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 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.     

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.     

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.     

Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release

Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15°, or hallux valgus (HV) angle > 30°]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1° preoperatively and 14.6° postoperatively. The respective values for the IM angle were 17.8° and 7.8°. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15° or HV angle > 30 °). Received: 28 July 1999     

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.     

Ludloff截骨治疗中重度拇外翻的临床疗效观察

目的研究Ludloff截骨术对中、重度拇外翻的治疗效果。方法 2007年9月至2008年10月对26例（34足）中、重度拇外翻患者使用Ludloff截骨配合远端软组织手术进行矫形手术治疗,截骨使用螺钉固定。男4例,女22例,年龄48～67岁,平均58岁。术后采用AOFAS评分对患足进行临床功能评价,同时拍负重位足的正侧位X线片进行影像学评价,比较术后AOFAS评分及跖拇角和第一二跖间角的变化,了解患者的满意程度。结果平均随访时间25个月（19～36个月）。在最后一次随访时,31足基本无痛,3足偶有疼痛或轻微疼痛。患者对拇外翻畸形纠正满意。AOFAS评分为从术前的51分（27～65分）提高到术后的88分（72～96分）,HVA从术前的31°（21°～42°）改善为10.3°（7°～15°）,IMA从术前的17°（16°～23°）改善为术后的7.8°（6°～10°）。23例（31足）患者对治疗效果满意,3例（3足）比较满意。所有患者均对外形满意。没有严重的并发症出现。结论 Ludloff截骨术是治疗中重度拇外翻可靠有效的方法。     

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.     

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.     

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.     

Fixation of metatarsal osteotomies in the treatment of hallux valgus

Osteotomies as a treatment for hallux valgus require careful preoperative planning and meticulous attention to surgical technique. The procedure selected should be tailored to fit the deformity. For a patient with mild hallux valgus, the chevron osteotomy is the most intrinsically stable of the distal osteotomies and has the least potential for complications. Interest in the Ludloff osteotomy has had a resurgence because of its improved stability compared with more traditional osteotomies for correction of metatarsus primus varus. This osteotomy, however, is less forgiving and more dependent on technique than other procedures. The proximal chevron osteotomy, with plantar-to-dorsal screw placement, is easier to perform than the Ludloff and provides excellent stability. Regardless of the osteotomy used, screw fixation has been shown to be mechanically superior to all other modes of fixation (K-wire, staples, or no fixation). Postoperatively, a hard-soled postoperative shoe that permits weight-bearing on the heel and lateral foot is recommended; however, for the more unstable osteotomies and for those performed in patients with poor bone quality, a period of non-weight-bearing should be considered. Future studies with cyclic loading may help modify these current postoperative restrictions.     

Large displacement distal chevron osteotomy for the correction of hallux valgus deformity.

In order to assess outcomes and complications, a retrospective study of 38 bunionectomy cases with large displacement distal chevron osteotomy (greater than or equal to 40% lateral translation) for hallux valgus was performed. Follow-up ranged from 12 to 130 months (average, 31 months). Subjective analysis consisting of the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale was performed. Preoperative and postoperative radiographic intermetatarsal (IM) angles and hallux abductus angles were measured and compared. The average postoperative AOFAS score was 93.5. The average preoperative IM angle was 15.03 degrees (range 8 degrees-24 degrees) and the average postoperative IM angle was 4.84 degrees (range, -1 degree-11 degrees). The average preoperative hallux abductus angle was 29.39 degrees (range, 16 degrees-53 degrees) compared to the average postoperative hallux abductus angle of 11.39 degrees (range, 2 degrees-28 degrees). It was found that an average lateral translation of 9.8 mm was able to achieve a relative change of the IM angle of 10 degrees. Evidence is presented that supports the fact that large displacement distal chevron osteotomies can be safely performed for the correction of metatarsus primus varus greater than 15 degrees associated with 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.     

The scarf osteotomy for severe hallux valgus

We reviewed the outcome of 33 patients (45 feet) treated by scarf osteotomy for hallux valgus deformity with an intermetatarsal (IM) angle equal to or greater than 16 degrees. The average follow-up was 26 months. The hallux valgus angle improved by an average of 21.1 degrees from a preoperative mean value of 32.1 degrees. The IM 1-2 angle improved an average of 9.9 degrees from a preoperative mean value of 18.3 degrees. American Orthopedic Foot and Ankle Society (AOFAS) score changed from a preoperative average of 35.7 points to 89.8 at follow-up. Our midterm results indicate that the scarf osteotomy provides an effective method for the treatment of severe bunion deformity.     

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.     

Correction of hallux valgus and metatarsus primus varus. Using the Cedell technique

The Cedell procedure consists of: a proximal valgus osteotomy of the first metatarsal bone to correct the metatarsus primus varus, a soft tissue plasty at the first metatarsophalangeal joint with lateral release, and tightening of the medial capsule to correct the hallux valgus. A total of 45 operations in 31 patients (2 men and 29 women) were performed. Forty-one of these operations were followed. The average age at surgery was 24 years (range 16 to 43 years), and the average follow-up time was 23 months (range 8 to 56 months). The postoperative decrease in the intermetatarsal angle averaged 10 degrees, and the average decrease in the metatarsophalangeal angle was 26 degrees. Only a few postoperative complications were observed. At the time of follow up, 75% of the patients had no pain, 23% had only slight pain, and 2% had severe pain. Ninety-five percent were cosmetically satisfied with the operation. The Cedell operative technique has proved to be an effective procedure to correct the combined hallux valgus and metatarsus primus varus in younger patients.     

Basal osteotomy with lateral soft tissue release and medial plication in the correction of moderate to severe hallux valgus

Moderate and severe hallux valgus usually consists of metatarsus varus and incongruency of the joints. Basal osteotomy and distal soft tissue release provides adequate correction of intermetatarsal angle (IMA) and joint alignment.This is a retrospective study of 26 feet in 20 patients. American Orthopaedics Foot and Ankle Society Score (AOFAS) and subjective grading system for patient's satisfaction were used for assessment. The surgical technique consisted of crescentic basal osteotomy, lateral distal soft tissue release and medial capsular plication according to Roger Mann. Fourteen osteotomies were fixed with K wires and Barouk Screws were used in 12 feet. Patients were mobilised in high heeled shoe post-operatively.Average age was 55.2 years and average follow-up was 25.8 months. The average preoperative hallux valgus angle (HVA) and IMA were 37.38 and 17.27°, respectively. The average post-operative HVA and IMA were 13.3 and 6.4°, respectively. All incongruent joints became congruent after surgery. Sesamoid position improved in 25 feet. Average AOFAS score was 88.8. Ninety-four percent patients were highly satisfied.Complications included breakage of K wire in one leading to change in practice, decreased sensations over medial side of toe in three and mild metatarsalgia in one foot.Basal osteotomy with distal soft tissue release provides good correction of moderate to severe deformity and has high patient satisfaction. Barouk screw provides stable fixation.     

微创截骨治疗(足母)外翻的远期疗效分析

目的 评价微创截骨治疗(足母)外翻的远期疗效.方法 对1996年2月至1999年5月在我院行微创截骨治疗的(足母)外翻患者进行回顾性分析,共79例(150足)获得5年以上随访,男6例(10足),女73例(140足);年龄13～75岁,平均47岁.术后随访5.3～13.2年,平均7.5年.观察手术前、后(足母)外翻角(hallux valgus angles,HVA),第一、二跖骨间角(intermetatarsal angles,IMA),胫侧籽骨位置(tibial sesamoid bone position,TSP),(足母)趾-跖趾-趾间关节美国足与踝关节协会(American orthopedic foot and ankle society,AOFAS)评分,第一跖趾关节活动度和第二、三跖骨头下胼胝体(肼胝痛)等指标.根据温建民等的临床疗效评价标准(2001年)对临床疗效进行评价.结果 临床疗效评价优56足,占37.3%;良88足,占58.7%;差6足,占4.0%;优良率为96.0%(144/150).术后AOFAS评分为60～100分,平均(84.20±4.32)分.HVA较术前矫正20.97°;IMA较术前矫正4.95°;TSP较术前矫正1.22;第一跖趾关节活动度减少0.67°.术前合并有跖骨头下疼痛97足,占64.7%.术后疼痛消失35足(23.3%),疼痛改善54足(36.0%),疼痛无改善(或加重)8足(5.3%).结论 微创截骨治疗(足母)外翻方法简单、并发症少、远期疗效肯定,是治疗(足母)外翻的一种较好的、疗效可靠的手术方法.