Intermetatarsal Angle Research Articles

Complications of First Tarsometatarsal Joint Arthrodesis

Category: Bunion Introduction/Purpose: Hallux valgus, a term introduced by Carl Hueter (1) to define static subluxation of the first metatarsophalangeal joint characterized by lateral deviation of the hallux and medial deviation of the first metatarsal, (1,2) is a disease for which different corrective surgical techniques can be used, depending on its severity. First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is one of the surgical procedures used in the treatment of severe hallux valgus, among other alterations (3-5). Despite the high satisfaction rate and high corrective power, this technique is not without complications. The main com- plications include delayed union, malunion, chronic edema, persistent pain, nonunion, joint stiffness, recurrent deformity, and varus deformity (6). However, there is little scientific evidence of these complications after first TMTJ arthrodesis. The purpose of this study was to report the complications of first TMTJ arthrodesis performed by orthopedic surgeons specializing in foot and ankle surgery. Methods: This study was approved by the institutional research ethics committee and registered at Plataforma Brasil. We evaluated 16 patients undergoing first TMTJ arthrodesis, who denied any comorbidities. The procedures were performed by 7 different orthopedic surgeons specializing in foot and ankle surgery with different levels of experience, ranging from 1 to 29 years of experience in the field. All patients underwent arthrodesis with plates and screws. The plate was placed on the plantar aspect of the first tarsometatarsal in 4 patients and on the anteromedial aspect in all other patients. The dorsomedial incision was used, centered on the first TMTJ, for the 12 cases in which the plate was positioned in the dorsomedial region, and the medial incision was used for the 4 cases in which the plate was positioned on the plantar aspect. Also, articular cartilage was resected using a chisel and microperforations. All 16 patients were followed up in an outpatient clinic at 1, 2, 4, 6, 12, and 24 weeks postoperatively. The follow-up visits included the evaluation of anteroposterior, lateral, and oblique radiographs of the foot, clinical alignment of the hallux, and patients' signs and symptoms. For all patients, postoperative care included immobilization in a non-weight-bearing cast for 4 weeks, initiation of physical therapy with range of motion gain at 4 weeks, and partial weight- bearing at 6 weeks Results: We evaluated 16 patients operated on over an 18-month period (from February 2017 to August 2018). We measured preoperative and postoperative hallux valgus and intermetatarsal angles (Table 1). Eight patients had either major or minor complications (Table 2). Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (Figure 1) - 1 with associated nonunion (Figure 2), and 1 had wound dehiscence. Conclusion: Based on our study, we can conclude that first TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to avoid complications as much as possible, such as the use of implants to increase stability, instruments for better articular cartilage resection, and improvement in the correction of the pronation deformity of the hallux. The limitations of our study prevent us from drawing a robust conclusion and defining consistent parameters related to the main factors that may affect the various complications described in the study. Therefore, we believe that data are still scarce to provide a concrete basis, and further studies are needed to make substantiated conclusions.

Metatarsophalangeal and Metatarso-Sesamoid Joint Interaction in Hallux Valgus Deformity: A Case- Control Study

Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Hallux valgus deformity (HVD) is a complex 3D distortion that involves varus, dorsiflexion and pronation of the first metatarsal. Deformity is usually assessed by conventional 2D measurements such as hallux valgus and intermetatarsal angle. Weightbearing CT (WBCT) 3D Distance Mapping (DM) and Coverage Mapping (CM) allow assessment of relative positioning between opposing articular surfaces, providing information in regards to articular coverage and joint subluxation, that can potentially influence development of arthritic degeneration and symptoms, as well as dictate outcomes. The aim of this study was to develop a DM and CM algorithm to assess metatarsophalangeal (MTP) and metatarso-sesamoid (MS) joint interaction in HVD patients and compare it to healthy controls. We hypothesized that significant MTP and MS joints lateral subluxation would be observed. Methods: In this IRB-approved study, we included 9 HVD patients (mean age 37.1y; 6F/3M) and 5 controls (mean age 39y; 4F/1M) that underwent foot WBCT foot. Bone segmentation of WBCT images for the first and second metatarsals, first and second proximal phalanxes as well as tibial and fibular sesamoids was performed using specific software. Joint interaction with DM and CM of the first and second MTP joints, as well as MS joints were calculated. The surface of the MTP joints were divided in a 2x2 grid using principal axes to provide a more detailed analysis. DMs were color coded to facilitate data interpretation (Figure). Blue color represented expected normal joint interaction (distances from 1 to 3 mm), yellow/red color symbolized increased joint distances (distances from 3 to 5 mm) and pink color indicate completely uncovered articular areas (distances >5mm). Comparisons were performed with independent t-tests/Wilcoxon. P values <.05 were considered significant. Results: Examples of coverage maps for an HVD patient and a control are presented in the attached Figure, demonstrating the obvious lateral and dorsal displacement of the distance maps for joint interaction of the first MTP joint, with decreased articular coverage of the medial aspect of the joint. When comparing first MTP joint articular coverage (CMs), HVD patients demonstrated significantly decreased coverage of the dorsomedial quadrant (77%, p=0.0002), and significantly increased coverage of the plantarlateral (182%, p=0.005) and dorsolateral quadrants (44.9%, p=0.035). Findings are consistent with lateral first MTP joint subluxation and dorsiflexion of the first metatarsal. The second MTP joint demonstrated findings consistent with early hammertoe dorsiflexion contracture and dorsolateral joint subluxation, with significantly decreased articular coverage of the plantarmedial quadrant (88%, p=0.01). No significant changes in joint coverage were observed for the MS joints, however a significant widening of the fibular MS joint was noticed (76.7%, p=0.013). Conclusion: In this case-control study, we developed a Distance and Coverage Map WBCT Algorithm to objectively assess 3D joint interaction, articular coverage and subluxation in HVD. We observed significant amount of first and second MTP joint subluxation in HVD patients when compared to controls, with a plantarmedial and dorsolateral direction for respectively the first and second MTP joints. No significant joint subluxation of the metatarso-sesamoid joint was noted. Our hope is that DM and CM can optimize diagnosis, staging, and assessment of treatment and outcomes in hallux valgus and lesser toe deformities. Additional prospective and appropriately sized studies are needed.

