Hallux Valgus Patients Research Articles

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.

Early effectiveness of modified minimally invasive Chevron-Akin osteotomy for moderate to severe hallux valgus

To explore early effectiveness of modified minimally invasive Chevron-Akin (MICA) osteotomy in the treatment of moderate to severe hallux valgus. A clinical data of 49 patients (61 feet) with moderate to severe hallux valgus, who met the selection criteria between December 2019 and October 2022, was retrospectively analyzed. There were 7 males (8 feet) and 42 females (53 feet) with an average age of 38.0 years (range, 15-59 years), including 37 of unilateral foot and 12 of bilateral feet. There were 41 feet of moderate hallux valgus [hallux valgus angle (HVA) 20°-40°] and 10 feet of severe hallux valgus (HVA>40°). All patients underwent modified MICA osteotomy. A transverse osteotomy on the distal end of the first metatarsal bone was performed to replaced the traditional Chevron osteotomy, and three Kirschner wires were used to assist in three-dimensional correction. The other treatments were the same as traditional MICA osteotomy. The HVA, inter metatarsal angle (IMA), Hardy score of the sesamoid, and American Orthopaedic Foot and Ankle Society (AOFAS) score of 61 feet before operation and at last follow-up were recorded, and the results were compared between the various severity of hallux valgus. All patients were followed up 6-24 months with an average of 12.0 months. After operation, the redness and swelling around the incision occurred in 1 foot; limited mobility of the metatarsophalangeal joint occurred in 2 feet; mild numbness of the skin occurred in 5 feet; mild inversion of the great toe occurred in 2 feet. No complication such as tendon injury was found. X-ray films showed no abnormal healing, nonunion, or necrosis of the metatarsal head after osteotomy. The healing time of osteotomy ranged from 3 to 4 months, with an average of 3.2 months. At last follow-up, the HVA, IMA, Hardy score of sesamoid, and AOFAS scores all significantly improved when compared with preoperative levels ( P<0.05). The AOFAS scores were excellent in 45 feet, good in 15 feet, and fair in 1 foot, with an excellent and good rate of 98.4%. The above indicators for moderate or severe hallux valgus patients were significantly improved when compared with preoperative levels ( P<0.05). The changes between pre- and post-operation in HVA, IMA, and Hardy scores of severe hallux valgus were all greater than those of moderate hallux valgus, with significant difference in HVA change between groups ( P<0.05), while there was no significant difference in the other two changes ( P>0.05). Modified MICA osteotomy can achieve good orthopedic effects and early functional improvement in the treatment of moderate to severe hallux valgus.

Muscle synergy and kinematic synergy analyses during sit-to-stand motions in hallux valgus patients before and after treatment with Kinesio taping

ObjectivesTo explore the impact of hallux valgus (HV) on lower limb neuromuscular control strategies during the sit-to-stand (STS) movement, and to evaluate the effects of Kinesio taping (KT) intervention on these control strategies in HV patients.MethodsWe included 14 young healthy controls (HY), 13 patients in the HV group (HV), and 11 patients in the HV group (HVI) who underwent a Kinesio taping (KT) intervention during sit-to-stand (STS) motions. We extracted muscle and kinematic synergies from EMG and motion capture data using non-negative matrix factorization (NNMF). In addition, we calculated the center of pressure (COP) and ground reaction forces (GRF) to assess balance performance.ResultsThere were no significant differences in the numbers of muscle and kinematic synergies between groups. In the HV group, knee flexors and ankle plantar flexors were abnormally activated, and muscle synergy D was differentiated. Muscle synergy D was not differentiated in the HVI group.ConclusionAbnormal activation of knee flexors and plantar flexors led to the differentiation of module D in HV patients, which can be used as an indicator of the progress of HV rehabilitation. KT intervention improved motor control mechanisms in HV patients.

Radiographic Assessment of Transverse Tarsometatarsal Instability Complicated by Metatarsus Adductus in Hallux Valgus Patients.

Objective evaluations of transverse tarsometatarsal (TMT) hypermobility/instability are lacking. This study aims to radiographically explore the relationship between transverse TMT instability and metatarsus adductus (MA) in hallux valgus (HV). This study retrospectively analyzed 207 feet with varying degrees of HV, employing the distance between the first and second metatarsals (M1-2 distance) to assess transverse TMT instability of the first ray. Participants were categorized into MA and non-MA groups. It was found that the M1-2 distance significantly increased with the hallux valgus angle (HVA) and metatarsus adductus angle (MAA), demonstrating significant differences between the MA and non-MA groups. The measurement of M1-2 distance showed high reliability, and its cutoff value was determined to be 4.05 mm. Additionally, the results suggest that the widening of the M1-2 distance may be a predisposing factor for MA in HV patients, highlighting its role in the pathogenesis of this foot condition. These findings highlight the need for a comprehensive assessment of TMT instability on both the axial and sagittal planes for the surgical planning of HV, particularly when complicated by a large MAA. Based on these insights, reoriented first-TMT arthrodesis might be recommended for HV with significant MA to address potential multiplanar instability.

