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.     

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.     

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.     

A radiographic study of the relationship between metatarsus adductus and hallux valgus

The relationship between metatarsus adductus and hallux valgus was evaluated on 100 dorsoplantar weight-bearing radiographs. The metatarsus adductus angle varied positively with the degree of hallux valgus. By using measures of correlation, a significant linear association was found for women (r =.53, P <.001) and men (r =.48, P <.001). The relationship was strongest in women when all cases of abnormal metatarsus adductus (>24 degrees ) were associated with abnormal degrees of hallux valgus (>15 degrees ). This relationship was different in men in that abnormal metatarsus adductus angles were not always associated with abnormal hallux valgus angles. With male and female data combined, the prevalence of metatarsus adductus was 55% in subjects with hallux valgus deformity compared with 19% in subjects without hallux valgus. A Chi(2) test showed this to be a significant difference in the distribution of the data (P =.002). The data of this study suggests that there may be a clinical association between metatarsus adductus and hallux valgus. The need to further evaluate the role of metatarsus adductus angle in hallux valgus surgery is emphasized.     

Can the Syndesmosis Procedure Prevent Metatarsus Primus Varus and Hallux Valgus Deformity Recurrence? A 5-Year Prospective Study

One of the main objectives of hallux valgus surgery is correction of the metatarsus primus varus deformity by osteotomy, arthrodesis, or soft tissue correction. The syndesmosis procedure uses intermetatarsal cerclage sutures to realign the first metatarsal and also induces a syndesmotic bonding between the first and second metatarsals to prevent metatarsus primus varus deformity recurrence. The purpose of the present study was to demonstrate radiologic evidence of the effectiveness of the syndesmosis concept and to identify the incidence and nature of deformity recurrence. A total of 55 feet from 60 consecutive procedures were followed regularly at 6 fixed points for 5 years. The radiologic inclusion criterion was a first intermetatarsal angle?>9° or metatarsophalangeal angle?>20°. The initial postoperative radiographs showed significant correction of the intermetatarsal angle from a preoperative average of 14.5° to 4.3° (p?<?.0001). It had increased to 7.0° during the first 6 postoperative months but remained within the normal upper limit of 9° and exhibited no further significant changes for the subsequent 4.5 years (p?=?.0792). Hallux valgus deformity correction also correlated with metatarsus primus varus deformity correction. Three (5%) second metatarsal stress fractures occurred, and all recovered uneventfully. In conclusion, we have report the findings from a detailed medium long-term follow-up study showing, to the best of our knowledge, for the first time that metatarsus primus varus and hallux valgus deformities can be effectively corrected and maintained using a specific surgical technique. Also included are 6 relevant radiographs and photographs of the included and excluded feet in the online Supplementary Material for reference.     

Correction of juvenile hallux valgus deformity associated with metatarsus primus adductus using epiphysiodesis technique

A 4.5-year follow-up retrospective study on the use of epiphysiodesis procedure for juvenile hallux valgus deformity and metatarsus primus adductus deformity shows a good reduction of deformity in nine patients with minimal change in one patient that can be explained due to the timing of the procedure. This is a minor operation for juvenile bunion deformities, using epiphyseal arrest techniques. The only complication to this procedure was one case with a noted metatarsus primus elevatus due to incomplete epiphyseal arrest from dorsal to plantar. This procedure has been found to be a safe and effective way of dealing with juvenile hallux valgus deformity when metatarsus primus adductus is the deforming force. It should be stated that in all cases a follow-up biomechanical examination and casting for orthotics took place and to date no complications, other than what has been previously mentioned, has occurred. I shall continue to perform this procedure where indicated and shall report my findings as they become available.     

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.     

New concepts in metatarsal head osteotomies: reverse buckling techniques

The deformity of hallux abducto valgus is often accompanied by the deformity of metatarsus primus varus. These deformities are often attributed to familial tendencies, faulty structure, and impaired function. However, once manifest, the deformity of metatarsus primus varus is partially maintained through medial retrograde buckling of the abducted hallux. In selected flexible deformities, Stable surgical correction may be obtained through the principles of reverse buckling.     

Correction of metatarsus primus varus associated with hallux valgus deformity using the arthrex mini tightrope: a report of 44 cases

Metatarsus primus varus must be addressed during correction of moderate to severe hallux valgus deformity. As an alternative to proximal osteotomy or first tarsometatarsal fusion for hallux valgus correction, this study presents a series of patients treated using the Arthrex Mini TightRope. A total of 36 patients (44 operations) with hallux valgus and metatarsus primus varus underwent correction using the Arthrex Mini TightRope. Assessment included measurement of radiographic parameters, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot outcomes score, and the SF-12. The average hallux valgus angle improved from 32.2° to 15.2° (P < .0001). The average first intermetatarsal angle improved from 14.6° to 8.2° (P < .0001). The average distal metatarsal articular angle improved from 17.0° to 9.6° (P < .0001). The average AOFAS midfoot outcomes scores improved from 45.44 to 84.72 (P < .0001). Postoperative SF-12 physical and mental scores averaged 52.99 and 56.63. Only one patient had recurrence of deformity. Correcting metatarsus primus varus in association with hallux valgus deformity using the Arthrex Mini TightRope should be considered a treatment option. This technique is less invasive and seems capable of maintaining correction while allowing for early weight bearing and avoiding the need for a proximal first metatarsal osteotomy or Lapidus procedure.     

