Abductor hallucis release in congenital metatarsus varus

Summary Adduction of the forefoot diagnosed in the young child generally corrects spontaneously. Resistant forefoot adduction is usually combined with a degree of supination of the forefoot and described as congenital metatarsus varus.In true congenital metatarsus varus there is a contraction or shortening of the abductor hallucis muscle and tendon which is considered to be the primary deforming factor.In the early severe or resistant deformity correction can be achieved by either division of the tendon with release of its capsular attachment, or, in the more severe deformity, by complete release of the abductor hallucis muscle from its extensive attachment to bone and soft tissues.

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Résumé L'adduction de l'avant-pied découverte chez l'enfant jeune se corrige spontanément en règle générale. Dans le cas contraire, elle s'associe habituellement à un certain degré de supination de l'avant-pied et elle est alors décrite comme metatarsus varus congénital.Dans le véritable metatarsus varus congénital il existe une rétraction ou une brièveté du tendon et du muscle abducteur du 1 ^er orteil que l'on considère comme le facteur déterminant de la déformation.Dans les cas de déformation d'emblée sévère ou persistante, la correction peut être obtenue soit par section du tendon et de son insertion sur la capsule, soit, dans les cas les plus graves, par désinsertion complète du muscle abducteur du 1 ^er orteil, tant au niveau de l'os que des parties molles.

     

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.     

The Incidence of the Intermetatarsal Facet of the First Metatarsal and Its Relationship to Metatarsus Primus Varus: A Cadaveric Study

The purpose of this study was to determine the incidence of the intermetatarsal facet on the lateral aspect of the base of the first metatarsal and its role in the medial angulation of the proximal metatarsal base as it relates to metatarsus primus varus. A total of 77 human first metatarsals were examined for the presence of the intermetatarsal facet. The intermetatarsal facet was seen on the lateral aspect of the first metatarsal base, superior to the tuberous attachment of the peroneus longus tendon. The obliquity of the first metatarsal base was measured on metatarsals with and without the intermetatarsal facet. The intermetatarsal facet was present on 22 of 77 first metatarsals, or 29% of specimens. The proximal obliquity angle was 2.92 degrees in metatarsals without the facet and 4.63 degrees when the facet was present. This increase in the medial obliquity of the proximal first metatarsal base in the presence of an intermetatarsal facet was statistically significant (P < .002). The intermetatarsal facet between the first and second metatarsals may have a role in an increased medial obliquity of the first metatarsal base and is present in approximately 30% of the population.     

改良截骨治疗肘内翻畸形

目的 总结改良楔形截骨交叉克氏针加“8”字钢丝内固定治疗青少年肘内翻的临床效果。方法 对28例青少年肘内翻者行改良肱骨髁上楔形截骨、交叉克氏针固定加“8”字钢丝固定术治疗。结果随访6个月～3年,肘关节活动均恢复正常,术后提携角均在0°～10°,无肘内翻复发。结论 对青少年肘内翻采用改良楔形截骨交叉克氏针加“8”字钢丝固定术有利于截骨角度的控制、增加截骨面的接触面积、提高截骨端固定的稳定性,有利于骨愈合及早期功能锻炼。     

Articular geometry of the medial tarsometatarsal joint in the foot: Comparison of metatarsus primus adductus and metatarsus primus rectus

The three-dimensional surface geometry of the medial tarsometatarsal joint ("first metatarsocuneiform") of the first ray was analyzed to determine if the shape of the joint is distinct in the medially deviated first metatarsal with metatarsus primus adductus (MPA). Clinical evaluation of 29 cadaver feet identified 13 feet with MPA and 16 with metatarsus primus rectus (MPR). Three-dimensional (3D) coordinates x, y, z of the first metatarsal and medial cuneiform joint facets of the feet were digitized on a Coordinate Measuring Machine (accuracy = 0.01 mm) and the data fitted with B-spline surfaces from which 3D curvature maps were generated. Comparison of means of surface-averaged maximum and minimum principal curvatures and root-mean-square curvatures showed significant (p < .0005) differences between the MPA and MPR subsets, male and female subsets, and metatarsal and cuneiform subsets. These results show that the articular shape of the medial tarsometatarsal joint in feet with MPA is significantly less contoured, or is flatter, than the same joint in normal or MPR feet. Results also showed that the female joints are more curved than male joints, and that metatarsal and cuneiform facets closely conform in shape to each other. These preliminary results may be related to questions concerning the anatomical and functional basis for the first metatarsal deviation, for radiographic presentation of the joint and surgical options in correcting related forefoot deformities.     