Induced fatigue impact on plantar pressure in females with mild hallux valgus

Fatigue has been established to change plantar pressure distribution, yet its impact on hallux valgus (HV) patients, who exhibit morphological and biomechanical changes in the foot, remains insufficiently studied. Twenty-eight female participants, comprising 16 with mild HV and 12 healthy controls, were recruited. Plantar pressures were recorded pre- and post-fatigue using the Footscan platform during self-selected-speed walking trials, fatigue protocol was performed on a treadmill. Foot was segmented into 10 anatomical regions for calculating parameters including maximal force, peak pressure, impulse, contact duration, contact area, and force time-series, alongside assessing the distribution of medial and lateral contact forces (Foot balance) across the groups. During post-fatigue, patients with mild HV demonstrated adaptive changes in plantar pressure distinct from healthy controls, with significant reductions in maximal force, peak pressure, and impulse in the M1 and M2 regions and increases in the M3–M5 regions. In contrast, the control group exhibited an opposite pattern, concentrating pressure in the M1 and M2 regions post-fatigue. The force time-series analysis revealed significant disparities between HV patients and controls, particularly in the M4 and M5 regions, where HV patients showed a less pronounced and lower passive peak in forces. Results show that women with mild HV demonstrate adaptive changes in plantar pressure post-fatigue, distinctly different from healthy individuals, aiding in preventive strategies for fatigue-induced foot injuries for HV patients.

A Simplified Preoperative Radiographic Assessment for Metatarsus Adductus Associated With Hallux Valgus.

Radiographic measurements for the assessment of metatarsus adductus (MTA) have a broad range of interpretation without a consensus regarding surgical indications. The "Plumbline" (PL) radiographic assessment method helps identify MTA and determines if physical space is available to align the first metatarsal to the longitudinal foot axis without the need to realign the lesser metatarsals. Forty-five neutral weight-bearing anterior-posterior (AP) radiographs of patients scheduled for surgical intervention for isolated hallux valgus (HV) or combined MTA/HV deformities were reviewed. The cohort was grouped based on the presence of MTA using a Sgarlato's angle (SA) of 15°, with 23 patients in the HV-only group and 22 patients in the MTA group. A mean preoperative SA of 8.7° (SD: 2.1; range: 5.4-13.4) and 26.6° (SD: 5.1; range: 18.2-36) were found in the HV-only and MTA groups, respectively. Subjects with an SA ≤ 15° (N = 22) were found to have a negative PL (100%) and subjects with an SA > 15° (N = 23) displayed a positive PL (100%). The PL technique provided a simple method and clear visual reference for determining the presence of MTA in HV patients without the need to measure traditional radiographic angles.Level of Evidence: Retrospective, Level IV, Diagnostic.

Eligibility for knee arthroplasty is associated with increased risk of acquired hallux valgus - a Mendelian randomized study

ObjectiveClinically, it has been found that patients undergoing knee replacement have a high incidence of concomitant hallux valgus. In this study, we analyzed whether patients with osteoarthritis who underwent surgery and those patient who did not have surgery had an increased risk of hallux valgus by Mendelian randomization and performed reverse causal analysis.DesignGenomewide association study (GWAS) data for osteoarthritis, categorized by knee arthritis with joint replacement, knee arthritis without joint replacement, hip arthritis with joint replacement, and hip arthritis without joint replacement.And acquired hallux valgus were downloaded for Mendelian randomized studies. MR analysis was performed using inverse variance-weighted (IVW), weighted median, and MR-Egger methods. MR-egger regression, MR pleiotropic residuals and outliers (MR-presso), and Cochran's Q statistical methods were used to evaluate heterogeneity and pleiotropy.ResultsThe IVW results indicate that, compared to healthy individuals, patients who meet the criteria for knee osteoarthritis joint replacement surgery have a significantly higher risk of acquired hallux valgus. There were no significant causal relationships found for the remaining results. No significant heterogeneity or multiplicity was observed in all the Mr analyses.ConclusionOur study supports the increased risk of acquired hallux valgus in patients eligible for knee replacement. There is necessary for clinicians to be concerned about the hallux valgus status of patients undergoing knee arthroplasty.

