Hallux Surgery Research Articles

DOES A HIGH PREOPERATIVE PAIN CATASTROPHIZATION SCORE INFLUENCE THE OUTCOMES FOLLOWING HALLUX SURGERY?

BackgroundSurgical intervention for hallux valgus and hallux rigidus is an option for patients presenting with severe pain and deformity. Literature suggest that patients with high Pain Catastrophisation Scores (PCS) have poorer outcomes in spinal and to a lesser extent in arthroplasty surgery. There is however very little evidence pertaining to foot and ankle surgery.AimWe aimed to study whether catastrophisation as measured by PCS influenced the outcomes following surgery for Hallux valgus and rigidus.MethodologyEthical approval for this prospective portfolio study was obtained from NRES Committee South Central and Oxford. Approval was granted from the local R&D department prior to data collection. All patients listed for surgery for hallux pathology to the four senior authors were invited to participate. Recruitment into the study started in September 2017 and is ongoing. Pain catastrophising score (PCS), Manchester Oxford Foot Questionnaire (Mox-FQ), Visual analog scale (VAS) for pain and EQ-5D-3L questionnaires were completed Pre-op (baseline), and at 3, 6 and 12- months post-surgery.Results93 patients with minimum follow-up of 6 months were analysed using SPSS software. A P-value of less than 0.05 was considered significant. The mean age of the patients was 58.5 years and 83% were women. 70% of the patients had surgery for hallux valgus and rest for rigidus. Both PROMS and PCS improved significantly following surgical intervention. Patients with higher pre-operative PCS had a worse 6-month PROM score and more pain.ConclusionThis study confirms that pre-operative catastrophisation as demonstrated by a high PCS score has an adverse effect on outcomes following hallux surgery. Risk stratifying patients based on their Pre-op PCS scores may be a useful strategy to identify those at risk of poorer outcomes. We recommend that behavioural change interventions should be considered to try to improve outcomes in patients with pre-op PCS.

Comparison of Resorbable and Non-Resorbable Osteosynthesis Material in Hallux Surgery: A Systematic Review.

There are various pathologies that involve the hallux, among which hallux valgus is the most common. When conservative treatment fails, it is necessary to resort to a surgical approach. The fixation elements for osteotomies in the hallux are usually composed of metallic materials; however, today, there are numerous resorbable materials that offer numerous advantages over conventional materials. In this article, the objective is to analyze the scientific evidence through the systematic analysis of the existing literature in relation to the effectiveness of resorbable versus non-resorbable osteosynthesis material in the surgical correction of hallux deformities and compare the complications as well as the patient satisfaction and quality of life between both fixation methods. A systematic review of the literature available in the PubMed, EMBASE, Web of Science and Scopus databases and 10 studies were included. The documents were chosen following the eligibility and exclusion criteria, including experimental and observational studies evaluated with the Jadad and Newcastle-Ottawa methodological quality scale, respectively. Data were extracted from valid studies for the review, and the variables functionality, pain, angular corrections, complications, satisfaction and quality of life were observed. In conclusion, there is limited scientific evidence regarding the effectiveness of resorbable versus non-resorbable osteosynthesis material in the surgical correction of hallux deformities. All observed variables are similar regardless of the surgical technique and osteosynthesis material used.

Percutaneous, MIS and open hallux valgus surgery.

