employed for decades for pain related to arthritis and other associated abnormalities. Despite the commonality of the procedure there continues to be questions regarding functional expectations following the procedure especially when employed for correction of hallux valgus deformity. We surveyed 60 patients who had a tri plane MTP joint arthrodesis at mean 28.4 months (median 27.8) regarding their activities of daily living and sports activity through a direct conversation. Secondary endpoints assessed were return to activity, deformity correction and arthrodesis healing rate based on chart review and weightbearing radiographs. The primary outcomes showed robust return to all activities of daily living with 96.7% able to walk without restrictions and or pain, 98.3% were able to walk at a normal pace and 95% responded that loss of motion of their big toe did not affect their daily function. Regarding return to sports all patients that participated in sports before surgery resumed participation after with a trend toward increased sports activity. Early return to walking in a fracture boot was noted in this cohort at mean 4.1 days, return to athletic shoe at mean 6.3 weeks and full unrestricted activity at mean 13.3 weeks with no non-unions identified on radiographic or clinical exam. Deformity correction of the typical components of hallux valgus deformity was similar to previously published studies. This data set supports the hypothesis that patients undergoing first MTP joint arthrodesis can expect rapid and full return to activities of daily living and sports with a low complication rate.

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.

How Adductor Hallucis Reattachment Affects Outcomes Following Scarf Osteotomy in Hallux Valgus Correction: A 4- to 8-Year Follow-Up Retrospective Comparative Study

This study observed the differences between 2 adductor hallucis release techniques (nonreattachment vs reattachment) in 4- to 8-year follow-up outcomes of scarf osteotomy combined with distal soft tissue release (DSTR) in moderate to severe hallux valgus correction. A retrospective review of moderate to severe hallux valgus patients treated with scarf osteotomy with DSTR was conducted. The patients were divided into 2 groups based on adductor hallucis release techniques (without and with reattachment to the metatarsophalangeal joint capsule). The demographic-matching process divided the samples into 27 patients per group. A comparison of last follow-up of clinical foot ankle ability measure (FAAM) for activity of daily living (ADL) and numerical rating scale for pain during 2 hours of ADL and radiographic outcomes (hallux valgus angle (HVA) and intermetatarsal angle (IMA) was analyzed. A p < .05 was considered a statistically significant difference. The final follow-up of FAAM for ADL was statistically better in the reattachment group as the median was 79.0 (IQR = 4.00) versus 76.0 (IQR = 4.00), p = .047. However, this difference did not achieve minimal clinical importance difference (MCID). The last follow-up of IMA was also statistically better in the reattachment group as the mean was 7.67 (SD = 3.10) versus 10.5 (SD = 3.59), p = .003. DSTR with adductor hallucis reattachment has statistically better IMA correction and maintenance than nonreattachment for moderate to severe hallux valgus correction using scarf osteotomy at 4- to 8-years follow-up. However, the better clinical outcomes did not achieve MCID.

The distal metatarsal articular angle in hallux valgus deformities. Comparisons of radiographic and weightbearing CT scan measurements with variations in hindfoot position

BACKGROUND

When evaluating hallux valgus (HV) deformity with anteroposterior (AP) foot radiographs, the distal metatarsal articular angle (DMAA) has been the subject of frequent debate. Although a straightforward indicator of structural alignment of the distal first metatarsal articular surface, inter- and intraobserver measurements can vary widely. Alterations in the radiographic appearance of bony "structure" with positional changes of the foot/foot bones in HV deformities in no small part contributes to these inaccuracies. The aim of this study was to determine the effect of hindfoot position on the DMAA.

METHODS

Four different radiologic images were obtained for 15 subjects with HV: three AP foot radiographs (standard weightbearing, foot supinated, foot pronated) and one weightbearing CT (WBCT) scan. For each image, five investigators measured the DMAA in order to assess reliability.

RESULTS

Mean DMAA values measured from the images indicated that the angle was highest with the pronated foot (15.3 (95% CI, 10.3-20.3) degrees) and lowest when measured from the CT image (11.6 (95% CI, 7.3-16.0) degrees). For all image types, the intraclass correlation coefficient was greater than 0.9 and statistically significant (P < 0.0005).

CONCLUSION

Hindfoot positions affected radiographic DMAA/mean DMAA values, with values highest with feet in pronated attitudes. Unlike radiographic projections, the WBCT appears less likely to overestimate DMAA and is not subject to variations in foot positioning. In the preoperative evaluation of HV deformities, this points to the potential use of WBCT as a reference standard. For markedly severe HV deformities that may present with AP radiographs with marked first metatarsal head "roundness," the use of WBCT is the intuitive choice. The results indicate excellent reliability in measurements of DMAA between all five investigators. As such, the measurement method used to determine DMAA in this study was dependable and reproducible.

LEVEL OF EVIDENCE

Level II.

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.