Preoperative Degenerative Changes at the Medial Sesamoid-Metatarsal Joint Is Associated with Postoperative Patient-Reported Outcomes in Hallux Valgus

Introduction/Purpose: While hallux valgus (HV) is understood to be a triplanar deformity of the first metatarsal, less is known about the contribution of the sesamoid-metatarsal joint (SMJ) to pain and function. Osteoarthritis of the SMJ is frequently present in HV feet, with an incidence rate ranging from 32% to 81%. Following surgical correction, approximately 10% of HV patients remain dissatisfied, but factors affecting postoperative outcomes are poorly understood. The primary aim of our study was to describe the relationship between degenerative changes at the SMJ as measured on weightbearing CT (WBCT) scans and 1-year patient-reported outcome scores following a modified Lapidus procedure for correction of HV. We hypothesized that decreased joint space at the SMJ would affect postoperative patient-reported outcomes. Methods: This study included 48 consecutive patients who underwent a modified Lapidus procedure for HV, had preoperative and at least 5-month postoperative WBCT scans, and had preoperative PROMIS scores and at least 1-year postoperative PROMIS Physical Function (PF), Pain Interference, and Pain Intensity scores. For each patient, the first metatarsal and sesamoids on pre- and postoperative WBCT scans were segmented using Disior Bonelogic software and uploaded to Geomagic Design X to perform distancing mapping. The minimum and average distances between the first metatarsal head and medial sesamoid (medial-SMJ) for each patient pre- and postoperatively were calculated. Sesamoid subluxation was measured on WBCT scans using the grading system from 0 to 3 (Yildirim et al.). A simple linear regression model was used to investigate the correlations between minimum preoperative and postoperative medial-SMJ distances and 1-year postoperative PROMIS scores in patients with postoperative reduction of the sesamoids (grade 0). Results: Preoperatively, the mean minimum and average medial-SMJ distances were 0.76 ± 0.37 mm and 1.54 ± 0.33 mm, respectively. Postoperatively, the mean minimum and average medial-SMJ distances were 1.08 ± 0.25 mm and 1.73 ± 0.24 mm, respectively. Thirty-five of 48 patients had a complete reduction of the sesamoids. Lower preoperative minimum distances at the medial-SMJ were significantly correlated with worse 1-year PROMIS PF scores (r=0.405, P=0.016) (Figure 1). Similarly, lower preoperative minimum distances at the medial-SMJ were significantly correlated with worse 1-year PROMIS Pain Intensity scores (r=-0.350, P=0.039) but did not reach significance for 1-year PROMIS Pain Interference scores (r=-0.286, P=0.095). The postoperative minimum medial-SMJ distance was not correlated with 1-year PROMIS PF, Pain Interference, and Pain Intensity scores. Conclusion: In HV patients undergoing a modified Lapidus procedure with postoperatively reduced sesamoids, decreased joint space at the medial sesamoid-metatarsal head articulation was associated with worse 1-year postoperative function as measured by PROMIS PF scores and worse 1-year postoperative pain as measured by PROMIS Pain Intensity scores. In contrast, postoperative degenerative changes at the SMJ were not found to be associated with patient-reported outcomes. Our results suggest that pre-existing SMJ arthritic changes may affect postoperative outcomes and may be a source of dissatisfaction following HV surgery despite appropriate correction of the deformity. Figure 1. Preoperative medial sesamoid to the first metatarsal head minimum distance relative to 1-year PROMIS Physical Function, Pain Intensity, and Pain Interference scores. A simple linear regression demonstrates a significant association between preoperative medial sesamoid –metatarsal head minimum joint distance and 1-year PROMIS Physical Function (r=0.405, P=0.016) and Pain Intensity (r=‒0.305, P=0.039) scores.

Preoperative Degenerative Changes at the Tibial Sesamoid-Metatarsal Joint in Hallux Valgus: Association With Postoperative Patient-Reported Outcomes After Modified Lapidus Procedure.

Degenerative changes at the sesamoid-metatarsal joints (SMJs) may be a source of pain following hallux valgus surgery. The aims of this study were to describe degenerative changes at the SMJs on weightbearing computed tomography (WBCT) scans and, secondarily, investigate their association with 1-year patient-reported outcome scores following a modified Lapidus procedure for hallux valgus. We hypothesized that reduced joint space in the SMJs would correlate with worse patient-reported outcomes. Fifty-seven hallux valgus patients who underwent a modified Lapidus procedure had preoperative and minimum 5-month postoperative WBCT scans, and preoperative and at least 1-year postoperative PROMIS physical function (PF), pain interference, and pain intensity scores were included. Degenerative changes at the SMJs were measured using distance mapping between the sesamoids and first metatarsal head on preoperative and postoperative WBCT scans. The minimum and average distances between the first metatarsal head and tibial sesamoid (tibial-SMJ) for each patient preoperatively and postoperatively were measured. Sesamoid station was measured on WBCT scans using a 0 to 3 grading system. Linear regression was used to investigate the correlations between minimum preoperative and postoperative tibial-SMJ distances and 1-year postoperative PROMIS scores. The median minimum and average tibial-SMJ distances increased from 0.82 mm (interquartile range [IQR] 0.40-1.03 mm) and 1.62 mm (IQR 1.37-1.75 mm) preoperative to 1.09 mm (IQR 0.96-1.23 mm) and 1.73 mm (IQR 1.60-1.91 mm) postoperative (P < .001 and P < .001), respectively. In a subset of patients with complete sesamoid reduction, we found an association between preoperative minimum tibial-SMJ distance and 1-year postoperative PROMIS PF scores (coefficient 7.2, P = .02). Following the modified Lapidus procedure, there was a statistically significant increase in the tibial-SMJ distance. Additionally, in patients with reduced sesamoids postoperatively, reduced preoperative tibial-SMJ distance correlated with worse PROMIS PF scores. Level IV, case series.

