Hallux Abductus Research Articles

Distal Chevron Osteotomy with Lateral Soft Tissue Release for Moderate to Severe Hallux Valgus Decided Using Intraoperative Varus Stress Radiographs

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.

Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the Literature

Rotation of the first metatarsal, as a component of hallux abducto valgus, is rarely discussed and is not addressed as a component of most hallux valgus corrective procedures. We believe frontal plane rotation of the first metatarsal to be an integral component of hallux abducto valgus deformity (the “third plane of deformity”) and believe de-rotation is necessary for complete deformity correction. We observed the change in angular measurements commonly used in the evaluation of hallux valgus deformity in patients who underwent a modified lapidus procedure. We measured the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position on weightbearing radiographs of 25 feet in 24 patients who had undergone tarsal metatarsal corrective arthrodesis and lateral capsular release. Specific attention was given to reduction of the frontal plane rotation of the first metatarsal during correction. Our results showed a change in the angular measurements observed by 4 investigators as follows. The mean change in the intermetatarsal angle was 10.1° (p < .0001). The mean change in the hallux abductus angle was 17.8° (p < .0001). The mean change in the proximal articular set angle was 18.7° (p < .0001). The mean change in the tibial sesamoid position was 3.8 (p < .0001). Also, a consistent valgus, or everted position of the first metatarsal, was noted as a component of the hallux abducto valgus deformity in our patient population and was corrected by varus rotation or inversion of the metatarsal. We also reviewed the current literature related to anatomic changes in the first ray in the patient with hallux valgus deformity and reviewed our hypothesis regarding the reduction in the proximal articular set angle, which we believe to be related to frontal plane rotation of the first metatarsal, resulting in a radiographic artifact.

Effect of custom-made foot orthoses in female hallux valgus after one-year follow up

Subtalar joint hyperpronation plays a fundamental role in the development of hallux valgus (HV). Foot orthotics have used to treat this condition and are aimed at preventing progression of the deformity. The aim of this study was to determine if the use of custom-made foot orthotics for 12 months prevented the advancement of HV in women. Prospective trial, using a repeated-measures design. Fifty-four women with mild to moderate HV were divided into two groups: the experimental group used custom-made foot orthoses, and the control group used no treatment. First intermetatarsal (IMA) and hallux abductus (HAA) angles were measured at the beginning of the study and after 12-months follow up. Inter-group comparisons were made of these angles at both times of measurement, and intra-group comparisons between the two times of measurement. The initial HAA was similar in both groups (19.92 ± 4.25 degrees for the control group, 20.55 ± 5.10 degrees for the experimental group; p = 0.392), and also the IMA (10.56 ± 2.45 degrees for the control group, 10.86 ± 2.33 for the experimental group; p = 0.618) There were no significant differences in the follow-up values of these angles (p = 0.395 and p = 0.288, respectively). There were no significant intra-group differences in the comparisons of the initial and follow-up angles. HV did not have a significantly slower evolution in participants of the experimental group compared with controls. Custom-made orthoses appear to have no effect in the evolution of mild and moderate HV during a 12 month period. Clinical relevance Subtalar joint hyperpronation plays a fundamental role in the development of hallux valgus. Conservative management typically involves the use of foot orthotics which is aimed at preventing the progress of the condition. The use of foot orthotics however should be used as a long term management strategy (beyond 12 months).

A Study of the Proximal Wedge Shelf Osteotomy for Correction of Large IM Angle HAV Deformity

Many procedures have been identified to correct hallux abducto valgus deformity of the foot. Due to surgical skill level, complexity, and risk of complications, more procedures have been defined for distal than proximal correction. The senior author has used an alternative proximal procedure to correct larger hallux abducto valgus deformities, which may prove to be as effective as traditional procedures. The purpose of this study was to examine the short-term clinical and radiographic results of the proximal wedge shelf osteotomy and evaluate its potential as a satisfactory option for correction of larger bunion deformities. The study revealed many positive outcomes as measured radiographically in preoperative and postoperative hallux abductus, intermetatarsal and metatarsal elevation/declination angles, and clinically by first metatarsophalangeal joint scores and patients' subjective postoperative responses. From a review of the literature and results of the study, the authors conclude that the wedge shelf osteotomy can be used as an effective alternative for correcting larger bunion deformities with an intermetatarsal angle as large as 20° and a hallux valgus angle up to 38°. The advantages of this procedure include ability to correct in more than one plane, good bone-to-bone contact, and ease of fixation with 2 screws in an easily visible dorsal-to-plantar area. Disadvantages include the technical challenge of the procedure and its learning curve and some shortening of the first metatarsal. Levels of Evidence : Therapeutic Level IV.

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.

Foot Biomechanics in Patients with Diabetes Mellitus

We sought to identify the biomechanical characteristics of the feet of patients with diabetes mellitus and the interrelationship with diabetic neuropathy by determining the range of joint mobility and the presence and locations of calluses and foot deformities. This observational comparative study involved 281 patients with diabetes mellitus who underwent neurologic and vascular examinations. Joint mobility studies were performed, and deformities and hyperkeratosis locations were assessed. No substantial differences were found between patients with and without neuropathy in joint mobility range. Neuropathy was seen as a risk factor only in the passive range of motion of the first metatarsophalangeal joint (mean ± SD: 57.2° ± 19.5° versus 50.3° ± 22.5°, P = .008). Mean ± SD ankle joint mobility values were similar in both groups (83.0° ± 5.2° versus 82.8° ± 9.3°, P = .826). Patients without neuropathy had a higher rate of foot deformities such as hallux abductus valgus and hammer toes. There was also a higher presence of calluses in patients without neuropathy (82.8% versus 72.6%; P = .039). Diabetic neuropathy was not related to limited joint mobility and the presence of calluses. Patients with neuropathy did not show a higher risk of any of the deformities examined. These findings suggest that the etiology of biomechanical alterations in diabetic people is complex and may involve several anatomically and pathologically predisposing factors.

The Unreliability of the Intermetatarsal Angle in Choosing a Hallux Abducto Valgus Surgical Procedure

Conventional thinking holds that high intermetatarsal and hallux abductus angles (>15° and >25°, respectively) are associated with a hypermobile first ray and require a Lapidus procedure to achieve satisfactory correction for the treatment of hallux valgus. However, normal first ray motion may be misinterpreted as hypermobility, and it is possible to take advantage of this motion to correct some portion of a large hallux abductovalgus deformity with distal procedures, such as the Austin or first metatarsophalangeal joint fusion. We retrospectively examined radiographs of 61 patients with first intermetatarsal and hallux abductus angles greater than 15° and greater than 25°, respectively, who had undergone hallux abductovalgus correction via Lapidus, Austin, or first metatarsophalangeal joint fusion. Preoperative and postoperative radiographic measurements of the intermetatarsal and hallux abductus angles were made. The results revealed no statistically significant differences in the amount of correction achieved by any of the 3 procedures in comparison with the others. We concluded that, given appropriate patient selection, an Austin or first MTPJ fusion could reliably correct large intermetatarsal and hallux abductus angles that, in the hands of many surgeons, are often treated by means of Lapidus arthrodesis.

Inverted Z-scarf Osteotomy for Hallux Valgus Deformity Correction: Intermediate-term Results in 55 Patients

The Z-scarf osteotomy is used for hallux valgus deformity correction by foot and ankle surgeons worldwide. Inverting the Z-scarf osteotomy configuration strengthens the construct in both sawbone and cadaver models, but clinical results of this configuration have not been reported in the literature. This retrospective study evaluates the subjective and intermediate-term postoperative radiographic results of 73 inverted Z-scarf osteotomy procedures for hallux valgus correction in 55 patients from January 1994 to December 2003. The modified University of Maryland 100-Point Painful Foot Center Scoring System demonstrated 52 patients (95%) with good to excellent results at a mean follow-up of 5 years (range 2–11 years). Radiograph measurements revealed the following: first-second intermetatarsal angle mean, 6.1° (range 2–14°), average reduction 4.6°; hallux abductus angle mean, 11.0° (range –8–30°), average reduction 10.1°; tibial sesamoid position mean, 2.3; first metatarsal protrusion distance mean, –2.1 mm. Two patients (2 of 73 feet) developed major complications: one progressed to clinically acceptable hallux varus; another sustained compromise of one fixation screw with minor displacement at the distal osteotomy that healed in satisfactory position after non–weight-bearing immobilization. There were no cases of osteonecrosis, delayed union, or nonunion. The inverted Z-scarf osteotomy, with advantages in both mechanical strength and technique of execution over the traditional configuration, demonstrates high patient satisfaction, restoration of normal radiographic parameters, and a low complication rate in this study.

Mini TightRope System for Hallux Abducto Valgus Deformity

This case report reviews the presentation and treatment of a 68-year-old diabetic woman with severe hallux abducto valgus deformity and progressively worsening pain and joint stiffness. The patient had a history of two distinct episodes of postoperative deep venous thrombosis and was deemed inappropriate for cast immobilization. The Arthrex Mini TightRope system was used in an attempt to reduce significantly increased intermetatarsal and hallux abductus angles, with the advantage of immediate postoperative weightbearing. An Integra K2 hemi-joint implant was also used to address the marked osteoarthritis at the first metatarsophalangeal joint. The potential role that this fixation technology may play in forefoot surgery is then discussed, along with its limitations and possible complications.

Plantar pressures determinants in mild Hallux Valgus

While podobarometric techniques have been applied to the study of pressures in Hallux Valgus (HV), little is known about its clinical and radiological determinants. So, the aim of the present study was to determine the plantar pressure pattern in participants with mild HV, comparing to a control group, and their clinical and anthropometric determinants. Biofoot/IBV ® in-shoe system was used to evaluate 79 participants with mild HV. Computerized measurements of the 1st intermetatarsal angle (IMA) and the hallux abductus angle (HAA) were made on antero-posterior radiographs. The clinical outcome was assessed using the AOFAS score. The dependent baropodometric variables and the independent clinical and anthropometric variables were subjected to a multiple regression analysis. In both groups, the highest average pressure was in the 2nd metatarsal head (MTH). The mean pressure under the Hallux was significantly higher in HV group (controls, 146.5 ± 92.5 kPa; HV, 328.5 ± 113.2 kPa; p < 0.001). An 18.6% of average pressure under the 1st MTH was accounted for pain, first ray alignment and total AOFAS score. Variations of the HAA explained 26.8% of the mean Hallux pressure. Women with mild HV present with pathologically increased pressure under the Hallux, which is caused by the altered alignment of the first ray. Pain and clinical result were associated with the pressure under the 1st MTH and the remaining variables were only moderate predictors of dynamic plantar pressures.

Early Weight Bearing After Modified Lapidus Arthodesis: A Multicenter Review of 80 Cases

The modified Lapidus arthrodesis involves fusion of the first tarsometatarsal, which typically takes about 6 weeks to consolidate. Postoperative protocols typically involve non-weight bearing until bone consolidation occurs, however, with a stable fixation construct, protected weight bearing can be initiated earlier than 6 weeks into the postoperative period. Studies specifically evaluating an early weight bearing protocol after lapidus arthrodesis do not exist; such a protocol is the focus of this investigation. A multicenter retrospective review of 80 feet in 76 patients who underwent a Lapidus arthrodesis by 2 different surgeons, involving a similar fixation technique and an early weight-bearing protocol, was performed. All patients were allowed protected weight bearing after the first postoperative visit, at approximately 2 weeks into the postoperative course. Patients began protected weight bearing at a mean 14.8 (95% CI 14.0, 15.6) days postoperative. All 80 feet proceeded to successful union (100% union), and the mean time to union was 44.5 days (95% CI 43.0, 46.0). No hardware was broken, and no complications requiring surgical revision were observed before solid boney fusion was achieved. Statistically significant ( P < .001) improvements in the first intermetatarsal, hallux abductus, and lateral metatarsal angles were observed; and no cases of pathological first ray elevatus were encountered. The duration of time to bone healing in the cohort described in this article was similar to the rates described in previous reports describing Lapidus arthrodesis managed with a considerably longer duration of initial postoperative non–weight bearing. This study demonstrates that early weight bearing of the Lapidus arthrodesis can be performed without compromising correction or the rate of osseous union. This is the first study that specifically evaluates the early weight bearing protocol after lapidus arthrodesis.

Fixation of Akin osteotomy for hallux abductus with absorbable suture

The Akin osteotomy is a widely used procedure where various fixation methods are available, predominantly with the use of metallic component (wire, screw, staple etc.). The aim of this study is to demonstrate the results of our modified Akin procedures, where the fixation of the phalangeal osteotomy is achieved by absorbable suture, without metallic component. Between July 2004 and October 2008, authors performed their first 22 consecutive Akin procedures with the above technique. Mean age of patients was 49 [standard deviation (SD) 17, range 19-69] years. Mean follow-up time was 26 (SD 13, range 8-57) months. Mean correction of the distal articular set angle (DASA) was 9.4 (SD 7.1, range 5-28) degrees. Mean shortening of the proximal phalanx was 1.8 (SD 1.0, range 0.3-4.1) mm. Among the 22 osteotomies, there was no evidence of non-union, delayed union, excessive bone callus, or loss of correction. 100% of the patients would undergo the procedure again, 91% (20/22) were completely satisfied; and 9% (2/22) were satisfied, including the one complication case. The method presented in this study for fixation of the akin osteotomy showed results identical to the ones using conventional (metal) fixation techniques concerning radiological (correction of DASA, shortening of the proximal phalanx), and clinical (complication rate, subjective satisfaction rate) findings, without the risk of complication due to hardware irritation.

Radiographic correlates of hallux valgus severity in older people

BackgroundThe severity of hallux valgus is easily appreciated by its clinical appearance, however x-ray measurements are also frequently used to evaluate the condition, particularly if surgery is being considered. There have been few large studies that have assessed the validity of these x-ray observations across a wide spectrum of the deformity. In addition, no studies have specifically focused on older people where the progression of the disorder has largely ceased. Therefore, this study aimed to explore relationships between relevant x-ray observations with respect to hallux valgus severity in older people.MethodsThis study utilised 402 x-rays of 201 participants (74 men and 127 women) aged 65 to 94 years. All participants were graded using the Manchester Scale - a simple, validated system to grade the severity of hallux valgus - prior to radiographic assessment. A total of 19 hallux valgus-related x-ray observations were performed on each set of x-rays. These measurements were then correlated with the Manchester Scale scores.ResultsStrong, positive correlations were identified between the severity of hallux valgus and the hallux abductus angle, the proximal articular set angle, the sesamoid position and congruency of the first metatarsophalangeal joint. As hallux valgus severity increased, so did the frequency of radiographic osteoarthritis of the first metatarsophalangeal joint and a round first metatarsal head. A strong linear relationship between increased relative length of the first metatarsal and increased severity of hallux valgus was also observed.ConclusionsStrong associations are evident between the clinical appearance of hallux valgus and a number of hallux valgus-related x-ray observations indicative of structural deformity and joint degeneration. As it is unlikely that metatarsal length increases as a result of hallux valgus deformity, increased length of the first metatarsal relative to the second metatarsal may be a contributing factor to the development and/or progression of hallux valgus.

Scarf-Akin Osteotomy Correction for Hallux Valgus: Short-term Results from a District General Hospital

This study assessed the radiological measurements, American Orthopaedic Foot and Ankle Society (AOFAS) scores, and patient satisfaction associated with performance of the scarf osteotomy, combined with an Akin osteotomy, for the treatment of hallux valgus in patients at a general hospital. Thirty-five patients were assessed before surgery, and at 6 months following performance of the scarf first metatarsal osteotomy plus Akin osteotomy. The mean first intermetatarsal and hallux abductus angles reduced from 14.1° ± 3.5° to 10.0° ± 3.2° and 32.1° ± 9.9° to 16.4° ± 7.9°, respectively, and these differences were statistically significant ( P < .001). The mean first to second metatarsal sagittal plane length ratio was unchanged by the osteotomy ( P > .05). The mean global AOFAS Hallux Metatarsophalangeal-Interphalangeal score increased from 58.8 ± 11.6 to 86.4 ± 11.6, and this difference was statistically significant ( P < .0001). Of the 35 patients (36 operated feet), 20 (57.1%) were extremely satisfied, 10 (28.6%) were satisfied, and 5 (14.3%) were unsatisfied with the results of the surgery. Based on these results, we concluded that the improved radiographic angles and AOFAS scores observed in this study were comparable to previously reported results, and our findings indicated that, in the setting of a general hospital, the scarf osteotomy combined with the Akin osteotomy is a safe, versatile and useful procedure for the treatment of hallux valgus.

The Multiplanar Effect of First Metatarsal Osteotomy on Sesamoid Position

The standard classification system used to measure the sesamoids in the evaluation of hallux abductovalgus is a uniplanar description of a multiplanar deformity. Additionally, it cannot accurately describe a true measure of sesamoid positional change in the perioperative period because the first metatarsal is laterally transposed during corrective surgery. The intended emphasis of this investigation is to evaluate the sesamoid position in multiple planes relative to a stationary anatomical landmark following first metatarsal osteotomy for the surgical correction of hallux abductovalgus deformity. A retrospective radiographic review of 46 feet in 38 patients demonstrated statistically significant ( P < .001) differences between preoperative and postoperative values for the first intermetatarsal angle, hallux abductus angle, sesamoid rotation angle, tibial sesamoid position, and tibial sesamoid grade. However, there was no significant difference in the sesamoid position in both the transverse ( P = .07) and frontal ( P = .29) planes when measured relative to the stationary second metatarsal. Based on the preceding results, the appropriate expected surgical outcome of hallux abductovalgus correction may be to relocate the first metatarsal on top of the relatively immobile sesamoids.

Application of an Interosseous Suture and Button Device for Hallux Valgus Correction: A Review of Outcomes in a Small Series

A relatively new method to treat a bunion deformity by means of positional correction rather than structural realignment via osteotomy has been used in a series of 5 patients. This approach to first ray correction entails the use of an interosseous suture and button device that is positioned under tension between the first and second metatarsals, thereby reducing the first intermetatarsal angle. The median age of the group of patients was 51 years (range, 16-71 years), and the median follow-up duration was 20 months (range, 8-64 months). Statistically significant reductions in the first intermetatarsal and hallux abductus angles were observed between the preoperative and immediate postoperative measurements ( P = .0006 and P = .0044, respectively) and between the preoperative and long-term postoperative measurements ( P = .0189 and P = .0305, respectively), and, although loss of correction was observed between the immediate and long-term postoperative first intermetatarsal and hallux abductus angles, these changes were not statistically significant ( P = .1369 and P = .1193, respectively). In 3 (60%) of the cases, complications developed that required revisional surgery and removal of the device. In the other 2 (40%) cases, the surgical procedure was modified and satisfactory outcomes were obtained, although minor complications occurred in both. Based on our experience with these patients, the modified surgical procedure shows some effectiveness in treating hallux abductovalgus, although further evaluation of the technique is warranted.

Hallux rigidus: A cross-sectional study to evaluate clinical parameters

Background Hallux rigidus (HR) is a common condition with history and physical examination used to help evaluate pathology, grade clinical changes and to inform treatment. Method A cross-sectional study was undertaken to evaluate the demographics of and clinical parameters encountered in HR. In 110 subjects (180 feet) aged 18–70 years (mean 52 years) a standardized history and physical examination was undertaken. Clinical parameters associated with HR were evaluated. The Foot Health Status Questionnaire (FHSQ) was used to measure health-related quality-of-life dimensions. Results Seventy (64%) subjects had bilateral HR and 73 (66%) were female. Mean HR onset was 44 (14–68 years) years and median HR duration 6 years (1–33 years). A history of 1st MTPJ trauma presented in 22% of subjects; 74% of whom had unilateral HR. Eighty-four (47%) feet had pes planus based on a positive Foot Posture Index. A correlation between pes planus and 1st MTPJ pain was found ( r = 0.84, p = 0.05). In 74% of feet, hallux abductus interphalangeus angle (HAI°) was greater than normal (≤10°). A correlation between HAI and reduced 1st MTPJ ROM was found ( r = 0.92, p = 0.05). Second toe length was the same as the hallux in 111 feet (62%). A correlation between valgus hallucal rotation and 1st MTP joint pain in HR was found ( r = .78, p = .05). A positive relationship was found between 2nd toe length and 1st MTPJ pain ( p = 0.001 < 0.05). A correlation between hallucal interphalangeal joint (IPJ) hyperextension and 1st MTPJ pain was found ( r = 0.78, p = 0.01). A positive relationship was found between lesser MTPJ pain and supination at propulsion ( p < 0.001). There was no evidence of Achilles tendon contracture. The FHSQ results concur with clinical findings. Conclusions HR was associated with female gender, bilateral involvement, older age groups, increased HAI°, 2nd toe length similar to hallux, hallucal IPJ hyperextension, lesser MTP joint pain, flat foot and certain gait alterations. HR was not associated with Achilles tendon tightness or footwear. The content validity of clinical parameters of HR needs to be established by formal research prior to their inclusion in a classification of HR.

Symptomatic Medial Exostosis of the Great Toe Distal Phalanx: A Complication Due to Over-correction Following Akin Osteotomy for Hallux Valgus Repair

The authors present the case of a 54-year-old female who developed a painful compression lesion localized to the medial aspect of the base of the distal phalanx of the great toe as a complication of hallux valgus surgery. Preoperative radiographic evaluation of the patient's foot revealed the first ray to be longer than the second, a 12 degrees first intermetatarsal angle, a 33 degrees hallux abductus angle, and an exostosis at the medial aspect of the base of the hallux that was not considered by the surgeon to be important. Correction of the hallux valgus deformity was performed with a combination of scarf and Akin osteotomies, and the intermetatarsal and hallux abductus angles reduced to 2 degrees and 8 degrees , respectively. By 2 months postoperative, the patient was complaining of pain at the medial aspect of the distal phalanx of the hallux associated with shoe pressure. The pain correlated both clinically and radiologically with the exostosis at the base of the distal phalanx, and had become symptomatic only after the hallux had been operatively realigned. At 6 months postoperative, percutaneous exostectomy was undertaken to remove the exostosis. Pain relief was complete, thereafter, and after 2 years of postoperative follow-up the patient remained pain free. The clinical importance of a medial exostosis localized to the base of the distal phalanx of the hallux must be taken into consideration whenever hallux valgus correction is undertaken, and this is particularly important whenever an Akin osteotomy is being considered. 4.

Cross-sectional study to evaluate radiological parameters in hallux rigidus

Backgound Hallux rigidus (HR) is a common condition with X-rays used to evaluate its pathology, grade joint changes and to inform treatment. Method A cross-sectional study was undertaken to evaluate radiological foot parameters in HR. In 110 subjects (180 feet) aged 18–70 years (mean 52 years) standard weight-bearing X-rays were examined using dorsal plantar and lateral views. Results Seventy (64%) subjects had bilateral HR and 73 (66%) were female. The mean onset of HR (denoted by first metatarsophalangeal (MTP) joint restriction/pain) was 44 (14–68 years) years and median HR duration was 6 years (1–33 years). Flat or chevron-shaped metatarsal heads presented in 131 (73%) feet and a history of first MTP joint trauma in 22% (74% of whom had unilateral HR). In 74% of feet hallux abductus interphalangeus angle (HAI°) was greater than normal (≤10°). Correlations between first MTP joint narrowing and sclerosis ( r = 0.76, p = 0.01) and increased HAI° and first MTP joint narrowing ( r = 0.34, p = 0.01) was found. The mean hallux equinus angle of 11° was outside the normal range (16–18°). Abnormal sesamoid morphology presented in 117 (65%) feet (30% irregular or hypertrophic). Proximal sesamoid displacement was greater than that seen in non-HR. Metatarsus primus elevatus was within normal range (≤8 mm) in 160 (89%) feet. The first metatarsal was longer than the second metatarsal in 66 (37%) feet although the first metatarsal was longer than the third metatarsal in 131 (73%) feet and may be responsible for altered forefoot function in HR. Conclusions HR was associated with female gender, bilateral involvement, older age groups, flat or chevron-shaped metatarsal head, longer proximal phalanx, increased HAI° and a first metatarsal longer than the third metatarsal. For radiological parameters to be considered valid for inclusion in a classification of HR their content validity needs to be established by formal research.

The Effect of Adductor Tendon Transposition in the Modified McBride Procedure

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