Distal Soft Tissue Release Research Articles

Modified Chevron osteotomy for treatment of Hallux valgus

Background And Objective: Hallux valgus is the most common forefoot deformity in adults, especially in females. Almost 150 different procedures have been described for the treatment of Hallux valgus deformity. Modified distal metatarsal Chevron osteotomy with distal soft tissue release is one of the most effective procedures for the correction of mild to moderate Hallux valgus deformity.
 Methods: This is a prospective observational study conducted at Department of Orthopedic Surgery Services hospital Lahore from Jan 2018 to Jan 2019 After Taking permission from the hospital ethical review board, this prospective observational study was carried out at the Services institute of medical sciences Lahore. A total number of 20 patients of age between 25-65 years were included in the study. There were 16 females and 4 males with four patients having mild while 16 patients had moderate Hallux valgus.Written consent was obtained from each patient.Each patient underwent dorsoplantar and lateral views in weight-bearing position including Axial Sesamoid view of the foot. On x-rays we measured the Hallux valgus angle(HV), inter-metatarsal (IMA) while clinically each patient was assessed for American orthopedic foot and ankle society score(AOFAS) pre-operatively.In all these patients we performed the Modified chevron osteotomy with lateral soft tissue release and medial eminence excision with capsular repair.Post-operative follow-up was done at two weeks, six weeks, 3 months and at one year. And each follow-up of these patients were assessed radiologically for HV angle and IMA.Clinically each patient was assessed for AOFAS score.
 Results: 
 Total no of patients enrolled in our study were 20 with 16 females and 4 males. The age range was 25-65 years(37.5). Four patients had mild Hallux valgus while 16 patient had moderate Hallux valgus.Pre-operative mean AOFAS score was 56.50 ± 3.54 with a range of 50-70. Six patients had B/L Hallux valgus deformity. Thus a total no. of 23 feet in 20 patient underwent Modified Chevron osteotomy with distal soft tissue release. Before surgery the mean HV angle was 31.52°±6.44° with a range of 20°-40° while mean IMA was 18°±1.10° with range of 12°-20°.The AOFOS score improve from 56.50±3.54 pre-operatively to 85.95±6.15 with range of 75-98 after 06 weeks post-operatively and remained static at 03 months and after 06 months post-operatively.It further Improve to 94±1.25 after 01 year at the final follow up.The mean HV angle was improve from 31.52°±6.44° pre-operatively to 6.4°±1° after 06 weeks with a range of 4°-8° and6.42°±1° after 01 year with a range of 4°-7° post operatively.The mean IMA improved from 18±1.10 pre-operatively to 5.4±1.30 with range of 4°-8° after 06 weeks post-operatively and 5.6°±1.1° with the range of 4°-8° at the end of 01 year.The osteotomy union time was 10-16 weeks after the surgery.There was no recurrence of the deformity, Infection, stiffness of the joint and avascular necrosis of metatarsal head noted post-operatively at the end of one year. First metatarsal shortening was 4-6 mm (mean 3.6±1.2mm) at the final follow up.
 Conclusion: 
 Modified chevron osteotomy with distal soft tissue release is a good procedure for correction of mild to moderate Hallux valgus. It allows a significant lateral displacement of distal fragment (4.5mm). This osteotomy improves the foot biomechanics, has got durable functional and cosmetic result.The patient satisfaction was also good (90.5%).

How Adductor Hallucis Reattachment Affects Outcomes Following Scarf Osteotomy in Hallux Valgus Correction: A 4- to 8-Year Follow-Up Retrospective Comparative Study

