Preliminary Results and Learning Curve of the Minimally Invasive Chevron Akin Operation for Hallux Valgus

Minimally invasive surgery is increasing in popularity. It is relevant in hallux valgus surgery owing to the potential for reduced disruption of the soft tissues and improved wound healing. We present our results and assess the learning curve of the minimally invasive Chevron Akin operation for hallux valgus. A total of 120 consecutive feet underwent minimally invasive Chevron Akin for symptomatic hallux valgus, of which 14 were excluded. They were followed up for a mean of 25 (range 18 to 38) months. The patients were clinically assessed using the American Orthopaedic Foot and Ankle Society score. Complications and patient satisfaction were recorded. The radiographs were analyzed and measurements recorded for hallux valgus and intermetatarsal angle correction. The mean age of the patients undergoing surgery was 55 (range 25 to 81) years. Of the 78 patients, 76 (97.4%) were female and 2 (2.6%) were male; 28 (35.9%) cases were bilateral. The mean American Orthopaedic Foot and Ankle Society score improved from 56 (range 23 to 76) preoperatively to 87 (range 50 to 100) postoperatively (p < .001). The mean hallux valgus and intermetatarsal angles preoperatively were 29.7° (range 12° to 46°) and 14.0° (range 8° to 20°). The corresponding postoperative angles were 10.3° (range 0° to 25°) and 7.6° (range 3° to 15°; p < .001). The patients were satisfied with the results of surgery in 87% of cases (92 of 106). The incidence of reoperation was 14% (15 of 106). These are the only reported results for this technique. They display a steep associated learning curve. However, the results are promising, and the learning curve is comparable to that for open hallux valgus surgery.     

距足母囊近端截骨并钛板内固定治疗中重度足母外翻

目的探讨距足母囊近端2.0 cm处Z型截骨并T型微型钛板内固定治疗中重度足母外翻的临床疗效。方法2009年11月至2013年6月,对50例(81足)中重度足母外翻患者行第一跖骨远端Z型截骨后T型微型钛板内固定治疗。结果术后随访3~36个月,患者足母外翻角(halluxv algus angle,HVA)减少了11°~23°,平均13.1°,跖骨间角(intermetatarsal angle,IMA)减少了5°~10°,平均6.6°。采用美国足踝矫形学会Maryland足功能评分系统评分:90~100分,79足,80~89分2足,优良率100%,未见感染,截骨处均获骨性愈合,畸形无复发。结论距足母囊近端截骨并微型钛板内固定治疗中重度足母外翻疗效可靠,值得推广。     

Reduction of Intermetatarsal Angle after First Metatarsophalangeal Joint Arthrodesis in Patients with Hallux Valgus

We present a radiographic review of 94 patients who underwent first metatarsophalangeal joint arthrodesis. The main focus of our review was to assess the change in the intermetatarsal angle (IMA). The change in the IMA was measured for the entire group and for 2 subgroups (IMA 11° to 15° and IMA >15°). The results of the angular measurements for the total data set were as follows: mean preoperative first IMA, 15.32° (range 11° to 24°), mean postoperative IMA, 9.88° (range 3° to 18°), and mean change in IMA of 5.44° (range −2° to 13°; p < .001). Group 1, with an IMA of 11° to 15°, included 52 patients, with a mean change in the IMA of 4.21° (range −2° to 9°; p < .001). Group 2, with an IMA greater than 15° (range 16° to 24°), included 42 patients, with a mean change in the IMA of 6.83° (range 2° to 13°; p < .001). The change in the preoperative to postoperative IMA in group 1 compared with that in group 2 was statistically significant (p < .001). The results of the present study have confirmed the observations of previous investigators that arthrodesis of the first metatarsophalangeal joint for hallux abducto valgus deformity results in a reduction of the IMA and that a proportionately larger reduction can be expected when the IMA is larger.     

Observed Changes in Radiographic Measurements of the First Ray after Frontal Plane Rotation of the First Metatarsal in a Cadaveric Foot Model

We observed the changes in the angular measurements commonly used in the evaluation of the first metatarsal and first metatarsophalangeal joint in cadaveric specimens before and after frontal plane rotation of the first metatarsal. Measurements of the first and second intermetatarsal angle (IMA), hallux abductus angle, proximal articular set angle, and tibial sesamoid position (TSP) were taken after varying degrees of varus and valgus rotation of the first metatarsal. Standard dorsoplantar radiographs were taken at 0°, 10°, 20°, and 30° of valgus rotation of the first metatarsal and repeated at 10°, 20°, and 30° varus rotation of the first metatarsal. The data were analyzed using a mixed linear model to compare the change in each angle measurement over the range of valgus and varus rotation. The change in the TSP was significant in both valgus and varus rotations (p = .0004 and p = .028, respectively), an increase in valgus rotation causing an increase in the TSP and an increase in varus rotation causing a decrease in TSP. The change in the IMA was significant compared with valgus rotation (p = .028), showing that as the valgus rotation increased, the IMA also increased. However, compared with the varus rotation, the correlation was not significant (p = .18). The proximal articular set angle and hallux abductus angle measurements, compared with metatarsal rotation, showed positive trends but were not statistically significant. From our results and a review of the published data, we have hypothesized that frontal plane rotation of the first metatarsal is an integral component of hallux abducto valgus pathologic features, specifically in relation to the TSP and IMA.     

