Distal First Metatarsal Dome (Crescentic) Osteotomy for Repair of Mild to Moderate Hallux Valgus Deformity

Hallux valgus is one of the most common foot deformities. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use. Distal osteotomies have long been done for mild to moderate deformities. Although presented previously, based on a review of the literature, this technique does not appear to be regularly used by many surgeons. This article presents a distal metatarsal osteotomy as easy to perform and useful for the repair of mild to moderate hallux valgus deformity, wherein the first metatarsal angle measures less than 14 degrees.     

A Comparison of the Crescentic and Mau Osteotomies for Correction of Hallux Valgus

We retrospectively compared crescentic and Mau osteotomies used to treat a total of 39 cases of hallux abductovalgus. Follow-up was possible in 10 of the crescentic cases (mean 228 days) and 24 of the Mau cases (mean 245 days). Preoperatively, the mean first intermetatarsal and hallux abductus angles were 17.5 degrees and 35.4 degrees , respectively, in the crescentic group; and 16.6 degrees and 31.3 degrees , respectively, in the Mau group. Postoperatively, these same radiographic angles were 11.7 degrees and 18.9 degrees , respectively, in the crescentic group; and 9.8 degrees and 12.9 degrees , respectively, in the Mau group, and these differences were not statistically significant. Complications included metatarsus primus elevatus (crescentic 7, Mau 2), lesser metatarsal transfer lesion (crescentic 1, Mau 0), nonunion (crescentic 5, Mau 1), revisional surgery (crescentic 0, Mau 1), and transarticular hardware (crescentic 3, Mau 0). The incidence of complications in the crescentic group was 60%, whereas that in the Mau group was 37.5%; this difference was not statistically significant (P = .276). Analysis by the type of complication revealed statistically significant differences between the crescentic and Mau groups in regard to metatarsus primus elevatus (70% versus 8.3%, P = .001), transarticular hardware (30% versus 0%, P = .02), and nonunion (50% versus 4.2%, P = .006). In conclusion, crescentic and Mau osteotomies satisfactorily corrected the first intermetatarsal and hallux abductus angles in patients that fit our inclusion criteria, although the incidence of postoperative metatarsus primus elevatus, delayed union, and transarticular hardware placement, was higher in the crescentic osteotomy group. Level of Clinical Evidence: 2.     

Proximal Metatarsal Osteotomy in Hallux Valgus

In order to obtain an optimal correction of hallux valgus and to prevent its recurrence, the authors have applied a surgical technique which combines a proximal valgus osteotomy of the first metatarsal bone with an excision of the pseudoexostosis and a distal soft tissue plasty at the first metatarsophalangeal joint. The procedure is based on an etiological theory regarding metatarsus primus varus as the primary cause of the deformity, which is in accordance with the opinion of many other authors. The osteotomy corrects the malposition of the first metatarsal bone thereby reducing the deformity and preventing its recurrence. The soft tissue plasty alleviates secondary contractures that prevent a full correction of the big toe. A series of 43 consecutive patients (46 feet) with a follow-up period of 5–44 months and extracted from a total number of 99 operated cases is presented. The result was excellent in 78 per cent, good in 11 per cent and poor in 11 per cent. The reason for a less than excellent result was almost always inadequate correction of the deformity, at the level of the first metatarsal bone, or the big toe, or both.     

Components of the Wilson Osteotomy That Are Effective on Hallux Valgus Repair

Wilson osteotomy of the first metatarsal is a technically simple and reliable operation for the correction of the hallux valgus (HV) deformity. The major anatomic components of the osteotomy are the osteotomy angle and the distance of the osteotomy to the first metatarsophalangeal (MTP) joint. Lateralization of the first metatarsal head is the rationale for correction of the deformity. The main disadvantage of the technique is the considerable shortening of the first metatarsal. The relation between the amount of HV correction, first metatarsal shortening, and the anatomic parameters of the osteotomy was evaluated. Radiographs of 46 feet of 32 patients were retrospectively evaluated after an average follow-up period of 31.4 months. From the preoperative, early postoperative, and last control radiographs, the amount of HV correction, first metatarsal shortening, the osteotomy angle, the distance of the osteotomy to the first MTP joint, and lateralization of the first metatarsal head were measured. The presented study indicated that the osteotomy angle and the lateral displacement of the metatarsal head have a significant correlation with the amount of HV correction. Distance of the osteotomy to the first MTP joint has no relevance with the repair of the deformity. A positive linear correlation was present between the osteotomy angle and the first metatarsal shortening. Because the amount of first metatarsal shortening has significant influence over the clinical result, the main aim in a Wilson osteotomy should be maximum lateral displacement of the metatarsal head with a minimum osteotomy angle.     

