Bunion surgery using locking-plate fixation of proximal metatarsal chevron osteotomies

BACKGROUND: Symptomatic large hallux valgus deformities commonly require surgical intervention with a proximal metatarsal osteotomy. A number of fixation methods have been described for proximal chevron osteotomies; one of the most recent is locking plates. METHODS: We retrospectively reviewed the records of 16 consecutive patients (20 feet) with severe bunion deformities who had locking-plate fixation of proximal chevron osteotomies. Clinical evaluation focused on osteotomy healing, transfer lesions, and hardware-related complications. Preoperative and postoperative radiographic evaluation included the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), medial 1-2 intermetatarsal distance (MIMD; the amount of narrowing of the foot), sesamoid position, first metatarsal elevation, and metatarsal length change. A postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was obtained in all patients. RESULTS: The average radiographic improvements were HVA, 16.0 degrees, IMA, 7.6 degrees, and MIMD, 9.0 mm. Sesamoid position improved in 16 of 20 feet. First metatarsal elevation averaged 0.8 degrees, and the average metatarsal shortening was less than 1 mm. The AOFAS score averaged 94.1 points. Two complications were unrelated to plate fixation. CONCLUSIONS: The locking plate held alignment and position of the first ray after chevron osteotomy without clinical evidence of transfer lesions or hardware-related symptoms. Locking plates may improve stability of the proximal metatarsal after a chevron osteotomy for correction of hallux valgus.     

Proximal spherical metatarsal osteotomy for the foot with severe hallux valgus

BACKGROUND: A proximal spherical metatarsal osteotomy was devised to correct not only varus deviation of the first metatarsal, but also dorsiflexion. We expected to increase the medial longitudinal arch by adding plantar flexion at the osteotomy site. To investigate the limitations of this procedure for feet with severe hallux valgus, a followup study was performed on patients with preoperative hallux valgus angles greater than or equal to 40 degrees. MATERIALS AND METHODS: Forty-eight feet in 37 patients (10 male, 27 female) (60 years; range, 20 to 84 years) were investigated. Mean followup was 4 years and 1 month, ranging from 2 to 8 years. The spherical osteotomy was performed using a curved chisel. A distal soft tissue procedure was done at the same time. Twenty feet received combined operations for their combined deformities. RESULTS: While 81% of patients were satisfied with the results, 50% of those with preoperative hallux valgus angles greater than or equal to 50 degrees had postoperative hallux valgus angle greater than or equal to 20 degrees. In these patients, correction of metatarsus primus varus was good, but correction of valgus deviation of the hallux was fair. Mean correction toward plantar flexion was 1.5 degrees and no increase in arch height was achieved. CONCLUSION: The proximal spherical osteotomy could consistently achieve satisfactory results for the patients with hallux valgus angles less than 50 degrees. However, the corrections were worse in feet with more severe deformities. Furthermore, plantarflexion at the osteotomy site was offset by displacement at the first tarsometatarsal joint. If plantarflexion is indispensable, arthrodesis of the tarsometatarsal joint is recommended.     

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.     

Scarf osteotomy for hallux valgus deformity: an intermediate followup of clinical and radiographic outcomes

BACKGROUND: The scarf osteotomy is a versatile and reproducible procedure for the correction of moderate to severe hallux valgus deformity (intermetatarsal angle 12 to 20 degrees hallux valgus angle 20 to 46 degrees). METHODS: We evaluated the results of 27 consecutive scarf osteotomies at an average followup of 16.1 months. Radiographic parameters, foot pressure analysis, and AOFAS scores were analyzed before and after surgery. RESULTS: Hallux valgus angles improved from 34.5 to 16.9 degrees, intermetatarsal angles improved from 15.4 to 10.1 degrees, AOFAS scores improved from 54.5 to 86.5. There was no change between the preoperative and postoperative relative lengths of the first and second metatarsals, defined as the difference between the first and second metatarsal lengths. The measurement was based on the anteroposterior standing radiographs and measured by a line intersecting the midway point at the diaphyseal-metaphyseal junction of the metatarsal and extending from the most proximal to distal aspects of the bone. The angle of Meary (talo-first metatarsal angle) did not change, except in one patient. Foot pressure analysis showed no evidence of transfer metatarsal lesions. The complication rate was 1.1% including superficial infection and recurrence. CONCLUSIONS: The scarf osteotomy provides a predictable and effective correction of moderate to severe hallux valgus deformities.     