Hallux Valgus Plantar Pressure Distribution before and after a Distal Metatarsal Osteotomy.

Background: Hallux valgus (HV) morphological alterations impact forefoot kinetics. Surgery aims to restore both the morphology and function. Plantar pressure (PP) distribution systems represent an innovative additional tool to evaluate the hallux functional outcome after surgery in order to assess the hallux dorsiflexion, coupled with plantar flexion of the first ray. However, the literature reports limited evidence regarding the rebalancing of the plantar pressure distribution following surgery. The purpose of the present study was to examine the PP distribution in HV patients before and after a distal metatarsal osteotomy using a novel anatomically based protocol for in-shoe plantar load analysis during gait. Methods: A consecutive series of 18 patients with mild-to-moderate symptomatic HV who underwent a distal metatarsal osteotomy (S.E.R.I. technique) were prospectively evaluated using clinical scores (AOFAS and NRS), radiographic parameters (hallux valgus angle, intermetatarsal angle), and PP measurements via W-INSHOE© (Medicapteurs, Balma, France). Data were collected preoperatively and 12 months after surgery. Results: At 12 months follow-up, 3 patients were lost to follow-up, leaving 15 patients (24 HV) for examination. Both clinical and radiographical outcomes showed significant improvements from the pre- to postoperative periods. The PP distribution pattern revealed a significant increase in the peak pressure under the first metatarsal head associated with a significant increase in the peak pressure under the central metatarsals area between the pre- and postoperative periods. Conclusions: PP measurement systems hold promise as an additional clinical tool, yet current findings remain inconclusive. Further long-term follow-up studies that incorporate additional parameters are warranted.

Improvement of Valgus Deviation of the Lesser Toes of Moderate to Severe Hallux Valgus After Proximal Chevron Metatarsal Osteotomy and Akin Osteotomy.

This study examines the correction of lesser toe valgus deviation following proximal chevron metatarsal osteotomy (PCMO) and Akin osteotomy in moderate to severe hallux valgus patients, while identifying influencing factors. Among 89 patients (116 feet), those with moderate to severe hallux valgus underwent PCMO and Akin osteotomy. Radiologic assessments included preoperative metatarsus adductus angle (MAA), hallux valgus angle (HVA), intermetatarsal angle (IMA), valgus angles of the second to fourth metatarsophalangeal joints, and hallux valgus recurrence. Assessments included visual analog scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient satisfaction over an average follow-up of 30.6 ± 21.2 (range, 12-99) months. The mean preoperative HVA of 34.4 degrees decreased to 8.7 degrees at final follow-up. The valgus angles of the second, third, and fourth toes improved by 37.1%, 27%, and 44.5%, respectively. In metatarsus adductus patients, lesser toe valgus angles were significantly higher both preoperatively and at final follow-up. Hallux valgus recurrence patients had higher preoperative and final follow-up IMA and valgus angles in the second and third toes. Nonrecurrence patients showed greater decreases in these angles. A larger HVA correction corresponded to a greater decrease in lesser toe valgus deviation. VAS and AOFAS scores improved significantly at the last follow-up. The study found a significant reduction in the valgus angle of the second, third, and fourth toes after PCMO and Akin osteotomy in moderate to severe hallux valgus cases, without additional surgeries on lesser toes. The lesser toe angular reductions were less pronounced in patients with metatarsus adductus or with hallux valgus recurrence. Level IV, case series.

Hallux Valgus: The Influence of Intersesamoid Crista's Osteoarthritis on Frontal Plane Pronation

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to find potential associations between sesamoid's crista osteoarthritis and the frontal plane deformity in HV cases. Our study showed a moderate correlation between the crista's OA and the intermetatarsal angle (IMA), the hallux valgus angle (HVA) and the alpha angle. In severe hallux vulgus deformed specimens, with an eroded inter-sesamoid crista, frontal plane pronation was not as prevalent nor severe as in those without osteoarthritic degeneration. Severe hallux valgus cases with a completely eroded crista, showed lower pronation, and higher IMA, when compared to specimens with a preserved anatomy. This brings to light the inter-sesamoid crista's unique function in retaining the IMA. Understanding the role the frontal plane plays in hallux valgus' biomechanics and in its radiographic appearance is vital to change the current paradigm.