联合趾截骨手术在外翻矫形中的价值

目的探讨趾截骨手术（Akin截骨术）在外翻畸形矫形中的价值。方法我院2010年5月至2011年4月联合使用Akin截骨术治疗外翻患者32例49足。在本组患者中,术前均拍摄患足负重正位X线片,测量外翻角、跖间角、远侧关节固定角,依据跖间角分别采用Chevron截骨术（Austin手术）,跖楔关节融合手术（Lapidus手术）或第一跖骨基底斜楔形截骨（Juvara手术）。术后及随访测量外翻角、跖间角、远侧关节固定角改变。采用AOFAS评分对患足进行功能评价。结果所有患者平均随访12个月。外翻角由术前（39.7±7.5）°纠正为（16.1±7.6）°,P〈0.05,平均纠正（25.9±9.5）°;跖间角由术前（15.4±3.9）°纠正为（7.6±2.5）°,P〈0.05,平均纠正（7.1±3.0）°;远侧关节固定角由术前（6.3±2.7）°纠正为（-5.3±4.0）°,P〈0.05,平均纠正（11.4±4.0）°;AOFAS得分由术前平均43.5分提高至85.6分,P〈0.05。结论 Akin截骨术是外翻矫形程序中的一种辅助手术,可以改善疗效、降低复发率且操作简便、安全。     

The Spike Osteotomy for Hallux Valgus: A Clinical and Radiological Evaluation

A distal metatarsal osteotomy with soft tissue correction is a frequently performed operation to correct mild to moderate hallux valgus deformity. This is a prospective study of 28 feet in 25 patients who underwent spike osteotomy of the first metatarsal with medial capsulorraphy for symptomatic hallux valgus. The osteotomy is a distal metatarsal osteotomy with a spike fashioned in the plantar and lateral quarter of the proximal fragment and impacted into the trough created in the center of the distal fragment, providing lateral and plantar shift of the distal fragment. The American Orthopaedic Foot and Ankle Society's rating scale was used for functional assessment, and a visual analog scale gauged pain. The average follow-up was 27 months. The rating scale score improved from a mean preoperative value of 39/100 to 84/100. Twenty-six feet had complete pain relief, whereas 2 feet had a lesser degree of persistent metatarsalgia. A review of preoperative and postoperative radiographs showed that the hallux valgus angle improved from a mean 36 degrees preoperatively to 18 degrees postoperatively. Likewise, the mean 1 to 2 intermetatarsal angle improved from 13 degrees to 7.3 degrees. There was no incidence of avascular necrosis. Fourteen patients (16 feet) rated the outcome as excellent, 10 (11 feet) as good, and 1 patient with asymptomatic mild hallux varus deformity rated the result as fair. These results demonstrate that the spike osteotomy is a suitable operation for treatment of mild to moderate hallux valgus.     

Oblique Displacement Osteotomy According to Crawford Adams for Hallux Valgus

Correction of hallux valgus by oblique displacement osteotomy ad modum Crawford Adams was carried out in 54 cases, of which all but 3 were examined clinically and radiologically 1 year or more after the operation. The median age was 32 years. Seventy-eight per cent were satisfied with the operation, and 64 per cent were totally free of pain. A feeling of stiffness in the first metatarso-phalangeal joint and/or intermittent pain during walking was found in 22 per cent of the patients, all of whom were dissatisfied with the operation. Adams' osteotomy was found to give a satisfactory correction of the deformity of hallux valgus, but the length of the first metatarsal bone could not be maintained.     

距足母囊近端截骨并钛板内固定治疗中重度足母外翻

目的探讨距足母囊近端2.0 cm处Z型截骨并T型微型钛板内固定治疗中重度足母外翻的临床疗效。方法2009年11月至2013年6月,对50例(81足)中重度足母外翻患者行第一跖骨远端Z型截骨后T型微型钛板内固定治疗。结果术后随访3~36个月,患者足母外翻角(halluxv algus angle,HVA)减少了11°~23°,平均13.1°,跖骨间角(intermetatarsal angle,IMA)减少了5°~10°,平均6.6°。采用美国足踝矫形学会Maryland足功能评分系统评分:90~100分,79足,80~89分2足,优良率100%,未见感染,截骨处均获骨性愈合,畸形无复发。结论距足母囊近端截骨并微型钛板内固定治疗中重度足母外翻疗效可靠,值得推广。     

Preliminary Results and Learning Curve of the Minimally Invasive Chevron Akin Operation for Hallux Valgus