This study observed the differences between 2 adductor hallucis release techniques (nonreattachment vs reattachment) in 4- to 8-year follow-up outcomes of scarf osteotomy combined with distal soft tissue release (DSTR) in moderate to severe hallux valgus correction. A retrospective review of moderate to severe hallux valgus patients treated with scarf osteotomy with DSTR was conducted. The patients were divided into 2 groups based on adductor hallucis release techniques (without and with reattachment to the metatarsophalangeal joint capsule). The demographic-matching process divided the samples into 27 patients per group. A comparison of last follow-up of clinical foot ankle ability measure (FAAM) for activity of daily living (ADL) and numerical rating scale for pain during 2 hours of ADL and radiographic outcomes (hallux valgus angle (HVA) and intermetatarsal angle (IMA) was analyzed. A p < .05 was considered a statistically significant difference. The final follow-up of FAAM for ADL was statistically better in the reattachment group as the median was 79.0 (IQR=4.00) versus 76.0 (IQR=4.00), p=.047. However, this difference did not achieve minimal clinical importance difference (MCID). The last follow-up of IMA was also statistically better in the reattachment group as the mean was 7.67 (SD=3.10) versus 10.5 (SD=3.59), p=.003. DSTR with adductor hallucis reattachment has statistically better IMA correction and maintenance than nonreattachment for moderate to severe hallux valgus correction using scarf osteotomy at 4- to 8-years follow-up. However, the better clinical outcomes did not achieve MCID.

Plantar pressures values related with appearance of mechanical hyperkeratosis before and after surgery of mild hallux valgus.

Hyperkeratoses are thickenings of the stratum corneum, provoked by deviation of the ray and excessive plantar pressures. They are very common under the first metatarsal head (MTH) and on the big toe when there exists hallux valgus. The objective of this study was to assess plantar pressures pre- and post-surgery to try to define the threshold values that could determine the appearance of keratopathies. Seventy-nine patients (100 feet) who had undergone percutaneous distal soft-tissue release and the Akin procedure were evaluated prospectively. The BioFoot/IBV® in-shoe system was used for objective baropodometric functional evaluations of the heel, midfoot, first through fifth MTHs, hallux, and lesser toes. The presence or absence of a hyperkeratosis (HK) or plantar callus under the first MTH or hallux was recorded. The average follow-up time at which the measurements were repeated was 28.1 months. Pre-surgery, 62 feet presented a painful HK on the big toe, while post-surgery, only 9 of the feet presented the same lesion. Patients who presented a prior HK at the first metatarsophalangeal (MTP) joint had a mean pressure of 417.2 ± 254.5 kPa as against a value of 359.6 ± 185.1 kPa for the rest. Post-surgery, these values dropped to 409.8 and 346.3 kPa, respectively. Patients with HK presented an 11% greater mean pressure than those without. The values obtained with the BioFoot/IBV® system in the present study can therefore be considered predictive of the appearance of HK under the first MTH and on the side of the big toe.

Modified Chevron Osteotomy with Distal Soft Tissue Release for Treating Moderate to Severe Hallux Valgus Deformity: A Minimal Clinical Important Difference Values Study.

ObjectiveTo explore whether modified Chevron osteotomy together with distal soft tissue release would correct moderate to severe HV deformity and what is the minimal clinical important difference (MCID) for objective and subjective evaluating parameters.MethodsFrom March 2018 to January 2019, 40 hallux valgus patients (including moderate to severe) were enrolled in this retrospective study. The cohort included four males and 36 females. The average age at surgery was 50.95 (range 22–75) years. All patients underwent modified Chevron osteotomy together with distal soft tissue release and completed at least one follow‐up at clinic. The American Orthopaedic Foot and Ankle forefoot score (AOFAS, forefoot), Visual Analog Scale (VAS), and Foot Function Index (FFI) were all collected before and after surgery. Besides, the hallux valgus angle (HVA), 1st–2nd intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were measured both before surgery and at last follow‐up. All MCID values were calculated by employing distribution‐based method.ResultsThirty‐seven patients (92.5%) showed satisfied result at a mean 14.3‐month follow‐up (range 13–22 month). Two patients complained about residual pain at the bunion, and overcorrection (hallux varus) occurred in one patient. Meanwhile, no patient observed nonunion. Being female, age more than 60, residual HVA deformity (>15°), and post IMA more than 9° showed no statistical relationship with the post‐operation residual pain (P > 0.05). However, high VAS score before surgery (more than 7) showed strong correlation with residual pain (P < 0.01). The subjective MCID value was 9.50 for AOFAS, 18.92 for FFI, and 1.27 for VAS, respectively.ConclusionThe modified Chevron osteotomy together with distal soft tissue release could achieve a satisfied result for moderate to severe HV deformity at early follow‐up. The residual pain was associated with severe pain before surgery (VAS more than 7).

