First-second Intermetatarsal Angle Research Articles

Lateral soft tissue release with distal chevron metatarsal osteotomy in moderate and severe hallux valgus.

The purpose of this study was to evaluate the radiographic outcomes of distal chevron metatarsal osteotomy associated with lateral joint capsule split as only lateral soft tissue release in patients with symptomatic moderate and severe hallux valgus (HV) deformity. Ninety patients (103 feet) at our institution between January 2014 and December 2019 were included in the present retrospective study. Each patient was evaluated preoperatively and at final follow-up by means of weight bearing radiographs lateral and dorsoplantar views. We analyzed hallux valgus angle (HVA), first-second intermetatarsal angle (IMA) and medial sesamoid position (MSP). The mean follow-up time was 21.8 months (range 6-69.4). The mean of the HVA improved, from 36.6 to 24.3º, the IMA from 13.05 to 9.93º and the MSP from 2 to 1. Our study demonstrates that the deformity recurrence rate after surgery is 69.9%. Radiologic HV recurrence was defined by a final HVA equal or more than 20 degrees at final follow-up. Level of Evidence, IV.

3D Analysis of Metatarsal Torsion by Computed Tomography in Normal, Hallux Valgus, and Hallux Rigidus Feet.

One factor contributing to rotational deformity of the first metatarsal in hallux valgus is torsion of the metatarsal itself. Hallux rigidus also involves reduction of the longitudinal arch, but metatarsal torsion has not been discussed. We hypothesized that metatarsal torsion may be a morphologic change unique to hallux valgus. We compared 3-dimensional (3D) torsion of the first to fifth metatarsals between feet with hallux valgus, feet with hallux rigidus, and healthy control feet to investigate differences in the effects on pathologic conditions. Participants were women of East Asian descent. There were 16, 16, and 14 feet in the control, hallux valgus, and hallux rigidus groups, respectively. One randomly selected control foot was designated as the reference foot. For comparison, nonweightbearing computed tomography images of the metatarsals were reconstructed in 3D, and the proximal and distal areas were superimposed on the reference foot. Torsion angle was defined as the rotational angle of the distal part of the articular axis relative to the proximal area. In the hallux valgus group, correlations of torsion angle with hallux valgus angle and intermetatarsal angle were calculated. The hallux valgus group had greater average pronation torsion in the first metatarsal than the control group and hallux rigidus group (11 and 13 degrees greater, respectively, P < .01). No significant differences were observed for the second to fifth metatarsals (P > .05). There was no significant correlation with hallux valgus angle or first-second intermetatarsal angle in the hallux valgus group (P > .05). Hallux valgus feet had pronation deformities in the first metatarsals not observed in control or hallux rigidus feet, meaning that torsion toward pronation (eversion) in the first metatarsal was unique to hallux valgus. Improved surgical correction to diminish pronation may be necessary in patients with hallux valgus patients because of first metatarsal pronation in the first tarsometatarsal to normalize mechanical first-ray alignment.Level of Evidence: Level III, case-control stud.

Postoperative Maintenance of Sagittal Plane Positioning of the First Metatarsophalangeal Joint After Arthrodesis with an Isolated Dorsal Plate Construct: A Retrospective Review of 43 Feet.

First metatarsophalangeal joint arthrodesis with isolated dorsal plating without a lag screw and without a compressive mechanism incorporated into the plate is not well studied. Although surface area for bony fusion is increased, there is concern for lower fusion rates and progressive loss of sagittal plane positioning. We present fusion rates and progressive sagittal plane deviation with isolated dorsal plate fixation. A retrospective review was performed of 41 patients (43 feet) who underwent first metatarsophalangeal joint arthrodesis with isolated dorsal plate fixation. Patients were excluded if another form of fixation was used, if there was a compressive feature to the dorsal plate, or if a lag screw was used. Preoperative, immediate postoperative, and final postoperative radiographs were reviewed to assess radiographic alignment and fusion about the first metatarsophalangeal joint. Specific attention was placed on hallux dorsiflexion in relation to the first metatarsal. Statistical significance was set at P ≤ .05 a priori. Patients were followed for an average of 55.7 weeks. Overall union rate was 97.62%. The average time to union was 42.55 days. Reoperation rate was 4.65%, with one patient requiring revisional arthrodesis with a lag screw construct. Hallux abduction and first-second intermetatarsal angle correction reached significance (P < .00001). Hallux dorsiflexion increased by 1.05° between initial postoperative and final postoperative radiographs (P = .542). Although fusion rates and progressive loss of sagittal plane position have been concerns for first metatarsophalangeal joint arthrodesis with an isolated dorsal plate construct, these results suggest this to be a stable construct without loss of positioning over time.

A Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity.