The Lapidus procedure: a prospective cohort outcome study

BACKGROUND: Multiple reports are found in the literature about the surgical treatment of hallux valgus deformities. Few, however, are prospective outcome studies. The purpose of this study was to prospectively look at the functional outcome of patients with moderate and severe hallux valgus deformities (intermetatarsal angle of more than 14 degrees and a hallux valgus angle of more than 30 degrees) after the Lapidus procedure. METHODS: Indication for surgery and inclusion into the study was failure of nonoperative management for metatarsus primus varus and painful hallux valgus deformities. Data was collected using the AOFAS Hallux Metatarsophalangeal Interphalangeal Scale, Visual Analog Pain Scale, clinical examination, weightbearing radiographs, and a patient satisfaction questionnaire. Data was collected preoperatively, 6 weeks after surgery, 6 months after surgery, and then yearly. One hundred and five feet in 91 patients were followed for an average of 3.7 years (range, 18 months to 6.2 years). Sixty-two patients were female and 29 were male. The average age at surgery was 41 years (range, 20 years to 71 years). RESULTS: The AOFAS Hallux Metatarsophalangeal Interphalangeal Scale scores increased from 52 preoperatively to 87 points at most recent follow-up (p <.001). The average intermetatarsal angle preoperatively was 18 degrees and 8.2 degrees at most recent follow-up. Between the 1-year and 3.7-year follow-up visits, only.3-degree increase of the intermetatarsal angle was noted. The average hallux valgus angle preoperatively was 37 degrees and 16 degrees at most recent follow-up. Less than 1-degree increase in the hallux valgus angle was noted between the 1-year to 3.7-year follow-up visits. Complications included tarsometatarsal nonunion in seven patients. Five patients lost correction and all seven patients had a revision procedure done for pain. Removal of hardware was necessary in eight patients, minor wound problems occurred in two patients, superficial neuroma in two patients, and transfer metatarsalgia in four. CONCLUSIONS: The Lapidus procedure obviously is not the answer to all bunion deformities, but with proper technique and attention to detail it is an excellent alternative treatment for moderate to severe metatarsus primus varus and hallux valgus deformities.     

The SCARF osteotomy for the correction of hallux valgus deformities

The authors report their experience with a modified SCARF osteotomy with three years follow-up. Correction of moderate to severe hallux valgus deformities was achieved using a Z step osteotomy cut to realign the first metatarsal bone. A retrospective analysis was undertaken in 89 consecutive patients (111 feet). Results were analyzed by clinical examination, a questionnaire including the AOFAS forefoot score, and plain roentgenograms. Hallux valgus and intermetatarsal angle improved at mean 19.1 degrees and 6.6 degrees, respectively. Mean forefoot score improved from 50.1 to 91 points out of 100 possible points. Satisfactory healing time was expressed by an average return back to work of 5.8 weeks and back to sport of 8.3 weeks. Persistence or recurrence of hallux valgus was seen in seven patients (6%). The complication rate was 5.4% including superficial wound infection, traumatic dislocation of the distal fragment, and hallux limitus. The presented technique provides predictable correction of moderate to severe hallux valgus deformities.     

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.     

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

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.     

