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.     

Tibial sesamoid planing procedure: an appraisal of 26 feet

The authors present their findings upon evaluation of 26 feet that had undergone a tibial sesamoid planing procedure. A preoperative method of radiographic evaluation is also presented. The subjective success rate was determined to be 88.8%, whereas the objective success rate was 76.9%, and a successful procedure was performed on feet with a first metatarsal declination angle not exceeding 8 degrees. It was also determined that the apparent postoperative changes in the hallux abductus and intermetatarsal angles were 0.73 degrees and 0.6 degrees, respectively. The authors believe this procedure does not significantly alter the biomechanics of the first metatarsophalangeal joint postoperatively.     

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.     

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.     

Predicting articular erosion in hallux valgus: Clinical, radiographic, and intraoperative analysis

The authors present a prospective intraoperative evaluation of the articular wear pattern of the first metatarsal, tibial and fibular sesamoids, and base of the proximal phalanx of 166 feet undergoing hallux valgus surgery. The collected data were compared with various clinical parameters and radiographic measurements to determine if any of these variables can predict the incidence and location of articular erosion. The incidence and predictability of the location of the articular erosion increased significantly as the patient's age ( P = .000), intermetatarsal angle 1-2 ( P = .004), hallux abductus angle ( P = .000), tibial sesamoid position ( P = .016), and proximal articular set angle ( P = .02) increased. The association of foot type (ie, digital length pattern), metatarsal protrusion distance, metatarsal head shape, and hallux abductus interphalangeus was not significant. Therefore, preoperative clinical parameters (ie, age) and radiographic measurements (ie, intermetatarsal angle 1-2, hallux abductus angle, tibial sesamoid position, and proximal articular set angle) can directly define the incidence and location of articular erosion and are helpful in the preoperative assessment of the hallux valgus deformity. In addition, nearly every first metatarsophalangeal joint evaluated had some degree of articular erosion and, in certain circumstances (ie, advanced age and increased proximal articular set angle), it was universal and extensive.     

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.     

Stabilization of the Chevron procedure for hallux valgus deformity with a capsuloperiostal flap.

This article reports on the use of a Chevron procedure in the treatment of hallux valgus for better stabilization of the osteotomy. This procedure was performed on 31 feet of 24 patients, Twenty-two of the patients were female and two were male. The average age was 41 and average follow-up time was 14 months. The average correction of the 1-2 intermetatarsal angle was 3.8 degrees and average correction of the hallux valgus angle was 15.3 degrees. On the follow-up, 93.5% of the feet were pain free and 81% did not have any discomfort with shoewear. There were two cases of superficial infection, and two patients complained of dysesthesia or hypoesthesia after the operation. Results revealed less correction loss, shorter union time, less metatarsophalangeal stiffness, and more postoperative patient tolerance. The authors attached the distally based "V"-shaped medial capsuloperiostal flap to the metatarsal shaft and, because of obtained stability, used no internal fixation or postoperative cast but only night splint, allowed weightbearing on the heel as soon as the patient tolerated it, and encountered no displacement of fragments, malunion, or recurrence of the deformity.     

Arthrodesis of the first metatarsophalangeal joint: a review of the literature and long-term retrospective analysis

A retrospective analysis of arthrodesis of the first metatarsophalangeal joint was done to determine the procedure's long-term subjective and objective results. The authors reviewed the long-term results of arthrodesis in 25 patients with 32 operated feet. The average age was 54.8 years (range 22 to 72 years), and the average length of follow-up was 31.9 months (range 12 to 84 months). The patients were questioned regarding pain, activity, cosmesis, and willingness to have the operation performed again. The subjective results were good or excellent in 26 feet (81% success rate). The primary postoperative complaints were pain in the interphalangeal joint (four feet), and a callosity or pain under the first metatarsal head (four feet). Radiographic examination revealed that the procedure provided a good reduction of the hallux valgus angle (preoperative average 33.7 degrees; postoperative average 17.4 degrees) and intermetatarsal angle (preoperative average 16.2 degrees; postoperative average 12.0 degrees). The authors believe that this procedure is a reliable, effective treatment whenever stability is required at the first metatarsophalangeal joint.     

Clinical and radiological results after modified distal metatarsal osteotomy for hallux valgus

BACKGROUND: The chevron osteotomy is an acceptable method for correction of mild and moderate hallux valgus, but can result in instability at the osteotomy site. The purpose of this study was to present clinical and radiological results with our modified technique of osteotomy. MATERIALS AND METHODS: We performed a modified technique of distal osteotomy of the first metatarsal on 77 feet of 46 patients with symptomatic hallux valgus; followed up for an average of 52 months. RESULTS: All of the patients experienced satisfactory pain relief and acceptable cosmesis. The mean postoperative reduction in the intermetatarsal angle was 6.5 degrees and of the metatarsophalangeal angle was 23.0 degrees. There was no loss of correction and there was no discrepancy in preoperative and postoperative lengths of the first metatarsal during the followup period. CONCLUSION: We found our modified distal metatarsal osteotomy to be an effective method of correcting hallux valgus.     

First metatarsophalangeal arthrodesis for treatment of hallux rigidus: a retrospective study.

This was a retrospective study of 17 patients (21 operated feet) treated with first metatarsophalangeal arthrodesis for hallux rigidus of varying severity levels. Patients were evaluated according to a modified American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal rating scale containing 60 subjective and 30 objective points. At an average follow-up time of 28.1 months, patients demonstrated a mean subjective improvement from 21.2 to 47.8/60, with mean total scores improving from 39.1 to 75.6/90. A comparison of pre- and postoperative radiographic angular measurements demonstrated a significant improvement (p = .001) in intermetatarsal, first metatarsal declination, and lateral talo-first metatarsal angles. Significant positive correlations were found between subjective results and patient age (p = .05) and the preoperative lateral talo-first metatarsal angles (p = .001).     

The geriatric bunion: correction of metatarsus primus varus and hallux valgus with the Swanson total joint implant

The authors have evaluated the long-term results of the Keller/Mayo bunionectomy with replacement of the first metatarsophalangeal joint with a Silastic double-stemmed implant (Swanson design). Examination of 50 preoperative and postoperative radiographs revealed a decrease in the hallux abductus angle of 21.46 +/- 2.66 degrees, and the intermetatarsal angle of 6.40 +/- 0.67 degrees; both of these figures have a statistically significant probability value of 0.05 attached. The mean patient age at time of surgery was 61.31 years; the mean follow-up time was 5.01 months. A literature review of implant arthroplasty for correction of hallux abducto valgus deformity is also presented.     

Early results of the modified Peterson bunion procedure for adolescent hallux valgus

Adolescent hallux valgus has a high recurrence rate after conventional surgical corrections. Excellent results have been reported with a double osteotomy of the first metatarsal fixed with a 3/16" transarticular pin. The present study reports the early results of using a medial plate and screws with an osteoperiosteal distally based flap to correct metatarsophalangeal joint subluxation, decrease recurrence from laxity in the medial capsular repair, and avoid intra-articular damage. The study included 18 feet in 16 patients (8 males, 8 females). All osteotomies healed primarily without complications, though there was recurrence in 3 undercorrected feet (2 patients). The average preoperative hallux valgus angle of 34 degrees was reduced to 16 degrees at a minimum 1-year follow-up. The average intermetatarsal angle improved from 14 degrees (before operation) to 6 degrees. No patient has requested plate removal.     

Scarf osteotomy for hallux valgus deformity: Radiological outcome,metatarsal length and early complications in 118 feet

BackgroundScarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia.MethodsWe enrolled 106 patients (118 feet) and assessed patients’ pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted.ResultsHallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45 mm. The Coughlin method showed the highest interrater reliability (ICC = 0.96).ConclusionsSignificant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability.Level of evidenceLevel IV.     

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.     

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.     

A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus: short-term follow-up and analysis.