Various modifications of distal chevron metatarsal osteotomy (DCMO) have been introduced for correcting moderate hallux valgus deformity; however, the amount of correction may be limited, and complications, such as the recurrence of the deformity and avascular necrosis of the metatarsal head, have been a problem. This study aimed to present a modified 90-degree DCMO technique that overcomes the previously reported shortcomings and to report a successful short-term radiographic outcome. Sixty-eight consecutive patients who underwent the operation with our modified DCMO technique and twenty-two consecutive patients with the conventional DCMO technique (control group) were retrospectively analyzed. The radiographic measurements were evaluated preoperatively, at two months post operation, and at the final follow-up. Both groups showed a significant correction of the hallux valgus angle, first-second intermetatarsal angle, distal metatarsal articular angle, and sesamoid position at the final follow-up, while the amount of correction was significantly greater in the modified DCMO group. In both groups, there were no cases of complications such as avascular necrosis of the metatarsal head, nonunion, and surgical site infection appearing throughout the follow-up period. Therefore, the modified 90-degree DCMO technique is effective and safe, which could serve as a favorable option to treat moderate hallux valgus deformity.

Preoperative foot and ankle radiographic evaluation for total knee arthroplasty

PurposeTo radiographically evaluate the ankle and foot complications in preoperative patients for total knee arthroplasty (TKA) in Japan. MethodsThis study included 500 legs of 500 patients who planned to undergo primary TKA in affiliated hospitals of our university from August 2020 to November 2021. Hip to calcaneus view, anterior view of the ankle joint, and anterior and lateral views of the foot were taken within 1 month preoperatively. We measured hip-knee-ankle angle (HKA), mechanical ankle joint axis point (MAJAP), lateral distal tibial angle (LDTA), tibio-plafound inclination (TPI), talar inclination (TI), ankle joint line convergence angle (A-JLCA), talo-first metatarsal angle (TMA), calcaneal pitch angle (CPA), hallux valgus angle (HVA), first-second intermetatarsal angle (M1M2A), first fifth intermetatarsal angle (M1M5A), talonavicular coverage angle (TNCA), and percentage of Takakura Tanaka classification. ResultsMean measured values were as follows: HKA: 11.0°; MAJAP, 39.6%; LDTA: 92.2°; TPI: 6.9°; TI: 7.2°; A-JLCA: 0.3°; TMA:−4.3° (<−4° in 247 feet, 49.4%); CPA: 15.9°(<20° in 366 feet, 73.2%); HVA: 16.8° (mild in 70 feet, 14.0%; moderate in 42 feet, 8.4%; severe in 23 feet, 4.6%); M1M2A: 11.1°(>9° in 373 feet, 74.6%); M1M5A: 31.1°(≥30° in 321 feet, 64.2%); TNCA: 10.6° (≥7° in 375 feet, 75.0%); Takakura Tanaka classification Stage ​≥ ​IIIa in 108 feet, 21.6%. ConclusionsMild-to-severe hallux valgus was noted in 26.5% of patients and Stage IIIa or higher ankle osteoarthritis in 21.6%, and abnormal alignment—including flat feet—was indicated in some patients. Patient's knee, foot, and ankle symptoms should be considered before TKA.

Sesamoid Position Change Over 2 Years After Distal Chevron Osteotomy for Moderate to Severe Hallux Valgus: A Prospective Cohort Study.

Sesamoid position change after distal chevron osteotomy for moderate to severe hallux valgus is not well known in the literature. The objective of this study was to determine whether the sesamoid position changed over 2 years after distal chevron osteotomy for moderate to severe hallux valgus. Ninety-seven patients who underwent distal chevron osteotomy for moderate to severe hallux valgus were prospectively assessed for 2 years. There were 91 females, and the mean age was 54.9 (SD 10.9) years. The Self-Reported Foot and Ankle Score (SEFAS) was used for functional assessment. Foot pain was assessed by a 0-10 visual analog scale (VAS), and patient satisfaction by a 5-point Likert scale. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), metatarsal head displacement, and sesamoid position by the AOFAS criteria were analyzed. Patients were classified according to the medial sesamoid position on the first postoperative weightbearing radiograph (1º-WB-Xray) into the reduced sesamoid group (66 patients) and nonreduced sesamoid group (31 patients). All patients were assessed preoperatively and postoperatively at 1 month and 2 years. On the 1º-WB-Xray, IMA was significantly lower in the reduced group (P = .038), but HVA (P = .063) and DMAA (P = .246) were not significantly different. At the final follow-up, no patients in the reduced group had sesamoid position change from 1º-WB-Xray, whereas 8 (25.8%) patients in the nonreduced group had change of their sesamoid positions. The SEFAS was not significantly different between groups preoperatively (P = .386) or at 1 month postoperation (P = .064). The final SEFAS, VAS pain, and satisfaction scores were significantly better in the reduced group, although the clinical significance of these changes remains unknown. A nonreduced position of the sesamoids obtained in surgery can cause their increased malposition over 2 postoperative years and statistically less functional outcomes. Level II, prospective cohort study.