Flexion Dislocation After Limb Lengthening: Correction With Distal Femoral Osteotomy, Quadriceps Release, and Physeal-Sparing Medial Patellofemoral Ligament (MPFL) Reconstruction

Background: Patellar instability is a common clinical condition in skeletally immature individuals. Surgical treatment is considered when risk of recurrence is high. Indications: Distal femoral osteotomy is indicated in the setting of obligate flexion dislocation where femoral valgus contributes to a shortened lateral column, with concurrent quadriceps procedures considered for chronic contracture and medial patellofemoral ligament (MPFL) reconstruction for added stabilization. Technique Description: This procedure is performed in a stepwise manner as some components may not be necessary based on the patient’s specific anatomy. The procedure begins with a lateral iliotibial (IT) band soft tissue release or lengthening if possible. The distal femoral osteotomy is then performed utilizing a lateral opening wedge technique. Bone graft is placed in a structural fashion to maintain the correction while a locking plate is inserted. In patients with chronic lateral patellar dislocation, correction of bony alignment may not completely restore tracking. If lateral maltracking persists after further distal soft tissue release, a VY-lengthening quadricepsplasty can be considered. To perform this, the vastus lateralis (VL) is first released. In this patient, the patella was able to be stabilized centrally after VL release, and therefore, the VY-plasty was not performed. The soft tissue attachments for the final MPFL reconstruction are then prepared, including two at the superomedial and midbody of the patella and one at the adductor tendon. The whip-stitched graft is then passed through the adductor sling followed by the patellar periosteal tunnels with the knee in slight flexion to ensure centralization within the trochlear groove. Examination under anesthesia before final fixation of the reconstruction should demonstrate 1A lateral translation. Results: Correction of distal femoral valgus with osteotomy, in isolation or in combination with other patellar stabilizing procedures, has demonstrated significant improvement in patient-reported outcomes and reduced redislocation rates. However, large cohort studies are limited. Discussion/Conclusion: Both osseous and soft tissue abnormalities are important to consider in since they can contribute in varying degrees to patellar maltracking. Therefore, assessment of patellar tracking should be performed frequently to guide extent of surgical correction necessary.

Percutaneous Hallux Valgus: An Algorithm for the Surgical Treatment.

Objective To present the clinical and radiographic results of hallux valgus surgical correction using four percutaneous techniques, chosen according to a predefined radiographic classification. Methods We prospectively evaluated 112 feet in 72 patients with hallux valgus operated over the course of 1 year. Percutaneous distal soft tissue release (DSTR) and the Akin procedure (DSTR-Akin) were performed in mild cases. In mild to moderate hallux valgus with distal metatarsal joint angle > 10°, we added the Reverdin-Isham (RI) osteotomy. In moderate cases with joint incongruity, we performed the percutaneous chevron (PCH). Finally, a Ludloff-like percutaneous proximal osteotomy fixed (PPOF) with a screw was proposed in severe cases with an intermetatarsal angle (IMA) > 17°. According to these criteria, 26 DSTRs-Akin, 36 PCHs, 35 RIs, and 15 PPOFs were performed. The mean follow-up was of 17.2 months (range: 12 to 36 months). The mean age at operation was 58.8 years (range: 17 to 83 years), and 89% of the patients were female. Results The mean preoperative hallux valgus angle (HVA) and the IMA decreased from 21° to 10.2° and from 11.2° to 10.3° respectively in the DSTR-Akin. In the RI, the mean HVA decreased from 26.6° to 13.7°, and the IMA, from 11.2° to 10.3°; in the PCH, the mean HVA decreased from 31° to 14.5°, and the IMA decreased 14.9° to 10.7°; as for the PPOF, the mean HVA decreased from 39.2° to 17.7°, and the IMA, from 11.8° to 6.8°. The average ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) increased from 49.2 to 88.6. The rate of complications was of 11%. Conclusion Our treatment protocol does not differ much from the classic ones, with similar results as well. We have as advantages less aggression to soft tissues and better cosmetic results. Level of Evidence: level IV, prospective case series.

First Tarsometatarsal Joint Loading After Sequential Correction of Hallux Valgus Using a Proximal Opening Wedge Metatarsal Osteotomy and Distal Soft Tissue Procedure.