Three-dimensional Weight-Bearing CT Distance and Coverage Mapping Assessment of the 1st MTPJ and Sesamoid Joints in Patients with Hallux Valgus Deformity

Category: Bunion Introduction/Purpose: Three-dimensional (3D) Distance-Mapping (DM) and Coverage-Mapping (CM) use WBCT images to evaluate multiplanar elements of Hallux Valgus (HV), such as sesamoid subluxation, through analyzing joint space and joint coverage across entire bony interfaces. Previous methods have struggled to characterize sesamoid subluxation consistently, and the reliable assessment of these deformity patterns is essential in guiding HV treatment and impacts recurrence rates following correction. The objective was to (1) develop a 3D WBCT CM and DM algorithm to characterize the surface interaction of the 1st metatarsophalangeal-joint (MTPJ) and metatarsal-sesamoid joints in HV patients and controls (2) correlate DM and CM measurements with WBCT semi-automatic angular measurements in HV patients and controls (3) correlate DM, CM, and angular measurements with Visual Analog Scale (VAS) scores in HV patients. Methods: Retrospective case-control study assessing HV patients. 51-feet with HV who underwent a WBCT of the affected foot and 54-feet were included. Semi-automatic segmentation protocol extracted bone models, which were analyzed with specialized software. The 1st-MTPJ surface was divided into two-by-two grids to provide a more detailed analysis. Distance measurements obtained were used to create color-coded distance maps. Blue color represented expected distances in joint interaction (1 to 5 mm), red or yellow color represented arthritis or impingement (0 to 1mm), and pink color represented subluxation (&gt;5mm). Further, color-coded coverage maps highlighted areas of relative coverage ( &lt; 5mm) or uncoverage (&gt;5mm) contrasting areas with normal joint interaction or subluxation (Figure). Pearson’s correlations were used to describe association between intraarticular distances, or JSW (joint space width), and coverage measurements with the following: intermetatarsal angle (IMA), Hallux-Valgus- Angle (HVA), Distal-Metatarsal-Articulation-Angle (DMAA), Visual-Analog-Scale (VAS), and Body-Mass-Index (BMI). P-values less than 0.05 were statistically significant. Results: Interobserver reliability was high for 1st-metatarsal-head (ICC 0.846,p &lt; 0.001), medial-sesamoid-articulation (ICC 0.854,p &lt; 0.001), and lateral-sesamoid-articulation (ICC 0.832,p &lt; 0.001). HV patients demonstrated significantly decreased coverage in comparison to controls (42.7% vs. 50.1%,p &lt; 0.001) and a relative decrease in 1st-MTPJ-coverage (-14.7%,p &lt; 0.001) in comparison to controls. In HV, articular coverage was higher in patients for the plantar lateral quadrant (HV 88.6% vs. 83.0% Controls,p=0.0002) and decreased in dorsal-medial (HV 8.8% vs. 18.7% Controls,p &lt; 0.0001) and plantar-medial quadrants. (HV 46.2% vs. 78.8% Controls,p &lt; 0.0001). Significantly decreased coverage was observed in HV-patients in both the medial sesamoid- articulation (HV 31.1% vs. 54.4%, p&lt; 0.0001) and lateral sesamoid-articulation (HV 22.6% vs. 46.0%,p &lt; 0.0001). Correlations between the first-metatarsal-head distance/coverage measurements and BMI, pre-op VAS, IMA, HVA, and DMAA are summarized in figure. Conclusion: We developed a quantifiable WBCT distance and coverage map algorithm to assess 3D-joint-interaction, joint- coverage, and subluxation in patients with HV. We observed significant subluxation of the 1st-MTPJ in patients with HV when compared to controls, as well as significant subluxation of the metatarsal-sesamoid joint at the medial and lateral sesamoid-joints, with an apparent medial and dorsal deviation of the first-metatarsal, lateral and plantar deviation of the proximal-hallux-phalanx and Lateral subluxation of the sesamoids. Increased coverage of the 1st-metatarsal-head was associated with decreased IMA and DMAA. However, we found no significant correlation between the Visual-Analogue-Scale-(VAS) and DM, CM, and semi-automatic measurements.

