Distal Soft Tissue Reconstruction Research Articles

Assessment of the Initial Result of Screw Fixation for Proximal Crescentic Metatarsal Osteotomy with Distal Soft Tissue Reconstruction in Severe Hallux Valgus Treatment.

Proximal crescentic metatarsal osteotomy and distal soft tissue reconstruction have been introduced to correct severe HV. The intrinsically unstable proximal first crescentic osteotomy depends on enough force fixation for stability. It is necessary to judge the number of fixation screws for osteotomy. Fifty-two feet of 50 adult patients with severe HV were included in this study. The treatment was proximal crescentic metatarsal osteotomy with a single screw and distal soft tissue reconstruction in Group 1 and the fixation with two screws with distal soft tissue reconstruction in Group 2. Clinical and radiological follow-ups were assessed after 4 and 12 months of operation. In Group 1, HVA decreased from 46.4 ±3.28 to 19.9 ±4.70 after 12 months of operation and from 45.1 ±3.45 to 19.1 ±4.70 in Group 2. Regarding the intermetatarsal angle (IMA) in Group 1, it was changed from 18.5 ±1.98 to 9.25 ±1.11 after 12 months of operation. For group 2, it decreased from 18.3 ±1.81 to 9.53 ±1.70. Meanwhile, the AOFAS score improved from 63.1 to 83.9 after 12 months of operation in Group 1 and improved from 64.3 to 82.8 in Group 2. Furthermore, the VAS score reduced from 4.5±1.01 to 1.7± 0.43 in Group 1 and from 4.7±0.92 to 1.7±0.55 in Group 2 after 12 months of operation. There were no significant differences identified between Group 1 and Group 2 in terms of VAS and AOFAS scores and HVA and IMA measurements. There is less complication in two-screw fixation for crescentic osteotomy compared to a single-screw fixation.

Randomised control trial on the optimal duration of non-weight-bearing walking after hallux valgus surgery

IntroductionHallux valgus surgery is one of the most commonly performed operations in Orthopaedics. Multiple surgical techniques have been described including arthrodesis, osteotomies and soft tissue procedures. The endoscopic-assisted distal soft tissue procedure is one of the minimally invasive surgical options with a good long-term outcome. The rehabilitation protocol for this soft tissue procedure consists of 6-weeks of non-weight bearing walking. This prolonged period of non-weight-bearing walking may ensure a good stabilization of the alignment but is difficult for the patient from a social-economical perspective. In addition, earlier mobilisation has other theoretical advantages including less atrophy and better range of motion. The objective of this trial is to investigate the effect of an earlier weight-bearing regime at 2-weeks post-surgery. MethodsRandomised control trial of patients undergoing the endoscopic-assisted distal soft tissue procedure. Allocation and randomization of subjects were performed immediately after completion of surgery to avoid intra-operative biases. The control group underwent the usual protocol of 6-weeks of non-weight-bearing walking while the intervention group underwent 2-weeks of post-operative non-weight-bearing walking. Foot function was measured using the Foot and Ankle Outcome Score (FAOS) at the baseline, 12-week post-surgery and 26-weeks post-surgery. The hallux valgus angle, 1,2 inter-metatarsal angle and tibial sesamoid position were also measured during those time-points. ResultsA total of 51 participants completed the study, 29 in the control group and 22 in the early weight-bearing group. 1 patient form the early weight-bearing group was complicated with hallux varus requiring revision surgery. All the patients had significantly improved radiological angles and foot function in both the control and early weight-bearing group. At the 12-week time point, the radiological angles were the same for both groups but foot function was significantly better in the early weightbearing group. DiscussionEarly postoperative weight-bearing did not lead to pre-mature implant failures or increased recurrence rates. It actually resulted in fewer symptoms like stiffness, lessened pain, better performance in daily activities and a better quality of life. ConclusionEarly weight-bearing walking at 2-week after distal soft tissue reconstruction of hallux valgus is not only safe, it may help accelerate the rehabilitation process and allow patients to return their usual life faster.The translational potential of this article: Being a clinical trial, our results are directly translatable to hallux valgus patients. The results of this study show that a shortened non-weight bearing duration after hallux valgus surgery improves foot function at 12 weeks while not affecting recurrence risks.