Background:The proximal opening wedge osteotomy (POWO) of the first metatarsal (TMT-1) is commonly performed in the operative treatment of hallux valgus. Limited work has been dedicated to study POWO’s effect on the TMT-1 joint, however. The purpose of this study is to evaluate the changes in TMT-1 joint contact stress following POWO of the first metatarsal.Methods:Five fresh-frozen cadaveric below-knee specimens (mean age: 73 years) with hallux valgus deformities (mean hallux valgus angle [HVA]: 37.4 ± 8.5 degrees) were studied. The specimens were loaded to 400 N on an MTS servohydraulic load frame. Joint contact characteristics at TMT-1 joint were measured with a Tekscan pressure sensor (Model 6900, 1100 psi; Tekscan Inc, Boston, MA) with various opening wedge sizes of 3, 5, and 7 mm both without and with a distal soft tissue release (DSTR). The contact force, area, and peak contact stress were compared among groups using analysis of variance and post hoc multiple comparisons over the untreated (Dunnett test, P < .05).Results:The mean contact force was 47.7 ± 33.5 N for untreated specimens. This increased sequentially with opening wedge size and reached statistical significance for 7-mm opening wedge (129.7 ± 62.3 N, P = .01) and 7-mm wedge + DSTR (134.8 ± 60.5 N, P = .008). The mean peak contact stress was 2.8 ± 1.3 MPa for the untreated specimens and increased incrementally with wedge size to 5.7 ± 3.0 MPa for 7-mm wedge only (P = .03) and 5.6 ± 2.5 MPa for 7-mm wedge + DSTR (P = .05). The contact area increased with corrections, but none reached significance.Conclusion:With increasing opening wedge size, loading of the TMT-1 joint increases. Joint stresses higher than 4.7 MPa have been shown to be chondrotoxic, potentially predisposing patients to arthritic joint changes following POWO.Level of Evidence:XXXXXX

Correction of More Hallux Valgus Pathologic Disorders with a Single Distal Osteotomy: A New Surgical Technique

Hallux valgus, one of the most common deformities of the great toe, may cause pain, dysfunction, and impaired gait pattern. In this retrospective study we report the results of a new type of distal metatarsal osteotomy combined with distal soft-tissue release in patients with mild-to-moderate hallux valgus deformity. This new technique was used in the management of 32 feet of 31 patients (eight men and 23 women) with mild-to-moderate hallux valgus. Hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle were measured on preoperative, early postoperative (6-8 weeks), and late (1 year) postoperative radiographs. American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal score was calculated. Sesamoid position, by considering medial sesamoid position, and metatarsal shortness were also measured. Statistically significant differences were detected between the preoperative and late postoperative measurements of the hallux valgus angle, distal metatarsal articular angle, intermetatarsal angle, and sesamoid position parameters in patients operated on with this technique. Improvement was 14° for the hallux valgus angle, 4° for the distal metatarsal articular angle, and 4° for the intermetatarsal angle. Sesamoid position was also improved, and the mean American Orthopaedic Foot and Ankle Society score was significantly improved. Metatarsal shortness greater than 2 mm was observed in two patients without resulting in any clinical discomfort. This new technique was easy, safe, and promising in patients diagnosed as having mild-to-moderate hallux valgus deformity.

Peak Contact Stress of TMT-1 Joint after Sequential Correction of Hallux Valgus Using a Proximal Opening Wedge Metatarsal Osteotomy (PMO) and Distal Soft Tissue Procedure

