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.     

Surgical considerations in hallux abducto valgus with rheumatoid arthritis

The rheumatoid arthritis patient often suffers with forefoot complaints. The most frequently seen pedal deformities are hallux abducto valgus and metatarsus primus adductus. Various surgical procedures have been developed to treat these disabling problems. Arthroplasty has been successfully utilized to relieve pain, but often leaves an unpleasant cosmetic result due to shortening and possible return of the deformity. Arthrodesis and implant arthroplasty are alternatives, but introduce other risks and complications for the patient and surgeon.     

Reliability of metatarsus adductus angle and correlation with hallux valgus

BackgroundMetatarsus adductus is a common congenital foot deformity. Variable prevalence values were reported using different techniques in different populations.Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods.The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus.Materials and methodsWeight bearing dorsoplantar radiographs of 150 feet were examined for 5 angles commonly used in assessing metatarsus adductus: angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference), Engel's angle and modified Engle's angle. The prevalence of metatarsus adductus was assessed according to published criteria for different techniques. Inter and intra-observer reliabilities of these angles were evaluated on 50 X-rays. Linear regression tests were used to assess the correlation between hallux valgus and different angles used in assessing metatarsus adductus.ResultsIntraclass correlation coefficients were high for intra- as well as inter-observer reliability for the 5 angles tested. Prevalence of metatarsus adductus ranged (45–70%) depending on the angle used in the same population. Only the metatarsus adductus angle using the 4th metatarso-cuboid joint as a reference demonstrated significant correlation between metatarsus adductus and hallux abductovalgus angles.ConclusionFive techniques commonly used in assessing metatarsus adductus demonstrated high inter and intra-observer reliability values. Prevalence of metatarsus adductus and the correlation between the severity of this deformity and hallux valgus angle is sensitive to the assessment method.     

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.     

The Syndesmosis Procedure Correction of Hallux Valgus Feet Associated With the Metatarsus Adductus Deformity

Metatarsus adductus and hallux valgus are common foot deformities. Corrective surgery of hallux valgus feet with metatarsus adductus deformity can be challenging and experience a high deformity recurrence rate. The purpose of this study was to demonstrate if the syndesmosis procedure can correct such feet satisfactorily without osteotomies and arthrodesis. 75 hallux valgus feet in 45 patients with a Sgarlato's metatarsal adductus angle ≥15° were studied after having undergone the syndesmosis procedure for an average of 20.22 months. Their average preoperative intermetatarsal angle of 12.56° was improved to 6.00° (p < .001) and metatarsophalangeal angle from 35.61° to 23.46° (p < .001) significantly. Their average American Orthopedic Foot and Ankle Society's clinical scores improved significantly from 56.41 to 90.53 points (p < .001). Fifty-five feet (73.33%) had preoperative metatarsal calluses, and all but 3 had a noticeable reduction in severity. Forty-one patients (91.11%) were able to return to their desired activities and footwear. All relevant raw data formed this study, including x-ray and photographic images, were submitted as Supplementary Material for online viewing and reference. Despite the possible intrinsic rigidity of metatarsus adductus forefoot, this study demonstrated that hallux valgus feet with metatarsus adductus deformity could be corrected anatomically and functionally with the soft tissue syndesmosis procedure and without correcting the preexisting metatarsus adductus deformity. This study also supports the notion that the MA deformity accentuates hallux valgus alignment preoperatively and postoperatively, and possibly all feet in general.     

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.     

Intrasubject Radiographic Progression of Hallux Valgus Deformity in Patients With and Without Metatarsus Adductus: Bilateral Asymmetric Hallux Valgus Deformity

