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.     

Hallux rigidus: demographics, etiology, and radiographic assessment

PURPOSE: The purpose of the study was to evaluate the demographics, etiology, and radiographic findings associated with hallux rigidus in patients treated surgically over a 19-year period in a single surgeon's practice. METHODS: Patients treated for hallux rigidus by cheilectomy and metatarsophalangeal joint fusion were identified from 1981 to 1999. Patients who had diabetes, inflammatory arthritis, infectious arthritis, crystalline arthritis, multiple forefoot deformities, neuromuscular disorders, or had died were excluded. A chart review and evaluation of preoperative radiographs were completed on all eligible patients. All identified patients were invited for a follow-up examination that included standard and stress radiographs, range-of-motion testing, Harris mat study, gait analysis, first ray mobility measurement, and standardized questionnaire assessment. RESULTS: One hundred ten of 114 (96.5%) patients with a diagnosis of hallux rigidus returned for the final evaluation. Eighty cheilectomy patients (93 feet) and 30 arthrodesis patients (34 feet) were evaluated. The mean age at onset in the current study was 43 years (13-70 years) and only six patients developed symptoms at an age of less than 20 years. Hallux rigidus was graded based on a five-grade clinical-radiographic system. The mean follow-up was 8.9 years. Ninety-five percent of patients with a positive family history had bilateral disease at the final follow-up. At the initial examination in the current study, 81% of patients had radiographic and clinical evidence of unilateral disease, but at the final follow-up 79% of patients had radiographic and clinical evidence of bilateral disease. Eleven percent of patients in the present series had pes planus based on either a positive Harris mat study and/or heel valgus. There was no evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that the concurrent presentation of hallux valgus and hallux rigidus was not common. Ninety-three of 127 feet (73%) had a chevron or flat metatarsophalangeal joint. Thirty-five feet were noted to have mild or moderate metatarsus adductus. A long first metatarsal was no more common in patients with hallux rigidus than in the general population. The mean first ray elevatus was 5.5 mm and was well within acceptable limits of normal. The mean first ray mobility was 5 mm in arthrodesis patients and 5.8 mm in cheilectomy patients. CONCLUSION: Hallux rigidus was not associated with elevatus, first ray hypermobility, a long first metatarsal, Achilles or gastrocnemius tendon tightness, abnormal foot posture, symptomatic hallux valgus, adolescent onset, shoewear, or occupation. Hallux rigidus was associated with hallux valgus interphalangeus, bilateral involvement in those with a familial history, unilateral involvement in those with a history of trauma, and female gender. Metatarsus adductus was more common in patients with hallux rigidus than in the general population but a clear correlation was not found. Additionally, a flat or chevron-shaped metatarsophalangeal joint was more common in hallux rigidus patients.     

Hallux valgus repair. DuVries modified McBride procedure

The DuVries modification of the McBride procedure was investigated in 72 feet in 47 patients with hallux valgus deformity. Overall, the patient satisfaction rate was 92%. The hallux valgus averaged 32 degrees preoperatively, and 16 degrees postoperatively. The intermetatarsal angle averaged 14 degrees preoperatively and 9 degrees postoperatively. Anatomic realignment of the remaining tibial sesamoid was achieved in 28% of the feet. As a result of realignment of the first metatarsophalangeal joint, the intractable plantar keratosis beneath the second metatarsal head was resolved in 19 of 20 feet. Six patients developed a hallux varus deformity that averaged 7.5 degrees. All cases of hallux varus had medial displacement of the tibial sesamoid. The number of patients who could withstand unrestricted shoe wear increased from ten patients preoperatively to 30 patients postoperatively. The patient activity level increased in two thirds of the cases. The distal soft-tissue procedure produces the most predictable correction in patients with a hallux valgus deformity measuring less than 30 degrees. In more severe deformities, a proximal metatarsal osteotomy should be added to the procedure.     

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.     

Distal soft tissue procedure and proximal metatarsal osteotomy in hallux valgus

The results of a distal soft tissue procedure and a proximal metatarsal osteotomy in patients with symptomatic hallux valgus deformity were reviewed. The series consisted of 33 patients (47 feet; mean age of patients, 44 years). The average followup period was 48 months. At followup, 41 feet (29 patients, 85%) were free from pain at the first metatarsophalangeal joint. In six feet (four patients), the pain was improved but persisted. The mean hallux valgus angle was 38 degrees before surgery and 13.8 degrees after surgery. The mean intermetatarsal angle was 17.7 degrees before surgery and 7 degrees after surgery. The postoperative hallux valgus angle and intermetatarsal angle in patients who had pain at the first metatarsophalangeal joint after surgery were greater than those in patients without pain after surgery. This procedure corrects the hallux valgus deformity and relieves the symptoms, but careful attention should be paid to the surgical technique to obtain consistent and satisfactory results.     