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:The proximal opening wedge metatarsal osteotomy (PMO) of the first metatarsal is a common procedure for the surgical treatment of moderate to severe hallux valgus. Although with a long track record of success, limited work has been dedicated to this procedures effect on the first tarsometatarsal (TMT-1) joint. The purpose of this study is to evaluate the changes in TMT-1 joint contact stress in the diseased and corrected state following an opening wedge osteotomy of the proximal metatarsal. In addition, the effect of a distal soft tissue release (DSTR) was evaluated as it related to both radiographic correction and TMT-1 joint contact stress.Methods:Seven fresh-frozen cadaveric below knee specimens (mean age: 69yrs) with hallux valgus deformities (mean HVA: 31.7+-12.0degs) were obtained for the study. The specimen was loaded up to 400N on an MTS servo hydraulic load frame with the tibia at 90-degree to the neutrally position foot. Joint contact characteristics at TMT-1 joint were measured with a Tekscan pressure sensor (Model6900, 1100psi). A standard proximal metatarsal osteotomy was performed. Various sized metal wedges (3, 5, 7 mm) with locking plates and screws were inserted in the osteotomy for correction. Following initial tests, a complete distal soft tissue release (DSTR) was performed and the specimens were retested. Additionally, dorsoplantar weight bearing (400N) radiograph was obtained for each condition to measure intermetatarsal (IMA) and hallux valgus (HVA) angles. The contact force, area, and peak contact stress were compared among groups using ANOVA and post-hoc multiple comparisons over the untreated (Dunnett test, p<0.05).Results:The mean HVA decreased with wedge size and DSTR, reached to significant level with 7mm+DSTR (24.1 degs). The mean contact force was 39.7+-32.6 N for untreated specimens. This increased sequentially with opening wedge size and reached statistical significance 7mm opening-wedge (119.6+-53.8 N, p=0.03) and 7mm-wedge+DSTR (116.7+-58.3 N, p=0.04). The peak contact stress followed a similar trend (Figure 1). The mean peak contact stress was 2.3+-1.5 MPa for the untreated specimens and increased incrementally with wedge size to 5.3+-2.6 MPa for 7mm-wedge only (p=0.03) and 5.2+-2.1 MPa for 7mm- wedge+DSTR (p=0.04). Contact area increased with corrections, but none reached significance.Conclusion:The results from this study demonstrate that with sequentially increasing opening wedge size, loading properties through the TMT-1 joint increase. Prior work has demonstrated that joint stresses of over 4.7 MPa can be chondrotoxic, a value which was surpassed with our peak contact stress with the 7mm wedge. This has significant implications for the long-term health of the TMT-1 joint following PMO, potentially predisposing patients to arthritic joint changes. The optimal degree of correction with PMO to limit chondrotoxicity is not known at this time, and is a direction for future work.

The “AdductoValgus” Foot: Description of Deformity and Technique for Surgical Reconstruction

Category:Midfoot/ForefootIntroduction/Purpose:The literature is replete with descriptions of metatarsus adductus (pediatric patients) and metatarsus primus varus (adult patients) deformities along with recommendations for treatment. For adult deformities isolated to the first ray, a technique involving a cuneiform-metatarsal arthrodesis (e.g. Lapidus procedure) is often employed. There is a paucity of literature describing adult manifestations of adduction deformities involving multiple metatarsals. The senior author has treated a number of adult patients with these types of deformities. This case series is presented here with a description of the deformity and a technique for surgical reconstruction.Methods:Five patients having undergone surgical reconstruction for symptomatic midfoot/forefoot deformities involving adduction of multiple metatarsals (and valgus metatarsophalangeal joints) were retrospectively reviewed. The first ray deformities were treated with arthrodesis of the first metatarsal to the medial cuneiform, along with a distal soft tissue release and medial eminence resection as appropriate. Lesser ray deformities were corrected with oblique osteotomies of the metatarsal shafts (and metatarsophalangeal joint capsulorraphies and/or pinning as appropriate).Results:All patients went on to radiographic union of their arthrodeses and osteotomies. The midfoot (metatarsus adductus) deformities, and hallux valgus deformities, maintained correction compared to preoperative alignment. There were some lesser metatarsophalangeal joint valgus recurrences. There were no severe complications of deep infection or revision surgery. Conclusion: The “AdductoValgus” foot deformity presents in adult patients with adduction of multiple metatarsals and corresponding metatarsophalangeal joint valgus. The deformity can result in pain with mobility and difficulty with shoewear. Surgical reconstruction including first ray tarsometatarsal arthrodesis and osteotomies of the involved lesser metatarsals appears a viable option for deformity correction and symptomatic relief.

Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques.