Modified Chevron osteotomy combined distal soft tissue reconstruction to treat high-grade bunionette deformity

To explore the surgical method of using the modified chevron osteotomy combined distal soft tissue reconstruction to treat high-grade bunionette deformity. From June 2013 to June 2015, the modified chevron osteotomy combined distal soft tissue reconstruction was used for surgical treatment of high-grade bunionette deformity in the Department of Hand and Foot Microsurgery in Xuzhou Central Hospital.Twenty-six patients with 28 feet high-grade bunionette deformity were hospitalized for treatment, with 3 male (3 feet) and 23 female (25 feet) cases, aged 22-73 (mean 47.1) years old.The average fourth-fifth intermetatarsal angle, lateral deviation of the fifth metatarsal angle and metatarsophalangeal-fifth angle were measured on the pre-and post- operative anterior to posterior weight-beating X rays of treated feet.The American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale was used to evaluate the post-operative outcomes. All of 26 patients were followed, with a mean 15.7 months (range 8-25 months). Primarily healing of the wound was achieved in all cases.No postoperative infection and nonunion on the osteotomy site was found during the follow-up time.The fracture healing time was 6-15 (mean 12.2) weeks.All the patients had satisfactory appearance and sensory function without callosum and metastatic metatarsalgia at the final follow-up.The post-operative fourth-fifth intermetatarsal angle, lateral deviation of the fifth metatarsal angle and metatarsophalangeal-fifth angle were significantly lesser than the pre-operative at the 6th week after operation, respectively [(5.5±1.7)°, (2.1±0.8)°, (5.7±2.6)°vs (16.4±4.2)°, (6.0±2.2)°, (10.5±7.4)°; all P<0.01]. The post-operative AOFAS score was significantly greater than the pre-operative [(87.1±6.7) vs (62.3±9.8) points, P<0.001]. The modified chevron osteotomy combined distal soft tissue reconstruction is a safe and easy treatment option for the high-grade bunionette deformity and provides patient satisfaction results.

The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction to treat severe hallux valgus

To explore the method of the treatment for hallux valgus with the proximal crescentic osteotomy of the first metatarsal bone, combining with distal lateral soft tissue release. From January 2008 to December 2012, 21 cases 21 hallux valgus feet were treated by operative procedure, included 1 male (1 foot) and 20 females (20 feet), with the mean age of 52 years (range, 36-68 years). Among all patients were followed up for 12 to 26 months, with the mean 16 months. The preoperative, post-operative and final follow-up X-ray films of all patients were collected. The hallux valgus angle, intermetatarsal angle and distal metatarsal articular angle were measured and analyzed. The surgical outcome was evaluated combined with the AOFAS score. The average hallux valgus angle decreased from 42.3° ± 1.8° preoperatively to 14.5° ± 1.8 postoperatively, the average intermetatarsal angle did from 21.9° ± 1.7 to 9.1° ± 1.8°, and the average distal metatarsal articular angle did from 14.9° ± 1.8 to 7.2° ± 1.5, respectively. There were significant differences between the preoperative and postoperative roentgenographic index. AOFAS score was improved from 44.0 ± 1.8 preoperatively to 83.9 ± 2.2 at the final follow-up. The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction obtained satisfactory results in severe hallux valgus patients with big intermetatarsal angle.

Response to the comment on Schuh et al.: Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