2022 IFFAS Award for Excellence Winner: Minimally Invasive Chevron-Akin for Correction of Moderate and Severe Hallux Valgus Deformities

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The Minimally Invasive Chevron-Akin (MICA) technique has already demonstrated efficacy compared with other known surgical treatments for mild to moderate Hallux Valgus (HV) deformities. MICA combines percutaneous osteotomies with the benefits of modern rigid internal fixation. By minimizing soft-tissue disruption and allowing large translation of the metatarsal head up to 100%, surgeons have used this technique to address severe deformities as well. The study aim was to evaluate the radiographic parameters, clinical improvement, and potential complications in moderate to severe hallux valgus cases, operated using the MICA technique. Methods: This is a retrospective study conducted between January 2017 and December 2020, that included patients with moderate to severe HV, who underwent surgical correction using the MICA technique. The sample size calculation was based on the AOFAS questionnaire. Thus, to obtain the 0.8 power, including 70 cases in this study, was necessary. The AOFAS score and weight-bearing AP radiographic views for hallux valgus evaluation were applied pre-operatively, after a follow-up period of 6 months, after one year of follow-up, and after two years of follow-up. Visual Analogic Scale (VAS) was applied pre-operatively, after 1 year of follow-up, and after 2 years of follow-up. The following radiographic parameters were measured: metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and intermetatarsal angle (IMA) between the first and second metatarsals. To compare the measurements over time, Friedman's test was used. p<0.05 was considered to be statistically significant. Results: The average preoperative AOFAS score was 43.97 +- 17.89 and varied positively in the 6-month postoperative period, which was 90.17 +- 10.21 (p<0.01), maintained at 12 and 24 months. Preoperative VAS scores averaged 8.24 +- 1.51 and decreased to 1.37 +- 2.27 after 1 year and to 1.19 +- 2.23 after 2 years The initial IMA was 14.84 +- 3.57 degrees compared with a mean value of 8.1 +- 2.87 degrees (p<0.01) at six months and further decrease at 24 months postoperatively. The HVA showed a mean value of 30.37 +- 9.75 degrees preoperatively and 11.14 +- 6.8 degrees (p<0.01) at six months postoperatively, remaining stable in the postoperative evaluations at 12 and 24 months. The preoperative DMAA mean was 16.3 +- 8.55 degrees preoperatively and presented a significant drop (p<0.01) at the 6-months to 7.77 +- 5.44 degrees. Complications included painful hardware, neuropathic pain, and loss of correction. Conclusion: This study demonstrates that the MICA technique is a safe and effective procedure for correcting moderate to severe HV long-term, with a low rate of recurrence and severity of complications. Patients undergoing the surgical procedure in our series showed a significant reduction in radiographic parameters and a significant improvement in clinical scores, maintaining these results over time.The good results of this study justify the continued use of the technique and suggest the need to compare its results with other long-term studies and compare their effectiveness with open techniques.

