Hallux Valgus Interphalangeus Research Articles

Onychomycosis in Foot and Toe Malformations.

Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.

Intermetatarsal and Metatarsal-Phalangeal Angles Can Be Corrected by an Isolated Akin Osteotomy in Patients with Hallux Valgus Deformity

Introduction/Purpose: Akin osteotomy is a surgical technique commonly used in conjunction with osteotomies of the first metatarsal for correction of hallux valgus (HV) deformity. The main indication for an Akin osteotomy is the presence of hallux valgus interphalangeus (HVIF), defined as a HVIF angle >10º. Given that distal osteotomies can change the tendon vector forces, we hypothesize that in a patient with a mobile medial column, an isolated akin osteotomy could improve proximally some radiologic parameters of HV. The purpose of this study was to evaluate whether the isolated Akin osteotomy is able to correct proximally the intermetatarsal angle (IMA) and hallux valgus angle (HVA) in patients with HV deformity. Methods: Case series of consecutive patients with HV deformity treated with an isolated Akin osteotomy, were included in this study. The indications for this surgery were having a mild HV and overlapping of the hallux with the second toe as the main symptom. Patients with fractures, infections, prior surgeries in the forefoot, and concomitant metatarsal osteotomy or first tarsometatarsal fusion were excluded. Two independent evaluators measured the following parameters pre and post-operatively in anteroposterior(AP) feet x-rays: traditional and modified HVA (the latter defined as angle between the long axis of the 1st metatarsal and a line from the center of the base of the proximal phalanx and the tip of the distal phalanx), IMA, distal metatarsal articular angle (DMAA), and HVIF angle. Paired t-test was performed to compare the radiological parameters pre and post- surgery. The absolute intraclass correlation coefficient (ICC) was used to determine the interobserver agreement. P< 0.05 was considered significant. Results: Twenty AP feet x-rays of 12 females and 1 male with a mean age of 44.0 years (range 15 to 85) were included in the final analysis. The preoperative mean and standard deviation (SD) of traditional HVA, modified HVA, IMA, DMAA, and HVIF were 17.0º(7.5), 23.7º(6.5), 11.3º(1.6), 12.6(9.2), and 13.5º(6.0), respectively. The corresponding postoperative values were 9.8º(7.0), 14.4º(7.0), 9.5º(2.0), 11.2º(7.6), and 9.9º(4.9). There was a significant reduction in the traditional HVA (7.2º, p< 0.001), and modified HVA (9.3º, p< 0.001). Also, there was a significant decrease in the IMA (1.8º, p< 0.001), and HVIF (3.5º, p=0.001). Conversely, the DMAA did not change after the osteotomy. The interobserver agreement was moderate to excellent for all radiologic parameters. Conclusion: In this case series, an isolated Akin osteotomy significantly reduced the HVA and IMA. These results challenge the traditional knowledge that Akin only corrects the interphalangeal angle, and could help for a better biomechanical understanding of this deformity, including the effect in proximal correction of distal procedures. An isolated Akin osteotomy could be a plausible alternative for the correction of HV, especially for mild deformities.

Akin Osteotomy: A Review of Modern Fixation Techniques.

Akin osteotomy is commonly used to correct hallux valgus interphalangeus (HVI) deformity. The preferred implant for fixation remains an area of debate, often influenced by the surgeon's inclinations and expertise. This review compares the outcomes of contemporary fixation methods utilized in Akin osteotomy. PubMed served as the primary electronic database for the search. The interventions encompassed the use of screw(s), staple(s), and suture(s). The participants considered were adults aged 18 and above, undergoing Akin osteotomy either as a primary procedure or as an adjunct. Excluded were osteotomies performed via percutaneous or minimally invasive methods. Seven studies involving 590 feet were analysed, showcasing an impressive 99.8% overall union rate. The incidence of overall complications stood at 8.98%, with metal prominence notably higher in the screw fixation group (10.5%). All studies exhibited postoperative improvement in radiological angles. Screw, staple, and suture fixations demonstrated excellent union rates. While screws and staples offer robust osteotomy fixation, they pose risks of metal irritation and prominence. Suture fixation delivers comparable outcomes to the other two stabilization methods at a lower cost.

