Bunion Surgery Research Articles

Early results of an intraosseous device for arthrodesis of the hallux metatarsophalangeal joint.

Background:Arthrodesis of the hallux metatarsophalangeal (MTP) joint is commonly done as a primary procedure either to correct severe hallux valgus deformities or for rheumatoid arthritis, hallux rigidus, in patients with neuromuscular disorders and as a salvage procedure for failed bunion surgery or infection. Prominent metalwork frequently can cause soft tissue impingement and thus require removal. In contrast, osteosynthesis with a completely intraosseous implant has the advantage of less damage to the periosteal circulation. We describe a surgical technique and the early results of arthrodesis of the hallux metatarsophalangeal (MTP) joint using an intraosseous fixation device.Materials and Methods:Twelve consecutive patients operated with this method were retrospectively reviewed. The average age was 57 years (range 44–88 years). A retrospective review of radiographs and electronic medical notes was conducted. The patients were also asked to fill a satisfaction questionnaire.Results:Overall fusion rate was 91% with a mean hallux valgus angle of 15° (range 4–20°) and a mean dorsiflexion angle of 20° (range 7–30°). Complications included a case of failed fusion, a delayed union, and a case of persisting transfer metatarsalgia. At a mean followup of 14 months (range 5–28 months), the mean visual analog scale improved significantly from a mean of 8.4 (range 7–10) preoperatively, to a mean of 3.1 (range 0–7) postoperatively (P < 0.0001). The mean American Orthopaedic Foot and Ankle Society hallux score also significantly improved from 29.4 (range 10–54) to a mean of 73.3 (range 59–90) (P < 0.0001). The final result was satisfactory for 83% of the patients.Conclusions:The early results show intraosseous fixation to be a safe and efficient method for the fusion of the hallux MTP joint providing relief from pain and patient satisfaction.

Correction of Recurred Hallux Valgus Deformity by Endoscopic Distal Soft Tissue Procedure

The underlying reason for recurrence of hallux valgus deformity after bunion surgery is multifactorial and includes surgeon-based and patient-based factors as well as original components of deformity initially unaddressed at the index procedure. Surgical treatment of a recurred hallux valgus deformity should be undertaken using the same guidelines for correction of a primary hallux valgus deformity. It requires correction of bony alignment, restoration of joint congruity, and achievement of soft tissue balance. The purpose of this Technical Note is to describe the details of endoscopic soft tissue procedure to correct a recurred hallux valgus deformity. To successfully complete this procedure, adequate lateral release to achieve soft tissue balance around the first metatarsophalangeal joint with reduction of the sesamoid bones is mandatory.

3D ultrasound estimation of the effective volume for popliteal block at the level of division

Abstract Local anaesthetic injection between the tibial and commmon peroneal nerves within connective tissue sheath results in a predictable diffusion and allows for a reduction in the volume needed to achieve a consistent sciatic popliteal block. Using 3D ultrasound volumetric acquisition, we quantified the visible volume in contact with the nerve along a 5 cm segment. Methods We included 20 consecutive patients scheduled for bunion surgery. Ultrasound guided popliteal block was performed using a posterior, out of plane approach at the level of division of the sciatic nerve. Thirty mL of mepivacaine 1.5% and levobupivacaine 0.5% were slowly injected while assessing the injection pressure and the diffusion of the local anaesthetic. Volumetric acquisition was performed before and after the block to quantify the volume of the sciatic nerve and the volume of the surrounding hypoechoic halo contained inside the connective tissue in a 5 cm segment. Results All blocks were successful within 20 min after the injection. The total estimated volume contained inside the common connective tissue sheath was 6.8 ± 2.6 cm 3 . Of this, the volume of the halo surrounding the nerve was 4.4 ± 1.7 cm 3 and the volume inside the sciatic nerve was 2.4 ± 1.7 cm 3 . Conclusions The volume of local anaesthetic in close contact with the sciatic nerve can be estimated by volumetric acquisition. Our results suggest that the effective volume of local anaesthetic needed for a successful sciatic popliteal block could be reduced to less than 7 mL.