Radiographic Correction of Bunionette Deformity using Minimally Invasive Fifth Metarsal and Akinette Osteotomy

Category: Midfoot/Forefoot; Lesser Toes; Other Introduction/Purpose: Bunionette Deformity is defined as a painful lateral prominence of the fifth metatarsal head. Conservative treatment entails footwear and activity modification. Symptoms can be exacerbated in the athletic population and activities with specific footwear such as cycling, winter sports and water sports. In refractory cases, patients may pursue operative intervention. Historically, open surgical correction carried risks of wound complications, prolonged recovery time, and nonunion risk. Minimally invasive techniques have gained popularity due to the decreased risk of wound complications, preservation of blood supply and healing potential, and faster operative and recovery times. The purpose of the current study is to examine radiographic and clinical outcomes of minimally invasive bunionette correction with a sliding distal 5th metatarsal osteotomy and lateral closing wedge proximal phalanx (Akinette) osteotomy. Methods: A retrospective review examined 36 feet in 28 patients who underwent minimally invasive bunionette correction from 01/2021 to 12/2021. The study patients were treated at a single center by 3 participating providers trained in minimally invasive techniques. All patients underwent a distal 5th metatarsal osteotomy and Akinette osteotomy of the proximal phalanx. Length of follow up ranged from 3 to 12 months. Radigraphic measurements including 4,5 intermetatarsal angle (IMA), 5th metatarsophalangeal angle, and osteotomy displacement (mm) were compared pre and postoperatively. Patients were asked to complete postoperative satisfaction survey and lesser toe American Orthopaedic Foot & Ankle Society (AOFAS) score. Results: Preliminary analysis shows a radiographic 4,5 IMA correction of 4.9 degrees to 3.4 degrees. Fifth metatarsophalangeal angle was corrected from 20.3 degrees preoperatively to 5.3 degrees postoperatively. Average medial displacement of the metatarsal osteotomy was 2.64 mm. There was one nonunion of the 5th metatarsal in a revision case that had previously been treated at an outside facility with open techniques, which was treated with bone grafting. Two other patients underwent revision surgery for complications from concomitant procedures that were performed (1 lapidus nonunion and 1 lapidus wound dehiscence). There were no wound or neurovascular complications involving the 5th ray. Conclusion: Our data shows that minimally invasive bunionette correction with sliding 5th metatarsal and Akinette osteotomy leads to reliable radiographic correction and clinical improvement. This operation has favorable safety profile with low incidence of complications and a high union rate.

Comparison Between Hallux Rigidus Parameters Assessed by Conventional Radiographs and Weight- Bearing CT

Category: Midfoot/Forefoot; Other Introduction/Purpose: The etiology of hallux rigidus (HR) is not well understood and its association with first-ray hypermobility, hallux valgus and metatarsus primus elevatus (MPE) has not been clearly proven. Recent studies have supported MPE in HR by measuring on weightbearing radiographs (WBR), but there are limitations of WBR due to variation in X-ray projection and superimposed metatarsals. WBCT represent a reliable tool for radiographic analysis of the first ray and can be important for the study pathologies such as HR, which involve several anatomical points to be evaluated for a correct clinical- radiographic diagnosis Our objective was to evaluate radiographic parameters associated with Hallux Rigidus via WBR and WBCT for convergent validity and to evaluate the use of the classification system used in conventional radiography with WBCT. Methods: This is a single-center, retrospective study from prospectively collected data. 20 symptomatic hallux rigidus patient with weightbearing radiograph and WBCT were enrolled from October 2014 to December 2020. Measured parameters included hallux valgus angle (HVA), intermetatarsal angle (IMA), 1st TMT joint version, First and second metatarsal lengths, 2nd cuneiform- 2nd metatarsal angle, Talus-1st Metatarsal angle, First and second metatarsal declination angles, and MPE. MPE was measured as the direct distance between 1st and 2nd metatarsals (modified Horton index). All patients were graded according to the radiographic criteria of Coughlin and Shurnas classification on radiographs and WBCT, separately. Paired T-test was performed to compare radiographic measurements with WBCT. Results: Mean age was 55.9. HVA (15.73° in X-ray vs 14.04° in WBCT), AP first TMT version (16.25° vs 16.47°), 2nd cuneiform- 2nd metatarsal angle (24.54° vs 26.60°), Talus-1st Metatarsal Angle (-7.67° vs -7.89°) were not different between radiograph and WBCT. MPE was measured higher in WBCT by 0.86 mm compared to radiograph. First metatarsal declination angle was lower in WBCT by 2.9° indicating increased MPE. When graded with radiographic findings, 5 (25%) patients were grade 1, 5 (25%) patients were grade 2 and 10 (50%) grade 3, when graded with WBCT, 1 (5%) patient had grade 1, 3 (15%) patients were grade 2 and 16 (80%) grade 3. When graded radiologically, subchondral cyst in proximal phalanx and metatarsal head were better delineated resulting in higher radiographic grade with WBCT. Dorsal subluxation/translation of first metatarsal at first TMT joint was observed 3 (15%) in radiograph and 9 (45%) in WBCT. Conclusion: Hallux Valgus Angle, AP first TMT version, 2nd cuneiform-2nd metatarsal angle, Talus-1st Metatarsal Angel demonstrated consistent measurements in radiograph and WBCT. MPE was measured higher in WBCT when measured with direct distance (0.86 mm) between the first and second metatarsals using modified Horton index and first metatarsal declination angle (2.9°). When graded with WBCT, the subchondral cyst in the proximal phalanx and metatarsal head were better delineated leading to higher grade in WBCT which infer WBCT grading system for HR can aid in early detection of advanced HR with high radiographic grades and potentially guide treatment accordingly.