A Novel Classification for Diabetic Foot Ulcers of the First Ray.

Diabetic foot ulcers of the first ray result from several distinct biomechanical mechanisms related to anatomical deformities, which must be addressed if surgical offloading is contemplated. The objective of this study was to create a classification of the anatomical deformities of first-ray ulcers that could lead to better standardization of treatment and reporting. The authors performed a file review of patients with diabetic neuropathy diagnosed with first-ray ulcers over a period of 3 years in an outpatient setting. Anatomical deformities were diagnosed clinically and reported with ulcer location. The primary classification was the metatarsophalangeal joint, the interphalangeal joint, and the distal phalanx. Records for 59 patients (mean age, 62 years) with University of Texas A1 and A2 ulcers were reviewed. Mean ulcer duration was 2 months. The more common deformities were hallux valgus (41%), hallux valgus interphalangeus (14%), and hallux malleus (20%), and these were primarily associated with metatarsophalangeal, interphalangeal joint, and tip-of-toe ulcers, respectively (P < .0001). By classifying ulcer locations, the relevant corrective surgery may be chosen. Although some prophylactic procedures may be safe and effective, prophylactic hallux valgus correction in the diabetic foot requires further study.

A Radiographic Analysis of Hallux Valgus Interphalangeus and Biplanar Proximal Phalanx Closing Wedge “MoAkin” Osteotomy in Hallux Rigidus Treated with a Synthetic Cartilage Implant

Category: Midfoot/Forefoot Introduction/Purpose: 'MoAkin' biplanar proximal phalanx closing wedge osteotomy with dorsal cheilectomy has been described as an effective procedure for treatment of hallux rigidus with hallux valgus interphalangeus (HVI). Its role as an adjunct procedure to first metatarsophalangeal joint hemiarthroplasty using a synthetic cartilage implant has not been well described. The purpose of this radiographic analysis was to examine radiographic changes associated with the MoAkin osteotomy performed in patients who underwent first MTPJ hemiarthroplasty using the Cartiva implant. Methods: A retrospective study of all patients with hallux rigidus and HVI treated with a synthetic cartilage implant and MoAkin osteotomy between 2009 and 2020 was conducted. Radiographs were performed preoperatively and at six- and/or twelve-month postoperatively, and evaluated using standardized measurement techniques. Hallux valgus angle (HVA), interphalangeal angle (IPA), and intermetatarsal angle (IMA) were measured. Results: Fifty-four patients were included in the study (37 male; 17 female). Mean preoperative HVA, IPA, and IMA were 11.7+- 4.2 degrees, 15.8+-4.6 degrees, and 8.2+-2.4 degrees, respectively. Mean six-month postoperative HVA, IMA, IPA were 7.7+-4.2 degrees, 15.7+-5.7 degrees, and 8.2 +- 3.0 degrees. Mean twelve-month postoperative HVA, IMA, IPA were 8.0+-4.5 degrees, 15.2+-6.1 degrees, and 8.1+-2.9 degrees. No statistical differences were found between the six-month and twelve-month radiographic analysis (p&gt;=0.59). There was a statistically significant reduction in the hallux valgus angle at six and twelve-month follow up compared to the preoperative angles (p&lt;0.001, d=0.73-1.16). No statistically significant differences were noted in terms of IPA and IMA (p&gt;=0.31). Conclusion: MoAkin osteotomy improves the hallux valgus angle in patients with hallux rigidus and HVI undergoing first MTPJ hemiarthroplasty with the Cartiva implant. Further studies are warranted to evaluate the impact of these radiographic findings on patient-reported outcomes and other clinical outcomes.