Estimación del volumen de anestésico local en contacto con el nervio ciático en el bloqueo poplíteo

Local anaesthetic injection between the tibial and commmon peroneal nerves within connective tissue sheath results in a predictable diffusion and allows for a reduction in the volume needed to achieve a consistent sciatic popliteal block. Using 3D ultrasound volumetric acquisition, we quantified the visible volume in contact with the nerve along a 5cm segment. MethodsWe included 20 consecutive patients scheduled for bunion surgery. Ultrasound guided popliteal block was performed using a posterior, out of plane approach at the level of división of the sciatic nerve. Thirty ml of mepivacaine 1.5% and levobupivacaine 0.5% were slowly injected while assessing the injection pressure and the diffusion of the local anaesthetic. Volumetric acquisition was performed before and after the block to quantify the the volume of the sciatic nerve and the volume of the surrounding hypoechoic halo contained inside the connective tissue in a 5cm segment. ResultsAll blocks were successful within 20min after the injection. The total estimated volume contained inside the common connective tissue sheath was 6.8±2.6cm3. Of this, the volume of the halo sorrounding the nerve was 4.4±1.7cm3 and the volume inside the sciatic nerve was 2.4±1.7cm3. ConclusionsThe volume of local anaesthetic in close contact with the sciatic nerve can be estimated by volumetric acquisition. Our results suggest that the effective volume of local anaesthetic needed for a successful sciatic popliteal block could be reduced to less than 7ml.

Joint Manipulation Under Anesthesia for Arthrofibrosis After Hallux Valgus Surgery

Arthrofibrosis is a known complication of hallux valgus surgery. Joint manipulation under anesthesia has been studied for adhesive capsulitis of the shoulder; however, a paucity of published data exists on the use of this modality in the foot and ankle. The purpose of the present study was to investigate the outcomes of first metatarsophalangeal joint manipulation for arthrofibrosis that occurred as a complication of bunion surgery. The study population consisted of patients attending a single foot and ankle specialty clinic who were evaluated for arthrofibrosis after bunion surgery. Patients who underwent joint manipulation under anesthesia were asked to complete a research visit in which a clinical examination was performed and the presence and severity of joint pain were assessed. A total of 38 patients (34 females, 4 males, 53 feet), with a mean age of 55.7 ± 11.8 (range 30 to 83) years, agreed to participate. The mean follow-up period was 6.5 ± 3.4 (range 1 to 17) years. The visual analog scale scores improved significantly from baseline to the final follow-up visit (baseline 6.5 ± 1.5, range 2 to 10; final follow-up visit 2.3 ± 1.5, range 0 to 6; p < .001). Furthermore, joint motion had increased significantly (p < .001) for both dorsiflexion and plantarflexion at the final follow-up examination. The final range of motion (dorsiflexion, r = −0.431, p = .002; plantarflexion, r = −0.494, p < .001) correlated highly with patient self-reported pain in the first metatarsophalangeal joint. Our findings suggest that joint manipulation could be a useful modality for increasing first metatarsophalangeal joint mobility and alleviating pain in patients who experience arthrofibrosis after surgical correction of hallux valgus.

Does bunion surgery actually narrow the foot? Assessment of outcomes of surgery using traditional angles and a new radiographic measure of severity‐ the forefoot: hindfoot ratio. Correlation with clinical outcomes

Background Various angles have been used to grade the severity of hallux valgus deformity. They are useful in surgical planning but do not correlate with symptom severity or improvement. We feel that there is a fundamental mismatch between the width of the forefoot and the width of the hindfoot and that this is more clinically relevant, we describe two techniques for measuring this. We aim to measure the degree of foot narrowing after surgery and moreover how this correlates to the severity of preand post operative outcomes.

Using multimedia to enhance the consent process for bunion correction surgery

Obtaining informed consent from patients considering bunion surgery can be challenging. This study assessed the efficacy of a multimedia technology as an adjunct to the informed consent process. A prospective, cohort study was conducted involving 55 patients (7 males, 48 females) who underwent a standardized verbal discussion regarding bunion correction surgery followed by completion of a knowledge questionnaire. A multimedia educational program was then administered and the knowledge questionnaire repeated. Additional supplementary questions were then given regarding satisfaction with the multimedia program. Patients answered 74% questions correctly before the multimedia module compared with 94% after it (P < 0.0001). Patients rated the ease of understanding and the amount of information provided by the module highly. Eighty-four percent of patients considered that the multimedia tool performed as well as the treating surgeon. Multimedia technology is useful in enhancing patient knowledge regarding bunion surgery for the purposes of obtaining informed consent.