Minimally invasive surgery is increasing in popularity. It is relevant in hallux valgus surgery owing to the potential for reduced disruption of the soft tissues and improved wound healing. We present our results and assess the learning curve of the minimally invasive Chevron Akin operation for hallux valgus. A total of 120 consecutive feet underwent minimally invasive Chevron Akin for symptomatic hallux valgus, of which 14 were excluded. They were followed up for a mean of 25 (range 18 to 38) months. The patients were clinically assessed using the American Orthopaedic Foot and Ankle Society score. Complications and patient satisfaction were recorded. The radiographs were analyzed and measurements recorded for hallux valgus and intermetatarsal angle correction. The mean age of the patients undergoing surgery was 55 (range 25 to 81) years. Of the 78 patients, 76 (97.4%) were female and 2 (2.6%) were male; 28 (35.9%) cases were bilateral. The mean American Orthopaedic Foot and Ankle Society score improved from 56 (range 23 to 76) preoperatively to 87 (range 50 to 100) postoperatively (p < .001). The mean hallux valgus and intermetatarsal angles preoperatively were 29.7° (range 12° to 46°) and 14.0° (range 8° to 20°). The corresponding postoperative angles were 10.3° (range 0° to 25°) and 7.6° (range 3° to 15°; p < .001). The patients were satisfied with the results of surgery in 87% of cases (92 of 106). The incidence of reoperation was 14% (15 of 106). These are the only reported results for this technique. They display a steep associated learning curve. However, the results are promising, and the learning curve is comparable to that for open hallux valgus surgery.     

A Better Treatment for Moderate to Severe Hallux Valgus: Scarf + Akin Osteotomy Combined with Lateral Soft Tissue Release in a Single Medial Incision

ObjectiveTraditional lateral soft tissue release (LSTR) was conducted by an additional dorsal first web incision, as the malformed thick scar and neuritis were common after surgery. A new method of lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) should be recommended. The objective is to investigate the clinical effectiveness and safety of scarf + Akin osteotomy (SAO) combined with lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) for moderate to severe hallux valgus.MethodsPatients who were performed surgery for hallux valgus from April 2014 to June 2020 were retrospectively reviewed. The visual analog scale (VAS) was recorded before surgery and during follow‐up, as well as the forefoot score of the American Orthopaedic Foot and Ankle Society (AOFAS). Patient satisfaction was evaluated at the follow‐up time. The preoperative and follow‐up weightbearing X‐ray were conducted in all patients. The radiological parameters of hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured. Tibial sesamoid position (TSP) was also recorded according to seven‐part grading system. The quantitative data were performed as mean ± standard deviation or median ± interquartile range. Student''s t test was performed in HVA, IMA, and DMAA. The TSP, VAS, and AOFAS were statistical analyzed by Mann–Whitney U test. p value of <0.05 was considered significant.ResultsThere were 123 feet conducted surgery in 96 patients. The AOFAS score improved a lot which was preoperative 39 to 100 at the follow‐up time and VAS was 4 to 0 (p < 0.001). A total of 63 (51.2%) patients were very satisfied, 47 (38.2%) were satisfied, five (4.1%) were undecided and eight (6.5%) were not satisfied. The HVA, IMA, DMAA, and TSP were all decreased after surgery and were statistically significant (p < 0.001).ConclusionThe SAO combined with a LSTR‐SMI‐DFFM for moderate to severe hallux valgus is effective and safe with pretty good clinical and radiographic results, as well as minimal complications. The corrections of AOFAS and VAS conformed to the minimum clinically important difference (MCID).     

Distal Oblique Metatarsal Osteotomy for Hallux Valgus Deformity: A Clinical Analysis

We compared the outcomes of the distal oblique metatarsal (DOM) osteotomy, which is parallel to the articulation surface of the proximal phalanx, with those of the chevron osteotomy and evaluated whether displacement and shortening of the first metatarsal have any effect on the incidence of metatarsalgia and patient satisfaction. Patients treated with the DOM osteotomy (n = 30) or distal chevron osteotomy (n = 31) were evaluated retrospectively. The chevron and DOM osteotomies both provided significant improvement in the first intermetatarsal angle (p < .001), hallux valgus angle (p < .001), distal metatarsal articular angle (p < .001), range of first metatarsophalangeal joint motion (p < .001), American Orthopaedic Foot and Ankle Society score (p < .001), and sesamoid position (p < .001), without any significant differences between the 2 groups. Patient satisfaction and metatarsalgia also were not different between the study groups. The DOM osteotomy group had higher plantar displacement (0.1 ± 0.1 mm versus 1.0 ± 0.1 mm; p < .001) and absolute shortening of the first metatarsal (1.0 ± 0.4 mm versus 6.8 ± 1.0 mm; p < .001). In conclusion, the DOM osteotomy is an alternative treatment method for mild and moderate hallux valgus.     

