Lesser Toe Deformities Research Articles

Morphology of the Toe Flexor Muscles in Older Adults With Toe Deformities.

It has been suggested that atrophied or weak toe flexor muscles are associated with the formation of toe deformities, but there is little evidence to support this theory. This study aimed to determine whether the size of the toe flexor muscles differed in older adults with and without toe deformities. Forty-four older adults (>60 years) were recruited for the study. Each participant had their feet assessed for the presence of hallux valgus or lesser toe deformities. Intrinsic and extrinsic toe flexor muscles were imaged with an ultrasound system using a standardized protocol. Assessor-blinded measurements of muscle thickness and cross-sectional area were taken using Image J software. Participants with lesser toe deformities (n = 20) were found to have significantly smaller quadratus plantae (P = 0.003), flexor digitorum brevis (P = 0.013), abductor hallucis (P = 0.004), and flexor hallucis brevis (P = 0.005) muscles than the participants without any toe deformities (n = 19). Female participants with hallux valgus (n = 10) were found to have significantly smaller abductor hallucis (P = 0.048) and flexor hallucis brevis (P = 0.013) muscles than the female participants without any toe deformities (n = 10; P < 0.05). This is the first study to use ultrasound to investigate the size of the toe flexor muscles in older adults with hallux valgus and lesser toe deformities compared to otherwise healthy older adults. The sizes of the abductor hallucis and flexor hallucis brevis muscles were decreased in participants with hallux valgus, whereas the quadratus plantae, flexor digitorum brevis, abductor hallucis, and flexor hallucis brevis muscles were smaller in the participants with lesser toe deformities.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients.

Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities. Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort. Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS ( P < .001 and P < .001) and SF-36 ( P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively. Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients. Level, III comparative series.

Foot health-related quality of life among elderly with and without lesser toe deformities: a case-control study.

PurposeThe aim of this study was to compare the health-related quality of life impact related to foot health and health in general in older adults with lesser toe deformities (LTD) and without any foot conditions.MethodsA case–control observational study was carried out following the Strengthening the Reporting of Observational Studies in Epidemiology criteria. A total of 100 older adults with a mean age of 74.39±6.02 years were recruited at an outpatient clinic; 50 of these subjects had LTD (case group) and 50 subjects were without any foot conditions (control group). Presence of LTD was determined in both feet using the Kelikian push-up test, and the Foot Health Status Questionnaire scores were self-reported.ResultsThe case group showed lower scores in quality of life in relation to health in general and to foot health specifically. Statistically significant differences (p<0.05) between case and control groups were shown by means of the Wicoxon test.ConclusionA negative impact in quality of life in relation to foot health should be considered in older adults with LTD, regardless of gender.

Rheumatoid arthritis in review: Clinical, anatomical, cellular and molecular points of view.

Rheumatoid arthritis (RA) is the most common chronic autoimmune disease of the joints affecting close to 0.5-1.0% of the general population. Although the etiopathogenesis of RA remains elusive, the involvement of dendritic cells and type 17 T-helper cells appears to be pivotal in maintaining a state of chronic inflammation. RA is generally characterized by small joint involvement. A chronic inflammatory process leads to joint destruction and to tendon and ligament laxity and disintegration. These processes result in an imbalance of forces acting on the joints causing joint deformities including swan neck deformity, boutonniere deformity of the hands, flexion deformity of the wrist, lesser toe deformities, and others. In some instances, bony erosions subsequent to the RA disease process can result in life-threatening events including, for example, atlanto-axial subluxation, which can cause myelopathy and paralysis; and basilar invagination, which can cause brain stem injury and imminent death. Although less commonly involved, larger joints are not spared, as evidenced by the involvement of the elbow, hip, and shoulder joints in a sizable proportion of RA patients. The progression and prognosis of this disease entity are variable, guarded and dependent on the efficacy and response to treatment modalities employed. Inadequate management results in disease progression, which ultimately leads to joint erosion, destruction, deformities and substantial decrease in the functional quality of life. Clin. Anat. 31:216-223, 2018. © 2017 Wiley Periodicals, Inc.