Dear Prof. Pecina, We greatly appreciate the comments offered by Dr. He and Dr. Peng regarding the recent publication “Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity” [1]. To the raised claims I would like to comment as follows: He and Peng detected six studies included in our meta-analysis to be suspicious for double-counting patients [2–7]. I reviewed these publications once again and concluded that for the publications from Coughlin et al. [2, 3] this is not the case. Coughlin’s publication from 2005 entitled “Proximal metatarsal osteotomy and distal soft tissue reconstruction as treatment for hallux valgus deformity” was a review article which contains results of 27 juvenile patients (33 feet) with hallux valgus. These patients were operated over an 11-year period and were part of the patient cohort from Coughlin’s study concerning juvenile hallux valgus published in 1995 [8]. The 103 patients (122 feet) treated with proximal crescentic osteotomy whose results were presented in 2007 [3] were all operated between September 1999 and May 2002. Therefore, the authors did not include overlapping patient data from Coughlin et al. Sammarco et al. reported results of the proximal chevron osteotomy in 1993 and in 1998 [4, 5]. The first study comprised 43 patients (51 feet) with a mean age of 48 years (range 12–81) [4]. The second study included 55 patients (72 feet) with a mean age of 56 years (range 24–81) [5]. In this case there are perhaps some patients who were included in both studies. However, in the study cohort from 1998 they reviewed the case records of 69 patients and, due to the deaths of unrelated causes of two patients (two feet), the lack of adequate follow-up from six patients (eight feet) and the exclusion of six patients with adolescent bunion or rheumatoid arthritis (six feet), 55 patients with 72 operated feet remained. This demonstrates that not the whole patient cohort from the former published study was included in the later study. Lee at al. published a prospective randomized study comparing two axial K-wires with a supplementary transverse K-wire for proximal chevron osteotomy fixation [6]. The two cohorts contained 32 patients (41 feet) and 33 patients (44 feet), respectively. One year later Lee et al. published a retrospective comparative study with a patient group treated with unilateral and a group operated upon simultaneously for hallux valgus correction (52 patients, 69 feet) [7]. All patients in this study underwent the same surgical technique, in particular axial K-wire fixation with two K-wires. The apprehension of He and Peng could indeed be correct in that we included some of Lee’s patients in duplicate into meta-analysis. Concerning the publication language, the authors did not restrict our systemic search to any languages. During the review process all publications revealed by the online databases MEDLINE, EMBASE, CINAHIL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, using the MeSH terms “(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR ludloff) AND osteotomy” have been reviewed. Studies had to meet the inclusion criteria and a manual reference check of all accepted papers was performed to supplement the electronic search. Finally, only English- and German-language studies were eligible for meta-analysis We would like to provide the funnel plots for delta IMA (Fig. 1) and delta HVA (Fig. 2). In consequence of a limitation in figure submission and publication the authors renounced the attachment of the drawn funnel plots in our original paper. Fig. 1 Funnel plot for the delta intermetatarsal angle (IMA) meta-analysis Fig. 2 Funnel plot for the delta hallux valgus angle (HVA) meta-analysis He and Peng raised some legitimate thoughts regarding our publication “Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity” [1]. After careful reflection we concluded that the study from Sammarco et al. [4] and the axial K-wire fixation group from Lee et al. [6] should be excluded from meta-analysis. As already mentioned, further high-quality prospective comparative studies are required and might change the observed effects.

Management of Severe Hallux Valgus Using Combined Proximal Closing Osteotomy with a Distal Soft Tissue Reconstruction

Background: many surgical procedures were described for correction of hallux valgus and the type of operation is based upon; foot length, width and redressibility of the transverse arch, hallux valgus evaluation of possibility of its passive redression and radiographic examination of foot. Aim of the work: To evaluate the results of hallux valgus surgery combining the distal soft tissue reconstruction (DSTR) or modified McBride procedure and proximal closing wedge osteotomy of the first metatarsal base. Patients and methods: This prospective study, was performed in King Abdul-Aziz Hospital, Taif, Saudi Arabia. The study was approved by the local committee of human research, and all patients gave written informed consent to participation. Ten patients (8 women and 2 men) with mean age of 28 years (18-40 years) were included in the study with 16 surgeries. The mean postoperative follow-up was 36 months (28 – 48). The operative technique performed in these patients was a combination of DSTR with closing osteotomy of the first metatarsal base. Results: The mean pre-operative intermetatarsal 1-2 angle (IMA) revealed by radiographs was surgically corrected from 20.3 degrees at the baseline to the mean degree of 7.9. The mean pre-surgical hallux valgus angle (HVA) was 44.9 degrees proved by radiographs was surgically improved to 11.7 degrees, and 3 years after operation it reached 12.3 degrees (mean). Ninety percent of patients were satisfied with their surgical results and cosmetic improvements were achieved in 93.7 % (15/16 feet in 9 patients). Conclusion: The combination of wedge osteotomy of the first metatarsal base and the distal soft tissue reconstruction (DSTR) or modified McBride procedure is suit­able in the treatment of young patients having severe forms of hallux valgus and minimum arthritic changes in metatarsophalangeal joint with increased IM.