Reversal of Acute Complex Regional Pain Syndrome Using the Practical Application of Neurodiagnostic Evaluation Process: A Case Study

In 2005, a patient in my practice developed complex regional pain syndrome type 1 (CRPS 1) after bunion surgery. The condition was properly diagnosed within 4 weeks with a diagnostic technique that I routinely use to diagnose chronic musculoskeletal pain, and it was successfully treated. The tests, which are based on primitive and postural reflexes in infants, were adapted to reflect normal and abnormal motor behaviors in adults after provocation of reflexes of the autonomic nervous system (afferent C fibers in peripheral nerves). Approximately 60 days after my patient's operation, the tests indicated a positive reflex at the posterior tibial nerve in the operated foot. Surgery to remove an accessory ossicle from the talus adjacent to this nerve resolved the CRPS 1 within 2 weeks. Since CRPS 1 is a dysfunctional state of the autonomic regulatory control of pain, it was postulated that a test based on autonomic nerve function could isolate the source of CRPS 1. The Practical Application of Neurodiagnostic Evaluation process was shown to be diagnostic for the cause of acute CRPS 1 and to allow its reversal. Further evaluation of the test for diagnosis and treatment of CRPS is needed.

Prevention and treatment of hallux valgus

In hallux valgus, one of the most common conditions affecting the forefoot, the first metatarsophalangeal joint is progressively subluxed due to lateral deviation of the hallux and medial deviation of the first metatarsal. Patients usually complain of medial prominence pain, commonly referred to as "bunion pain," plantar keratotic lesions, and lesser toe deformities such as hammer toe or claw toe deformities. The etiology of hallux valgus is multifactorial. Narrow high-heeled shoes or excessive weight-bearing have been suggested to be extrinsic factors contributing to the condition, and many other intrinsic factors also exist, such as genetics, ligamentous laxity, metatarsus primus varus, pes planus, functional hallux limitus, sexual dimorphism, age, metatarsal morphology, first-ray hypermobility, and tight Achilles tendon. When we evaluate patients with hallux valgus, careful history taking and meticulous examination are necessary. On the radiographic evaluation, we routinely measure the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle, which are valuable parameters in decision making for bunion surgery. To prevent the development and progression of hallux valgus, a soft leather shoe with a wide toe box is usually recommended. The use of a toe separator or bunion splint may help in relieving symptoms. The purpose of hallux valgus surgery is to correct the deformity and maintain a biomechanically functional foot. When we decide on an adequate surgical option, we should consider the patient's subjective symptoms, the expectations of the patient, the degree of the de-formity, and the radiographic measurements in order to correct the deformity and prevent complications after surgery.

Ultrasound-Guided Ankle Block for Forefoot Surgery

Ankle blocks typically include the block of 5 nerves, the 4 branches that trace their origin back to the sciatic nerve plus the saphenous nerve (SaN). The sensory area of the SaN in the foot is variable. Based on our clinical experience, we decided to study the sensory distribution of the SaN in the foot and determine whether the block of this nerve is necessary as a component of an ultrasound-guided ankle block for bunion surgery. One hundred patients scheduled for bunion surgery under ankle block were prospectively studied. We performed ultrasound-guided individual blocks of the tibial, deep peroneal, superficial peroneal, and sural nerves. After obtaining complete sensory block of these nerves, we mapped the SaN sensory territory as such area without anesthesia on the medial side of the foot. Every nerve block was successful within 10 minutes of injection. The saphenous territory extended into the foot to 57 ± 13 mm distal to the medial malleolus. This distal margin was 22 ± 11 mm proximal to the first tarsometatarsal joint. The proximal end of the surgical incision was located 1 cm distal to the first tarsometatarsal joint. In only 3 patients (3%), the area of SaN innervation reached the proximal end of the planned incision. Ultrasound-guided ankle block is a highly effective technique for bunion surgery. The sensory territory of the SaN in the foot seems to extend only to the midfoot. According to our sample, 97% of the patients undergoing bunion surgery under an ankle block would not benefit from having a SaN block.

First Web Space Soft Tissue Release in Bunion Surgery: Functional Outcomes of a New Technique

The current approach to soft tissue release in bunion surgery is through an incision in the dorsum of the first web space between the first and second metatarsals. However, the soft tissue release through this approach can be excessive or inadequate for the correction required. In addition, it leaves a visible scar. A new technique described here provides a stepwise protocol to limit the extent of soft tissue release to only what is required for the correction. The purpose of this study was to evaluate functional outcomes of the new technique. The authors conducted a retrospective chart review of 76 patients (88 procedures) and functional outcome analysis of 38 patients (44 procedures) who underwent first web space release utilizing the new technique. The mean followup was 3.8 years. The mean age was 50.8 (range, 24 to 74) years; 98% were female patients and 2% were male. The majority of the patients (89%) had good or excellent results. The surgical scar was hidden between the first and second toes in the web fold. The average Olerud-Molander score was 86.4 out of 100. None of the patients reviewed had nerve injury, recurrence of deformity, hallux varus, or revision surgery. The new technique for the first web space soft tissue release was a reliable technique that can be used as an adjunctive surgical procedure in correction of hallux valgus. Since the incision is in the web fold, the resulting scar is hidden.