First Metatarsophalangeal Arthrodesis in Hallux Rigidus and Hallux Valgus: A Comparison of Patient Reported and Clinical Outcomes

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: No prior study has compared the patient reported outcomes of first metatarsophalangeal arthrodesis between hallux rigidus and hallux valgus patients. Furthermore, we sought to examine the impact of postoperative radiographic hallux alignment on outcomes scores within each group. Methods: A retrospective review of 98 patients who received primary metatarsophalangeal arthrodesis from January 2010 to March 2020. Clinical complications including non-union were collected. PROMIS Physical Function, PROMIS Pain Interference, and the Foot Function Index Revised Short Form scores were obtained via telephone. Patients were grouped based on preoperative radiographic alignment of the first hallux yielding 43 hallux rigidus and 55 hallux valgus patients. Clinical and patient reported outcomes were compared between these pathologies. Results: No differences in the rate of wound complications, radiographic union, and revision surgery were found. At median of 2.4 years (3.9 IQR) postoperatively, PROMIS and FFI scores did not vary by pathology group. For both groups, PROMIS scores were similar to the general population of the United States. In sub-analysis, the postoperative dorsiflexion angle in the hallux rigidus group and the postoperative hallux valgus angle in the hallux valgus group were correlated with more favorable outcomes scores. Conclusion: We found no differences in the patient reported outcomes of first metatarsophalangeal arthrodesis in hallux rigidus and hallux valgus patients. The radiographic measures of hallux alignment most directly related to the underlying pathology may correlate with patients’ perceived level of pain and function postoperatively.

Association between Postoperative Medial: Middle Intercuneiform Joint Gapping and Recurrence Rates in Hallux Valgus

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) is a triplanar deformity of the first metatarsal, which may extend beyond the first ray. Compared with normal feet, previous studies have found that HV patients have an increase in hypermobility of the joints along the medial column and at the medial – middle (MM) intercuneiform joint. Despite increased instability at the MM intercuneiform joint, no study has investigated its clinical significance. The primary purpose of this study was to determine if postoperative widening of the MM intercuneiform joint was associated with recurrence in HV patients who undergo a first tarsometatarsal fusion (modified Lapidus procedure). A secondary purpose was to investigate whether other HV imaging parameters were associated with a widening of the MM intercuneiform joint. Methods: This study included 52 consecutive HV patients who underwent a modified Lapidus procedure and had preoperative and at least 5-month postoperative weightbearing CT (WBCT) scans. Preoperative and postoperative measurements of HV deformity, including the intermetatarsal angle and hallux valgus angle (HVA) on plain radiographs and triplanar pronation angle and sesamoid station from WBCTs, were performed as previously described. MM intercuneiform distance was measured on the coronal multiplanar reconstructed WBCT scans after reorienting the axial and sagittal planes such that the coronal cuts were orthogonal to the intercuneiform joint (Figure 1A). Recurrence of the HV deformity was defined as a postoperative HVA ≥ 20°. Paired t-tests were used to compare preoperative and postoperative imaging parameters, and Mann-Whitney U tests were used to compare measurements between patients with and without HV recurrence. Pearson correlation coefficients were used to explore associations between preoperative and postoperative measurements and the change in MM intercuneiform distance. Results: Nine of 52 patients (17.3%) had recurrence of their HV deformity. For the entire cohort, the mean preoperative and postoperative MM intercuneiform distances were 0.73 mm (standard deviation (SD) 0.3) and 1.08 mm (SD 0.5), respectively. In patients with and without HV recurrence, the mean widening at the MM intercuneiform joint was 0.69 mm (95% confidence interval (CI) 0.52-0.86) and 0.27 mm (95% CI 0.17-0.38, P&lt; 0.001), respectively. Patients with recurrence had significantly greater widening of the MM intercuneiform joint than patients without recurrence (P=0.001, Figure 1B and Table 1). While no preoperative imaging parameters were associated with a change in the MM intercuneiform distance, increasing postoperative sesamoid position (r=0.32, P=0.022) and HVA (r=0.28, P=0.046) were correlated with a greater change MM intercuneiform joint gapping. Conclusion: In patients undergoing a modified Lapidus procedure for correction of their HV deformity, postoperative widening of the MM intercuneiform joint was associated with recurrence of the HV deformity. As understanding of the HV deformity continues to evolve, our study suggests that there is a complex interplay between deformity at the hallux metatarsophalangeal (MP) joint, reduction of the metatarsosesamoid joint complex, and the instability at the tarsometatarsal and intercuneiform joints. This may guide surgical correction as surgeons may need to address both intercuneiform instability and correction at the hallux MP joint in order to decrease HV recurrence rates.