Basal medial opening wedge first metatarsal osteotomy stabilized with a low profile wedge plate

Twenty patients underwent 25 basal medial opening wedge osteotomies of the first metatarsal stabilized using a low-profile wedge plate in combination with a distal soft tissue release, distal metatarsal osteotomy and Akin osteotomy as required for correction of a hallux valgus deformity. The mean clinical and radiographic follow-up was 12.2 months. Pre- and post operative radiographs available in 15 cases showed that the median hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were corrected from 45.5 to 13.1, 17.7 to 9.2 and 243 to 10.0 degrees respectively (p < 0.001). Final radiographic assessment for the whole series showed a median final HVA and IMA of 14.1 and 9.1 respectively. Radiographic union was noted in all but one case which was asymptomatic. One wound infection was treated with oral antibiotics, one hallux varus deformity required soft tissue reconstruction and there was one recurrence. The outcome was reported as good or satisfactory by the patients for 20 of 25 feet. Three patients reported stiffness in the first MTP joint, which improved with joint injection and manipulation. Two plates were removed for prominence. The basal medial opening wedge osteotomy stabilized with a low profile wedge plate was an effective addition for correcting a moderate to severe hallux valgus deformity as part of a double or triple first ray osteotomy.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Evaluation of scarf osteotomy for management of hallux valgus deformity

Hallux valgus is a complex progressive deformity affecting the forefoot. The main pathologic anatomy concerns the first metatarsophalangeal joint, including a varus or medial deviation of the first metatarsal and pronation deformity in the longitudinal axis. The goal of this study was to evaluate a series of consecutive patients over a 2-year period after a scarf osteotomy of the first metatarsal. A scarf osteotomy was performed on 31 consecutive patients with moderate to severe hallux valgus deformity (intermetatarsal angle, 13-22°; hallux valgus angle, 20-44°). Twenty-nine women and 2 men had an average age of 57 years (range, 21-71 years) at the time of surgery. Preoperative and postoperative evaluations included standing anteroposterior and lateral radiographs, American Orthopaedic Foot and Ankle Score (AOFAS) score, physical examination, and foot pressure analysis by weight-bearing ink prints. Patients were evaluated radiographically and clinically in the initial postoperative period (≤1 month), intermediate postoperative period (2-6 months), and final follow-up (12-36 months). Twenty-eight feet were available for analysis. Five of the 28 feet had concurrent surgeries on the lesser toes for hammer-toe correction or preoperative metatarsalgia. Paired Student t test on the 28 feet showed a statistically significant improvement (P<.0001) between pre- and postoperative intermetatarsal angle, hallux valgus angle, and AOFAS score. One foot had recurrence of the hallux valgus deformity. Paired analysis of variance of the 27 feet without recurrence showed a statistically significant improvement in the pre- and postoperative parameters (P<.0001). From this subset, the multiple-comparison Student-Newman-Keuis post hoc test showed a statistically significant (P<.0001) preservation of the correction in the intermediate follow-up period to final follow-up at an average 28 months.     

Hallux valgus and first ray mobility. A prospective study

BACKGROUND: There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. METHODS: All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. RESULTS: Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the post-operative hallux valgus deformity, or the magnitude of hallux valgus correction. CONCLUSIONS: A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.     

Scarf osteotomy in hallux valgus: a review of 72 cases

The Scarf osteotomy is now widely used for the correction of hallux valgus. The aim of our study was to evaluate the results after Scarf osteotomy considering patient's satisfaction as well as the clinical and radiological results. Between 1996 and 1999, 72 feet underwent a Scarf osteotomy of the first metatarsal and, in 11 feet, an additional Akin osteotomy of the proximal phalanx, for the correction of hallux valgus (55 patients: 49 female, 6 male; mean age: 52 years). The hallux valgus angle improved significantly, from 32 degrees preoperatively to 18 degrees at follow-up (minimal follow-up: 6 years; mean: 7.5 years). A second operation was necessary in two patients because of recurrence of hallux valgus, and a fusion of the first metatarsophalangeal joint was performed in two patients. At the time of latest follow-up 78% of the patients were satisfied or very satisfied with the result. The Scarf osteotomy combined with Akin's closing wedge osteotomy is a safe and effective procedure for the treatment of moderate hallux valgus deformities.     