The aim of this study was to systematically evaluate the available literature on minimally invasive surgical (MIS) treatment for hallux valgus and to provide an overview of the different surgical techniques. A systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane database was performed including studies from January 2001 to 1 January 2018. The radiological outcomes (hallux valgus angle (HVA), intermetatarsal angle (IMA)), complication rates, and clinical outcome scores were evaluated. The MINORS scale was used to assess the methodological quality of included articles. Of 278 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 2279 procedures in 1762 patients. The surgical techniques were divided into five categories: the Bosch technique, MIS Chevron-Akin, Reverdin-Isham procedure, Endolog system, and techniques involving distal soft tissue release and fixation. Results regarding radiological correction, clinical outcomes, and complication rate varied widely. The studies included were of too little level of evidence to allow for data pooling or meta-analysis. There were too few studies on each surgical technique category to assess whether one is more effective than the rest. However, there is some evidence that the Chevron and Akin showed the most potential for improvement of the HVA and the Endolog for the IMA. An overall complication rate of 13% was obtained among all included studies. Appropriately powered randomized controlled trials, utilizing validated outcome measures, blinded assessors, and long-term follow up are needed to assess the efficacy of MIS techniques.

Foot Width Changes Following Hallux Valgus Surgery

Category: Midfoot/Forefoot Introduction/Purpose: Hallux valgus is one of the most common deformities of the adult foot, and can adversely affect quality of life, with common complaints including pain, footwear restrictions and cosmesis. Every clinician is familiar with the patients’ concerns regarding the postoperative foot appearance and footwear anticipations. Surprisingly, although patients are concerned with postoperative foot width, there are only scarce reports on this issue. This study was undertaken to evaluate the impact of hallux valgus surgical treatment on foot width. Methods: Study included 71 consecutive cases with moderate to severe hallux valgus treated with Scarf osteotomy, distal soft tissue release and Akin osteotomy as needed. Patients were included only if pre- and postoperative weightbearing X-rays at minimum 6 months followup were available. The average age was 55.7 years (range, 20 to 76), with average follow-up of 20.7 months (range, 6 to 96). Patients’ medical records were reviewed for clinical data, surgical technique and radiographic measurements. The radiographic measurements included hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), and foot width. Foot width was assessed by measuring both the bony width (BW: maximal distance between the medial cortex of 1st metatarsal head and lateral cortex of the 5th metatarsal head) and the soft tissue width (STW: maximal distance between most medial soft tissue outline and the most lateral soft tissue outline at the level of metatarsal heads). Results: Preoperative HV deformity (mean HVA 35.8, IMA 14.1 and DMAA 15.2) was successfully corrected (postoperative mean HVA 13.7, IMA 6.9 and DMAA 7.7). Overall bony foot width was reduced by 5% and soft tissue foot width by 2% postoperatively. Further analysis showed there were 13 feet (18.3%) with increased (&gt;5%) bone width, 26 feet (36.6%) with no change (±5%) and 32 feet (45.1%) for which width decreased in more than 5% postoperatively. Patients with the widest foot before surgery, had a decrease in foot width following surgery whereas, patients with the narrowest foot width, had an increase in foot width. Magnitude of preoperative deformity (as assessed by HVA, IMA and DMMA measurements) or amount of correction had low correlation (&lt;0.2) with postoperative foot width. Conclusion: While the ability of surgery to correct HV deformity is well established and reported in the literature, its effect on foot width is less understood or predictable. Overall, the postoperative reduction of foot with was modest. Furthermore, while postoperative foot width (both bony and soft tissue) decreases or does not change in 4 out of 5 patients, there are cases in which foot width actually increases.

Percutaneous proximal oblique osteotomy fixed (ludloff) to the surgical treatment of severe hallux valgus