Early Outcomes, Revisions, and Patient Satisfaction Following Synthetic Cartilage Implant for Hallux Rigidus

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Hallux rigidus is a common condition estimated to affect 1 in 40 adults older than 60 years old. Patients experience functional limitations secondary to progressive pain and stiffness of the 1st metatarsophalangeal (MTP) joint.Historically, 1st MTP arthrodesis has been considered the gold-standard treatment for end-stage hallux rigidus. In 2016, the US Food and Drug Administration (FDA) approved the use of a synthetic cartilage implant (SCI) for the treatment of hallux rigidus grades 2-4 with an aim to improve pain and preserve range of motion at the 1st MTP joint. Studies evaluating patient satisfaction and need for reoperation have varied considerably (4-20%). We aim to evaluate outcomes, complication rate, revision rate, and overall satisfaction for patients undergoing primary SCI for hallux rigidus.Methods:In a single-institution retrospective study, we evaluated patients undergoing primary SCI for hallux rigidus between August 2016 to May 2020 by three fellowship-trained foot and ankle surgeons. Preoperatively, patient demographics, age at the time of surgery, laterality, body mass index (BMI), hallux rigidus grade, hallux valgus angle, and first-second intermetatarsal angle were collected. Operative reports were reviewed for concomitant procedures and implant size. Postoperatively, we recorded all additional treatments for continued pain or stiffness and need for revision surgery or conversion to arthrodesis. Patients were surveyed via email or telephone by an author not previously involved in their care administering patient reported outcomes (PROs): PROMIS physical function (PF), and pain interference (PI) surveys, foot and ankle SANE score, and a satisfaction survey.Results:A total of 59 feet in 56 patients underwent a primary SCI procedure for hallux rigidus. Patients were classified as grade 2 (32%), 3 (59%), or 4 (2%). Nineteen (34%) patients underwent additional procedures, and 8 (14%) had a history of prior surgery to the MTP joint. Forty-five patients (80%) completed surveys at an average of 19.5-month follow-up. The majority (58%) considered surgery a success and 42% reported being unsatisfied or very unsatisfied. Mean (+-SD) post-operative foot and ankle SANE, PROMIS PF and PI scores were 57 (+-27), 48 (+-7) and 54 (+-9), respectively. The overall revision rate was 11% (6/56) with 3 patients undergoing conversion to arthrodesis. The majority of patients (61%) stated they would undergo the procedure again.Conclusion:Consistent with existing literature, we found that the majority of patients undergoing the procedure were satisfied and would undergo the procedure again. Further, post-operative PRO scores were favorable, even when factoring in patients who were less satisfied. While our revision rate (11%) is consistent with early studies of the implant, 42% reported being unsatisfied or very unsatisfied with their procedure. These findings emphasize the importance of preoperative patient counseling regarding post- operative limitations, risks, satisfaction, and revisions rates. Further investigation into factors that may predict successful outcomes is needed to inform surgical decision-making and appropriate patient selection for this procedure.

Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study

BackgroundThe objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome. MethodsEighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed. ResultsAt the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2–0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6–3.2; p = 0.012) were significant predictor of patient satisfaction. ConclusionAt two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.

Feasibility study of hallux valgus measurement with a deep convolutional neural network based on landmark detection.

To develop a deep learning algorithm based on automatic detection of landmarks that can be used to automatically calculate forefoot imaging parameters from radiographs and test its performance. A total of 1023 weight-bearing dorsoplantar (DP) radiographs were included. A total of 776 radiographs were used for training and verification of the model, and 247 radiographs were used for testing the performance of the model. The radiologists manually marked 18 landmarks on each image. By training our model to automatically label these landmarks, 4 imaging parameters commonly used for the diagnosis of hallux valgus could be measured, including the first-second intermetatarsal angle (IMA), hallux valgus angle (HVA), hallux interphalangeal angle (HIA), and distal metatarsal articular angle (DMAA). The reference standard was determined by the radiologists' measurements. The percentage of correct key points (PCK), intragroup correlation coefficient (ICC), Pearson correlation coefficient (r), root mean square error (RMSE), and mean absolute error (MAE) between the predicted value of the model and the reference standard were calculated. The Bland-Altman plot shows the mean difference and 95% LoA. The PCK was 84-99% at the 3-mm threshold. The correlation between the observed and predicted values of the four angles was high (ICC: 0.89-0.96, r: 0.81-0.97, RMSE: 3.76-6.77, MAE: 3.22-5.52). However, there was a systematic error between the model predicted value and the reference standard (the mean difference ranged from - 3.00 to - 5.08°, and the standard deviation ranged from 2.25 to 4.47°). Our model can accurately identify landmarks, but there is a certain amount of error in the angle measurement, which needs further improvement.