Three-Dimensional Assessment to Hallux Valgus Correction Using Lapicotton Technique

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The first-ray and the medial column play a crucial role in preserving the tripod of the foot. Changes to structural properties of the first-ray, along with collapse of the medial-longitudinal-arch, have been associated with hallux valgus (HV). Thus, restoring the first-ray plays an important role when correcting the mechanical function of the foot tripod in the setting of HV combined with medial-longitudinal-arch collapse. The LapiCotton technique combines the mechanical advantages of Cotton osteotomy and modified Lapidus procedures by maintaining the length of the first-ray and preserving the medial- longitudinal-arch by plantar inclination of the distal part of first-ray. The aim of this study was to evaluate the effectiveness of the LapiCotton procedure in correcting selected radiographic parameters in patients with combined VH with medial-longitudinal arch collapse. Methods: Preoperative and postoperative Weight Bearing CT (WBCT) scans were obtained from HV patients who underwent unilateral LapiCotton procedure. Postoperative scans were obtained roughly three months after the date of surgery. Semi- automatic measurements were applied to 22 WBCT images across a total of 11 patients enrolled into the study using the Disior® Bonelogic® Software. Measurements of the hallux valgus angle (HVA), meary sagittal measurement, and intermetatarsal angles were taken from preoperative and postoperative scans. These scans were then compared using intraclass correlation coefficients and paired t-tests to evaluate the efficacy of the Lapicotton technique in treating HV with P-valus &lt; 0.05 being significant. Results: HVA was found to be significantly larger (p=.026) in the preoperational group (Mdn = 27.52) than the postoperational group (Mdn = 20). In addition, the Meary sagittal measurement was found to be significantly different between groups (p=.033), with a larger value seen in the preoperational group (Mdn = -14.28) compared to the post-operational group (Mdn = -11.15). It was also observed that the IMA was significantly larger (p=.003) in the preoperative group (Mdn = 15.68) compared to the postoperative group (Mdn = 11.26). The sesamoid rotation was found to be higher in the preoperative group (Mdn = -17.71) than the post operative group (Mdn = -24.98), however, these values were not significantly different from one another (p=.203). Conclusion: The LapiCotton procedure proved to be effective in correcting radiographic parameters in patients with HV combined with collapse of the medial longitudinal arch. Reliable correction of HV, along with correction of medial longitudinal arch collapse, was quantified based on semi-automated WBCT measurements of HVA, IMA and Meary angle. LapiCotton produced significantly different measurements for both HVA and IMA postoperatively, providing evidence that the LapiCotton procedure can successfully correct medial longitudinal arch collapse in patients with HV, as well as radiographically reduce the severity of the deformity.

Prevalence of Progressive Collapsing Foot Deformity in Hallux Valgus Patients

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) and progressive collapsing foot deformity (PCFD) are very common foot and ankle conditions in the adult population. Both could potentially disrupt the tripod construct of the foot which leads to chronic pain and arthritis. Several procedures were described to address HV deformity depending on deformity characteristics. PCFD could alter the management plan for HV if they occur simultaneously. The aim of this study was to detect the prevalence of PCFD in HV patients and study the frequency of individual PCFD classes. Methods: In this retrospective IRB approved study, patients &gt; 18 years old who were evaluated for symptomatic hallux valgus and had a weight bearing computed tomography (WBCT) imaging were included. Patients were considered for further analysis if they have a hallux valgus angle (HVA) &gt; 15° or inter-metatarsal angle (IMA) &gt; 9°. All relevant demographic data were extracted. Two fellowship trained foot and ankle orthopaedic surgeon measured the following parameters: foot and ankle offset (FAO%) (Class A), talo-navicular coverage angle (TNCA) (Class B), Meary’s angle (Class C) and middle facet subluxation (MFS%) (Class D). Cases that showed FAO% &gt; 4.6% and MFS% &gt; 28.7% were diagnosed as PCFD. The prevalence of PCFD classes (A,B,C and D) was calculated using threshold values for its respective radiographic marker. Descriptive statistics were performed. Results: Thirty-four cases were included. 16 cases were females (46.06%) and 16 (46.06%) were right side. The average age was 52.51 years (SD ± 17.75), the average BMI was 30.14 (SD ± 7.15). The average HVA was 26.82 (SD ± 9.98) and the average IMA was 15.41 (SD ± 3.53). 13 patients (38.24%) had MFS% and FAO% above the threshold values. The average FAO was 4.75% (SD ± 4.92) and the average MFS was 29.17% (SD ± 15.89). Prevalence of Class A (FAO%) was 20 (58.82%), Class B (TNCA) was 12 (35.29%), Class C (Meary’s angle) was 15 (44.12%) and Class D (MFS%) was 16 (47.06%). Conclusion: Progressive collapsing foot deformity is prevalent in the hallux valgus population (38.24%). Class C which indicates medial column instability was prevalent in 44.12% of the cases. Given this high prevalence of PCFD, we believe that in addition to the classic hallux valgus parameters, PCFD classes evaluation could favor a surgical approach over another such as first tarsometatarsal joint procedures over isolated distal first metatarsal procedures to correct the HV deformity and simultaneously halt PCFD progression.