The first metatarsophalangeal joint meniscus and its relation to hallux valgus deformity—An anatomical and clinical study

Background

This study describes the anatomy and incidence of the metatarsophalangeal (MTP) joint meniscus, a structure not mentioned before in literature.

Methods

An anatomical cadaver study on 102 feet was performed with special attention to the first MTP joint anatomy. These results were compared with the per-operative findings in a clinical prospective study on 100 consecutive hallux valgus surgeries.

Results

On cadavers this meniscus is more common in patients with hallux valgus. Clinically, in patients with a mild hallux valgus the meniscus is found in more than half of cases during surgery, while it is seldom found in patients with moderate or severe deformities.

Conclusions

The presence of this structure seems to stabilize the MTP joint preventing progression of the hallux valgus deformity and may explain the pain, which is often seen in mild bunions in younger, patients. Once the rotational deformity increases the meniscus tears and slips into the joint. In the more advanced hallux valgus deformity this meniscus plays little function and seems to disappear, leading to arthrosis.     

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients’ mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p?=?.179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p?=?.215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.     

Rheumatoid forefoot reconstruction. A long-term follow-up study

BACKGROUNDS: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present. METHODS: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author. RESULTS: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints. CONCLUSIONS: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschnerwire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Arthrodesis procedures for salvage of the hallux metatarsophalangeal joint

First metatarsophalangeal (MTP) fusion has been recommended as a means to salvage various great toe deformities. These deformities include failed hallux valgus procedures, failed silicon implants, previous infection, rheumatoid arthritis, post-traumatic conditions, hallux rigidus, severe hallux valgus deformities, and neuromuscular disorders. A variety of complications, such as hallux varus, first MTP joint instability, infection, recurrent hallux valgus, and avascular necrosis of the first metatarsal head can develop from hallux valgus deformity treatment procedures.     

Acute traumatic hallux valgus

Post-traumatic hallux valgus is an uncommon condition with sporadic reports. The deformity usually develops in a gradual manner following direct injury to the first ray; including injury to the first metatarsophalangeal joint, the first metatarsal bone or the first metatarsal-cuneiform joint. A case of acute traumatic hallux valgus following metatarsal neck fractures of the lesser rays is reported. We believe that understanding the importance of the transverse ‘tie-bar’ system in the pathogenesis of post-traumatic hallux valgus deformity avoids unnecessary surgery to the great toe.     

Die „Ludloff“-Osteotomie zur Korrektur der Hallux-valgus-Deformität

OBJECTIVE: Correction of a symptomatic hallux valgus deformity. INDICATIONS: A hallux valgus deformity in which the intermetatarsal angle I-II exceeds 15 degrees and the shaft of the first metatarsal is broad enough to allow a rotational osteotomy. CONTRAINDICATIONS: Hypermobility of the first ray. Severe osteoporosis. Degenerative arthritis of the first metatarsophalangeal joint. SURGICAL TECHNIQUE: Longitudinal incision over the first intermetatarsal space. Division of the metatarsosesamoid ligament together with the tendon of the adductor hallucis muscle. Opening of the lateral articular capsule of the first metatarsophalangeal joint allowing a tension-free realignment of the head of the first metatarsal with the sesamoids. Medial longitudinal incision along the first metatarsal starting over the medial cuneiform bone and ending at the proximal phalanx of the great toe. Oblique osteotomy of the proximal two thirds of the first metatarsal in a proximal dorsal to distal plantar direction and lateral rotation of the distal fragment around a proximally placed 3-mm AO screw. Additional fixation with one BOLD screw. Trimming of the protruding bone and of bunion. Medial metatarsophalangeal capsulorraphy. RESULTS: Between September 1998 and October 1999, 76 feet underwent a Ludloff osteotomy. Patients were followed up clinically and radiographically for 36 months (24-56 months). The mean hallux valgus angle was reduced from 37 degrees to 14 degrees and the mean intermetatarsal angle I-II from 18 degrees to 9 degrees. Using a four-point scale 81% of the patients were satisfied or very satisfied with the result of the operation. 95% of them felt no or very mild pain.     