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of >4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of <4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

Results of an Interim Analysis of a Prospective Multicenter Study Assessing Radiographic and Patient Outcomes Following Triplanar Tarsometatarsal Arthrodesis with Early Weightbearing

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing. Methods: This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up. Results: 165 patients underwent TMTA with at least 6 months follow-up (mean (SD): 17.8 (7.7); min, max: 5.8, 37.3). Mean age was 41.0 (range:14-58) years; 91.5% of patients were female. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.7) and 56.8 (45.6), respectively. Significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS was -3.7(-4.0, -3.3); Walking/Standing (MOxFQ) change was -35.2 (-39.6, -30.8); and Physical Function (PROMIS) change was 8.7 (7.1, 10.3). Fifteen (9.1%) patients experienced hardware complications, yet maintained radiographic correction to date. No patients (0/58) with 24 months follow-up have experienced recurrence. Conclusion: These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.

Intermetatarsal Screw Fixation Reduced Intermetatarsal Angle Following Modified Lapidus Procedures

Category: Midfoot/Forefoot Introduction/Purpose: The Modified Lapidus arthrodesis is a historically established surgical technique for treatment of hallux valgus, providing quality patient outcomes and reproducible results. Addition of a transverse first to second intermetatarsal screw spanning the base of the metatarsals in this procedure can increase stability. However, no study evaluates the radiographical parameters following application of this intermetatarsal screw fixation to procedures without first to second intermetatarsal screw fixation. The purpose of this study was to assess the quality of radiographic parameters between individuals receiving a first to second intertarsal screw fixation to those that did not receive intermetatarsal screw fixation following a non-saw cut Modified Lapidus procedure. Methods: A retrospective review was performed on 74 patients that underwent a Modified Lapidus arthrodesis between 2016- 2020 at a single institution. Preoperative indications for the procedure included first ray instability, first ray hypermobility, hallux abductovalgus, and metatarsal primus elevatus. Inclusion criteria consisted of skeletally mature patients undergoing non sawcut Modified Lapidus procedure. Patients that received the procedure due to a traumatic event or patients with concomitant second metatarsal arthrodesis were excluded. Review of patient's charts was performed. Basic demographics data, implant type, and radiographic parameters including intermetatarsal angle (IMA) and first metatarsal length were obtained from preoperative as well as postoperative films. Results: A total of 74 patients who underwent a Modified Lapidus arthrodesis were included in the study. A group of 43 patients received the Modified Lapidus arthrodesis with the addition of a first to second intermetatarsal screw fixation compared to a group of 31 patients who only received the Modified Lapidus arthrodesis procedure. The average IMA in all patients prior to surgery was 13°. The patients who received intermetatarsal screw fixation had significantly higher IMA reductions between preoperative and postoperative films than those who did not receive the intermetatarsal screw (-8.41° vs. -5.78°, p=.005). The difference in first metatarsal length on preoperative and postoperative films was less in patients who received the screw fixation but this was not statistically significant. Conclusion: The Modified Lapidus procedure is a commonly used procedure to treat hallux valgus. The results of this study found that the addition of a first to second intermetatarsal significantly reduced the IMA when compared to individuals who did not receive the screw construct. These findings will help surgeons further delineate if an intermetatarsal screw is required and how it will contribute to the radiographic parameters of interest.

The Occurrence Parallelism of the 1st and 2nd Ray in Mid Foot Fracture Dislocations. A Review of 234 Cases