Proximal oblique-domed osteotomy of the first metatarsal for the treatment of hallux valgus associate with flat foot: effect to the correction of the longitudinal arch of the foot

Introduction Flat foot and/or metatarsal primus varus are the major causes of hallux valgus, and it is important to correct these deformities in order to prevent the recurrence of this condition. We demonstrate the clinical and radiological assessment of the correction of hallux valgus, metatarsal primus varus, and flat foot after proximal oblique-domed osteotomy of the metatarsus with distal soft tissue reconstruction. Materials and methods Twenty-seven feet of 22 patients with moderate or severe hallux valgus who had undergone proximal oblique-domed osteotomy were studied. After the adductor hallucis tendon was cut at the attachment of the proximal phalanx and at the sesamoid bone, the osteotomy was performed 3 cm dorsal-distal to the metatarsocuneiform joint to transfer distal fragment approximately 5 mm in the plantar direction, and rotated laterally decreasing the first–second intermetatarsal angle to 5 degrees. Results The mean AOFAS score was 54.1 ± 2.8 points at pre-operation and 92.8 ± 4.8 points at the most recent follow-up (P < 0.0001). Significant improvement was seen between the hallux valgus angle (P < 0.0001), first–second intermetatarsal angle (P < 0.0001), first–fifth intermetatarsal angle (P < 0.0001), talar pitch (P = 0.0032), and calcaneal plantar angle (P = 0.0327) before surgery and at one year after surgery. The average improvement of the talar pitch and calcaneal plantar angle was 2.6 ± 1.4 and 2.4 ± 1.5 degrees, respectively. Conclusion This study suggest that proximal oblique-domed osteotomy of the metatarsal as a surgical procedure for the treatment of moderate or severe hallux valgus with flat foot can be recommended to correct the longitudinal arch of the foot and the first–second intermetatarsal angle.     

Radiographic Outcomes Following Primary Arthrodesis of the First Metatarsophalangeal Joint in Hallux Abductovalgus Deformity

The purpose of this study was to evaluate the radiographic outcomes of primary metatarsophalangeal joint arthrodesis for hallux abductovalgus deformities. Between January 2004 and March 2009, 56 consecutive patients (58 feet) underwent primary arthrodesis of the metatarsophalangeal joint (MTPJ) for severe hallux abductovalgus deformity and or hallux rigidus. Results were assessed by primary radiographic outcome measurements (hallux valgus and first-second intermetatarsal angle). Overall, the mean hallux valgus (HA) angle improved significantly from 31.9° to 13.4° (P < .01). The mean first-second intermetatarsal (IM) angle correction was also signficantly reduced from 14.0° to 9.7° (P < .01). When separated by deformity group (mild, moderate, and severe), the mean hallux valgus and first-second intermetatarsal angles demonstrated statistically significant correction in all groups when comparing preoperative and postoperative values (P < .01). Primary arthrodesis provides predictable radiographic outcomes and effective correction for patients with differing severity of hallux abductovalgus deformity and arthritis of the first metatarsophalangeal joint. A separate proximal osteotomy for severe metatarsus primus varus correction may not be necessary because of the correction achieved at the metatarsophalangeal joint arthrodesis level. The results of this study demonstrate that as the severity of the preoperative deformity increases, the amount of postoperative radiographic (HA and IM angle measurement) correction after MTPJ arthrodesis will improve correspondingly.     

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.     

Associated deformities and hypermobility in hallux valgus: an investigation with weightbearing radiographs

BACKGROUND: Hallux valgus has been reported to recur after surgical correction in patients subsequently diagnosed with hypermobility of the first ray, pronation of the foot, and pes planovalgus. An objective means of assessing the foot for these deformities preoperatively may avert a poor outcome. This investigation evaluated the efficacy of full-length weightbearing radiographs to recognize associated deformities in patients with hallux valgus before surgery. METHODS: This study compared five parameters from anteroposterior and four parameters from lateral weightbearing pedal radiographs of patients with moderate to severe hallux valgus to a control group to identify differences in the alignment of the midfoot and the first metatarsal-medial cuneiform joint. An examination for clinical evidence of hypermobility was also performed on both groups. RESULTS: The hallux valgus group demonstrated increased abduction and dorsiflexion of the midfoot. The mean talonavicular coverage angle and lateral talo-first metatarsal angle of this group was greater than the mean values for the controls. Radiographic evaluation also revealed differences in the alignment of the first metatarsal-medial cuneiform joint in the sagittal plane. The hallux valgus group possessed a mean of 2 mm of dorsal translation and 2 degrees of dorsiflexion at this joint compared to the controls. CONCLUSIONS: Weightbearing radiographs permit the recognition of associated malalignments of the foot in patients with hallux valgus. The comparisons performed in this study identified deformities consistent with pes planovalgus and hypermobility of the first ray in patients with moderate to severe hallux valgus. The results of our study support a recommendation for a thorough evaluation of full-length, biplanar weightbearing radiographs via the measurement of midfoot and first ray alignment for concomitant deformities of the foot in patients with hallux valgus.     