The Wilson bunion procedure modified for improved clinical results

The Wilson procedure for correction of hallux abducto valgus is modified for use in three specific clinical conditions. The modifications are outlined and demonstrated in the preoperative conditions of 1) juvenile hallux abducto valgus, 2) functional hallux limitus, and 3) postoperative metatarsus primus elevatus. The rationale and biomechanical considerations for the modified Wilson bunion procedure are discussed.     

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.     

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.     

Radiographic Measurements of Patients With Juvenile Hallux Valgus Compared With Age-Matched Controls: A Cohort Investigation

The purpose of this study was to investigate radiographic measurements in a cohort of patients with juvenile hallux valgus (with a hallux valgus angle > 15 degrees ) using standardized weightbearing x-rays compared with an age-matched control group. First metatarsal protrusion distance, metatarsus primus adductus angle, metatarsus adductus, first metatarsal cuneiform angle, calcaneal inclination angle, and talocalcaneal angles were assessed with discriminant functional analysis. A total of 37 sets of data were analyzed from patients with a mean age of 13.45 +/- 1.75 years. The study identified 2 significant components of juvenile hallux valgus: a positive first metatarsal protrusion distance (P <.001) and metatarsal primus adductus angle (P = .002). Discriminant functional analysis was then used to determine the best predictors of juvenile hallux valgus. This analysis allowed only 1 variable, metatarsal protrusion distance, as a predictor of whether juvenile hallux valgus was present (P < .001), with 94.3% accuracy. This study showed that a positive metatarsal protrusion distance is a significant component of juvenile hallux valgus.     

Single absorbable polydioxanone pin fixation for distal chevron bunion osteotomies

The distal chevron osteotomy is a well-established technique for correction of symptomatic mild to moderate metatarsus primus varus with hallux valgus deformity. Fixation of the osteotomy ranges from none to bone pegs, Kirschner wires, screws, or absorbable pins. We evaluated one surgeon's (J.K.D.) results of distal chevron osteotomy fixation with a single, nonpredrilled, 1.3-mm poly-p-dioxanone pin and analyzed any differences in patients with unilateral or bilateral symptomatic metatarsus primus varus with hallux valgus deformities. All osteotomies healed without evidence of infection, osteolysis, nonunion, or necrosis. Equal correction was achieved in unilateral and bilateral procedures. The technique is quick and easy, and adequate fixation is achieved.     

Percutaneous sagittal plane closing wedge osteotomy of the first metatarsal

Osteotomy of the first metatarsal in the sagittal plane is useful in correction of numerous deformity of the foot. Plantarflexion osteotomy of the first metatarsal can be used to treat hallux rigidus, hallux limitus, forefoot varus in flatfoot deformity and iatrogenic metatarsus primus elevates. Dorsiflexion osteotomy of the first metatarsal is an important component in surgical correction of pes cavus. It is also indicated in recalcitrant diabetic neuropathic ulcers at the first metatarsal head. We described a minimally invasive technique of sagittal plane corrective osteotomy of the first metatarsal, which can be either a plantarflexion or dorsiflexion one.     

Supination stress of the great toe for assessing intraoperative correction of hallux valgus

Background  

We have devised a new intraoperative technique (supination stress of the great toe) in which correction of hallux valgus and metatarsus primus varus, and reduction of the sesamoids could be simultaneously obtained at hallux valgus surgery. The purpose of this study was to prospectively investigate the efficacy of supination stress for assessing intraoperative correction of hallux valgus.     

Treatment of the juvenile bunion by Mitchell osteotomy

Twelve patients who had a total of 18 Mitchell bunionectomies were reviewed to assess the long-term results of the procedure. Although metatarsus varus correction was maintained in all cases, hallux valgus recurred in 11 of the 18 cases. Sixty-seven percent reported complete relief or improvement of preoperative pain. Although lateral metatarsalgia did occur, the most common area of persistent pain remained the first metatarsal. Six of 18 procedures had marked loss of active joint motion, associated with pain and an unsatisfactory result. Of 18 procedures, 11 (61%) were satisfied with the results of their osteotomy. Although the Mitchell osteotomy corrected the metatarsus primus varus in each case, the current series shows a discouraging incidence of later recurrence of hallux valgus and restriction of metatarsophalangeal motion causing the abandonment of this procedure for the management of juvenile bunion.     

The Hallux and Rheumatoid Arthritis

The purpose of this report is to consider involvement of the great toe by rheumatoid arthritis, defining significant deformities, describing clinical patterns and discussing the pathomechanics of these findings, in what is an ongoing disease. 200 consecutive patients admitted to hospital with classical or definite rheumatoid arthritis were screened for pain or deformity of the great toe. Feet that had undergone previous surgery or had other underlying pathology were excluded from the series. 194 feet were found to have halluceal involvement. Although hallux valgus was the commonest deformity it was found in combination with other significant deformities in many cases. Hallux rigidus was an important lesion in this series as was interphalangeal hyperextension. Other important lesions encountered were metatarsus primus varus and medial rotation of the toe; their relationship to hallux valgus is discussed.