Category: Trauma Introduction/Purpose: The parallel nature of the 1st and 2nd metatarsal has been reported in Lisfranc type injuries to the midfoot, reportedly the result of the lateral and dorsal subluxation of the 2nd metatarsal base. In this study, our aim was to explore the prevalence of parallelism in midfoot injuries and the associated features. Methods: Setting: Multicentre observational study Methods: Data was retrospectively collected from three centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. Parallelism was defined as a 1/2 intermetatarsal angle of less than 6. All statistics was performed using SPSS 26. Results: A total of 234 cases were included in the study. All 234 had undergone non-weightbearing (NWB) radiographs, with 80 patients who had also undergone (WB) weightbearing radiographs. The prevalence of parallelism was 21.3% (17/80) in the WB radiographs and 20.1% (47/234) in the NWB radiographs. The average IMA in the non-parallel group was 9.45 (95% CI 9.12,9.77) and 4.18 (95% CI 3.78, 4.57) in the parallel group. Concomitant lateral column injury was the only factor with a significant association with parallelism (p=.015). Other factors such as bone or ligamentous injury (p=.657), medial column injury (p=.085) and central column injury (p=.323) did not have a significant association. Conclusion: Parallelism in midfoot fracture dislocations occurs in approximately 20% of cases. If present, a high index of suspicion to the presence of a lateral column injury should be maintained due to its significant association.

Outcomes of V-cut Osteotomy on the First Metatarsal Head Combined with Fixation in Mortise-shaped Bone Groove-Plasty and Akin Osteotomy on the First Toe for Hallux Valgus Correction.

Hallux valgus (HV) is a common foot deformity, and recurrence is one of the most serious complications after HV correction. As a result, the surgical technique with a lowerrecurrence rate is a dream. The purpose of the article should be to observe the correction effect of hallux valgus using a novel "V-cut" osteotomy on the first metatarsal head combined with fixation in mortise-shaped bone groove-plasty technique. Twenty-three consecutive patients (40 feet) with HV were included from March 2019 to May 2020, who were all treated using single screw fixation with V-cut osteotomy on the first metatarsal head combined with mortise-shaped metatarsal bone groove-plasty and Akin osteotomy on the first toe for hallux valgus correction. With a mean follow-up time of 21.7 months, the visual analogue scale (VAS) score and American Orthopedic Foot and Ankle Society (AOFAS) forefoot score and the changes of the hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were evaluated during the clinical follow-up. The paired t test was used for analytical statistics. The VAS score improved from 6.78 ± 1.74 to 1.87 ± 1.45 and the AOFAS score improved from 53.9 ± 12.3 preoperatively to 94.7 ± 6.8 in the latest follow-up postoperatively (P < 0.01). Besides, the HVA improved from 30.0 ± 6.1° to 5.7 ± 2.8° (P < 0.01); the IMA changed from 13.1 ± 2.8° into 3.3 ± 1.6° (P < 0.01); and the DMAA ameliorated from 27.0 ± 8.4° to 5.9 ± 3.5° (P < 0.01). Only five toes had slight numbness and stiffness in early postoperative period, and these symptoms disappeared completely at 6 months after the surgery. Only one foot was corrected to excess. One screw stern protruding beneath the skin happened, which needed secondary screw removal under local anesthesia. Single screw fixation with V-cut osteotomy on the first metatarsal head combined with fixation in mortise-shaped metatarsal bone groove-plasty and Akin osteotomy on the first toe is an effective way with low recurrence rate for HV correction.

Comparison of minimally invasive and traditional Chevron osteotomy in treating patients with mild to moderate hallux valgus

To compare minimally invasive and traditional Chevron osteotomy in treating patients with mild to moderate hallux valgus. Clinical data of 36 patients (36 feet) with mild to moderate hallux valgus from January 2019 to February 2021 were retrospectively analyzed, and divided into minimally invasive osteotomy(minimally invasive group) and traditional Chevron osteotomy(traditional group). There were 16 patients in minimally invasive group, including 1 male and 15 females, aged from 36 to 60 years old with an average of(49.0±9.5) years old;9 were mild and 7 were moderate according to Mann classification;treated with minimally invasive osteotomy with hollow screw fixation. There were 20 patients(20 feet) in traditional group, including 2 males and 18 females, aged from 38 to 65 years old with an average of(50.0±9.2) years old;11 were mild and 9 were moderate according to Mann classification;treated with traditional Chevron osteotomy. Hallux valgus angle (HVA), intermetatarsal angle (IMA) before and after operation at 12 months bewteen two groups were observed and compared, and American Orthopedic Foot and Ankle Society (AOFAS) forefoot score and visual analogue scale (VAS) before and after operation at 6 weeks and 12 months between two groups were compared. Thirty-six patiens were followed up from 14 to 30 months with an average of (21.00±5.77) months. All incisions were healed well at stageⅠwithout infection. There were no significant differences in HVA, IMA, AOFAS forefoot scores and VAS before and after operation at 12 months between two groups(P>0.05). However, AOFAS forefoot scores and VAS of minimally invasive group was significantly better than that of traditionl group at 6 weeks after operation (P<0.05). Postoperative HVA, IMA, AOFAS forefoot scores and VAS at 12 months bewteen two groups were improved better than that of preoperation(P<0.05). Compared with traditional Chevron osteotomy, minimally invasive osteotomy has less trauma and quicker recovery. Both of them has similar clinical effects, and could receive satisfactory clinical effects, while treatment of minimally invasive osteotomy should pain attention to learning curve.