Clinical results with the Ludloff osteotomy for correction of adult hallux valgus

BACKGROUND: Biomechanically, the Ludloff osteotomy fixed with lag screw compression has been shown to be more rigid than proximal crescentic and other proximal first metatarsal osteotomies for correction of symptomatic hallux valgus with a moderate to severe increase in the first intermetatarsal angle. The Ludloff osteotomy may, therefore, have a lower incidence of dorsal malunion and transfer metatarsalgia than other proximal first metatarsal osteotomies, such as the crescentic or chevron. METHODS: We reviewed the results of 82 consecutive cases of moderate to severe hallux valgus deformities corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. RESULTS: Follow-up was possible in 70 cases (85%) at an average of 30 months (range, 18 to 42 months). Preoperatively, the mean hallux valgus and first intermetatarsal angles were 31 degrees and 16 degrees, respectively. Postoperatively, these values improved to an average of 11 degrees and 7 degrees. In the sagittal plane, the first metatarsal was plantarflexed by an average of 1 mm, and there were no symptomatic transfer lesions of the second metatarsal. The mean AOFAS hindfoot score improved from 54 to 91 points. Complications included prominent hardware requiring removal (5), hallux varus (4), delayed union (3), superficial infection (3), and neuralgia (3). CONCLUSIONS: The use of the Ludloff oblique first metatarsal osteotomy resulted in excellent correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. With the plane of the osteotomy and rigidity of fixation, immediate ambulation was possible with minimal risk of dorsiflexion malunion of the first metatarsal.     

The modified Ludloff osteotomy for correction of severe metatarsus primus varus with hallux valgus deformity

AIM: The present study investigates the clinical and radiological mid-term results of the modified Ludloff osteotomy, a proximal metatarsal osteotomy for surgical correction of severe metatarsus primus varus with hallux valgus deformity. METHOD: 70 feet in 67 patients from 25 to 78 years (average age 56 years) were included in this prospective study. The patients were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot metatarsophalangeal interphalangeal score, which was used preoperatively and at an average follow-up of 37 +/- 6 months. Weight-bearing foot radiographs were analysed according to AOFAS guidelines and statistical evaluation was made with the Wilcoxon signed-rank test. RESULTS: The average AOFAS score improved significantly (p < 0.0001) from 55.2 +/- 15.2 points preoperatively to 86.6 +/- 15.2 points at follow-up. Preoperatively, all patients complained of pain (20.2 +/- 9.6 points) which had improved significantly (p < 0.0001) at the latest follow-up (37.3 +/- 5.7 points). The average hallux valgus angle (HVA) was 37 +/- 8 degrees preoperatively and improved significantly to 12 +/- 11 degrees at follow-up (p = 0.0001). The intermetatarsal angle (IMA) improved significantly from 18 +/- 2 degrees preoperatively to 8 degrees +/- 4 degrees after 37 +/- 6 months (p = 0.0002). The sesamoid position improved significantly from preoperative to follow-up (p = 0.0003). Radiographic evaluation of the patients indicated that all examined osteotomies had healed after 37 +/- 6 months. CONCLUSION: This prospective investigation at intermediate follow-up using currently available outcome measures suggests that the Ludloff osteotomy is a suitable procedure for the surgical correction of severe metatarsus primus varus (IMA > 15 degrees ) with hallux valgus deformity.