There is some confusion in the terminology used when referring to MIS (Minimal invasive surgery) or percutaneous surgery. The correct term to describe these procedures should be percutaneous (made through the skin) and MIS should be reserved for procedures whose extent is between percutaneous and open surgery (e.g. osteosynthesis). Minimal incision surgery may be distinguished in first, second and third generation minimal incision surgery techniques.First generation MIS hallux valgus surgery is mainly connected with the Isham procedure; an intraarticular oblique and incomplete osteotomy of the head of the first metatarsal without fixation.The Bösch osteotomy and the SERI are classified as second generation MIS hallux surgery. They are both transverse subcapital osteotomies fixed with a percutaneous medial K-wire inserted into the medullary canal. For all these procedures, intraoperative fluoroscopic control is necessary.Open hallux valgus surgery can be divided into proximal, diaphyseal and distal osteotomies of the first metatarsal. Reviewing the available literature suggests minimally invasive and percutaneous hallux valgus correction leads to similar clinical and radiological results to those for open chevron or SCARF osteotomies. First generation minimally invasive techniques are primarily recommended for minor deformities. In second generation minimally invasive hallux valgus surgery, up to 61% malunion of the metatarsal head is reported. Once surgeons are past the learning curve, third generation minimally invasive chevron osteotomies can present similar clinical and radiological outcomes to open surgeries. Specific cadaveric training is mandatory for any surgeon considering performing minimally invasive surgical techniques.Cite this article: EFORT Open Rev 2021;6:432-438. DOI: 10.1302/2058-5241.6.210029

Outcomes of bilateral simultaneous hallux MTPJ fusion

BackgroundArthrodesis of the first metatarsophalangeal joint (MTPJ) is a frequently performed surgical procedure. Many patients have bilateral hallux MTPJ pathology requiring bilateral arthrodesis. There are concerns that bilateral simultaneous hallux surgery, under one anaesthetic, results in the patient being severely incapacitated in the early post-operative period. We hypothesize that bilateral simultaneous hallux MTPJ fusions does not compromise outcomes or the patients’ post-operative comfort and rehabilitation and is cost and time effective. MethodsIn this retrospective study, 16 patients who underwent bilateral simultaneous first MTPJ arthrodesis were compared to 16 patients who had unilateral MTPJ arthrodesis with regards to outcome, tolerance, cost and time effectiveness. Outcome measures were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Self-Reported Foot and Ankle questionnaire (SEFAS). ResultsThere was a significant improvement in the AOFAS scores post surgery in the bilateral group and according to the SEFAS grading, 14 patients (87.5%) had good or excellent outcome scores with 13 (81.25%) of these patients having excellent scores. This was comparable to the outcome scores in the unilateral group. Two patients developed non-unions bilaterally compared to one in the unilateral group. There is also a notable general cost saving and less time off work when bilateral fusions are done at the same setting. ConclusionBilateral simultaneous hallux MTPJ arthrodesis is an effective, convenient and cost effective option for patients requiring MTPJ fusions for bilateral hallux pathology. Level of evidenceLevel 4

Change of hallux alignment after metatarsal shortening offset osteotomy of lesser toe deformity without hallux surgery

Change of hallux alignment after metatarsal shortening offset osteotomy of lesser toe deformity without hallux surgery

Increasing the safety of minimally invasive hallux surgery—An anatomical study introducing the clock method

BackgroundThe purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures. MethodsTen fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section ResultsThe DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5–45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5–40). ConclusionsUsing the clock method the DMDN and DLDN were found consistently between 10 o’clock and 2 o’clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery.

Influence of socioprofessional category on the duration of sick leave after hallux surgery. A prospective study of 102 cases

IntroductionSurgery of the forefoot including the hallux involves procedures on one bone or more. Usually bone union occurs within 45 days after surgery. During convalescence, the patient can gradually return to his/her activities. The duration of sick leave (SL) can be used to evaluate the influence of convalescence on professional life. The goal of this study was to evaluate the influence of the socioprofessional category (SPC) on the duration of SL after surgery of the forefoot including the hallux. Patients and methodsThis was a single center, single surgeon prospective cohort study performed between January 2012 and March 2013. It included working patients over 18 who underwent hallux surgery associated or not with surgery of the lateral rays. A standardized questionnaire was filled out during the postoperative day 45 consultation to determine factors that could influence the duration of sick leave. Regression models (Cox model) were used to indentify variables associated with the duration of sick leave. ResultsAmong the operated patients, 102 were included and divided into 5 SPC. SL lasted a mean 45 days (from 8 to 90 days). The only predictive factors for the duration of SL on multivariate analysis using SPC 2 as a reference were SPC and the VAS (Visual Analogue Scale). The mean duration of SL was 15 days for SPC 2, 35 days for SPC 3, 47 days for SPC 4, 50 days for SPC 5 and 67 days for SPC 6. Discussion–ConclusionThe distribution of SPC was comparable to that of the working population in the Île de France. The SPC appears to be a predictive factor for the duration of SL after hallux surgery. Severe pain seems to increase the duration of SL. Surgeons and patients should be informed accordingly. Level of evidenceLevel IV.