Management of Severe Hallux Valgus Using Combined Proximal Closing Osteotomy with a Distal Soft Tissue Reconstruction

Background: many surgical procedures were described for correction of hallux valgus and the type of operation is based upon; foot length, width and redressibility of the transverse arch, hallux valgus evaluation of possibility of its passive redression and radiographic examination of foot. Aim of the work: To evaluate the results of hallux valgus surgery combining the distal soft tissue reconstruction (DSTR) or modified McBride procedure and proximal closing wedge osteotomy of the first metatarsal base. Patients and methods: This prospective study, was performed in King Abdul-Aziz Hospital, Taif, Saudi Arabia. The study was approved by the local committee of human research, and all patients gave written informed consent to participation. Ten patients (8 women and 2 men) with mean age of 28 years (18-40 years) were included in the study with 16 surgeries. The mean postoperative follow-up was 36 months (28 – 48). The operative technique performed in these patients was a combination of DSTR with closing osteotomy of the first metatarsal base. Results: The mean pre-operative intermetatarsal 1-2 angle (IMA) revealed by radiographs was surgically corrected from 20.3 degrees at the baseline to the mean degree of 7.9. The mean pre-surgical hallux valgus angle (HVA) was 44.9 degrees proved by radiographs was surgically improved to 11.7 degrees, and 3 years after operation it reached 12.3 degrees (mean). Ninety percent of patients were satisfied with their surgical results and cosmetic improvements were achieved in 93.7 % (15/16 feet in 9 patients). Conclusion: The combination of wedge osteotomy of the first metatarsal base and the distal soft tissue reconstruction (DSTR) or modified McBride procedure is suit­able in the treatment of young patients having severe forms of hallux valgus and minimum arthritic changes in metatarsophalangeal joint with increased IM.

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.

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.

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

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. 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. 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. 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.

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.

Proximal metatarsal osteotomy and distal soft tissue reconstruction as treatment for hallux valgus deformity

The correction of a hallux valgus deformity with a proximal 1(st) metatarsal osteotomy and distal soft tissue repair is achieved with a three-incision technique. A lateral soft tissue release and reconstruction at the first metatarsophalangeal joint releases contracted structures including the lateral capsule, the transverse inter-metatarsal ligament and the conjoint adductor tendon. Rarely is the lateral sesamoid excised. Through a medial incision, the medial eminence or exostosis is resected. The sesamoids are realigned and the medial capsule is reefed. With a third incision, a proximal first metatarsal osteotomy is performed that corrects a widened 1-2 intermetatarsal angle. With correction of the hallux valgus and the 1-2 intermetatarsal angle, pronation of the hallux is corrected. This correction is routinely used for hallux valgus deformities characterized by subluxation of the metatarsophalangeal joint. In the presence of a mild hallux valgus deformity an osteotomy may not be necessary. With degenerative arthritis or a congruent metatarsophalangeal joint, alternative surgical procedures are indicated.

Proximal metatarsal osteotomy and distal soft tissue reconstruction for hallux valgus in juveniles

Surgical correction of hallux valgus through a lateral soft tissue release, resection of the exostosis and proximal first metatarsal osteotomy. Hallux valgus with a subluxated metatarsophalangeal joint. Significant rigidity between first and second metatarsals. When the intermetatarsal angle is 50°. Presence of significant osteoarthritis or spasticity. First incision: longitudinal over dorsal aspect of first intermetatarsal space. Release of soft tissue contracture between lateral sesamoid and metatarsal head. Division of transverse metatarsal ligament. Release of lateral joint capsule. Second incision: longitudinal over exostosis. Inverted L-shaped incision of capsule, resection of exostosis. Capsulorrhaphy. Third incision: longitudinal over base of first metatarsal. Crescentic osteotomy, correction and internal screw fixation. Twenty-seven juveniles (33 feet), average age at surgery 15.9 years, average follow-up 5 years. Using the subjective rating scale 30 feet were excellent, 2 good and 1 fair. Based on the duPont rating scale the results were excellent in 29 feet, twice good and twice fair. The following complications were noted: hallux varus 4, breakage of Kirschner wire 1 and 1 undercorrection.

Salvage treatment of failed hallux valgus operations with proximal first metatarsal osteotomy and distal soft-tissue reconstruction.

We reviewed the results of 15 patients (16 feet) in whom a hallux valgus procedure had failed. Salvage was by proximal crescentic first metatarsal osteotomy with distal soft-tissue reconstruction. Results based on a clinical scale considering the level of pain, activity limitations, support requirement, footwear limitations, and alignment were good in 11, fair in two, and poor in three. Patients were satisfied with the results in 10 feet, satisfied with reservations in four feet, and dissatisfied in two feet. Complications were: transfer metatarsalgia in three, hallux varus in one, and osteotomy nonunion in one. One of the patients required reoperation to bone graft a proximal osteotomy. Metatarsal osteotomy was helpful in the salvage treatment of recurrent, symptomatic hallux valgus when the first metatarsophalangeal joint was functional and painless.