改良旋转Scarf截骨术在中重度踇外翻治疗中的应用

目的 探讨改良旋转Scarf截骨术在中重度踇外翻手术治疗中的临床疗效。方法 回顾性分析2018年1月至2019年6月于我院手术治疗的100例中重度踇外翻病人的临床资料,平均年龄为47.6岁（17~84岁）,其中男13例,女87例,双足病例38例,共138足,均应用改良旋转Scarf截骨术手术治疗。术前、术后均经X线负重正侧位检查,双盲法测量踇外翻角（HVA）、第一、二跖骨间夹角（IMA）、近端关节面固有角（DMAA）、胫侧籽骨位置。采用美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society,AOFAS）足踇趾、跖趾关节、趾间关节功能评分评价疗效。结果 术后平均随访18.7个月（12~30个月）。病人术后HVA、IMA、DMAA、胫侧籽骨位置均明显低于术前,差异均有统计学意义（P＜0.05）。末次随访时AOFAS评分[（94.7±5.8）分]较术前[（45.4±5.1）分]明显提高,差异有统计学意义（P＜0.05）。病人足疼痛、外形、功能明显改观,穿鞋及生活质量得到极大提高。结论 对于中重度踇外翻,采取改良旋转Scarf截骨术具有明确的临床疗效。     

Maintenance of Correction of First Metatarsal Closing Base Wedge Osteotomies Versus Modified Lapidus Arthrodesis for Moderate to Severe Hallux Valgus Deformity

A retrospective radiographic review of 57 feet was conducted to compare maintenance of correction of the modified Lapidus arthrodesis with the first metatarsal closing base wedge osteotomy for moderate to severe hallux valgus deformity. Radiographic parameters were measured on the preoperative, early postoperative, and greater than 11-month postoperative weightbearing radiographs. These measurements included the intermetatarsal angle, the hallux abductus angle, and the tibial sesamoid position. The patients who underwent the closing base wedge osteotomy had an average initial intermetatarsal correction of 10.4 degrees; for the modified Lapidus arthrodesis, it was 7.6 degrees. The patients who underwent the closing base wedge osteotomy had an average loss of intermetatarsal correction of 2.55 degrees from early to late postoperative radiographs; for the modified Lapidus arthrodesis, it was 1.08 degrees. Our results demonstrated that the modified Lapidus arthrodesis maintains correction to a greater degree than the first metatarsal closing base wedge osteotomy with statistical significance (P = .0039). Both the modified Lapidus arthrodesis and the first metatarsal closing base wedge osteotomy are effective procedures with respect to degree of radiographic correction for moderate to severe hallux valgus deformities.     

Percutaneous Osteotomies in Hallux Valgus: A Systematic Review

Percutaneous and minimally invasive surgery is one of the greatest advances in the operating field of orthopedic since the late 1990s. The potential advantages include a shorter operative time, quicker recovery, and reduced hospital stay compared with traditional open surgery. However, scientific validation of the safety and efficacy of hallux valgus (HV) percutaneous surgery remains inconclusive. The objective of the present study was to systematically review the published data and clinical evidence for percutaneous HV surgery, evaluate the scientific method of the reports, and clarify the indications, safety, efficacy, and potential risks of these surgical techniques. Two reviewers independently identified the studies using a PubMed search, with the keywords “hallux valgus,” “osteotomy,” “minimally invasive,” and “percutaneous.” Quality assessment was performed using the Coleman methodology scale, and each study was assigned a level of evidence and grade of recommendation. Eighteen studies were included and reported a total of 1534 procedures for percutaneous HV surgery on 1397 patients. Of the 18 studies, 14 (77.8%) were level IV, 2 (11.1%) were level III, and 2 (11.1%) were level II. Overall, the average angle correction of the HV deformity improved postoperatively. Regarding the complications, although some investigators revealed no major complications, others described deformity recurrence in 7.8%, stiffness of the first metatarsophalangeal joint in 9.8%, malunion in 4% to 8.7%, and infection rates ranging from 1.9% to 14.3%. The main indication for percutaneous HV surgery is the correction of mild deformities. The complication rate was elevated even in experienced surgeons. In conclusion, future research in percutaneous techniques should include adequately sized randomized control trials, standardization of treatment protocols, and the use of validated tools for the measurement of clinical outcomes.