第一跖列三平面截骨联合其余跖骨基底截骨治疗中重度跖内收型■外翻的早期疗效

目的探讨第1跖列三平面截骨联合其余跖骨基底截骨治疗中重度跖内收型[足母]外翻的早期疗效。方法2012年2月-2016年9月,收治10例(12足)中重度跖内收型[足母]外翻患者。男1例(2足),女9例(10足);年龄21~55岁,平均34.5岁。病程3~10年,平均5.8年。根据改良Sgarlato测量法对跖内收分度:中度4足、重度8足。术前美国矫形足踝协会(AOFAS)评分为(46.4±9.3)分;跖内收角(metatarsus adductus angle,MAA)为(25.41±3.66)°,[足母]外翻角(hallux valgus angle,HVA)为(41.42±9.67)°,第1-2跖骨间角(first-second intermetatarsal angle,1-2IMA)为(10.72±2.26)°。采用第1跖列三平面截骨联合其余跖骨基底截骨以及外侧软组织松解术治疗。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间18~24个月,平均21.4个月。1例(1足)术后出现转移性跖痛,对症处理后症状消失。X线片复查示截骨部位均愈合,愈合时间为2.4~3.2个月,平均2.8个月。末次随访时,MAA为(8.42±0.71)°、HVA为(13.29±1.03)°、1-2IMA为(4.41±0.48)°,AOFAS评分为(89.8±5.9)分,均较术前明显改善(P<0.05)。结论第1跖列三平面截骨联合其余跖骨基底截骨治疗中重度跖内收型[足母]外翻,可获得较好早期疗效。     

Association between preoperative dynamic plantar pressures and clinical outcomes at 6 months after hallux valgus surgery

BackgroundThe influence of preoperative plantar pressures on clinical outcomes following hallux valgus surgery has not been yet established. This study aimed to assess the relationship between preoperative dynamic plantar pressure measurements and clinical outcomes following hallux valgus surgery.Material and methodsA prospective cohort study where patients attending the foot and ankle unit between 2016 and 2017, diagnosed of hallux valgus requesting surgical correction were recruited consecutively and preoperative plantar pressure were measured. At 6-months after surgery, the foot condition and foot pain were measured, through the American Orthopedic Foot and Ankle Society Score (AOFAS), and using Visual Analog Scale (VAS), respectively. A multivariate logistic model was used to estimate the magnitude of the associations between the explanatory variables and outcomes.Results114 patients were included in the study. Significant differences between patients with and without pain at 6-months after surgery were found in mean force on first toe, peak pressure on third and fourth metatarsal head, and maximum force on fourth and fifth metatarsal head (p < 0.05). The multivariate logistic model showed significant association between the preoperative peak pressure on fourth metatarsal head (OR:0.996, p = 0.003), walking (OR:7.430, p < 0.001), orthopedic shoe after surgery period (OR:0.754, p = 0.019) and preoperative AOFAS (OR:0.947, p = 0.006), and the appearance of pain at 6-months after surgery.ConclusionThe presence of pain at six months after surgery was significantly associated with the preoperative peak pressure under the fourth metatarsal head.     

Effects of Total Hip Arthroplasty on Axial Alignment of the Lower Limb in Patients with Unilateral Developmental Hip Dysplasia (Crowe type IV)

BackgroundThe aim of this study was to evaluate the influence of total hip arthroplasty on axial alignment of the lower limb in adults with unilateral developmental hip dysplasia (Crowe type IV).MethodsWe retrospectively reviewed medical records of 50 adults who underwent total hip arthroplasty, in which the acetabular cup was placed in the anatomical position. The following parameters were measured before surgery, immediately after surgery, and two years later: mechanical axis deviation (MAD), tibiofemoral angle (TFA), femoral offset, hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (LDFA), mechanical medial proximal tibial angle, height of medial femoral condyle, height of lateral femoral condyle, and leg lengthening. Length of the resected femoral segment was also recorded from medical records.ResultsPreoperative MAD, TFA, HKA, and LDFA of the ipsilateral lower limb showed significant valgus deformity. MAD of the ipsilateral lower limb and valgus inclination were significantly smaller immediately after surgery than before, while TFA, HKA, femoral offset, and LDFA were significantly larger (P < 0.05). These parameters did not differ significantly between immediately after surgery and two years later (P > 0.05). Ipsilateral extremities were extended by a mean of 2.54 cm (range, 0 to 5.35 cm). The mean length of the femoral resected segment was 3.56 cm (range, 2.03 to 5.74 cm). The contralateral lower limb showed marginally smaller MAD and medial proximal tibial angle after surgery than before, but larger LDFA, TAF, and HKA.ConclusionsIn patients with developmental hip dysplasia who underwent total hip arthroplasty with placement of the acetabular component at the level of the anatomic hip center, axial alignment of the ipsilateral lower limb was immediately altered, and valgus inclination was significantly reduced. The procedure only slightly altered the axial alignment of the contralateral lower limb.