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.     

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.     

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.     

Sliding oblique osteotomy for the treatment of hallux abducto valgus associated with functional hallux limitus.

This is a retrospective study of 27 patients (35 feet) with hallux abducto valgus associated with hallux limitus who underwent a sliding oblique osteotomy for surgical treatment between August 1997 and June 1998. Radiographic analysis and range-of-motion measurements were evaluated with an average follow-up of 65 days (range, 26-100). Preoperative criteria included < 45 degrees of dorsiflexion of the first metatarsophalangeal joint with weightbearing, no evidence of degenerative joint disease at the first metatarsocuneiform joint, and no previous surgical procedures on the first ray. The average preoperative intermetatarsal angle was 9 degrees, hallux abductus angle 17 degrees, and first metatarsal declination angle 15 degrees. The average postoperative intermetatarsal angle was 6.6 degrees, hallux abductus angle 10.3 degrees, and first metatarsal declination angle 21.7 degrees. Eighteen patients (22 feet) had a follow-up of over 6 weeks, and the first metatarsophalangeal joint was evaluated. The average gain in postoperative range of motion with weightbearing was 22.3 degrees.     

Surgical treatment for hallux valgus with painful plantar callosities

We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989-1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively. At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.     

Metatarsophalangeal joint arthrodesis after failed Keller-Brandes procedure

BACKGROUND: Keller-Brandes resection arthroplasty for correction of symptomatic hallux valgus deformity can obtain early good results, but late complications, such as recurrence of the deformity and instability of the first ray, have been described. Arthrodesis of the first metatarsophalangeal, (MTP) joint can be done as a salvage procedure. The aim of this prospective study was to evaluate the clinical outcome of the arthrodesis and its effect on the biomechanics of the first ray. METHODS: Between October, 1999, and December, 2002, arthrodesis of the MTP joint was done after a failed Keller-Brandes procedure in 28 feet of 26 consecutive patients. Twenty patients (22 feet) with a minimum of 24 months followup were available for clinical and radiographic assessment. Pedobarographic measurements were obtained at latest followup in 16 patients (17 feet). RESULTS: Sixteen feet (72%) were pain-free and six feet (28%) had mild, occasional pain. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score increased from a preoperative 44 (range 29 to 67) points to 85 (range 73 to 90) points at longest clinical followup (average 34 months, range 23 to 48, p < 0.001). The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively (p < 0.001). Two feet had pseudoarthroses. Biomechanically, the MTP joint arthrodesis could not fully restore the function of the hallux but produced a significant improvement, allowing a more physiologic loading pattern under the hallux and the metatarsal heads. CONCLUSIONS: First MTP joint arthrodesis after a failed Keller-Brandes procedure is a technically safe and reliable technique. It resulted in a marked reduction of pain and gain of function that produced high patient satisfaction.     

The Effect of First Metatarsophalangeal Arthrodesis on Transverse Plane Deviation of the Second Toe: A Retrospective Radiographic Study

The purpose of this retrospective, radiographic study was to examine the effect of first metatarsophalangeal arthrodesis on the transverse plane deviation of the second metatarsophalangeal joint. Sixty-nine patients (76 feet) were separated into 3 groups based on preoperative diagnosis: group 1, hallux valgus; group 2, hallux rigidus; and group 3, rheumatoid forefoot deformity with concomitant lesser metatarsal head resection. Intermetatarsal, hallux abduction, and second metatarsophalangeal angles were measured on preoperative and follow-up anteroposterior radiographs. Multivariate analysis found a significant postoperative change (P < .001) in both the intermetatarsal and hallux abduction angles for all groups, but no significant change in the second metatarsophalangeal angle for any group. There was also no significant difference in the number of patients with medial versus lateral second toe deviation in each group. The addition of a second ray procedure, such as a digital arthrodesis or second metatarsal decompression osteotomy, in groups 1 and 2 did not correlate to the amount of change in second metatarsophalangeal deviation. However, there was a significant correlation (r = .330; P = .004) between the amount of change in the hallux abduction angle and the amount of change in the second metatarsophalangeal angle. A lack of change in the second metatarsophalangeal angle in patients with hallux valgus and hallux rigidus suggests that the creation of a stable medial buttress may protect the lesser digits. However, in patients with rheumatoid, this lack of change denotes a postoperative recurrence of lateral deviation of the second toe despite lesser metatarsal head resection and stabilization of the hallux.