Hallux Valgus Interphalangeus Measurement: Comparison of the Two Radiographic Methods

Category: Midfoot/Forefoot Introduction/Purpose: To determine the reliability of Delta PP (difference in medial and lateral proximal phalanx wall length) compared to HIA (hallux interphalangeal angle) in the assessment of HVI (hallux valgus interphalangeus) in both pre and postoperative radiographs. Methods: This was a retrospective observational study of 186 feet with hallux valgus. The number of cases required to adequately power the study was 128. Preoperative and postoperative hallux alignment were evaluated by two different radiological parameters, Delta PP and HIA. Inter-observer variability was assessed independently by two authors and compared using a intraclass correlation coefficient. Results: The intra-class correlation coefficient was more than 0.8 for all parameters, thus both HIA and Delta PP measurement provide reliable and reproducible data. Mean HIA significantly increased following surgical correction of hallux valgus. In comparison, the mean Delta PP decreased after correction. This postoperative increase in HIA indicates that pre-operative HIA underestimates the magnitude of HVI and therefore is an inaccurate tool for measuring HVI's contribution to the TVDH (total valgus deformity of the hallux) and to preoperative planning. However, the Delta PP was a greater determinant of the phalanx deformity's contribution to the TVDH. Conclusion: The outcome of our study shows that both HIA and Delta PP are reproducible when assessing the hallux valgus interphalangeus deformity, however, Delta PP quantifies the amount of correction obtained more precisely. The additional benefit of measuring the Delta PP is that it allows for accurate planning in determining the dimensions of the medial based wedge of the Akin osteotomy that needs to be resected.

Proximal to distal phalangeal articular angle of the first proximal phalanx: Reliability and correlation with round sign

BackgroundTo reduce the rate of correction loss in hallux valgus surgery, a proximal to distal phalangeal articular angle (PDPAA) of the proximal phalanx of the greater toe of> 8° is considered an indication for a combined Akin and Chevron osteotomy. The PDPAA is measured between the articular surfaces of the proximal phalanx of the greater toe. Viewed from a sagittal perspective, the joint surfaces are not perpendicular aligned to the phalanx axis. Therefore, the PDPAA might be confounded by pronation. This study aims to, first, evaluate the intra- and interobserver reliability of the PDPAA and, second, to analyze the correlation to first ray pronation. MethodsIn a consecutive series of 59 feet who underwent hallux valgus (HV) surgery, PDPAA, round sign and other angles were measured on weight-bearing radiographs pre- and postoperatively. After power analysis, the intraclass correlation coefficient (ICC) was used to calculate the intra- and interobserver reliability. The correlation of PDPAA with the round sign as well as angles defining the HV and the Hallux valgus interphalangeus (HVI) were evaluated. ResultsThe PDPAA showed an excellent intra- and interobserver reliability (ICC 0.92 and 0.89, p < 0.05). The round sign did not correlate significantly with the PDPAA (p = 0.51). However, the PDPAA showed a moderate correlation with the interphalangeal angle (r = 0.51, p < 0.05) and fair inversely with the intermetatarsal angle (r = −0.45, p < 0.05). ConclusionFirst, measurement of PDPAA is reliable. Second, PDPAA is not associated with first ray pronation, but a false low PDPAA is geometrically possible. A high PDPAA correlates with a relevant HVI and inversely correlates with the HV like the HVI. Hence, first ray pronation should be treated first and a remaining PDPAA of> 8° after intraoperatively reevaluation separately.

Hallux Valgus Interphalangeus Measurement: Comparison of the 2 Radiographic Methods.

To determine the reliability of Delta PP (difference in medial and lateral proximal phalanx wall length) compared with HIA (hallux interphalangeal angle) in the assessment of HVI (hallux valgus interphalangeus) in both preoperative and postoperative radiographs. This was a retrospective observational study of 186 feet with hallux valgus. The number of cases required to adequately power the study was 128. Preoperative and postoperative hallux alignment were evaluated by 2 different radiological parameters, Delta PP and HIA. Interobserver variability was assessed independently by 2 authors and compared using a intraclass correlation coefficient. The intraclass correlation coefficient was more than 0.8 for all parameters, thus both HIA and Delta PP measurement provide reliable and reproducible data. Mean HIA significantly increased following surgical correction of hallux valgus. In comparison, the mean Delta PP decreased after correction. This postoperative increase in HIA indicates that preoperative HIA underestimates the magnitude of HVI and therefore is an inaccurate tool for measuring HVI's contribution to the TVDH (total valgus deformity of the hallux) and to preoperative planning. However, the Delta PP was a greater determinant of the phalanx deformity's contribution to the TVDH. The outcome of our study shows that both HIA and Delta PP are reproducible when assessing the HVI deformity; however, Delta PP quantifies the amount of correction obtained more precisely. The additional benefit of measuring the Delta PP is that it allows for accurate planning in determining the dimensions of the medial-based wedge of the Akin osteotomy that needs to be resected. Level 4.