Postoperative Hallux Varus Treatment by Reverse Scarf Osteotomy.

Postoperative hallux varus is often accompanied by an abnormal decrease in the first-second (M1M2) intermetatarsal angle, which we have sought to correct by a reverse scarf-type osteotomy. A series of 36 hallux varus operated on by reverse scarf osteotomy, including 14 with prior osteotomies, was reviewed with an average follow-up of 56 months. The measurements were clinical: American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, subjective satisfaction index, joint mobility, and radiologic angles: M1M2 and first metatarsophalangeal angle. The M1M2 angle increased on average from 3 to 8 degrees whereas the average M1P1 angle of varus went from -21 to +9 degrees, including 2 patients who had a reoccurring valgus of 20 degrees. The median AOFAS score increased from 47 to 79, the VAS from 6.7 to 2.3, joint mobility lost an average of 9 degrees, and all those operated on were satisfied with the result. All operated bones healed without secondary displacement. The reverse scarf osteotomy is capable of correcting the intermetatarsal angle and at the same time correcting the postoperative hallux varus. Functional scores generally improved, including in patients with a reoccurring valgus and those with reduced mobility. The reverse scarf osteotomy can be performed to treat postoperative hallux varus with a mild intermetatarsal angle with reasonable clinical and radiologic results. Level III, retrospective cohort study.

The Role of Weightbearing Computed Tomography Scan in Hallux Valgus.

Hyperpronation of the first metatarsal in hallux valgus (HV) is poorly understood by conventional weightbearing radiography. We aimed to evaluate this parameter using weightbearing computed tomography (WBCT) and to understand its association with other standard measurements. Retrospective evaluation of WBCT and weightbearing radiographs (WBXRs) was performed for 20 patients with HV feet and 20 controls with no such deformity. Axial computed tomography images of both groups were compared for the first metatarsal pronation angle (alpha angle) and tibial sesamoid subluxation (TSS) grades. The HV angle (HVA), first-second intermetatarsal angle (IMA), first metatarsal-medial cuneiform angle (MMCA), Meary's angle, and calcaneal pitch (CP) angle of the study and control groups were compared on both WBXR and the corresponding 2-dimensional images of WBCT. All measurements were independently performed by 1 musculoskeletal radiology fellow and 1 foot and ankle surgical fellow. Measurements were averaged and interobserver reliability was calculated. The HV group demonstrated significantly higher values for TSS grade (P < .001) but not for alpha angle (P = .121) compared with controls. Likewise, significantly elevated HVA and IMA were noted in the HV group on both imaging modalities, while no such differences were observed for the CP angle. Higher MMCA and Meary's angle in the HV group were evident only on WBXR (MMCA, P = .039; Meary's, P = .009) but not on WBCT (MMCA, P = .183; Meary's, P = .171).Among all, the receiver operating characteristic (ROC) curves demonstrated the greatest area under the curve (AUC) for HVA, followed by IMA. The alpha angle performed only just outside the range of chance (AUC, 0.65; 95% CI, 0.52-0.69). The Pearson's correlations of the alpha angle, in the HV group, revealed a significant linear relationship with TSS grade and with HVA on WBXR, and only trended toward a weak linear relationship with IMA and with HVA on WBCT. The alpha angle, a measure of abnormal hyperpronation of the first metatarsal, was an independent factor that may coexist with other parameters in HV, but in isolation had limited diagnostic utility. "Abnormal" alpha angles were even observed in individuals without HV. Increases in IMA and MMCA were not necessarily associated with similar increases in alpha angle, despite moderate correlations with TSS grade and HVA on WBXR. Nevertheless, the WBCT was a useful method for assessing hyperpronation and guiding surgical management in individual cases. Level III, retrospective comparative study.