Hallux Valgus and First Ray Mobility

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. 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. 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 postoperative hallux valgus deformity, or the magnitude of hallux valgus correction. 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.

The Effect of Adductor Tendon Transposition in the Modified McBride Procedure

The modified McBride technique is widely used in bunion surgery. The aim of this report is to analyze the influence that transferring the adductor hallucis tendon had on the first intermetatarsal angle (IMA), hallux abductus angle (HAA), and tibial sesamoid position (TSP) when used to correct the hallux valgus deformity. A prospective study was conducted of 31 hallux abducto valgus patients. A modified McBride procedure was performed to repair the deformity. In 16 patients (group 1), the adductor tendon was transferred, and in 15 (group 2), it was not. The tendon transfer was at random. The preoperative and postoperative variables IMA, HAA, and TSP were measured and analyzed by means of univariate and multivariate statistics. In group 1, the preoperative values of the first IMA and the HAA averaged 13.5 degrees and 30 degrees , respectively, decreasing postoperatively to 10.3 degrees and 10.7 degrees . In group 2, the corresponding preoperative angles were 12.9 degrees and 25.6 degrees , and the postoperative angles were 9.7 degrees and 10 degrees . There were no statistically significant differences between the 2 groups in the correction of the IMA, HAA, and TSP. As measured by the aforementioned radiographic measurements, there is no advantage in transferring the adductor hallucis tendon to the first metatarsophalangeal joint capsule in the correction of hallux valgus.

Surgical Correction of Moderate and Severe Hallux Valgus

The painful bunion deformity is a common and relatively disabling condition that affects individuals of all ages. More than 150 procedures have been described for the treatment of hallux valgus, and the orthopaedic literature has focused predominantly on surgical management of this condition; however, successful treatment is often achieved with use of simple off-the-shelf orthotic devices and appropriate shoe-wear modifications. Given the potential for surgical complications, the substantial recovery period associated with bunion surgery, and patients' occasional dissatisfaction with the results of otherwise technically successful procedures, it is recommended that nonoperative treatment be initiated prior to proceeding with surgery. It is not uncommon for a patient with an asymptomatic bunion to actively seek surgical correction because of cosmetic concerns or because of an inability to wear fashionable shoes comfortably. While pain alone is not the only indication for surgery, it is not recommended that surgery be performed for cosmetic reasons alone. The American Orthopaedic Foot and Ankle Society has issued a position statement reflecting this1. Look for this and other related articles in Instructional Course Lectures , Volume 57, which will be published by the American Academy of Orthopaedic Surgeons in March 2008: • “Total Ankle Arthroplasty,” by James DeOrio, MD, and Mark Easley, MD Pain resulting from hallux valgus deformity is mechanical in nature and can have extrinsic and intrinsic causes. Most commonly, extrinsic pain is related to mechanical irritation of the prominent medial eminence by shoe-wear or is due to impingement of the hallux on the second digit. A painful callus may develop on the medial border of the hallux as a result of pronation of the digit, and pain beneath the second metatarsal head is also common as a result of the transfer of forces as the weight-bearing function of the hallux is compromised by …

Hallux Valgus and First Ray Mobility

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. 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. 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. 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.

Factors associated with satisfaction with bunion surgery in women: A prospective study

Background Hallux valgus is a common indication for foot surgery. Over 25% of patients are dissatisfied with the outcome. Objective To examine women's pre- and post-surgical characteristics, regarding satisfaction with surgery for hallux valgus (‘bunions’). Method Prospective cohort of 95 consecutive female patients (132 ‘foot cases’) undergoing bunion surgery. Baseline interview and questionnaire asked about attitudes to fashion and footwear, plus SF-36 general health survey. At 12 months post-surgery, patients who were ‘very pleased’ with their surgery were compared with everyone else regarding their pre-, peri- and post-operative characteristics. Results By 12 months, key SF-36 domains had significantly improved. The 75 foot operations ( n = 75/116, 64.7%) were associated with respondents being ‘very pleased’ with their foot surgery. Following adjustment, the odds of being ‘very pleased’ were severely reduced where respondents were not ‘very pleased’ their foot's appearance ( p < 0.001), or where foot pain was anything but absent ( p = 0.018). There was significant interaction between pre-operative expectations of resumption of hiking/sports activities and range of footwear able to be worn post-operatively. Conclusions The perceived appearance of their foot and range of shoes that women can wear, are crucial to womens’ satisfaction with the outcome of bunion surgery. The (total) alleviation of pain is also important.