Outcome of Concomitant First Metatarsophalageal and Tarsometatarsal Arthrodesis for Severe Hallux Valgus

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Arthrodesis of the first tarsometatarsal (TMT-1) joint is a widely accepted procedure for treatment of hallux valgus (HV) with medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high intermetatarsal angles (IMA). Similarly, metatarsophalangeal fusion (MTP-1) has been suggested for severe hallux valgus, metatarsophalangeal arthritis, and severe or recurrent deformities. Prior studies have demonstrated early outcomes in a small sample of patients. This study aimed to evaluate clinical and radiographic outcomes in patients with severe HV who underwent concomitant TMT-1 and MTP-1 arthrodesis for severe HV.Methods:All patients with symptomatic severe HV who failed conservative management and underwent concomitant MTP-1 and TMT-1 arthrodesis between January 2006 to December 2018 were included in our retrospective case series. Patients were operated on by one of three senior foot and ankle surgeons at a single tertiary center. Demographics, clinical outcomes, patient comorbidity information, and radiographic outcomes including baseline hallux valgus angle (HVA), IMA 1-2, hallux valgus interphalangeus angle, distal metatarsal articular angle, and sesamoid station were collected. The primary outcome was reoperation. Secondary outcomes were minor complications (local wound care, use of antibiotics, and skin dehiscence), visual analogue scale (VAS) pain scores, and change in radiographic measurements.Results:From 2006 to 2018, 42 patients (21.4% male, 78.6% female) at an average age of 62.6 years (range 48 to 80) met inclusion. At final average clinical follow up of 28 months, there were a total of 23 reoperations in 35.7% of patients at an average 18.5 months from index surgery (n=15; 1 revision TMT, 2 revision MTP, 1 hallux interphalangeal (IP) fusion, and 11 hardware removal). Minor complications were present in 7.1% of patients (n=3; 3 local wound care, 2 use of antibiotics, and 3 skin dehiscence). Average VAS score preoperatively and postoperatively was 5.5 to 1.9, respectively. Average preoperative HVA and IMA 1-2 angles were 35.6 and 15.3 degrees compared to postoperative angles of 9.0 and 9.3 degrees, respectively.Conclusion:The present study demonstrates concomitant MTP-1 and TMT-1 arthrodesis in cases of HV secondary to medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high IMA has a high correction capability and achieved normal HVA as well as normal IMA 1-2 at greater than two years. Concomitant MTP-1 and TMT-1 arthrodesis in patients with severe HV appeared to be safe and clinically successful.

Outcome of Bunion Correction with First Tarsometatarsal Arthrodesis in Adult Acquired Flatfoot Deformity Correction

Category:Bunion; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Arthrodesis of the first tarsometatarsal (TMT-1) joint is a widely accepted procedure for treatment of hallux valgus (HV) with medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high intermetatarsal angles (IMA). This study aimed to evaluate clinical and radiographic outcomes in patients with mild-to-severe HV who underwent TMT-1 arthrodesis and proximal hindfoot correction for adult acquired flatfoot deformity (AAFD).Methods:All patients with symptomatic HV and AAFD who failed conservative management underwent TMT-1 fusion and proximal hindfoot correction (medial displacement calcaneal osteotomy, lateral column lengthening, subtalar fusion, or tibiotalocalcaneal fusion) by one of three senior foot and ankle surgeons at a single tertiary center between January 2006 and December 2018 were included in our retrospective case series. Demographics, clinical outcomes, patient comorbidity information, and radiographic outcomes including hallux valgus angle (HVA), IMA 1-2, hallux valgus interphalangeus angle, distal metatarsal articular angle, and sesamoid station were collected. The primary outcome was change in HVA measured as the difference between final postoperative and preoperative weight bearing HVA measurements. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence), and change in radiographic measurements.Results:With an average follow up of 26 months, 155 patients (17.4% male, 82.6% female; average age 59.0 years old, range 18 to 84) met inclusion. The average change in HVA was -18.6 degrees (range +15.8 to -81.0). There was a total of 85 reoperations in 35.5% (n=55; 48 hardware removal). Minor complications were present in 18.7% (n=29; 25 local wound care, 23 use of antibiotics, and 10 skin dehiscence). 44.5% (n=69) had no evidence of recurrent HV while mild, moderate, and severe grade bunions were present in 40.0% (n=62), 5.2% (n=8), and 0.6% (n=1). Improvement in overall bunion grade was maintained in 69.7% (n=108) with no change in 19.4% (n=30). Hallux varus was present in 9.7% (n=15; 3 underwent TMT-1 arthrodesis).Conclusion:The present study demonstrates a significant improvement in HVA following TMT-1 arthrodesis and proximal hindfoot correction for AAFD. The majority of patients undergoing TMT-1 arthrodesis and proximal hindfoot correction for AAFD obtain and maintain improvement in the radiographic severity of their bunions. However, patients should be counseled concerning expectations with regards to outcomes associated with complex AAFD reconstructions.

Off-axis view radiographs for assessing hallux valgus interphalangeus in hallux valgus deformity: A comparison with the traditional anteroposterior standing radiographs

BackgroundThe newly described anteroposterior “off-axis view” (OAV) radiograph might help detect a hallux valgus interphalangeus (HVI) deformity more precisely compared to anteroposterior standing radiographs. MethodsA radiographic assessment of HVI angles was performed using preoperative standing anteroposterior and OAV radiographs for 67 ft. Intra- and interobserver agreement for all angles and their correlation with HV severity were analyzed. ResultsThe proximal-to-distal phalangeal articular angle showed less intra- and interobserver variance (intraclass correlation coefficient: 0.825) than did the other angles. OAV radiographs showed less interobserver reliability than did standing radiographs. HVI was underestimated significantly, by up to 5°, on standing radiographs compared to OAV radiographs (p < 0.001). The mean differences between OAV and standing radiographs were 3.7° and 5.0° for the proximal-to-distal phalangeal articular and hallux interphalangeal angles, respectively, and were more pronounced for moderate-to-severe HV deformities. ConclusionAngular measurements of HVI on traditional anteroposterior standing radiographs are significantly smaller than on OAV radiographs. Furthermore, angular measurements on OAV radiographs are associated with higher interobserver reliability. The most precise angle representing an HVI deformity might be the proximal-to-distal phalangeal articular angle. Clinical RelevanceOur findings may facilitate preoperative decision-making for additional akin osteotomy in HV correction. Level of EvidenceLevel II.

Reliability of the Radiographic Measurement of the Hallux Interphalangeal Angle.

The hallux valgus interphalangeus (HVI) deformity has a common association with hallux valgus and hallux rigidus. The HVI is formed by the angle between the long axes of the proximal and distal phalanges. The normal value for this angular deformity in the coronal plane is less than 10°. The aim of this study was to analyze the intra- and inter-observer reliability of measuring the interphalangeal angle by orthopaedic surgeons. This study is the first study to evaluate specifically the reliability and reproducibility of measuring the HVI angle. Twenty-one X-ray prints of weightbearing feet constituted a set. Sixteen qualified orthopaedic surgeons were asked to measure the HVI angle of all 21 X-ray images in the set. Three randomized sets were sent to each evaluator at 4-week intervals. After all 3 sets were measured, data were retrieved and statistically analyzed to determine the inter- and intraobserver variability and reliability in the measurement of the HVI angle. Reproducibility of the HVI measurement was assessed using 3 categories, which included the ability to measure the same angle 3 times and achieve: 3° or less, 5° or less, and more than 5° variation. The intraobserver reliability was found to be 5° or less in 85.2% of participants and the interobserver reliability was 81.2%. The researcher did not find significant correlation between the surgeons' level of experience with regard to the reliability of measuring the HVI angle. The inter- and intraobserver reliabilities of measuring the HVI angle is 81.2% and 85.2%, respectively. The level of experience of the surgeon does not improve this reliability. Level II.

Radiographic Analysis Between Two Commonly Used Measurements for Hallux Valgus Interphalangeus

Category:BunionIntroduction/Purpose:There is an increasing recognition of the contribution of hallux valgus interphalangeus (HVI) to the total deformity seen in hallux vallux valgus. The most commonly assessed radiological parameter is the hallux interphalangeus angle (HIA). Our aim in this study was to assess the reliability of the difference in medial and lateral proximal phalanx wall length (delta PP) in the assessment of hallux valgus interphalangeus in both the pre-operative and post-operative radiographs compared with the HIA.Methods:All patients undergoing scarf osteotomy for hallux valgus correction at our institution over a nine-month period were included. 40 feet in 36 patients were evaluated. Standard AP weight bearing radiographs preoperative and at 6 weeks post-surgery were evaluated by 2 independent observers. The standard PACS angular measurement tools were used for all measurements. The HIA and delta PP were measured along with hallux valgus angle (HVA) and intermetatarsal angle (IMA). Delta PP was calculated as the medial side length of the medial proximal phalanx minus the lateral side length of the proximal phalanx. SPSS 21 was used for statistical evaluation. Two-way random single measure intra-class correlation coefficient (ICC) was calculated to assess the interobserver agreement.Results:33 female and 3 male patients were assessed. The mean age was 58 years (range 26-80 years). 18 patients underwent an Akin osteotomy. Pre-operative mean HVA 33 degrees, IMA 15 degrees, HIA 4 degrees and delta PP 1.64 mm. Post-operative mean HVA 17 degrees, IMA 9 degrees, HIA 7 degrees and delta PP 1.03 mm. In the sub group that underwent an Akin osteotomy the HIA increased from 5.2 degrees to 8.8 degrees in contrast to the delta PP that reduced from 2.04 to 0.26 mm.Pre-operatively the inter observer agreement using ICC was HVA 0.74, IMA 0.82, HIA 0.65 and Delta PP 0.70. Postoperatively the interobserver agreement was HVA 0.71, IMA 0.55, HIA 0.57 and Delta PP 0.64.Conclusion:The delta PP was more reliable than the HIA, with an improved interclass agreement on both pre and post- operative radiographs. The mean post-operative HIA increased, this was also present in the group where an akin osteotomy had been performed. In contrast the delta PP reduced. We feel pronation of the toe may alter the radiographic measures for HVI assessment and affect the validity of the HIA measurements, however the delta PP reliability was less affected.Pre-operative radiographs had greater interobserver agreement across all measures than postoperative radiographs, which may reflect difficulties in determining the bony landmarks for measurement following surgery.

A radiographic analysis of the abnormal hallux interphalangeus angle range: Considerations for surgeons performing Akin osteotomies.

This study is aimed to determine the abnormal radiological hallux interphalangeus angle (HIA) range, which can assist surgeons in determining the required bone resection in an Akin osteotomy of the proximal phalanx of the great toe. Radiographs of 141 feet were analyzed. The mean HIA and range were calculated. The prevalence of hallux valgus interphalangeus (HVI) deformity was 78% (110/141). The mean HIA was 13.5° ± 4.5° (1.4-24.4). Fifty percent had abnormal HIA values of 10-15°, 40% had values of 15-20°, and 10% had greater than 20°. A large proportion of patients with HVI deformities may need greater than the standard 2-3-mm bone wedge removal during Akin osteotomy. The high prevalence and wide range of HVI deformities should alert surgeons to the possibility that greater than 3-mm bone wedge resections may be required. Level of Evidence: Level IV.