Early efficacy analysis of minimally invasive Chevron-Akin osteotomy for the treatment of mild to moderate hallus valgus

To explore early efficacy of minimally invasive Chevron Akin(MICA) osteotomy for the treatment of mild to moderate hallux valgus. From June 2019 to April 2021, a total of 26 patients (29 feet) with mild to moderate hallux valgus, including 1 male and 25 females aged from 19 to 78 years old with an average of(38.3±19.5) years old, were treated with MICA. Preoperative and postoperative hallux valgus angle(HVA), intermetatarsal angle(IMA) and shortening of the first metatarsal were observed and compared. American Orthopedic Foot and Ankle Society (AOFAS) forefoot scoring system and visual analogue scale (VAS) were applied to evaluate clinical outcome at the final follow-up, and complications were also recorded. All patients obtained followed up from 12 to 33 months with an average of(19.6±5.1) months. HVA and IMA was improved from (32.3±6.6)° and (11.7±3.2)° pre-operatively to (13.0±5.3)° and (6.1±3.2)° post-operatively, respectively, which had a significant difference (P<0.01). The average shortening of the first metatarsal was (2.7±1.1) mm. AOFAS and VAS was improved from (55.7±7.4) and (6.5±1.5) preoperatively and to (88.5±7.9) and (0.7±0.4) respectively at the final follow-up, which also had a significant difference(P<0.01). According to AOFAS score, 15 feet achieved an excellent result, 11 good and 3 moderate. MICA osteotomy is a safe and reliable surgical technique for mild to moderate hallux valgus with advantages of minimally invasive, rapid recovery, low complication rate and an effect improvement of hallux valgus deformity.

Minimally invasive osteotomy with absorbable screws in treating hallux valgus deformity

To evaluate clnical effect of minimally invasive osteotomy with absorbable screws in treating hallux valgus deformity. Clnical data of 31 patients with hallux valgus deformity were retrospective analyzed from January 2019 to December 2020, and divided into absorbable screws group (17 patients) and titanium cannulated screw group (14 patients). In absorbable screws group, there were 1 male and 16 females aged from 32 to 72 years old with an average of (54.53±12.12) years old;6 patients on the left side, 5 on bilateral and 6 on the right side;1 patient was mild, 11 moderate and 5 severe;treated with minimally invasive osteotomy and fixation of absorbable screws. In titanium cannulated screw group, there were 2 males and 12 females aged from 18 to 71 years old with an average of (47.57±15.68) years old;4 patients on the left side, 4 on bilateral and 6 on the right side;1 patient was mild, 9 moderate and 4severe;treated with minimally invasive osteotomy and fixation of titanium cannulated screw. Complications between two groups were observed, changes of hallux valgus angle (HVA)and intermetatarsal angle (IMA)were detected and compared before and after operation at 12 months, American Orthopedic Foot and Ankle Society(AOFAS) and visual analogue scale(VAS) before and after operation at 12 months were also compared. All 31 patients were followed up from 13 to 20 months with an average of (16.61±2.47) months. Patients in absorbable screws group were followed up from 14 to 20 months with an average of (16.88±2.80) months, while patients in titanium cannulated screw group were followed up from 13 to 19 months with an average of (16.29±2.05) months;there was no difference between two groups(P>0.05). One patient in absorbable screws group occurred numbness around incision, 3 patients in titanium cannulated screw group occurred complications, including numbness around incision in 1 patient, skin irritation due to internal fixation in 1 patient, and recurrence in 1 case;there was no statistic difference between two groups (χ2=1.651, P=0.199). There were no statistic difference in HVA and IMA between two groups before and after operation at 12 months(P>0.05). There were no statistic difference between two groups in AOFAS and VAS before and after operation at 12 months(P>0.05). Compare with mainstream fixation with titanium hollow screw after minmally invasive osteotomy, fixation with absorbable screw could achieve comparable clinical outcome on the basis of images and function evaluation.