Technique Tip: The Use of a Modified Interrupted Vertical Mattress Suture after Bunion Surgery

Technique Tip: The Use of a Modified Interrupted Vertical Mattress Suture after Bunion Surgery

Arthroscopic Release of First Metatarsophalangeal Arthrofibrosis

Various degrees of first metatarsophalangeal joint arthrofibrosis frequently occur in patients with bunion surgery or big toe trauma. In those patients with functional limitation who fail to respond to conservative treatment, surgery is indicated. We describe here an arthroscopic approach to first metatarsophalangeal release that is designed to improve functional results. Dorsomedial and dorsolateral portals are established at the medial and lateral sides of the extensor hallucis longus tendon. Through these 2 portals, the dorsal capsule is released and the medial and lateral joint gutters can be cleared up. The metatarsosesamoid compartment is approached through the straight medial portal and the working portal, the latter of which is located 4 cm proximal to the joint line between the abductor hallucis tendon and the medial head of the flexor hallucis brevis. Under visualization through the medial portal, adhesions around the sesamoid apparatus can be debrided with a shaver through the working portal. This completes the release of joint circumference and improves the motion range of the joint.

Fusion Rate of First Tarsometatarsal Arthrodesis in the Modified Lapidus Procedure and Flatfoot Reconstruction

The purpose of this study was to determine the overall first tarsometatarsal joint (TMTJ) union rate in patients after they had a modified Lapidus procedure or a TMTJ arthrodesis as part of a flatfoot reconstruction. We retrospectively reviewed the charts of 182 patients (201 feet) who had a modified Lapidus procedure or a TMTJ arthrodesis as part of a flatfoot reconstruction between May, 1997, and May, 2001; all had at least a 6-month followup. The data collected included age, gender, tobacco use, diabetic status, complications, and radiographic evidence of union. There were 167 women and 15 men. The right foot was operated on in 106 patients and the left foot in 95. The average age was 53 (range 11 to 87) years. First TMTJ arthrodesis healed uneventfully in 193 (96%), and eight (4%) had nonunions. Of those eight patients with nonunions, five had previous bunion surgeries, two were smokers, and one had diabetes. There were 25 (12%) patients with previous bunion surgeries and five of these (20%) had nonunions. Four patients (2%) had symptomatic nonunions resulting in revision. Of the 21 patients undergoing flatfoot reconstruction, none had a nonunion. One criticism of the modified Lapidus procedure is the unacceptable nonunion rate (10 to 12%). Out of the 201 feet, we had a 4% nonunion rate and a 2% revision rate, which is well below the reported nonunion rates. We also have found that patients with previous bunion surgery and recurrent deformity were at a higher risk for a nonunion. We believe that the modified Lapidus procedure and first TMTJ arthrodesis can achieve acceptable union rates and be successful for correcting hallux valgus with a hypermobile first ray and can also be applied to certain patients undergoing flatfoot reconstruction.

First Metatarsophalangeal Joint Motion After Hallux Valgus Correction: A Cadaver Study

Surgical correction of hallux valgus deformities often results in decreased first metatarsophalangeal joint (MTPJ) range of motion. Loss of motion has been shown to affect patient satisfaction. The purpose of this study was to evaluate the immediate change in MTPJ range of motion that occurs after a distal soft-tissue reconstruction (DSTR) and proximal metatarsal osteotomy (PMO). DSTR and PMO were done on 16 below-knee cadaver specimens with clinically apparent hallux valgus deformities. Two examiners assessed preoperative and postoperative dorsiflexion (DF), plantarflexion (PF), and the total range of motion of the first MTPJ. The hallux valgus angle (HVA) and 1-2 intermetatarsal angle (1-2 IMA) were measured on simulated weightbearing radiographs before and after operative correction. Changes in motion were analyzed and correlated with the angular measurements. The mean total range of motion preoperatively was 85.4 degrees (DF 70.5 degrees, PF 14.9 degrees) and significantly decreased (p < 0.005) 23.2 degrees to a postoperative value of 62.2 degrees (DF 47.9 degrees, PF 14.3 degrees). There was a significant (p < 0.005) decrease in DF (22.6 degrees) with the operative correction, but the loss of PF (0.6 degrees) was not significant (p = 0.7). There was no correlation between the magnitude of correction (HVA, 1-2 IMA) and the change in PF, DF, or total motion. Correction of a hallux valgus deformity with a DSTR and PMO is associated with an immediate loss of range of motion that primarily affects the DF arc of the first MTPJ. The selective loss of DF may be related to a nonisometric capsular repair or tight intrinsic musculature, although there was no correlation with the magnitude of angular correction. The immediate decrease in motion observed in this cadaver study underscores the importance of early postoperative joint mobilization to prevent long-term stiffness after bunion surgery.