The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery.

The purpose of this prospective study was to determine whether the more frequently quoted procedure and patient specific risk factors have any impact in the implementation of venous thromboembolism (VTE) prophylaxis following foot and ankle surgery. Two hundred and sixteen patients were included in the study. A variety of operative procedures was carried out with the common denominator being a below knee cast for at least 4 weeks and nonweightbearing for an average of 6 weeks in 130 patients. The remainder of the patients (88) had hallux surgery not requiring a cast and were allowed to weightbear. No patient received any form of thromboprophylaxis postoperatively. All patients were subjected to compression ultrasonography for deep vein thrombosis (DVT) between 2 and 6 weeks postoperatively. There was a 5.09% incidence of VTE (0.9% pulmonary embolism) overall. As no VTE (neither DVT nor pulmonary embolus) developed in the hallux subgroup, i.e. patients not requiring immobilization and were allowed to weightbear, the incidence of VTE in the cast/nonweightbearing group was 8.46%. The results are descriptive and only statistically analyzed where possible, as the sample size of the VTE group was small. There was no significant difference in number of risk factors and no association between gender in the VTE and non VTE groups. 90.9% of patients in the VTE group had a total risk factor score of 5 or more and 73.7% of patients in the non VTE group had a total risk factor score of 5 or more. The average timing to the diagnosis of VTE in this current study was 33.1 days. In view of the unacceptable incidence of VTE and the average total risk factor score of 5 or more (for which thromboprophylaxis is recommended) in the majority of the patients, the authors feel that the routine use of thromboprophylaxis in foot and ankle surgery requiring nonweightbearing in combination with short leg cast immobilization, is warranted. This prophylaxis should continue until the patient regains adequate mobility either by weightbearing (in or out of the cast) or removal of cast immobilization (weightbearing or nonweightbearing), usually between 28 and 42 days.

Poster 141: Osteosarcoma of the Mid Femur Presenting as Lumbago in a Young Adult Recovering From Hallux Surgery: A Case Report

Setting: An outpatient musculoskeletal medicine clinic. Patient: A 24-year-old man with subacute low back pain (LBP). Case Description: The patient was referred from his orthopedist with right-sided LBP in the sacroiliac region that came on gradually over a period of 2 weeks. He was 1 month postoperative from a right bunionectomy, for which he had been placed in a CAM walking boot. He noted his lumbago was worse with ambulation and at the end of the day, and improved with swimming. There was 4 out of 5 strength in his right hip abductors and knee extensors.

Poor Agreement Between Prospective and Retrospective Assessment of Hallux Surgery Using the AOFAS Hallux Scale

Retrospective assessment of preoperative status is common in nonprospective study designs. The aim of this study was to test the hypothesis that prospective and retrospective evaluations of the preoperative patient condition in hallux surgery gives equal results and therefore can be used interchangeably. One hundred and fifty-nine consecutive feet with hallux surgery were analyzed prospectively. Parallel to routine evaluation of the preoperative status, the AOFAS Hallux Scale was recorded prospectively. Two years after surgery, the medical records were re-evaluated for retrospective reconstruction of the AOFAS score. Simultaneously all patients were asked to assess their preoperative status retrospectively. Using the medical charts for retrospective assessments, the preoperative status was estimated too low compared to prospective evaluation. This effect was even more pronounced with the patients' own retrospective assessment of their preoperative status. Linear regression coefficient for prospective and retrospective data showed moderate correlation with r = 0.59 for the AOFAS Score using the medical charts and poor correlation of r = 0.24 using the patients' own retrospective assessments. Spearman's rank correlation index was p = 0.57 and p = 0.23, respectively. The coefficient of repeatability according to Bland and Altman was 25.7 and 48.7 points, respectively, for the AOFAS score. The difference between the mean values of prospective and retrospective assessment was 5.6 (13.0) points. This means that a retrospectively evaluated AOFAS Score may be 31.3 points below or 20.1 points above prospective assessments (61.6 points below or 35.7 points above compared to the patients' own retrospective self-assessments). Agreement between individual items using Kappa statistics showed poor results except for metatarsophalangeal joint motion. Prospectively and retrospectively evaluated AOFAS scores cannot be used interchangeably for clinical outcome evaluations. Retrospective scoring gives worse results even when evaluated using conscientiously recorded medical charts and therefore leads to overestimation of the effect of surgery. These data support prospective study designs to ensure the best outcome analysis for clinical evaluation of hallux surgery.