Distal Chevron Osteotomy Increases Anatomic Intermetatarsal Angle in Hallux Valgus

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Loss of correction in hallux valgus (HV) deformity following distal chevron metatarsal osteotomy (DCO) has been demonstrated in short-term follow-up with HV recurrence rates of up to 75% reported in the long-term. The purpose of this study was to evaluate the radiographic effect of the DCO on the anatomic and mechanical axes of the first metatarsal. Our hypothesis was that patients undergoing DCO would have improvement in the mechanical metatarsal axis but worsening of the anatomic axis.Methods:This was a retrospective single surgeon case series of all patients who underwent DCO for HV between 2017 and 2019. Patients were included if they had both preoperative and postoperative weightbearing foot radiographs. The primary outcomes were the change in anatomic first-second intermetatarsal angle (a1-2IMA, defined by the metatarsal diaphyseal axis) and the change in mechanical first-second intermetatarsal angle (m1-2IMA, defined by the axis from the center of the metatarsal head to the metatarsal base). Secondary outcomes included the change in hallux valgus angle (HVA) and medial sesamoid position (medial sesamoid in relation to the mechanical axis of the metatarsal). Change in second-third intermetatarsal angle (2-3IMA, defined by the metatarsal diaphyseal axis) was measured to control for any inconsistencies in radiographic technique. Given the relatively small patient cohort, the non-parametric Wilcoxon signed rank test and Mann Whitney U test were used for statistical analysis.Results:41 feet were included for analysis with a mean follow-up of 20.4 weeks. The a1-2IMA increased significantly (mean, 4.0 degrees, p<0.001) while the m1-2IMA decreased significantly (mean, 4.6 degrees, p<0.001) following DCO. There was a significant improvement in HVA (mean, 13.2 degrees, p<0.001). No changes were noted in 2-3IMA (mean, 0.0 degrees, p=0.834). (Table 1) Medial sesamoid position was improved in 22 feet (53.7%). Patients with improved sesamoid position were noted to have a significantly larger decrease in m1-2IMA (mean, 5.3 versus 3.8 degrees, p=0.01) and a smaller increase in a1-2IMA (mean, 3.4 versus 4.7 degrees, p=0.02) compared to patients with no improvement in sesamoid position.Conclusion:Distal chevron osteotomy for HV is associated with an increase in the anatomic intermetatarsal angle despite improvements in the m1-2IMA, HVA and medial sesamoid position. Patients with improved sesamoid position were associated with greater correction of the mechanical first metatarsal axis. Our findings may suggest the presence of intermetatarsal instability, which could limit the power of DCO in HV correction for more severe deformities and provide a mechanism for HV recurrence.

The Role of Weight-Bearing Computed Tomography Scan in Hallux Valgus

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:Hyperpronation of the 1st metatarsal in hallux valgus (HV) is poorly understood by conventional weightbearing radiography. We aimed to evaluate this parameter using weightbearing computed tomography (WBCT) and understand its association with other standard measurements.Methods:Retrospective evaluation of WBCT and weightbearing radiographs (WBXR) was performed for 20 patients with hallux valgus (HV) feet and 20 controls with no such deformity. Axial CT images of both groups were compared for 1st metatarsal pronation angle (α angle) and tibial sesamoid subluxation (TSS) grades. The hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), 1st metatarsal-medial cuneiform angle (MMCA), Meary’s angle, and calcaneal pitch (CP) angle of the study and control groups were compared on both WBXR and the corresponding 2D images of WBCT. All the measurements were independently studied by a dedicated musculoskeletal radiology fellow.Results:HV group demonstrated significantly higher values for TSS grade (p < 0.001) but not for α angle (p = 0.19) compared to controls. Pearson’s correlations of the α angle, in the HV group, revealed no significant linear relationship with TSS grades, IMA and MMCA, and only a moderate positive correlation with HVA as per WBXR (r = 0.38, p = 0.014) but not by WBCT (p = 0.084). Also, α angle performed within the range of a chance (AUC 0.64, 95% CI: 0.49 to 0.66) when measured by receiver operating characteristic (ROC) curves.Conclusion:The α angle - a measure of abnormal hyperpronation of the 1st metatarsal - is an independent factor that may co- exist with other parameters in HV, but in isolation has limited diagnostic utility. ‘Abnormal’ α angles may even be observed in individuals without HV deformity. An increase in the HVA, IMA, MMCA or TSS grade is not necessarily associated with a similar increase in the α angle and hence, the severity of HV deformity may not be judged on this parameter alone. The WBCT is a reliable method to assess hyperpronation and guide physicians during surgical management.

Clinical effect of metatarsal diaphysis Z-shaped rotating osteotomy in moderate and severe hallux valgus with metatarsophalangeal joint incongruency