Forty-seven patients (50 feet) underwent surgical intervention for symptomatic hallux rigidus between February 1998 and April 1999. Thirty-eight patients (41 feet) returned at 1 year for follow-up evaluation. Each foot was graded according to a four-stage hybrid radiographic grading system. At 1-year follow-up, 10 patients were classified as grade I, 17 as grade II, 12 as grade III, and 2 as grade IV. Subjective evaluation was based on a modified American Orthopaedic Foot and Ankle Surgery hallux metatarsophalangeal-interphalangeal 100-point scale. A pre- and postoperative objective physical examination and radiographic analysis were performed. Statistically significant differences between preoperative and postoperative values were found to exist for each portion of the subjective evaluation (p = .000); nonweightbearing dorsiflexion (p = .001); simulated weightbearing dorsiflexion (p = .003); metatarsal protrusion distance and angle of deviation of the second metatarsophalangeal joint (p = .000); and talar-first metatarsal angle (p = .015). For this specific patient population, the short-term results of surgical intervention for hallux rigidus provided subjective patient improvement and satisfaction, as well as a statistically significant but functionally minimal increase in first metatarsophalangeal joint dorsal range of motion. Additionally, in the 19 patients who underwent a periarticular decompression osteotomy, the intended correlation of plantar transposition of the capital fragment and offsetting the longitudinal shortening of the first metatarsal did not exist.     

First metatarsal head shape in juvenile hallux abducto valgus.

A round first metatarsal head has been implicated as a predisposing factor in hallux abducto valgus. The shape of one hundred first metatarsal heads was analyzed on 50 weightbearing dorsoplantar x-rays of 10-year-old children with a hallux abductus angle in excess of 15 degrees and osteophytic thickening of the first metatarsophalangeal joint. The metatarsals were subjectively described as either round or square. A measurement technique was then devised to quantify in millimeters the difference between the two types. Using chi-square analysis, a very strong statistical association (p less than 0.001) was found between the subjective assessment and the objective measurement. A weak relationship was found between the metatarsal head shape and the degree of hallux abducto valgus (HAV) (r = -0.294). While the trend of this correlation is consistent with accepted wisdom, that is, the squarer the metatarsal head the less the hallux abducto valgus, the association is not strong enough to scientifically confirm it. This finding along with the presence of so many square metatarsal heads in children with advanced HAV indicates that assessment of metatarsal head shape has little place in the scientific assessment of first metatarsophalangeal joint pathology.     

Early results of the modified Simmonds-Menelaus procedure for adolescent hallux valgus

Adolescent hallux valgus is a common problem, and there is no agreement about the best surgical technique to use to correct this deformity. Excellent results have been reported with a distal soft tissue procedure and an associated osteotomy at the base of the first metatarsal. The current study reports the early results of using an incomplete osteotomy at the base of the first metatarsal. No hardware was used to fix the osteotomy, and the postoperative immobilization was shorter. The study included 20 feet in 11 female patients. All osteotomies healed primarily without complications. The average preoperative hallux valgus of 31.2 degrees was reduced to 17.8 degrees at a minimum of 2 years follow-up. The average intermetatarsal angle improved from 13.5 degrees in the preoperative period to 11.3 degrees. Using the duPont bunion rating score as an outcome assessment, the authors had 4 excellent and 16 good results.     

BIOPRO resurfacing endoprosthesis versus periarticular osteotomy for hallux rigidus: short-term follow-up and analysis

Forty-four patients (47 feet) were enrolled in a prospective hallux rigidus study. A subjective evaluation, physical examination, and radiographic analysis were performed preoperatively and at a 1-year follow-up. Twenty patients (20 feet) underwent a periarticular osteotomy, with 16 patients (16 feet) returning. Seven patients (9 feet) underwent a BIOPRO resurfacing endoprosthesis, with all patients returning. The subjective evaluation was based on a modified American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal 100-Point scale. The physical examination included first metatarsophalangeal joint range of motion. Radiographic analysis included the metatarsal protrusion distance, transverse plane angulation of the second digit, lateral talo-first metatarsal angle, sagittal plane relationship of the first and second metatarsals, and hallux equinus angle. Statistically significant differences between preoperative and postoperative values were found for the periarticular osteotomy group for the metatarsal protrusion distance (P = .000), transverse plane angulation of the second digit (P = .000), and lateral talo-first metatarsal angle (P = .015). No other statistically significant differences between the pre-operative and post-operative values for either procedure group were found to exist. For this specific patient population the short-term results of surgical intervention for hallux rigidus, whether through a periarticular osteotomy or resurfacing endoprosthesis, provided subjective patient improvement and satisfaction, as well as, minimal increase in first metatarsophalangeal joint range of motion.     

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.