First Tarsometatarsal Joint Fusion for Hallux Valgus Deformity: A Retrospective Comparison of Two Fixation Constructs Regarding Initial Maintenance of Correction and Complications: Traditional Crossing Screw Fixation Versus Dorsomedial Locking Plate and Intercuneiform Compression Screw

Various fixation constructs exist to address hallux valgus when performing a first tarsometatarsal joint arthrodesis. The goal of this present study is to compare complication rates, and degree and maintenance of angular correction between a dorsomedial locking plate with intercuneiform compression screw construct versus traditional crossing solid screw fixation construct. The plate plus intercuneiform compression screw construct fixation utilized a combined sagittal saw and curette method of joint preparation while the crossed screw fixation group utilized a curette and bur technique. A retrospective review was conducted of consecutive patients who underwent a midfoot fusion using either constructs. Sixty four total feet in 56 patients were enrolled in the study. Twenty four consecutive patients (32 feet) who underwent a midfoot arthrodesis using the locking plate and intercuneiform fixation were fully fused (100%) by 10 weeks postoperatively, with no incidents of nonunion and one deep vein thrombosis event. Thirty two consecutive patients (32 feet) who underwent midfoot arthrodesis with crossing screw fixation had 2 nonunion events, one that was asymptomatic and the other that required a revision midfoot fusion. There was a statistically significant improvement from the pre-operative intermetatarsal angle, hallux abductus angle compared to the 10 week and 1 year radiographs (p < .05) for the entire cohort for both fixation constructs. There was a statistically significant increase in American College of Foot and Ankle Surgery first ray scores from pre-op to 1 year follow-up for both fixation constructs. Overall, the dorsomedial locking plate plus intercuneiform compression screw fixation construct better maintains Intermetatarsal angle (IMA) correction at midterm follow-up compared to the traditional crossing screw construct. Both cohorts overall demonstrate similar fusion rates at 10 weeks, nonunion events, incidences of broken hardware, hardware removal, deep vein thrombosis, neuritis at 1 year postoperatively, and hallux varus.

First metatarsophalangeal arthrodesis outcomes for hallux rigidus versus hallux valgus

BackgroundThis study compared radiographic and functional patient outcomes of 1st MTP arthrodesis between hallux rigidus (HR) and hallux valgus (HV) cohorts. MethodsA retrospective review was conducted at an academic medical center on patients who underwent 1st MTP arthrodesis during 2009–2021. In total, 136 patients (148 feet: HR=57, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years, range=0.25–6.14 years). Data collection included patient-reported outcome measures (PROMs), radiographic markers, and complication and reoperation rates. ResultsPROMs improved overall, with HV patients significantly improving the least. The HR group had a significantly smaller improvement in HV angle (HR=−3.6, HV=−17, Combined=−15 p < .001), intermetatarsal angle (H=−0.16, HV=−2.8, Combined=−2.6 p < .001), and 1st-5th metatarsal width (HR=−0.98, HV=−4.6, Combined=−4.6, p < .001). Complication and reoperation rates did not differ by group. ConclusionOutcomes of 1st MTP arthrodesis does not appear to differ between diagnostic indications of hallux rigidus, hallux valgus, or both. Level of EvidenceLevel III, Retrospective cohort study

A Better Treatment for Moderate to Severe Hallux Valgus: Scarf + Akin Osteotomy Combined with Lateral Soft Tissue Release in a Single Medial Incision.

ObjectiveTraditional lateral soft tissue release (LSTR) was conducted by an additional dorsal first web incision, as the malformed thick scar and neuritis were common after surgery. A new method of lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) should be recommended. The objective is to investigate the clinical effectiveness and safety of scarf + Akin osteotomy (SAO) combined with lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) for moderate to severe hallux valgus.MethodsPatients who were performed surgery for hallux valgus from April 2014 to June 2020 were retrospectively reviewed. The visual analog scale (VAS) was recorded before surgery and during follow‐up, as well as the forefoot score of the American Orthopaedic Foot and Ankle Society (AOFAS). Patient satisfaction was evaluated at the follow‐up time. The preoperative and follow‐up weightbearing X‐ray were conducted in all patients. The radiological parameters of hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured. Tibial sesamoid position (TSP) was also recorded according to seven‐part grading system. The quantitative data were performed as mean ± standard deviation or median ± interquartile range. Student's t test was performed in HVA, IMA, and DMAA. The TSP, VAS, and AOFAS were statistical analyzed by Mann–Whitney U test. p value of <0.05 was considered significant.ResultsThere were 123 feet conducted surgery in 96 patients. The AOFAS score improved a lot which was preoperative 39 to 100 at the follow‐up time and VAS was 4 to 0 (p < 0.001). A total of 63 (51.2%) patients were very satisfied, 47 (38.2%) were satisfied, five (4.1%) were undecided and eight (6.5%) were not satisfied. The HVA, IMA, DMAA, and TSP were all decreased after surgery and were statistically significant (p < 0.001).ConclusionThe SAO combined with a LSTR‐SMI‐DFFM for moderate to severe hallux valgus is effective and safe with pretty good clinical and radiographic results, as well as minimal complications. The corrections of AOFAS and VAS conformed to the minimum clinically important difference (MCID).

SERI Technique for Isolated Juvenile Hallux Valgus Patients: A Retrospective Evaluation With Mid-term to Long-term Follow-up.

Many different operative procedures have been described to treat hallux valgus, but many of them are inappropriate for active, skeletally immature patients. This retrospective evaluation aimed to show the efficacy of SERI (Simple, Effective, Rapid, Inexpensive) technique in young patients affected by mild to moderate hallux valgus deformity at a mid-term to long-term follow-up. All patients were clinically and radiographically evaluated, independently by 2 researchers, by American Orthopaedic Foot and Ankle Society (AOFAS) Hallux-Metatarsophalangeal-Interphalangeal score and radiographic examination. Twenty-nine feet, undergone SERI procedure, have been reviewed at a mean follow-up of 5 years. The mean AOFAS score was significantly improved from 59.7 preoperatively to a mean value of 90.7 at last follow-up. Mean correction degrees have been recorded for both angles (hallux valgus angle [HVA] -13.7° and intermetatarsal angle [IMA] -6.7°). The SERI technique represents a powerful surgical procedure for the treatment of painful, mild to moderate, juvenile hallux valgus. Recurrence and complication rate make this surgical approach effective, repeatable, and safe. Level IV, Retrospective case series.

Radiographic Outcomes from Minimally Invasive Bunion Surgery in Australia: A Retrospective Cohort Analysis of 169 Procedures Using the Minimally Invasive Chevron Akin (MICA) Procedure

Abstract Background: The emergence of minimally invasive techniques in foot and ankle surgery has aimed to reduce iatrogenic tissue insult by utilising the smallest possible incision area to achieve maximum correction of pathological structures. The objective of this study was to assess whether adequate hallux valgus correction can be achieved via the minimally invasive chevron akin (MICA) procedure. Methods: A retrospective analysis was conducted for a single-surgeon case series of 169 MICA procedures between June 2018 and June 2021 in Australia. Radiographic parameters were evaluated independently by two researchers using 1-2 intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) as key measures of procedural outcome. Results: 95% of participant-operations resulted in normal 1-2 IMA and HVA being obtained post-operatively in a cohort that largely consisted of moderate hallux valgus deformities; 1-2 IMA Reduction: 6.38° ± 3.24 (95% CI 5.89 to 6.87) and HVA Reduction: 20.17° ± 7.69 (95% CI 19.01 to 21.33). Conclusion: The results of this study help to further strengthen support for the use of minimally invasive bunion surgery as a primary treatment approach in mild to moderate hallux valgus.

Modified scarf osteotomy for hallux valgus: From a finite element model to clinical results.

Finite element (FE) analysis and clinical follow-up were used to evaluate the efficacy of modified scarf osteotomy for moderate-to-severe hallux valgus (HV). We retrospectively evaluated 42 patients (44 feet) who underwent modified rotational scarf osteotomy for moderate-to-severe HV at our institution between January 2010 and January 2019. Radiological indicators and subjective scores were recorded at different time points. To compare the results and elemental characteristics, a FE model of the metatarsophalangeal (MTP) joint that included anatomically realistic geometrical and structural characteristics was built. The biomechanical features and correction differences in dynamic loads as well as the incidence of troughing were estimated. Both the hallux valgus angle (HVA) and intermetatarsal angle (IMA) showed significant improvement 6weeks postoperatively (p < 0.05); additionally, the HVA increased from 6weeks postoperatively to the last follow-up, while the IMA showed no significant changes (p > 0.05). The subjective scores significantly improved from the preoperative period to the last follow-up. The percentages of troughing and recurrence were remarkably low in our pilot study because of the innate stability of the modified rotated fixation. Our preliminary findings suggest that modified rotational scarf osteotomy offers sufficient stability, correct HV deformity effectively, and good clinical outcomes for moderate to severe HV.

Reproducibility of the point connection technique for measuring hallux valgus angles using a smartphone application

Objective: A) To evaluate the reliability of a new technique for the measurement of both intermetatarsal and hallux valgus angles. B) To evaluate whether this technique can be performed with the aid of a smartphone application. Methods: Preoperative radiographs of 30 patients were evaluated by four observers, two experienced surgeons and two surgeons in training. They performed measurements of the intermetatarsal angle and hallux valgus angle using the classical method and using the new method, both employing a goniometer and a smartphone application. Analysis of agreement was done by quantifying the raw agreement and calculating the intraclass correlation coefficient (ICC). Results: The hallux valgus angle presented excellent agreement (ICC&gt;0.80) both using the traditional method and the point connection method, while the intermetatarsal angle presented a very good agreement (0.60&lt;ICC≤0.80) in both methods. Conclusion: The point connection technique showed good concordance rates when measured by smartphone applications, although it did not prove to be superior to the traditional one. Level of Evidence II; Diagnostic Study; Development of Diagnostic Criteria.