Category: Bunion Introduction/Purpose: to present the clinical and radiographic results of surgical correction of severe hallux valgus using percutaneous proximal oblique osteotomy (Ludloff) fixed with screw. Methods: we evaluated prospectively 15 feet in 14 patients with severe hallux valgus considering the hallux valgus angle (HVA) greater than 30 degrees and the intermetatarsal angle (IMA) greater than 17 degrees. The average follow-up was 18 months (12 to 36). Were submitted to percutaneous proximal oblique osteotomy, put a K wire proximal to dislocate the first metatarsal head and fixed the osteotomy with a screw (picture). After we associated this technique with percutaneous Akin procedure, exostectomy and distal soft tissue release. Patients were evaluated by the AOFAS score, followed by radiographic evaluation and by the degree of subjective satisfaction of Johnson. Results: we present as a result 15 feet operated on 14 patients being 93% female with an average age of 66.9 years (29 a 78), HVA of 39.7° (30 to 51), IMA of 18.6° (17 to 22) and 43 points of AOFAS, while postoperative the HVA was 18° (8 to 28), IMA 13.8° (7 to 17) and average AOFAS 86.6 points. We have complications in 33% of cases, we had 1 recurrence of deformity in less than 1 year, 1 transference metatarsalgia, 2 withdrawals of synthesis and 1 complaint of dorsal callosity due to probable elevation of 1 metatarsal. No major complications were noted. We present a patient unhappy with the result (recurrence case). Conclusion: the surgical technique described proved effective in the treatment of severe valgus halux with improvement of the AOFAS score, high level of patient satisfaction and good radiographic corrections.

Effectiveness of Percutaneous Proximal Closing Wedge Osteotomy With Akin Osteotomy to Correct Severe Hallux Valgus Determined by Radiographic Parameters.

Therapeutic, Level IV: Case series.

Consequences of Avulsion Fracture of the Proximal Phalanx Caused by a Technical Failure of Hallux Valgus Surgery

Several cases of avulsion fracture of the proximal phalanx of the big toe during the lateral capsular release procedure were observed. However, these fractures have not been reported as a complication of hallux valgus surgery. The purpose of the present study was to report the proximal phalanx base fracture as an unrecognized complication and to evaluate the clinical and radiographic consequences of this complication. We retrospectively reviewed 225 feet that had undergone hallux valgus surgery involving proximal chevron osteotomy and distal soft tissue release from May 2009 to December 2012. Of these 225 feet (198 patients), 12 (5.3%) developed proximal phalanx base fracture postoperatively. These patients were assigned to the fracture group. The remaining patients were assigned to the nonfracture group. Patients were followed to observe whether the fractures united and whether degenerative changes developed at the first metatarsophalangeal joint because of this fracture. The mean follow-up period was 36 (range 12 to 72) months. All the subjects in the fracture and nonfracture groups underwent weightbearing anteroposterior and lateral radiographs of the foot at the initial presentation and final follow-up point. The 2 groups were compared with respect to the hallux valgus angle, intermetatarsal angle, range of motion, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes. No significant differences were found in age, follow-up period, hallux valgus angle, intermetatarsal angle, range of motion of the first metatarsophalangeal joint, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes between the 2 groups. Ten (83.3%) of the 12 fractures healed, 2 (16.7% of the fractures, 0.89% of the operated feet) progressed to asymptomatic nonunion, and 3 (1.33%) developed first metatarsophalangeal joint degeneration. Avulsion fracture of the proximal phalanx of the big toe is an uncommon complication of hallux valgus surgery. It seems to be caused by excessive tension placed on the lateral soft tissues that attach to the base of the proximal phalanx at the time of plantarlateral soft tissue release. However, this fracture does not seem to cause significant clinical problems.

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.

Is it feasible to rely on intraoperative X ray in correcting hallux valgus?

The aim of the study was to prove whether the intraoperatively taken fluoroscopy pictures compared to the X rays taken 8 weeks and 3 months postoperatively picture the achieved correction reliably. In a prospective study, the pre- and postoperative standing foot X rays as well as the intraoperatively taken fluoroscopy pictures of 31 patients were analysed. The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were measured. In all cases, a tarso-metatarsal joint I arthrodesis combined with a distal soft tissue release was performed. The mean age was 54 (17-73) years. There was no significant difference between the measured angles in intraoperative fluoroscopy and standing X rays postoperatively taken. Despite the consideration that fluoroscopic pictures lack the loading criteria, we found reliable results in IMA and HVA.