Hallux Varus and Plantar Plate Repair

One of the most frequent problems encountered in foot and ankle are hallux valgus and lesser toes deformities. One of the complications after hallux valgus treatment is a iatrogenic hallux varus. This deformity can be solved at 2 levels, namely the skeletal level, through a metatarsal osteotomy to correct the varus component of the bone and at the soft tissue level, to compensate and rebalance soft tissue tension surrounding the metatarsophalangeal (MTP) joint. The soft tissue reconstruction may include capsular releases, capsulorraphies, tendon transfers, and augmentations such as nonreabsorbable suture reinforcement of some MTP capsular components. Lesser toe deformities have historically shown moderate to low levels of satisfaction after surgical treatment. Ten years ago the MTP component of lesser toes deformity was solved with some type of metatarsal shortening osteotomy and soft tissue release, specially including dorsal structures over the metatarsal head. Over the last few years’ knowledge from a series of articles have shown the importance in recognizing and repairing the MTP plate to regain stability and alignment at the joint. Different alternatives of repair exist at this level, and some of them are discussed in this article. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

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

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

Complication rates and short-term outcomes similar after hammertoe correction in older patients

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common lesser toe deformities and multiple methods exist for surgical treatment. The population continues to age and to date, no studies have looked specifically at outcomes in the geriatric cohort, who are often at greater risk of complications or functional compromise due to increased co-morbidities. This study examines differences in short-term outcomes of pain, improvement of SF-36 scores, and complication rates in younger compared to older patients who underwent surgical correction of hammertoe deformities. Methods: 47 patients undergoing surgical correction of hammertoe deformities were prospectively followed. All surgical procedures were performed by a single surgeon and the specific surgical technique was tailored to each patient’s deformity. All patients were treated with early mobilization and progressive weight-bearing as tolerated. Subjective assessment of function was obtained using pre-operative and post-operative Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of six-month follow-up. 38 patients met inclusion criteria for length of follow-up (5 males, 33 females). Patients were divided into two groups based on age at the time of surgery (those younger than sixty years old, and those older than sixty years old). The improvements in mean (+/- SEM) VAS and SF-36 scores for patients younger than sixty years were compared to outcomes of patients older than sixty years of age, and results were assessed for statistical significance using a student’s t-test. Results: The mean age was 46.4 +/- 4.1 years in the younger patients and 68.0 +/- 1.2 years in the older cohort. The mean improvement in VAS score from pre-op to six months post-op was 2.8 +/- 0.8 and 2.8 +/- 0.6 (p = 0.95) in the younger and older cohorts, respectively (Table 1). The mean improvement in SF-36 Physical Component Score from pre-op to six months post-op was 8.6 +/- 6.7 and 6.7 +/- 4.4 (p= 0.81) in the younger and older cohorts, respectively. The mean improvement in SF-36 Mental Component Score was 1.5 +/- 3.7 and 1.4 +/- 4.2 (p=0.99) in the younger and older cohorts, respectively. One complication occurred in the younger cohort (0.11%) and no complications were reported in the older cohort. Conclusion: Outcomes of surgical correction of hammertoe deformities in older patients were similar to outcomes in younger patients at short-term follow-up. The study had sufficient power to detect differences in means as small as 5-8% depending on the specific outcome parameter. This study establishes a cohort of patients who will be followed to determine the effect of age on long-term outcomes of pain, SF-36 scores, and complication rates of surgical correction of hammertoe deformities. Future studies will also compare radiologic outcomes of hammertoe deformities preoperatively and postoperatively.

Plantar Hyperkeratotic Patterns in Older Patients

Summary Background Plantar hyperkeratotic lesions are very common among the older population. Very little has been documented on the frequency or distribution of such lesions. The aim of this study is to analyse the location of plantar hyperkeratoses in a group of the older population, defining the patterns of the most significant manifestations thereof and analysing the correlation between them and different contributing factors. Methods It is a descriptive correlational study conducted on 850 participants who attended the Bellvitge Podiatry Hospital in Barcelona province, Spain, in 2015. Hallux valgus, lesser toe deformities and hyperkeratoses were documented on a topographical map of the foot. The existence of plantar hyperkeratoses was correlated with different variables from the medical record of each participant. Results Of the 850 participants, 529 (62%) presented with hyperkeratotic lesions. In all, 87 hyperkeratotic patterns were documented, the most common of which were the medial side of the first metatarsophalangeal joint (MTPJ) (8.7%), the medial side of the first MTPJ plus the medial side of the first interphalangeal joint (IPJ) (8.5%) and the medial side of the first IPJ (7.7%). In addition, the hyperkeratoses were associated with hallux valgus (p Conclusions The most common hyperkeratotic patterns were found on the first radius, corresponding to 36% of total lesions. In addition, hyperkeratotic lesions appear to be associated with the presence of hallux valgus and with lesser deformities of the second, third and fourth toes.

A Midterm Review of Lesser Toe Arthrodesis With an Intramedullary Implant

Therapeutic, Level IV: Case series.

Salvage of Lesser Toes Deformities: “Revision Forefoot”

Deformity of the digits and lesser metatarsals is a common surgical problem presenting to the foot and ankle surgeon. Although elective operative management is usually straightforward, even the most routine cases carry the risk of surgical complication, spanning from the simple to the devastating. Most often, it is difficult to determine the exact cause of failure in surgical treatment of lesser toe deformities. Some possibilities are: inadequate surgical procedure; choosing inadequate surgical technique; complications related to the surgical procedure; underestimation of the inherent risks and unrealistic expectations. This paper describes the authors’ approach to failed lesser toes surgical treatment. It presents a particular view of the problems resulting from lesser toes surgery, and an emphasis on revision operative procedures. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Study of Pes Planovarus.

Depending on the direction of the subtalar joint, a foot deformity generally tends towards pronation (pes planovalgus) or supination (pes cavovarus). However, the combination of hindfoot varus and flat midfoot/forefoot (pes planovarus) is an exception to this rule. Pes planovarus has so far only been referred to in connection with Müller-Weiss disease and congenital disease. We diagnosed pes planovarus in otherwise healthy patients without these diseases. Forty patients with 54 symptomatic feet who were treated between August 2012 and July 2016 were included (mean age, 44.1 ± 15.7 years; 15 male/25 female). They were selected from 1064 consecutive cases (3.8%). Inclusion criteria were hindfoot varus and flat midfoot/forefoot. Their symptoms, radiographs, and therapies within the first 3 months were retrospectively analyzed. The position in the hindfoot alignment view (HAV), talometatarsal-1 angle lateral (TMT1lat) and dorsoplantar (TMT1dp), talocalcaneal angle lateral (TCAlat) and dorsoplantar (TCAdp), and calcaneal pitch angle (CPA) were measured on a DICOM/PACS system. The mean radiological results (standard values from the literature in brackets) were as follows: the hindfoot was significantly in varus in the HAV (-6.9 ± 3.6 mm [-1.6 ± 7.2 mm]; P < .001), the TMT1lat was significantly flatter (-6.7 ± 5.8 degrees [8.4 ± 5.9 degrees]; P < .001), the TMT1dp was significantly less in abduction (1.5 ± 7.9 degrees [7.7 ± 8.2 degrees]; P = .005), the TCAdp showed no difference (25.9 ± 7.9 degrees [24.1 ± 5.7 degrees]; P = .118), the TCAlat was significantly larger (47.5 ± 6.1 degrees [43.4 ± 7.1 degrees]; P < .001), and the CPA was significantly flatter (17.6 ± 3.9 degrees [24.5 ± 3.0 degrees]; P < .001). The most frequent symptoms were stress-induced foot pain (n = 33), hallux valgus (n = 20), chronic ankle instability (n = 17), metatarsalgia (n = 15), chronic midfoot pain (n = 13), heel pain (n = 12), and lesser toe deformities (n = 8). Thirty-one feet were treated conservatively and 23 operatively. This study showed the existence of pes planovarus without Müller-Weiss disease or congenital disease. This unusual foot form leads to difficulties if standard treatment strategies are applied, which raises the issue of the correct treatment for such patients. Level IV, retrospective case series.

The pathology and management of lesser toe deformities.

Deformities of the lesser toes are common and can be associated with significant morbidity. These deformities are often multiple, and numerous treatment strategies have been described in the literature.The goal of surgical treatment is to improve symptoms by restoring alignment and function, and avoiding recurrence. In order to achieve this, it is essential for the treating surgeon to understand the normal anatomy and pathology of the various deformities.There is a paucity of prospective studies and randomised-controlled trials assessing the efficacy of specific interventions.We describe the normal anatomy and biomechanics of the lesser toes, and the pathology of commonly adult deformities. The rationale behind various treatment strategies is discussed and the results of published literature presented. Algorithms for the management of lesser toe deformities based on current literature are proposed.Cite this article: Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev 2016;1:409-419. DOI: 10.1302/2058-5241.1.160017.

Effect of First Ray Insufficiency and Metatarsal Index on Metatarsalgia in Hallux Valgus

Category: Midfoot/Forefoot Introduction/Purpose: There are two concepts that tried to explain the etiology of metatarsalgia in hallux valgus patients: First, the one that states that as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, that an increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However there is no current evidence that these facts predisposes for primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients. Methods: A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia. Results: One hundred twenty one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 Kg (IQR 58 – 72). Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6 IC95% 0.2-0.5), gastrocnemius shortening (OR 5.8 IC95% 2.8-12.3), metatarsal index (OR 0.3 IC95% 0.2-0.5) and weight (OR 2.5 IC95% 1.2-5.3) were significantly associated. Conclusion: Metatarsalgia occurs in almost a half of hallux valgus patients. It has a multifactorial etiology. Our finding questions the common theory that both the magnitude of hallux valgus deformity and an increased length of a lesser metatarsal by themselves, predisposes for primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately.

Management of Hallux Valgus Deformity in Patients with Metatarsus Adductus

Category: Bunion Introduction/Purpose: Metatarsus adductus (MA) is a congenital condition in which there is persistent adduction of the metatarsals, which has been shown to increase the risk of recurrence of hallux valgus in patients undergoing surgery. The rate of recurrence varies with the magnitude of the adductus, perhaps correlating with the type of surgery performed, ie. the treatment of the adductus deformity and not just the hallux valgus. The goal of this study was to further analyze a cohort of patients with severe MA and identify clinical/surgical factors that are associated with a lower rate of recurrent deformity. Methods: An IRB approved retrospective review between 2002-2012 was completed. All patients undergoing hallux valgus surgery were identified. Patients were included if adequate radiographic information /clinical records were available and if the MAA was greater than 31° (normal values for the MA angle are &lt; 20°). Clinical information collected included associated diagnoses, the presence of arthritis of the tarsometatarsal joints, the presence and degree of lesser toe valgus deformities and surgical procedures completed. Radiographic recurrence was defined as a postoperative HVA &gt; 20° (at most recent follow up). Results: A total of 19 patients with severe MA/hallux valgus were identified. The average age of patients in this group was 55 years (51-60). Eight patients had associated tarsometatarsal arthritis and ten patients had severe valgus lesser toe deformities. Nine patients were treated with a modified Lapidus procedure and 10 patients underwent a distal first metatarsal osteotomy. Of the 9 patients who were treated with a modified Lapidus procedure, 5 patients underwent simultaneous realignment arthrodesis of the 2nd/3rd TMT joints for management of simultaneous midfoot arthritis. One of these patients had radiographic recurrence of deformity. Of the 7 patients who underwent a distal first metatarsal osteotomy without realignment arthrodesis of the 5 had recurrence of deformity. When evaluating patients for treatment of lesser toe deformity, 11 patients who were treated with simultaneous distal metatarsal realignment osteotomies, did not have recurrence of hallux valgus. Conclusion: Based on our findings, the use of a modified Lapidus arthrodesis led to a lower rate of HV deformity recurrence in comparison to isolated distal first metatarsal osteotomies but only when performed in conjunction with realignment arthrodesis of the 2nd/3rd TMT joints and distal lesser metatarsal osteotomies. If the patient does not have arthritis of the lesser TMT joints proximal metatarsal osteotomies are sufficient for correction. Treatment of lesser toe deformity with distal osteotomies was associated with lower recurrence of HV deformity and should be included as part of the treatment algorithm.

Modified double plantar plate tenodesis.

Metatarsophalangeal joint instability of the lesser toe can cause acquired toe deformity. Plantar plate deficiency is the major pathology. Plantar plate repair can stabilize the joint but may result in iatrogenic transverse plane toe deformity in correction of claw toe deformity. Limited toe extension can be resulted after correction of crossover toe deformity by plantar plate tenodesis and extensor digitorum brevis transfer. A modification of the technique is proposed. The clinical outcomes of 10 patients with the modified procedure performed were assessed. The correction was full in all toes with no recurrence. The modified technique can stabilize the metatarsophalangeal joint and correct lesser toe deformity without the need of tendon transfer, osteotomy or sophisticated instrumentation.

Percutaneous Distal Osteotomies of the Metatarsal Bones: Surgical Technique and Results

Objective: This study presents clinical and radiological outcome of a percutaneous technique for the correction of hallux valgus and lesser toe deformities. Methods: We present a 36 months follow-up series of 32 patients who have been treated with the Reverdin- Isham osteotomy for the correction of hallux valgus, and a percutaneous technique for the correction of lesser toes deformities and metatarsalgia. Clinical outcome data were recorded with the AOFAS score. Radiologic evaluation consisted of weight bearing (AP, lateral and Walter-Muller) views pre and postoperatively at 6 weeks, 3, 6, 12 and 36 months after surgery. Results: At three year follow-up, the mean difference of the HVA was 9.2 (p<0.0001), of the IMA was 0.4 (p<6719), and the mean difference of the PASA was 15.9 (p<0.001). The AOFAS rose from 48.4 to 87.6. Most encountered complication was oedema that lasted for 6 months, especially in the patients who underwent the Weil osteotomy of II, III and IV metatarsal bone head for the treatment of metatarsalgia. Conclusion: Many minimal invasive techniques are becoming more and more recognized, with some indisputable advantages but also not free of objective difficulties. We believe that percutaneous distal metatarsal bone osteotomy represents a good option for the treatment of mild- to moderate hallux valgus, lesser toes deformities and metatarsalgia.

A pilot study investigating the utilization of crest pads for treatment of toe callus and ulceration

Patients with lesser-toe deformities are at increased risk of developing calluses and ulcers on the distal ends of the affected digits because of the increased pressures applied to these areas. The number of diabetic patients in the United States continues to increase, along with associated comorbidities such as peripheral vascular disease and peripheral neuropathy. These conditions predispose patients to developing foot ulcerations, especially if foot deformities are present. Crest pads are a simple-to-make, inexpensive option to treat calluses and ulcerations on the distal ends of digits; however, there is no research available that support their use. Crest pads consist of rolled gauze covered in moleskin, with a large opening that fits over several toes and lies on the dorsal aspect of the foot, with the padded portion resting under the toes. Over several days of use, the pad molds to the plantar aspect of the toes, offloading pressure from the distal end of the affected digit(s). The sample was obtained through a retrospective chart review of patients identified as having had at least one nail care visit and at least one follow-up visit at a vascular surgery practice between August 2011 and December 2014. Potential subjects with toe deformities who presented with callus or ulcer on the distal end of a digit were considered for inclusion, if they received a crest pad as part of their treatment plan. The scholarly project was a preintervention or postintervention design with subjects acting as their own controls. McNemar's test was used to analyze the results which were statistically significant (P < .0001 at first callus follow-up and P = .0002 at second callus follow-up) for callus, hemorrhagic callus, and/or ulcer improvement following the crest pad intervention. The results of this scholarly project support the use of crest pads in patients with lesser-toe deformities to treat distal toe calluses and/or ulcerations.

Effect of First Ray Insufficiency and Metatarsal Index on Metatarsalgia in Hallux Valgus

Two concepts have been proposed to explain the etiology of metatarsalgia in hallux valgus patients: First, as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However, there is no current evidence that these structural factors lead to primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients. A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia. One hundred twenty-one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 kg (interquartile range 58-72). Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6, 95% CI 0.2-0.5), gastrocnemius shortening (OR 5.8, 95% CI 2.8-12.3), metatarsal index (OR 0.3, 95% CI 0.2-0.5), and weight (OR 2.5, 95% CI 1.2-5.3) were significantly associated. Metatarsalgia occurs in almost half of hallux valgus patients. It has a multifactorial etiology. Our findings contradict the common theory that both the magnitude of hallux valgus deformity and an increased length of the lesser metatarsals, by themselves, lead to primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight, and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately. Level III, comparative series.

The Weil Osteotomy for Correction of Fixed Claw-Toe Deformity and Metatarsalgia

Aim: The aim of our study is to evaluate the efficacy of the Weil osteotomy to correct fixed claw lesser toe deformity with dorsal subluxation or dislocation of the MTP joint and overloading metatarsalgia. Material: 120 Weil osteotomies in 60 feet of 45 patients have retrospectively been studied with a minimum follow-up of 12 months (mean f.u. 17 months). Thirty-five patients were women and ten men. For the evaluation of the result we used the AOFAS grading scale. Antero-posterior and lateral weight bearing radiographs were taken preoperatively and at the time of follow-up. Forty patients had a correction of hallux valgus deformity although 5 of the lesser toe only. All patients received a PIP fusion for the correction of the claw deformity. Results: The subjective result was at their expectation for 39 patients and beyond their expectation for 5. One patient was dissatisfied. The AOFAS score improved from 45 preoperatively to 89 postoperatively. Thirty-nine patients did not complain of metatrsalgia although for five patients metatarsalgia improved and for 1 remained at preoperative level. Shoe wearing improved in all 42 patients although for 3 this was below their expectations. Conclusion: The Weil osteotomy combined with PIP fusion is capable of correcting stiff claw lesser toe deformities with dorsal sub luxation or dislocation of the MTP joint and significantly improve metatarsalgia.

Algorithm for Severe Hallux Valgus Associated With Metatarsus Adductus

Radiographic angles, such as the intermetatarsal angle, hallux valgus angle, and distal metatarsal articular angle, are commonly used to help guide operative planning for soft tissue and osseous treatment options for hallux valgus. Hallux valgus treatment in the setting of associated metatarsus adductus is less common and not well described. The presence of metatarsus adductus reduces the gap between the first and second metatarsals. Consequently, it complicates the measurement of the first-second intermetatarsal angle and can limit the area available for transposition of the first metatarsal head. A compensatory pronation is also created, which must be compensated for. We present 4 cases of patients that had hallux valgus with severe metatarsus adductus treated operatively, as well as a treatment algorithm. For concomitant correction of both the metatarsus adductus and the hallux valgus, a thorough surgical treatment algorithm was implemented to address the hallux, lesser toe deformities, and pes planus deformity. Postoperatively, the patients were kept non-weight bearing for 6 weeks, followed by gradual weight bearing in a protective boot. Physical therapy was instituted at the start of weight bearing to encourage a return to activities of daily living. At follow-up, patients reported significant relief of their pain symptoms with a narrower and improved appearance of the foot. No recurrence was noted. One patient used a medial arch support but was otherwise symptom free. Radiographic measurements improved on postoperative radiographs. For the treatment of hallux valgus with metatarsus adductus, the second and third metatarsals may need to be addressed for the first metatarsal to be laterally transposed adequately. Overall, this comprehensive approach addresses the hindfoot, midfoot, and forefoot for patients with hallux valgus associated with metatarsus adductus, with successful results.