Weight-bearing CT Scan Analysis in Hallux Valgus Surgery: Comparison between Open (Scarf) and Minimally Invasive (MIBA) Techniques

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) is one of the most prevalent foot deformities. Coronal metatarsal rotation (pronation) has been recognized as a key element in HV deformity and an important prognostic factor for recurrence. With the advent of weight-bearing CT (WBCT), accurate pronation measurement has improved. The Minimally Invasive Bosh Akin (MIBA) surgery has proven to be effective in treating HV deformity. Literature comparing MIBA radiological correction with traditional open techniques (scarf osteotomy) is lacking. Purpose: To compare the transverse and coronal plane deformity correction by WBCT in HV patients treated with open vs MIS technique. Methods: We retrospectively analyzed HV deformity in patients who underwent Scarf and MIBA surgery with preoperative and at least 3 months postoperative WBCT for comparison. Intermetatarsal angle (IMA), hallux valgus angle (HVA), and alpha angle (AA) for first metatarsal pronation was measured by 2 different observers. Pre and postoperative measurement changes were established by T-test for related samples. the p-value for statistical significance was set at &lt; 0.05. Results: 40 feet included. The mean preop IMA in scarf was 13.1, and 13.6 in MIBA (p= 0.7). Mean postop IMA in scarf was 4.9, and 6.8 in MIBA (p &lt; 0.05). The mean preop HVA in scarf was 25, 28.7 in MIBA (p=0.1). Mean postop HVA in scarf was 5.9, 13.1 in MIBA (p &lt; 0.05). Mean preop AA in scarf was 8.9, 8.9 in MIBA (p= 0.6). Mean postop AA in scarf was 6.3, 6.9 in MIBA (p=0.7). All feet had a significant improvement of IMA and HVA pre and postop (p &lt; 0,005). Scarf preop AA was 8.9 and 6.3 postop, which is a pronation change of -2.5 (p &lt; 0.05). MIBA preop AA was 8.9 and 6.9 postop, which is a pronation change of -2 (p=0.054). Conclusion: To the best of our knowledge, this is the only study that compares WBCT correction between Scarf and MIBA surgery. Both osteotomies have a significant power to correct transverse deformity, scarf corrects significantly better than MIBA when analyzing HVA and IMA. The scarf has a significant power to correct pronation, whereas MIBA shows a strong tendency.

Weight-bearing CT Scan Analysis in Hallux Valgus Treated with Minimally Invasive Surgery

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) is one of the most prevalent foot deformities. Coronal metatarsal rotation (pronation) has been recognized as a key element in HV deformity and an important prognostic factor for recurrence. With the advent of weight-bearing CT (WBCT), accurate pronation measurement has improved. The Minimally Invasive Bosh Akin (MIBA) surgery has proven to be effective in treating HV deformity. The literature analyzing correction of pronation in HV surgery is lacking. Purpose: To compare the transverse and coronal plane deformity correction by WBCT in HV patients treated with MIBA surgery. Methods: We retrospectively analyzed HV deformity in patients who underwent MIBA surgery with preoperative and at least 3 months postoperative WBCT for comparison. Intermetatarsal angle (IMA), hallux valgus angle (HVA), and alpha angle (AA) for first metatarsal pronation were measured by 2 different observers. The intraclass and interclass correlation were determined. Pre and postoperative measurement changes were established by T-test for related samples. the p-value for statistical significance was set at &lt; 0.05. Results: 37 feet were included. Intraclass correlation was 0.97 /0.92 for IMA; 0.95/0.91 for AA and 0.99/0.97 for HVA preoperative. Postop it was 0.97/ 0.96 for IMA, 0.97/0.92 for AA, and 0.98 and 0.96 for HVA. Interclass correlation was 0.95 for IMA; 0.7 for AA and 0.82 for HVA preoperative. Postop, was 0.82 for IMA, 0.8 for AA, and 0.79 for HVA. Mean preoperative / postoperative AA was 8.9 degrees and 6.9 degrees respectively, resulting in a first ray pronation change of –2.0 degrees, p&lt; 0.054. The media preoperative and postoperative IMA was 13.6 degrees and 6.8 degrees, demonstrating a significant change (P &lt; .005). The media preoperative and postoperative HVA was 28.7 (8.8) and 13.1 (9.0), demonstrating a significant change (P &lt; .005). Conclusion: To the best of our knowledge, this is the first study that evaluates the radiological changes in HV surgery with WBCT. The MIBA osteotomy for HV deformity has significant power to correct the transverse plane deformity. Even though the coronal plane deformity correction wasn’t statistically significant, it showed a strong tendency, which might be demonstrated by utilizing a bigger sample. The only measurement that didn’t have an excellent agreement was the preop AA.

Biomechanical Comparison between Rotational Scarf Osteotomy and Translational Scarf Osteotomy: A Finite Element Analysis.

Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis. The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three-point bending test. Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three-point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm). Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus.