Hallux Varus Research Articles

Traumatic hallux varus repair utilizing a soft-tissue anchor: A case report

Hallux varus is usually iatrogenic in nature; however, congenital and acquired etiologies have been described in the literature. The authors present a case of traumatic hallux varus secondary to rupture of the adductor tendon. Surgical correction was performed using a soft tissue anchor for maintenance of the soft tissues utilized for repair.

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies.

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.

The modified lapidus arthrodesis: A retrospective analysis

The authors present a review of 47 modified Lapidus arthrodesis procedures performed between 1985 and 1995. There were 29 females and 10 males. Eight patients underwent bilateral procedures. The average follow-up was 6.3 years (range, 1.5-10.6 years). The patients were evaluated preoperatively and postoperatively using standard weightbearing radiographs, clinical examination, and chart review. The average preoperative intermetatarsal angle was 13.8 degrees degrees, and the average postoperative intermetatarsal angle measured 2.1 degrees degrees, with a mean improvement of 10.8 degrees. The average effective shortening of the first metatarsal was 4.7 mm in those patients without bone graft. In patients whom bone graft was utilized, an average effective increase in first metatarsal length of 2.6 mm was identified. Complications included delayed union (n = 2), nonunion (n = 3), postoperative development of hyperkeratosis beneath the second metatarsal head (n = 4), elevation of the first ray (n = 3), and hallux varus (n = 2). There were no recurrences of hallux abducto valgus at follow-up. The average return to preoperative activity level was 13 weeks. Forty-two of the 47 procedures healed uneventfully. Of the remaining five feet, two required the use of a bone growth stimulator, and three required revisional surgery with autogenous bone graft to promote arthrodesis and restore alignment. In conclusion, the modified Lapidus arthrodesis is both a predictable and durable procedure for the correction of hallux abducto valgus.

Proximal metatarsal osteotomy and distal soft tissue reconstruction for hallux valgus in juveniles

Surgical correction of hallux valgus through a lateral soft tissue release, resection of the exostosis and proximal first metatarsal osteotomy. Hallux valgus with a subluxated metatarsophalangeal joint. Significant rigidity between first and second metatarsals. When the intermetatarsal angle is 50°. Presence of significant osteoarthritis or spasticity. First incision: longitudinal over dorsal aspect of first intermetatarsal space. Release of soft tissue contracture between lateral sesamoid and metatarsal head. Division of transverse metatarsal ligament. Release of lateral joint capsule. Second incision: longitudinal over exostosis. Inverted L-shaped incision of capsule, resection of exostosis. Capsulorrhaphy. Third incision: longitudinal over base of first metatarsal. Crescentic osteotomy, correction and internal screw fixation. Twenty-seven juveniles (33 feet), average age at surgery 15.9 years, average follow-up 5 years. Using the subjective rating scale 30 feet were excellent, 2 good and 1 fair. Based on the duPont rating scale the results were excellent in 29 feet, twice good and twice fair. The following complications were noted: hallux varus 4, breakage of Kirschner wire 1 and 1 undercorrection.

The crescentic first metatarsal basilar osteotomy for correction of metatarsus primus varus

The crescentic basilar first metatarsal osteotomy has been largely abandoned by the podiatric community in recent years in favor of proximal wedge-type osteotomies for the correction of metatarsus primus varus with large intermetatarsal angles. In most cases, this was due to the inherent instability of the osteotomy and difficulties with fixation. However, the crescentic osteotomy has the ability to correct in all three planes with less shortening than the wedge-type osteotomies. New fixation techniques, such as the small cannulated screw systems, have allowed for less technical difficulty in obtaining rigid internal fixation. In this article, the authors describe the results in 29 feet (27 patients) where the crescentic osteotomy was performed along with a metatarsaphalangeal joint procedure ranging from a McBride (with or without lateral sesamoidectomy) to a phalangeal osteotomy. Preoperative intermetatarsal angles ranged from 11 degrees to 22 degrees, with an average of 18.6 degrees. Postoperative intermetatarsal angles ranged from 2.6 degrees to 8.2 degrees with an average of 5.1 degrees. The preoperative hallux abductovalgus angles ranged from 25 degrees to 38 degrees, with an average of 33.6 degrees. The postoperative hallux abductovalgus angles ranged from 4 degrees to 18 degrees with an average of 11 degrees. Complications included one hallux varus, one delayed union, and three cases of superficial cellulitis that resolved with oral antibiotic therapy.

Cerclage fibreux in the treatment of hallux valgus.

Resection arthroplasty was performed in 62 feet, with follow-up at an average of 36 months (range, 17-68 months). All cases were performed using a combined cerclage fibreux. The mean age at operation was 61 years (range, 49-77 years). The mean score according to the hallux metatarsophalangeal-interphalangeal scale of the American Orthopaedic Foot and Ankle Society was 81 points (range, 25-100 points). Correction of the hallux valgus angle at follow-up averaged 23 degrees (range, 0-45 degrees). The first intermetatarsal angle had been corrected an average of 3 degrees (range, 0-14 degrees). Transfer metatarsalgia was encountered in eight patients. No hallux varus or cock-up deformity was detected.

Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10- to 22-year follow-up.

Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.

特発性内反母しの治療経験

An unusual case of idiopathic hallux varus is reported in this paper. A 63 year-old woman presented with hallux varus deformity accompanied with pain and showed no evidence of underlying inflammatory disease nor history of trauma. This case had 42 degrees of the pre-operative varus deformity. Muscle release and reconstruction without osteotomy resulted in good alignment of the great toe and the patient was cured of gait disturbance with pain.

Recalcitrant idiopathic hallux varus

We report the case of a 51-year-old woman who presented with sudden onset of hallux varus deformity without previous injury. The deformity was corrected surgically using an extensor hallucis brevis tenodesis procedure. This procedure failed to maintain correction of the deformity. She therefore underwent an uncomplicated first metatarsophalangeal joint arthrodesis. Despite failure of the failure of the extensor hallucis brevis tenodesis procedure, we believe this to be the treatment of choice in idiopathic hallux varus deformity as it neither sacrifices the extensor hallucis longus nor the interphalangeal joint of the hallux.

Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities

This is a retrospective study of 10 patients (13 feet) with moderate to severe hallux valgus who underwent a chevron or modified chevron osteotomy with multiple adjunctive soft-tissue releases for surgical treatment. Radiographic and subjective results were evaluated with an average follow-up of 24 months (range, 10-41). Preoperative criteria included an intermetatarsal (IM) angle of greater than 16 degrees (average of 18.4 degrees) and painful hallux valgus deformity. Average preop hallux abductus was 35.4 degrees (range, 25 degrees-48 degrees). The average reduction in the actual IM angle was (-) 5.2 degrees with a relative IM correction of (-) 11.6 degrees. Average postoperative hallux abductus angle was 7.0 degrees (range, 0 degree-22 degrees). Subjectively, all patients were satisfied with their results and stated they would have the procedure again. No complications were noted in this patient population, including, infection, avascular necrosis, hallux varus, and recurrence of deformity. The chevron osteotomy was found to be successful in this population with high intermetatarsal angles when appropriate consideration was given to correction of soft-tissue-deforming forces and contractures.

Bunion correction using proximal chevron osteotomy: a single-incision technique.

Proximal chevron first metatarsal osteotomy with lateral capsulotomy, adductor tenotomy, and binding of the first and second metatarsals was reviewed in 88 consecutive cases. Seventy-two cases in 55 patients are reported, with an average clinical follow-up of 41 months. The hallux valgus angle improved an average of 15 degrees , from 32.0 degrees preoperatively to an average of 17.0 degrees postoperatively. The intermetatarsal I-II angle improved an average of 5.5 degrees, from 15.3 degrees preoperatively to 9.0 degrees postoperatively. The lateral plantar first metatarsal angle did not change. First metatarsal length was decreased by 2.0 mm. Union occurred at an average of 2 months. Sesamoid position improved 49%, from a preoperative average subluxation of 80% to a postoperative average subluxation of 29%. Subjective foot score profiles improved from a preoperative average of 70.1/100 to a postoperative average of 94.4/100 with respect to pain, deformity, motion, disability, and cosmesis. There were 10 patients with complications, including three patients with delayed unions, two with second metatarsal stress fractures, one with hallux varus, two with hallux limitus, one with progressive arthritis, one with cellulitis, and one with hallux elevatus. Eighty-four percent of the patients stated that they would undergo the procedure again without reservation, 9% would proceed with reservation, and 7% would not proceed with surgery again if offered. This technique provides reliable successful long-term results for the treatment of moderate and severe symptomatic bunion, hallux valgus, and metatarsus primus varus.

Retrospective analysis of the Mau osteotomy and effect of a fibular sesamoidectomy

The purpose of this study was to evaluate retrospectively outcomes of the Mau osteotomy for hallux abducto valgus deformity. Twenty-two patients were evaluated by the senior author on an average of 14 months (range, 3-34 months) following their surgery. Preoperative and postoperative intermetatarsal (IM) and hallux abductus (HA) angles were evaluated as well as range of motion of the first metatarsophalangeal joint and patient satisfaction. The mean preoperative IM and HA angles were 16.1 degrees and 35.8 degrees. The mean reduction in IM and HA angles was 10.5 degrees and 23.5 degrees, respectively. Joint range of motion was 58 degrees of dorsiflexion (range, 42 degrees-80 degrees) and 11 degrees of plantarflexion (range, 0 degree-20 degrees). There were no cases of delayed healing or avascular necrosis. There were two patients (9%) with radiographic values consistent with hallux varus; however, neither patient had a clinical appearance of hallux varus and neither patient was displeased with the outcome. Ninety-one percent of patients returned to a soft shoe or sneakers in an average of 5.1 weeks following surgery. Eighty-two percent of patients had no pain at the time of their evaluation, and 96% of patients stated they were satisfied or very satisfied with the surgery. Comparing the subgroup of patients who underwent a Mau-Reverdin procedure with another subgroup undergoing a Mau-Reverdin fibular sesamoidectomy, there was a 3.7 degrees greater reduction of IM angle and 6.7 degrees greater reduction in HA angle in the subgroup with the fibular sesamoidectomy.

Salvage treatment of failed hallux valgus operations with proximal first metatarsal osteotomy and distal soft-tissue reconstruction.

We reviewed the results of 15 patients (16 feet) in whom a hallux valgus procedure had failed. Salvage was by proximal crescentic first metatarsal osteotomy with distal soft-tissue reconstruction. Results based on a clinical scale considering the level of pain, activity limitations, support requirement, footwear limitations, and alignment were good in 11, fair in two, and poor in three. Patients were satisfied with the results in 10 feet, satisfied with reservations in four feet, and dissatisfied in two feet. Complications were: transfer metatarsalgia in three, hallux varus in one, and osteotomy nonunion in one. One of the patients required reoperation to bone graft a proximal osteotomy. Metatarsal osteotomy was helpful in the salvage treatment of recurrent, symptomatic hallux valgus when the first metatarsophalangeal joint was functional and painless.

Acquired hallux varus and clinical tolerability.

This retrospective study was undertaken to determine the long-term clinical problems, residual disability, and need for further surgery in patients with iatrogenic hallux varus. Between 1975 and 1985, in 16 (19 feet) of 83 patients who underwent foot surgery for hallux valgus or metatarsus primus varus, hallux varus deformity was noted at 1-year follow-up on dorsoplantar roentgenograms obtained with the patients bearing weight. Thirteen of those patients (16 feet) were reexamined at an average of 18.3 years (220 months) after surgery. The average hallux varus deformity in this group was 10.1 degrees. Eleven patients (12 feet) rated their results as excellent. The average hallux metatarsophalangeal interphalangeal score for all patients was 91.5 points. Only those with extreme hallux varus deformity were dissatisfied or required further surgery.

Congenital hallux varus

Hallux varus is a forefoot deformity consisting of medical deviation of the first metatarsophalangeal joint. The congenital form is extremely rare, usually associated with other forefoot malformations. This pathology seems to be related to an incomplete duplication of the first ray, leading to progressive contracture of the medial structures. A case of a 37-year-old woman with congenital hallux varus neglected since childhood is presented. The surgical procedure is described, consisting of removal of the contracted scar tissue surrounding the first metatarsal bone, resection of a synchondrosis and the head of the second metatarsal. An aesthetically acceptable, painfree and functionally adequate foot was achieved.

The nonfixated austin bunionectomy: A retrospective study of one-hundred procedures

A retrospective evaluation of 64 randomly selected patients with 100 nonfixated Austin bunionectomy procedures was performed. A radiographic and a clinical evaluation were performed, including an analysis of preoperative and postoperative angles as well as postoperative complications. This study demonstrates a similar complication rate for nonfixated Austin bunionectomies as compared with previous studies with internal fixation. Removal of the fibular sesamoid was performed in 90% of the cases and did not increase the incidence of hallux varus. The nonfixated Austin bunionectomy is an acceptable alternative to the correction of hallux valgus. If internal fixation is utilized, the most cost-effective device should be used.

Acquired hallux varus.

Acquired hallux varus most commonly occurs after hallux valgus surgery. Sagittal plane, coronal plane, and varus deformities are present at the metatarsophalangeal joint. Evaluation of both the metatarsophalangeal and interphalangeal joints for mobility is necessary in surgical decision making. Not all patients require surgery. The anatomy, incidence, pathogenesis, evaluation, classification, and treatment of acquired hallux varus are discussed in this review.

Hallux valgus in men: effect of the distal metatarsal articular angle on hallux valgus correction.

The results of hallux valgus correction were reviewed for 34 male patients (41 feet). The severity of the preoperative deformity determined the operative technique of correction. A distal soft tissue procedure with proximal first metatarsal osteotomy was performed in 30 patients (35 feet) with an average correction of the hallux valgus angle of 22 degrees. A chevron procedure was performed in five cases and a McBride procedure in one other case, all with less severe deformities. Complications included one deep wound infection, one broken screw at the metatarsal osteotomy site, and three cases of hallux varus. No patients underwent reoperation. Undercorrection was noted in 10 of 35 cases (29%) where a distal soft tissue procedure with proximal first metatarsal osteotomy was performed. A nonsubluxated (congruent) metatarsophalangeal (MTP) joint associated with a hallux valgus deformity was present in 15 of 41 (37%) of all cases and 10 of 35 (29%) of cases that underwent a distal soft tissue procedure with proximal metatarsal osteotomy (DSTR with PMO). A subluxated (noncongruent) MTP joint associated with hallux valgus was present in 26 of 41 (63%) of all cases and 25 of 35 (71%) of cases undergoing a DSTR with PMO. There was a highly significant difference in the average distal metatarsal articular angle (DMAA) as measured in the nonsubluxated (congruent) MTP joints (20.7 degrees) and the subluxated (noncongruent) MTP joints with hallux valgus (10 degrees) (P = 0.0001). The average distal metatarsal articular angle for all cases undergoing DSTR with PMO was 13 degrees. When the postoperative hallux valgus angle was compared with DMAA, the average residual hallux valgus angle was 10.1 degrees. With a subluxated (noncongruent) first MTP joint with hallux valgus (a low DMAA), the percent of hallux valgus correction (hallux valgus correction [in degrees]/preoperative hallux valgus deformity [in degrees]) was 77%. In patients with a nonsubluxated (congruent) first MTP joint with hallux valgus (a high DMAA), the percent correction was 46%, an almost twofold difference in percent correction. There was a close correlation between the preoperative DMAA and the postoperative hallux valgus angle in both the subluxated and congruent subgroups (P = 0.0003). With an intra-articular repair (a DSTP with PMO), the magnitude of correction of a hallux valgus deformity is limited at the MTP joint by the distal metatarsal articular angle.

Idiopathic hallux varus

An unusual case of idiopathic hallux varus is reported. An 84-year-old Japanese woman presented with bilateral hallux varus deformity accompanied by pain during a 2-year period. A Keller arthroplasty resulted in good alignment of the great toes and relief of pain. It is postulated that the elongated lateral capsule and collateral ligament of the great toe in combination with a small first and second intermetatarsal angle produced lateral instability, causing the varus deformity and consequently contracture of the medial capsule.

Resection arthroplasty in the treatment of hallux valgus

Sixty-six feet operated on for hallux valgus in 1984 were reviewed. Keller-Brandes' operation was performed in all cases, together with Lelièvre's "fibrous cerclage" and flexor hallucis longus tendon anchoring to the sesamoid pad, as described by A. Viladot. In most cases, satisfactory clinical correction was achieved and the patients could wear standard shoes. More than half of the cases presented partial limitation of movement at the first metatarsophalangeal joint; however, flexion power of the big toe was preserved, and the range of motion was wide enough to allow a painless and limp-free gait. Radiologically, good correction of the angle between the first and second metatarsals and the metatarsophalangeal angle was obtained, but all cases presented proximal displacement of sesamoid bones. A baropodometric study showed that the toe-off phase of the gait does not change after this operation. In our series, central metatarsalgia was present in 17 feet; however, it did not compromise the functional result and was easily relieved with orthopaedic devices. Four feet showed radiographic images, suggesting necrosis of the first metatarsal head; all four were asymptomatic. The only case that required reoperation was the one that developed hallux varus deformity. The Keller-Brandes-Lelièvre-Viladot procedure is still a simple and effective method for the surgical treatment of hallux valgus in elderly people with osteoarthritis at the first metatarsophalangeal joint.