Modifizierte Chevron-Osteotomie mit lateralem Release und Schraubenfixation zur Behandlung der schweren Hallux-valgus-Deformität

This prospective study examined the clinical and radiological results of the Chevron osteotomy with screw fixation and distal soft tissue release up to an intermetatarsal angle of 19°. Furthermore, the results are presented for patients over the age of 70 years, and whether or not there is a higher complication rate. 86 feet of patients between 23 and 81 years were included in the study. Apart from the overall group, a group with an intermetatarsal angle of 16° to 19° and a group of patients over 70 years old were eavaluated. They were evaluated preoperatively and at follow-up after an average of 3.3 years according to the American Orthopaedic Foot and Ankle Society score. The AOFAS score showed a significant improvement from 55 points preoperatively to 90 points at follow-up. The preoperative hallux valgus angle decreased significantly from 32° to 5° and the preoperative intermetatarsal angle decreased from 14° to 6°. Patient satisfaction in the overall group was rated in 92 % as excellent or good. Also, the patient group with 16° to 19° angles and the patients over 70 years showed a significant improvement of clinical and radiological parameters. The complication rate was very low in all groups. The results show that the Chevron osteotomy is a very good surgical technique with few complications for the correction of splay foot with hallux valgus deformity. We showed that by using the modified technique with a long plantar arm, an excessive soft tissue release and screw fixation, the indication can be extended up to an intermetatarsal angle of 19° when using screw fixation. Furthermore the patients over 70 years of age showed a significant improvement of clinical and radiological parameters without serious complications such as avascular necrosis or dislocation of the metatarsal head.

Dynamic plantar pressure analysis and midterm outcomes in percutaneous correction for mild hallux valgus

Mild hallux valgus (HV), which can lead to alteration of the plantar pressure pattern with an overpressure under the hallux, can be repaired percutaneously. Our goals were to determine whether the percutaneous distal soft tissue release (DSTR)-Akin procedure restores the loading pattern and to evaluate which are the determinants of the measures of post-operative outcome. Seventy-nine percutaneous DSTR-Akin procedures were performed in the same number of patients. The plantar pressure patterns were evaluated using the BioFoot/IBV® in-shoe system and compared with measurements from 98 controls. The clinical and radiological outcome parameters measured were the pre- and post-operative AOFAS scores, and the first intermetatarsal, hallux abductus, and first metatarsal-hallux declination angles (FIMA, HAA, FMHDA) in weight-bearing radiographs. The mean follow-up was 28.1 (range 24-33) months. The plantar pressure analysis showed a significant decrease (328-152 kPa, p = 0.001) in the mean pressure under the hallux. Significant improvements occurred in the AOFAS scores, and angular deviations were reduced. The post-operative HAA correlated with the mean pressure under the 1st toe (r(2) = 0.132, p < 0.001). The DSTR-Akin percutaneous technique in mild HV restores physiological patterns of pressure on the hallux and achieves significant correction of radiographic angles and commensurate improvement in clinical status.

Endoscopic Distal Soft-Tissue Release in the Treatment of Hallux Valgus: A Cadaveric Study

To study the efficacy and safety of the lateral release of the endoscopic distal soft-tissue procedure in the treatment of hallux valgus. Twenty fresh-frozen foot and ankle specimens were used. Ligament-sacrificing release was performed in 10 specimens (group 1). Ligament-sparing release was performed in another 10 specimens (group 2). The relation between the metal rod that passed through the toe web and plantar portal wounds and neural structures, degree of completeness of release of the intermetatarsal ligament, adductor hallucis insertion, and lateral capsular structures was studied. The common digital nerve of the first intermetatarsal space ran along the medial side of the rod, the medial digital nerve of the second toe ran obliquely and plantar to the rod just proximal to the proximal edge of the intermetatarsal ligament, and the lateral digital nerve of the hallux ran along the plantar lateral border of the metatarsal head and fibular sesamoid in all specimens. The intermetatarsal ligament, adductor hallucis insertion, and lateral capsular ligamentous structures were released completely in all specimens in group 1. The intermetatarsal ligament was preserved and the lateral capsular ligamentous structures were completely released in all specimens in group 2. The adductor hallucis insertion was completely released in 7 specimens. No nerve injury or cartilage damage was noted in all 20 specimens. With the release of the intermetatarsal ligament, all lateral capsular ligamentous structures including the adductor were released, but with intermetatarsal ligament preservation, only 70% of the specimens had complete adductor release. There was no neural or articular cartilage damage in either group. The study provides an anatomic basis for safe practice of endoscopic distal soft-tissue release in the correction of hallux valgus deformity.