Distal Linear Metatarsal Osteotomy Combined with Akin Osteotomy for Hallux Valgus with Hallux Valgus Interphalangeus

Background: Minimally invasive distal linear metatarsal osteotomy is commonly performed to correct mild-to-moderate hallux valgus. The technique is easy to perform, fast, and has a low complication rate with satisfactory clinical results. However, it has so far not been applied to hallux valgus with concomitant hallux valgus interphalangeus deformity. Objective: We aimed to investigate the short-term clinical results of distal linear metatarsal osteotomy combined with Akin osteotomy in hallux valgus with concomitant hallux valgus interphalangeus deformity. Methods: We retrospectively reviewed 10 patients (10 feet) who underwent surgery for hallux valgus with hallux valgus interphalangeus between 2012 and 2016. Akin osteotomy was performed and fixated with a screw/K-wire, followed by distal linear metatarsal osteotomy and K-wire fixation. Clinical evaluations pre- and postoperatively used the Japan Society for Surgery of the Foot (JSSF) scale and the Visual Analog Scale (VAS). Radiography pre-and postoperatively assessed the hallux valgus, hallux valgus interphalangeus, and the intermetatarsal angle. Results: The mean follow-up period was 20.2 months. Both the JSSF and VAS score improved significantly, from 64.5 to 90.0 and from 5.5 to 1.1, respectively. In all patients, bone healing was complete within four months with no osteonecrosis of the metatarsal head or malunion at the osteotomy site. The hallux valgus angle improved from 31.5° to 7.7°, the hallux valgus interphalangeus angle from 17.2° to 5.8°, and the intermetatarsal angle from 11.7° to 5.5°. Conclusion: Distal linear metatarsal osteotomy combined with Akin osteotomy safely and effectively corrects mild-to-moderate hallux valgus with hallux valgus interphalangeus deformity.

Morphology of the first metatarsal head as a risk factor for hallux valgus interphalangeus

BackgroundThe aetiology of hallux valgus interphalangeus (HVI) is not well understood. First metatarsophalangeal joint stability, influenced by first metatarsal head shape, may be linked to HVI. We hypothesised that first metatarsal head shape is a risk factor for HVI. No published article could be found in the literature investigating this hypothesis. Methods127 standardised foot radiographs were analysed retrospectively. The hallux valgus angle (HVA) and interphalangeus angle (IPA) were measured. The first metatarsal head shape was divided into chevron, round and flat groups. Statistical analysis was then performed to investigate the relationship between first metatarsal head shape and the occurrence of HVI. ResultsThere was no statistically significant relationship between first metatarsal head shape and the occurrence of HVI. There was however a negative relationship between HVA and HVI. ConclusionsThe morphology of the first metatarsal head does not seem to be a risk factor for HVI. A known negative relationship between HVA and IPA is reinforced.Level of evidence: Level III, retrospective cohort.

Hallux valgus interphalangeus: reliability of radiological assessment

BackgroundReliable radiographic measurement of hallux valgus interphalangeus (HVI) deformity has a role in guiding surgical management. HVI can be assessed using:•Hallux interphalangeal angle (HIA).•Distal articular set angle (DASA).•Proximal to distal phalangeal articular angle (PDPA).The aim of the study is to investigate the reliability of these radiological parameters. MethodsSeventy foot radiographs in patients pre and post hallux valgus corrective surgery were assessed by 3 observers. HVI was assessed using the radiological measurements described above. Two-way random, single measure intra-class correlation coefficients were calculated to assess agreement. ResultsInter-observer reliability showed good agreement for DASA [ICC=0.77(0.61–0.88)], and excellent for HIA [ICC=0.92(0.85–0.96)] and PDPA [ICC=0.91(0.84–0.96)]. Intra-observer reliability was excellent for all angles; DASA [ICC=0.88 (0.76–0.95)], HIA [ICC=0.94(0.86–0.97)] and PDPA [ICC=0.83(0.65–0.92)]. ConclusionsReliability is good to excellent among these three radiological techniques for assessing HVI. The HIA and PDPA are slightly more reliable.

Percutaneous minimally invasive Akin osteotomy in hallux valgus interphalangeus: a case series.