Objective: To evaluate the clinical effect of Z-shaped rotating osteotomy of metatarsal diaphysis in patients with moderate and severe hallux valgus with metatarsophalangeal joint incongruency. Methods: We selected 36 patients (38 feet) with moderate and severe hallux valgus with metatarsophalangeal joint incongruency who underwent Z-shaped rotating osteotomy of metatarsal diaphysis in the First Affiliated Hospital of Army Medical University of Chinese PLA from September 2010 to January 2019. There were 2 males and 34 females with an average age of (49±18) years (18-77 years). Hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), congruency index, length of first metatarsal, and functional scores were evaluated before and 6 weeks after surgery and at the last follow-up. The data were compared by one-way ANONA or t test. Results: The congruency index was significantly improved from 0.75±0.11 before surgery to 0.95±0.07 at the last follow-up (t=11.728, P<0.01). HVA and IMA improved significantly at 6 weeks after surgery, however, HVA at the last follow-up showed an increased trend compared with that at 6 weeks after the operation, while no significant improvement in IMA. Although DMAA increased slightly 6 weeks after surgery when compared with that before surgery, there was no significant difference in it between the last follow-up and the 6 weeks after surgery, and no significant difference in the length of the first metatarsal at different time points (F=0.991, P>0.05). In terms of functional scores, American Orthopaedic Foot & Ankle Society (AOFAS) score increased from 50±9 before surgery to 80±17 at the last follow-up, while visual analogue scale (VAS) decreased from 5.8±1.1 to 2.7±1.5, Manchester-Oxford Foot Questionnaire (MOXFQ) score decreased from 70±13 to 25±19 (t=12.024, 13.439, 16.880, all P<0.05). Conclusions: The treatment of moderate and severe hallux valgus with metatarsophalangeal joint incongruency by Z-shaped rotating osteotomy of metatarsal diaphysis can significantly increase the congruency index of metatarsophalangeal joint and improve the metatarsophalangeal joint matching relations. It will not significantly increase the DMAA. A certain degree of radiographic recurrence occurs during a longtime follow-up, but it doesn't influence the symptoms and function.

Effectiveness of double metatarsal osteotomy for severe hallux valgus with increased distal metatarsal articular angle

To summarize the technique and effectiveness of double metatarsal osteotomy for treating severe hallux valgus with increased distal metatarsal articular angle (DMAA). Between June 2014 and December 2017, 64 patients (94 feet) of severe hallux valgus with an increased DMAA were treated with the double metatarsal osteotomy (distal metatarsal Reverdin osteotomy+proximal metatarsal open wedge osteotomy) combined with Akin osteotomy and soft tissue surgery to correct the deformity. There were 10 males (15 feet) and 54 females (79 feet) with an average age of 44.5 years (range, 26-66 years), including 34 of unilateral foot and 30 of bilateral feet. The Maryland metatarsophalangeal joint score of the American Orthopaedic Foot and Ankle Society (AOFAS) was 54.3±7.4 and the visual analogue scale (VAS) score was 6.0±2.0. The pre- and post-operative AOFAS score, VAS score, DMAA, hallux valgus angle (HVA), first-second intermetatarsal angle (1-2IMA), and the first metatarsal length (FML) were recorded and compared. All incisions healed by first intention. All patients were followed up 12-15 months, with an average of 13.2 months. The complications occurred in 4 feet, including 1 foot of hallux stiffness, 1 foot of numbness at the edge of the wound, 1 foot of metastatic metatarsalgia, and 1 foot of metatarsal bone necrosis. At 1 year after operation, the Maryland metatarsal joint score of AOFAS was 89.2±7.4, showing significant difference compared with preoperative score ( t=18.427, P=0.000); and the effectiveness was rated as excellent in 78 feet, good in 12 feet, poor in 3 feet, and bad in 1 foot, with an excellent and good rate of 95.7%. The VAS score was 1.5±2.0, showing significant difference compared with the preoperative score ( t=10.238, P=0.000). The X-ray films showed that the osteotomies achieved bony healing at 3 months after operation. There were significant differences ( P<0.05) in HVA, 1-2IMA, and DMAA between preoperation and 6 months and 1 year after operation; but no significant difference was found in FML between preoperation and 1 year after operation ( t=0.136, P=0.863). For the patients with severe hallux valgus with increased DMAA, the double metatarsal osteotomy can significantly relieve the clinical symptoms and improve the imaging parameters with less postoperative complications.

Short-term effectiveness of the first ray tri-plane osteotomy and other metatarsal basal osteotomy for hallux valgus with moderate and severe metatarsus adductus

To evaluate the short-term effectiveness of the first ray tri-plane osteotomy and other metatarsal basal osteotomy in treatment of hallux valgus with moderate and severe metatarsus adductus. Between February 2012 and September 2016, 10 patients (12 feet) of hallux valgus with moderate and severe metatarsus adductus were admitted and treated with the first ray tri-plane osteotomy and other metatarsal basal osteotomy and lateral soft tissue release. There were 1 male (2 feet) and 9 females (10 feet) with an average age of 34.5 years (range, 21-55 years). The disease duration ranged from 3 to 10 years (mean, 5.8 years). The degree of metatarsal adductus was moderate in 4 feet and severe in 8 feet according to modified Sgarlato measurement method. Preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 46.4±9.3. The metatarsus adductus angle (MAA) was (25.41±3.66)°, hallux valgus angle (HVA) was (41.42±9.67)°, and the first-second intermetatarsal angle (1-2IMA) was (10.72±2.26)°. All incisions healed by first intention. All patients were followed up 18-24 months, with an average of 21.4 months. One patient (1 foot) had metastatic metatarsalgia after operation, but the symptoms disappeared after symptomatic treatment. X-ray re-examination showed that all osteotomies healed, and the healing time was 2.4-3.2 months, with an average of 2.8 months. At last follow-up, MAA was (8.42±0.71)°, HVA was (13.29±1.03)°, 1-2IMA was (4.41±0.48)°, and AOFAS score was 89.8±5.9. There were significant differences in clinical and radiographic indexes between pre- and post-operation ( P<0.05). The first ray tri-plane osteotomy combined with other metatarsal basal osteotomy has a significant short-term effectiveness in the treatment of hallux valgus with moderate and severe metatarsus adductus.

Impact of crossover second toe on the postoperative outcome of distal chevron osteotomy for moderate to severe hallux valgus

BackgroundCrossover second toe is often presented in moderate to severe hallux valgus. However, its clinical impact on the postoperative outcome of hallux valgus is still unknown. MethodsThirty-five patients who had moderate to severe hallux valgus with crossover second toe were matched with 35 controls who did not have crossover second toe, according to preoperative hallux valgus angle and first-second intermetatarsal angle. Radiological parameters, Foot Function Index (FFI), and Visual Analog Scale (VAS) were assessed as postoperative outcomes at 3, 6, and 12 months after surgery. ResultsAt 3 months, the FFI in the crossover second toe group was lower than in the control group (p=0.001), while other outcomes were similar. On the other hand, there were no significant differences between the groups at 6 and 12 months, in terms of radiological parameters, FFI, and VAS. ConclusionsPatients who had moderate to severe hallux valgus with crossover second toe were at risk for slow functional recovery after surgical treatment in the short term, but, in the long-term, there was no difference in overall postoperative outcomes in patients with and without crossover second toe. Level of EvidenceLevel III, retrospective comparative study.

Rotational Distal Chevron Osteotomy for Correction of Hallux Valgus Associated with Metatarsus Adductus and Large Distal Metatarsal Articular Angle

Category:BunionIntroduction/Purpose:Hallux valgus treatment in the setting of associated metatarsus adductus is less common and not well described. The presence of metatarsus adductus reduces the gap between the first and second metatarsals. Consequently, it complicates the measurement of the first-second intermetatarsal angle and can limit the area available for transposition of the first metatarsal head. If distal metatarsal articular angle (DMAA) is also increased here, it is difficult to correct. We investigated the effects of rotational distal chevron metatarsal osteotomy (DCMO) on hallux valgus associated with metatarsus adductus and increased DMAA.Methods:Twelve patients, (12 female, 15 feet), of average age 59 (SD 23) with symptomatic hallux valgus associated with metatarsus adductus and increased DMAA underwent a rotation DCMO and were reviewed at an average of 12 months postoperatively. Clinically preoperative and postoperative AOFAS hallux MP-IP scale and satisfaction after the surgery were analyzed. Radiologically hallux valgus angle, the 1st intermetatarsal angle, DMAA before and after the operation was analyzed.Results:Distal Chevron osteotomy was done in 15 cases. After DCMO, The distal fragment was translated to laterally as far as possible and rotated to reduce DMAA. Clinically AOFAS scale was increased from 65.3 points preoperatively to 92.2 points postoperatively. Two patients were not satisfied with the results. Radiologically hallux valgus angle was decreased from 21.8° preoperatively to 8.5° postoperatively. The first intermetatarsal angle was decreased from 11.8° preoperatively to 6.7° postoperatively. DMAA was decreased from 15.8° preoperatively to 5.5° postoperatively.Conclusion:The rotational DCMO was an effective procedure for correcting hallux valgus associated with metatarsus adductus and increased DMAA. It allowed good realignment of the first MTP joint without the need for lesser metatarsal surgery to reduce the metatarsus adductus.

Short-term effectiveness of Scarf osteotomy and Akin osteotomy combined with soft tissue procedures in treatment of hallux valgus associated with mild to moderate metatarsus adductus

To evaluate the short-term effectiveness of Scarf osteotomy and Akin osteotomy combined with soft tissue procedures for hallux valgus associated with mild to moderate metatarsus adductus. The clinical data of 30 patients (48 feet) who were diagnosised hallux valgus associated with mild to moderate metatarsus adductus and treated by Scarf osteotomy and Akin osteotomy combined with soft tissue procedures between February 2013 and May 2015 were analyzed retrospectively. There were 2 males (2 feet) and 28 females (46 feet) with an average age of 29.4 years (range, 18-50 years). The disease duration was 3-12 years (mean, 6.1 years). The degree of metatarsal adductus was assessed by Sgarlato's measurement and Yu et al classification criteria, and the degree of metatarsal adductus was mild in 20 feet and moderate in 28 feet. Preoperative X-ray examination showed that the hallux valgus angle (HVA) was (39.4±5.6)°, the first-second intermetatarsal angle (1-2IMA) was (15.2±3.5)°, the metatarsus adductus angle (MAA) was (21.2±3.7)°. The American Orthopaedic Foot and Ankle Society (AOFAS) score was 51.7±10.0, and visual analogue scale (VAS) score was 4.9±2.7 before operation. Postoperative complications and the union time of osteotomies were recorded. At last follow-up, the HVA, 1-2IMA, and MAA were measured on X-ray films, and the AOFAS scores and VAS scores were recorded, then compared them with preoperative ones. Roles - Maudsley score was used to investigate patients' satisfaction. All the incisions healed by first intention. Thirty patients were followed up 24-27 months (mean, 26.4 months). Three patients (4 feet) occured metatarsalgia, and the pain relieved after treated by Custom-Made Orthotics. All the osteotomies were unoin, the healing time was 2-4 months (mean, 2.7 months). At last follow-up, the HVA and the 1-2IMA were (13.2±3.1)° and (5.1±2.3)°, respectively, showing significant differences when compared with preoperative ones ( t=14.606, P=0.000; t=22.356, P=0.000); the MAA was (21.0±3.4)° and there was no significant difference when compared with preoperative one ( t=0.789, P=0.434). The AOFAS and VAS scores were 91.8±7.5 and 1.1±1.0, respectively, showing signifiant differences when compared with preoperative ones ( t=13.787, P=0.000; t=14.781, P=0.000). Satisfaction survey showed that 28 patients were very satisfied and satisfied (93.3%), and 2 cases were not satisfied (6.7%). The short-term effectiveness of Scarf osteotomy and Akin osteotomy combined with soft tissue procedures for hallux valgus associated with mild to moderate metatarsus adductus is satisfactory, and no correction is required for metatarsal adductus.

Effectiveness comparison between Scarf osteotomy combined with Akin osteotomy fixed by absorbable screws and fixed by metal screws for the treatment of moderate to severe hallux valgus

To evaluate the effectiveness of Scarf osteotomy combined with Akin osteotomy in the treatment of moderate to severe hallux valgus with absorbable screws or metal screws fixation by clinical and radiological data. Between March 2014 and May 2016, the Scarf osteotomy combined with Akin osteotomy was used to treat 62 patients (83 feet) with moderate to severe hallux valgus. Twenty-five patients (35 feet) were fixed by absorbable screws (group A) and 37 patients (48 feet) were fixed by metal screws (group B). The difference in gender, age, affected side, etiology, severity, disease duration, preoperative hallux valgus angle (HVA) and first-second intermetatarsal angle (1-2IMA) measured in weight-bearing anteroposterior X-ray film, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analogue scale (VAS) scores between 2 groups ( P>0.05). The complications and healing time of 2 groups were recorded and compared. At last follow-up, the AOFAS and VAS scores, and HVA, 1-2IMA measured by weight-bearing anteroposterior X-ray film were used to evaluate the effectiveness. All incisions healed by first intention and no incision-related complication occurred in the two groups after operation. Both groups were followed up, the follow-up time in group A was 12-36 months (mean, 24.4 months) and in group B was 14-38 months (mean, 25.7 months). In group A, 1 foot was complicated with hallux varus, 2 feet had mild stiffness, 1 foot appeared metastatic metatarsal pain, and in group B was 2, 3, 2 feet, respectively. There was no recurrence of hallux valgus in both groups. The difference in the incidence of complications between the two groups after the first operation was not significant ( χ2=0.275, P=0.843). The removal rate of internal fixator in group B was 89.2% (33 cases) during the second operation, among which 3 cases had screw slip and 1 case had screw fracture. And 10.8% (4 cases) refused the second removal operation due to their age. Postoperative X-ray films showed that both groups had good healing at the osteotomy site, and there was no significant difference in healing time between the two groups ( t=1.633, P=0.285). At last follow-up, the AOFAS score, VAS score, HVA, and 1-2IMA were significantly improved in the two groups when compared with preoperative ones ( P<0.05); but no significant difference was found between the two groups ( P>0.05). The effectiveness of Scarf osteotomy combined with Akin osteotomy in the treatment of moderate to severe hallux valgus is significant, with few complications. Compared with being fixed by metal screws, being fixed by absorbable screws has the same effectiveness, but can avoid the risk of second operation to remove the internal fixator.