Radiographic analysis of metatarsus primus varus: 45 feet followed 15 months after distal metatarsal osteotomy and lateral soft-tissue release

We analyzed standardized radiographs of 45 feet in 41 patients with symptomatic hallux valgus and an intermetatarsal angle of 17 (15-23) degrees 15 (9-24) months after distal metatarsal osteotomy and lateral soft-tissue releases. A mean reduction in the ll-intermetatarsal angle of 12 degrees and hallux valgus angle of 24° was found. On average, the metatarsus primus varus angle improved by 4 degrees, the l-intermetatarsal angle by 3 degrees and the inclination angle of the first cuneiform by 4 degrees. We conclude that this operation corrects the metatarsus primus varus, without substantially altering the alignment of the long axis of the first metatarsal.     

Hallux valgus surgery: A simple method for evaluating the first-second intermetatarsal angle in the presence of metatarsus adductus

In hallux valgus surgery, the presence of metatarsus adductus complicates the evaluation of the first-second intermetatarsal angle(IMA) because it will produce an apparent reduction in the IMA because the second metatarsal is skewed closer to the first metatarsal. This can lead to an underestimation of how much the IMA should be reduced. The Kilmartin angle is a simple charting technique that will eliminate the influence of metatarsus adductus and indicate the true degree of metatarsus primus varus. This may facilitate better preoperative planning in hallux valgus surgery.     

Observed Changes in Radiographic Measurements of the First Ray after Frontal and Transverse Plane Rotation of the Hallux: Does the Hallux Drive the Metatarsal in a Bunion Deformity?

It is well known that the pathologic positions of the hallux and the first metatarsal in a bunion deformity are multiplanar. It is not universally understood whether the pathologic changes in the hallux or first metatarsal drive the deformity. We have observed that frontal plane rotation of the hallux can result in concurrent positional changes proximally in the first metatarsal in hallux abducto valgus. In the present study, we observed the changes in common radiographic measurements used to evaluate a bunion deformity in 5 fresh frozen cadaveric limbs. We measured the tibial sesamoid position, 1-2 intermetatarsal angle, and first metatarsal cuneiform angle on anteroposterior radiographs after frontal and transverse plane manipulation of the hallux. When the hallux was moved into an abducted and valgus position, a statistically significant increase was found in the tibial sesamoid position (p = .016). However, we did not observe a significant increase in the intermetatarsal angle (p = .070) or medial cuneiform angle (p = .309). When the hallux was manipulated into an adducted and varus position, a statistically significant decrease in the intermetatarsal angle (p = .02) and a decrease in the tibial sesamoid position (p = .016) was seen, with no significant change in the medial cuneiform angle (p = .360). We also observed a consistent rounding of the lateral aspect of the first metatarsal head and an increase in the concavity of the lateral metatarsal shaft, with valgus rotation of the hallux. From these observations, it is possible that the hallux could drive the proximal changes in the first ray that lead to metatarsus primus adducto valgus deformity.     

First cuneiform closing abductory osteotomy for reduction of metatarsus primus adductus.

The closing subtraction osteotomy of the first cuneiform effectively reduces pronounced obliquity of the first metatarsal cuneiform joint and predictably reduces the intermetatarsal angle in patients with metatarsus primus adductus. This osteotomy is combined with other procedures in surgical realignment of the first ray. Cases best suited for this procedure must be selected carefully. The procedure involves resecting the existing bone block from the opposing surfaces of the first and second metatarsal bases and from the distal one half of the opposing surfaces of the first and second cuneiforms. A triangular-shaped wedge of bone is then resected from the midbody of the first cuneiform while retaining a medial hinge. Closure of the first cuneiform osteotomy should require only minimal pressure. Two threaded Steinman pins transfix the osteotomy site. The vascular cancellous bone of the first cuneiform assures adequate healing of the osteotomy site.     

Pedal ectrodactyly: a case report with a new surgical management.

A case report is presented regarding a patient with type IV bilateral ectrodactyly treated with a double surgical approach: in forefoot to correct the malformation and in rearfoot to prevent secondary deformity of the subtalar joint. The forefoot was enlarged and in particular the second and third rays were absent. There was also a metatarsus primus varus with interphalangeal hallux abductus. The second cuneiform bone was removed with a wedge resection of the midfoot. The reduction in transverse diameter of the forefoot was obtained by cerclage of the first and fourth metatarsal bones. For hallux valgus, a percutaneous distal osteotomy of the proximal phalanx was performed. Several months after the forefoot correction, subtalar joint pronation was noted secondary to the altered forefoot mechanics and was treated with a subtalar Arthroereisis. The contralateral foot was addressed using similar techniques, except all procedures were done in a single surgical session. A favorable outcome for the patient 1 year and 6 months after surgery seems to justify this approach.     

Syndesmosis procedure: a non-osteotomy approach to metatarsus primus varus correction

BACKGROUND: Hallux valgus and metatarsus primus varus deformities usually are the result of failure of the supporting soft tissues rather than bone deformities. Since soft-tissue procedures have been shown to only be suitable for mild deformities, first metatarsal osteotomy has become an integral part of correcting moderate to severe deformities. A soft-tissue technique referred to as the "syndesmosis procedure" by the author was evaluated for its effectiveness in correcting metatarsus primus varus in feet with hallux valgus. METHODS: This is a retrospective clinical and radiographic study of six patients (11 feet) an average of 6 years and 10 months after the "syndesmosis procedure." A cerclage technique using absorbable suture (PDS) was used for the first metatarsal realignment, and its long-term maintenance depended on a syndesmosis (fibrous) bonding between the first and second metatarsal bases. RESULTS: The average preoperative hallux valgus angle of 29.5 (21 to 43) degrees improved to 13.5 (-2 to 24) degrees and the average preoperative metatarsus primus varus angle of 13.6 (12 to 16) degrees improved to 5.2 (2 to 8) degrees at an average of 85.7 (33 to 128) months. All patients were satisfied with their results and were able to return to sports and wearing high-heeled shoes as desired. Complications were few and mild. Followup American Orthopaedic Foot and Ankle Society Hallux scores averaged 93 points. CONCLUSIONS: This small but long-term retrospective study showed encouraging results for the correction of metatarsus primus varus deformity and a high patient satisfaction.     

Congenital metatarsus varus. A suggestion for a possible mechanism and relation to other foot deformities.

The pathogenesis of metatarsus varus was investigated by a series of dissections of 14 normal feet of stillborn or infants who died during the perinatal period. The deformity could not be produced without the surgical incisions described below. A valgus position of the hindfoot was produced by maximal dorsiflexion of the foot. The deformity of the fore part of the foot could not be produced even by extreme traction on the tibialis anterior tendon even after capsulotomy of the first tarsometatarsal joint. Only extensive capsulotomies in the tarsometatarsal joints distal to the joint of Chopart made it possible to displace the bones into the position analogous to metatarsus varus. It is suggested that metatarsus varus may be a deformity which occurs on a maximally dorsiflexed foot and that the primary mechanism of the forefoot deformity is a subluxation in the fore part of the foot. Secondary contractures of the soft tissues, and adaptive bone changes offer a possible explanation for lack of spontaneous recovery as well as the difficulties encountered in treating late cases.     

Pathology of congenital metatarsus varus and its relationship to other congenital deformities of the foot

Congenital metatarsus varus may be regarded as a deformity caused by a dislocation and in that respect is similar to congenital clubfoot and vertical talus but not to calcaneovalgus. The dislocation causes adaptive bone changes as well as secondary contracture of the soft tissues. That the dislocation in the forepart of the foot may occur in a maximally dorsiflexed foot also may explain the valgus position of the hindfoot. The secondary changes in bone and soft tissue may explain the lack of spontaneous recovery and the difficulties in effecting correction in severe cases. It is still not possible to explain why the dislocation arises.     

A new surgical technique for metatarsus primus varus correction with radical bunionectomy: a preliminary report

Dr. Panacos has developed a new surgical technique for correction of metatarsus primus varus. His technique, which is indicated in moderate to severe metatarsus primus varus (when the intermetatarsal angle exceeds 15 degrees), makes use of a stabilizing implant at the first metatarsal-cuneiform joint. Although the procedure has been performed on a limited number of patients, the author believes it to be superior to the osteotomy for metatarsus primus varus correction.     

Surgical Treatment of Congenital Hallux Varus

Background

The purpose of this study was to report outcomes of congenital hallux varus deformity after surgical treatment.

Methods

We evaluated ten feet of eight patients with a congenital hallux varus deformity, including four feet combined with a longitudinal epiphyseal bracket (LEB). There were seven male patients and one female patient with a mean age of 33 months (range, 7 to 103 months) at the time of surgery. Two patients were bilaterally involved. The mean duration of follow-up was 5.9 years (range, 2.3 to 13.8 years). Clinical outcomes were assessed according to the criteria of Phelps and Grogan. Surgical procedures included the Farmer procedure, the McElvenny procedure or an osteotomy at the first metatarsal or proximal phalanx.

Results

The clinical results were excellent in two feet, good in six and poor in two feet. The LEB was associated with hallux varus in four feet and were treated by osteotomy alone or in conjunction with soft tissue procedure.

Conclusions

Congenital hallux varus was successfully corrected by surgery with overall favorable outcome. Preoperatively, a LEB should be considered as a possible cause of the deformity in order to prevent recurrent or residual varus after surgery.     

Proximal opening wedge metatarsal osteotomy for correction of moderate to severe hallux valgus deformity using a locking plate

Purpose

Hallux valgus is a complex deformity of the first metatarsophalangeal joint, with varus angulation of the first metatarsal, valgus deviation of the great toe and lateral displacement of the sesamoids and the extensor tendons. The aim of the surgery is to achieve correction of the varus deviation of the 1st metatarsal which is considered by some as the primary intrinsic predisposing factor to hallux valgus deformity.

Methods

We retrospectively reviewed 85 patients (107 feet) who underwent an opening wedge osteotomy of the 1st metatarsal for correction of moderate to severe hallux valgus and metatarsus primus varus. A medially applied anatomic pre-contoured locking plate was used for fixation of the osteotomy.

Results

The mean IMA was decreased from 15.8 (range 12–22) degrees to 7.8 (range 0–12) degrees. The mean pre-operative HVA was 39 (range 21–52) degrees and the mean postoperative HVA was 11.8 (6–19) degrees. The pre-operative AOFAS score was 52 (SD 3.1) and the postoperative score was 85 (SD 5.2).

Conclusion

The proximal opening wedge metatarsal osteotomy is a safe, effective and reproducible technique for correction of moderate to severe hallux valgus deformity. The use of a locking plate provides enough control at the fragments, enhancing healing of osteotomy and maintenance of the correction even with a violated proximal lateral cortex.     

Medical capsular recession for severe varus deformities

Medial capsular recession is an effective method of correcting preoperative fixed varus knee deformities at the time of total knee arthroplasty. If the flexion and extension spaces are properly balanced and filled, knee stability is achievable. Sixty-eight knees that had medial capsular recession were followed for at least 2 years after surgery, 19 of them for more than 10 years, with a mean follow-up period of 4.8 years. Of these knees, 73% had less than 5° of postoperative varus/valgus instability with no deterioration during the followup period. Attenuation or rupture of the medial flap occurred in only two knees. There was no statistical difference in ultimate range of motion, alignment, or presence of bone-cement radiolucencies between knees with medial recession and those without medial recession.     

Post-surgical hallux varus. A case report

Sometimes a hallux varus occurs as a consequence of the treatment for a hallux valgus, determined by an alteration of the balance between the muscolo-ligamentous structure which crosses the first metatarso-phalangeal joint. This complication is poorly tolerated by patients. Various operations have been proposed to correct the varus, which includes the bone and the soft tissue. A clinical case has been presented which uses a split extensor hallucis longus transfer, distally sectioned and made to pass under the deep transverse intermetatarsal ligament, used as a pulley, and through a tunnel made in the bone at the proximal-lateral base of the proximal phalanx, and then tensioned and sutured to its medial side.