Phalangeal Akin osteotomy of the greater toe is a frequently used surgical procedure for correcting hallux valgus interphalangeus deformity. However, previous research did not investigate percutaneous techniques of the Akin osteotomy. It was the aim of this study to investigate feasibility, corrective potential, and safety of a percutaneous minimally invasive Akin osteotomy. We present a series of 81 feet, in which a percutaneous Akin technique was performed using a high-speed burr but no fixation device. The most important outcome parameters were determined as the proximal to distal phalangeal articular angle (PDPAA) (corrective effect of the osteotomy), the osteotomy healing (full, partly, no visibility of the osteotomy gap), and the integrity of the lateral cortical hinge. With regard to the main hypothesis we found significant changes in the PDPAA over the whole period of time (p<0.001). Post-hoc tests determined that the PDPAA changed from 10° pre-operatively (Md, IQR 4.3) to 2.3° post-operatively (Md, IQR 3.7) (p<0.001). Post-operatively no significant changes in PDPAA were found within the first sixweeks and from sixweeks to threemonths (no loss of correction). Osteotomy healing was satisfactory as well. Three months post-operatively, there were no patients with a fully visible osteotomy gap, 28.3% with a partly visible osteotomy gap, and 71.7% had no visible gap. Interestingly, we could not observe a statistically significant correlation between bone healing and the integrity of the lateral cortical hinge. From our findings we conclude that the minimally invasive Akin osteotomy without osseous fixation provides effective deformity correction without significant loss of correction thereafter. This procedure appears to be safe with regard to osseous healing. Surprisingly, the healing process of the osteotomy showed no dependence on the integrity of the lateral cortical hinge. Therapeutic, Level IV, retrospective case series.

Akin osteotomy as an adjunct to hallux MTPJ fusion

Category: Midfoot/Forefoot, Hallux MTP fusion Introduction/Purpose: It is not uncommon to note residual valgus at the hallux interphalangeal joint when performing a hallux MTPJ fusion. On occasion, despite optimum positioning of hallux MTPJ for fusion, we found that in some cases the hallux was still abutting the second toe. We noted that these cases had either a high hallux interphalangeus valgus angle or the proximal phalanx had a shorter, concave lateral border due to eccentric wear. These two variables were difficult to correct despite optimum positioning of the hallux MTPJ. Consequently the hallux abuts the second toe causing irritation. We have used Akin osteotomy as an adjunct to hallux MTPJ fusion to address this intraoperative problem Methods: Between 2013 to 2016 this technique was utilised in 16 patients in whom residual hallux valgus interphalangeus was noted once the hallux MTPJ was stabilised in the appropriate position. We used two 4.0 mm AO cannulated partially threaded screws inserted in a crossed configuration for MTPJ fusion and a 8 mm x 90 degree varisation staple for the Akin osteotomy. The Akin osteotomy was performed in the mid to distal diaphyseal region of the proximal phalanx to avoid the screw position. Postoperatively, patients were given a toe spica plaster cast and were advised to walk in a heel weight bearing wedge shoe for six weeks. Results: Despite the osteotomy not being in the metaphyseal region, we have not encountered any immediate post-operative complications. We accept that this technique may not be suitable when using plates and screws for fusion but would be suitable for use with screws or staples. We have not encountered any postoperative complications. All hallux MTPJ joints have fused and Akin osteotomies have healed uneventfully Conclusion: This technique has not been reported before. Akin osteotomy is commonly used as an adjunct to corrective hallux valgus surgery. It is a relatively quick and reproducible technique with minimal incidence of complications. We suggest that this technique be considered when carrying out a hallux MTPJ fusion, although may not be required in all cases.

Distal Akin osteotomy for hallux valgus interphalangeus

BackgroundThe aim of this study was to assess clinical and radiological outcomes in patients who underwent distal Akin osteotomy for hallux valgus interphalangeus (HVI). MethodsA series of 15 consecutive patients (17 feet) was retrospectively reviewed. All the patients were preoperatively and post-operatively evaluated with a physical and radiographic assessment (HVI angle). Satisfaction has been assessed through a satisfaction survey, the scale used consisted in three possible choice: very satisfied, satisfied, not satisfied. ResultsAmong 15 patients the 52.9% (9 patients) stated to be “very satisfied”, the 41.2% (7 patients) “satisfied” and just a 5.9% (one patient) was “not satisfied”.The mean HVI value decreased from 24.9°±7.8° preoperatively to 13.1°±5.8° postoperatively at last follow up (p<0.05). ConclusionsBased on these findings we can conclude that the distal Akin osteotomy can be considered safe and effective in the surgical correction of symptomatic HVI deformities.