Intra- and interobserver repeatability of radiographic measurements in hallux surgery

To test the hypothesis that the repro-ducibility of radiographic measurements of the first metatarsophalangeal angle and the intermetatarsal angle I-II can be increased by exact guidelines, we calculated the intra- and interobserver reliability of both methods. 4 independent observers (2 senior residents and 2 orthopedic trainees) evaluated 50 pre- and 50 postoperative plain dorsoplantar radiographs with their method of preference and then with Mitchell et al.'s method (1958).The mean intraobserver coefficient of repeatability for the metatarsophalangeal angle improved from 5.9° to 4.2° and for the intermetatarsal angle I-II, from 4.4° to 2.8°. The interobserver coefficient of repeatability improved from 6.5° to 5.0° for the metatarsophalangeal angle, and from 4.9° to 3.6° for the intermetatarsal angle I-II. This improvement in measurement accuracy was more marked for postoperative measurements, due to deformation of the metatarsal after the osteotomy which made it more difficult to find the longitudinal axis of the metatarsal. The improvements in the accuracy of measurements were also greater in the two inexperienced observers, since their measurements differed more when they had no exact guidelines for their drawings.

Intra- and interobserver repeatability of radiographic measurements in hallux surgery: improvement and validation of a method.

To test the hypothesis that the reproducibility of radiographic measurements of the first metatarsophalangeal angle and the intermetatarsal angle I-II can be increased by exact guidelines, we calculated the intra- and interobserver reliability of both methods. 4 independent observers (2 senior residents and 2 orthopedic trainees) evaluated 50 pre- and 50 postoperative plain dorsoplantar radiographs with their method of preference and then with Mitchell et al.'s method (1958). The mean intraobserver coefficient of repeatability for the metatarsophalangeal angle improved from 5.9 degrees to 4.2 degrees and for the intermetatarsal angle I-II, from 4.4 degrees to 2.8 degrees. The interobserver coefficient of repeatability improved from 6.5 degrees to 5.0 degrees for the metatarsophalangeal angle, and from 4.9 degrees to 3.6 degrees for the intermetatarsal angle I-II. This improvement in measurement accuracy was more marked for postoperative measurements, due to deformation of the metatarsal after the osteotomy which made it more difficult to find the longitudinal axis of the metatarsal. The improvements in the accuracy of measurements were also greater in the two inexperienced observers, since their measurements differed more when they had no exact guidelines for their drawings.

Scoring in forefoot surgery: a statistical evaluation of single variables and rating systems.

We assessed 13 scores for forefoot surgery and their single parameters in 200 cases of hallux surgery. Outcome expressed in descriptive terms from excellent to poor, as well as calculated as a numerical value differed to a great extent. The rank correlation between different scores showed poor conformity, in some combinations even slight negative correlations. The rank correlation between single parameters and the overall outcome gave good values for some variables included in most scores, e.g., walking distance, general activity, problems on uneven surfaces, shoe wear, cosmetics and pain. Little, if any, correlation was found for joint instability, range of motion of the MTP- and IP-joints, the use of walking aids and medication. We find a need for a generally accepted score, with parameters of high clinical relevance.