This study was to analyze intrasubject radiographic progression of the hallux valgus deformity by comparing the mildly and severely affected sides in patients with bilateral asymmetric hallux valgus in the whole group as well as the metatarsus adductus and the nonmetatarsus adductus subgroups. A total of 186 patients with bilateral asymmetrical hallux valgus deformity with a difference of 5° or greater in the hallux valgus angle were included, and 11 radiographic measurements were analyzed. The radiographic differences between the mildly and severely affected sides were compared. Correlation between the changes in the hallux valgus angle and those in other measurements was analyzed, and multiple regression analyses were performed. The anteroposterior talo-second metatarsal angle showed no significant difference between the mildly and severely affected sides. Changes in the intermetatarsal angle and sesamoid rotation angle were significantly associated with the progression of hallux valgus angle in the whole group as well as the nonmetatarsus adductus subgroup. Change in the intermetatarsal angle (p = .006) was the significant factor associated with the progression of hallux valgus angle in the metatarsus adductus subgroup. The anteroposterior talo-second metatarsal angle might be useful in evaluating the overall foot shape in the hallux valgus deformity. Progression of the hallux valgus deformity might be pathophysiologically different between those with and without metatarsus adductus.     

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.     

A comparison of radiographic measurements in normal, hallux valgus, and hallux limitus feet.

This study investigated the differences in weightbearing, foot radiographs among normal subjects, those with hallux valgus, and those with hallux limitus. An intrarater reliability study of various x-ray measurements was conducted, utilizing seven dorsoplantar and six lateral measurements. The results showed that metatarsus primus adductus, increased metatarsal width, and a positive first metatarsal protrusion distance were associated with hallux valgus, whereas increased hallux interphalangeal angle was associated with hallux limitus.     

Metatarsus primus varus. A statistical study

A survey of 6000 schoolchildren discovered 36 cases of unilateral and 60 cases of bilateral hallux valgus, defined as a metatarsophalangeal angle of more than 14.5 degrees, measured on standing radiographs. Metatarsus primus varus was found not only in the early stages of hallux valgus but in the unaffected feet of children with unilateral hallux valgus. Adduction of the first metatarsal is not due to differential growth of the cortices of the first metatarsal nor is it a consequence of malalignment of the metatarsocuneiform joint. The intermetatarsal angle did not correlate with the angle of metatarsus adductus nor with the intercuneiform angle.     

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.     

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.     

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.     

The unified forefoot. II. The relationship between hallux valgus and metatarsus primus adductus

The relationship between hallux valgus and metatarsus primus adductus is examined mathematically. A high correlation relationship is established involving the use of total lateral deviation as a parameter. A model mechanism is briefly explored.     

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.     

Treating Hallux Valgus Associated Metatarsus Adductus by Minimally Invasive Surgery: A Simple Solution for a Difficult Problem

This study aims to assess a novel minimally invasive surgical technique that addresses hallux valgus accompanied by metatarsus adductus.We retrospectively analysed the results of 20 patients (21 feet) that underwent a newly developed percutaneous osteotomy procedure of the lesser metatarsal bones in order to correct hallux valgus deformities accompanied by metatarsus adductus. We used x-ray studies in order to evaluate changes in the hallux valgus angle, the first intermetatarsal angle, and the metatarsal angle (using the modified Sgarlato method). We also compared the pre- and postoperative American Orthopaedic Foot and Ankle Society scores when available. The paired sample t test was used to compare variables.At a 1-y follow-up the mean hallux valgus angle, inter-metatarsal angle and the metatarsal angle have been reduced by 31.62 (-3 to 9), 3.86 (11-52) and 14.69 (4-36) respectively (p < .001 for all). The mean American Orthopaedic Foot and Ankle Society score (n = 15 feet available) has been improved by a mean of 44.53 (22-72, p < .001). In addition, the patient satisfaction rates were high. Patients suffered from mild to moderate midfoot pain during the first few weeks following surgery, which resolved when union occurred. No cases of lesser metatarsal nonunion have been documented.The presented minimally invasive method can be used effectively to correct hallux valgus that is associated with metatarsus adductus. Proximal minimally invasive metatarsal osteotomy can effectively correct hallux valgus accompanied by metatarsus adductus.     

Metatarsus adductus and hallux abducto valgus: their correlation

Metatarsus adductus has long been suspected to contribute to hallux abducto valgus. This paper gives statistical evidence on the relationship between metatarsus adductus and hallux abducto valgus in an attempt to support this long held belief.