Proximal Articular Set Angle Research Articles

Multiplanar, Multivariate Analyses of Hallux Valgus Radiographic Parameters

Hallux valgus is a complex condition understood to involve pathomechanics in all 3 of the cardinal planes. Despite this, the bulk of its historical evaluation has been in the transverse plane, and one might argue that the traditional and more commonly performed univariate and bivariate analyses within the literature do not comprehensively describe the potential interrelationships between the planes during perioperative assessment. Therefore this investigation aimed to evaluate relationships between common radiographic parameters measured in the three cardinal planes by means of a multivariate regression analysis. Serial analyses utilizing the first intermetatarsal angle, hallux valgus angle, tibial sesamoid position, proximal articular set angle, Engel's angle, first metatarsal inclination angle, and the sesamoid rotation angle were performed with varying dependent and independent variables. The tibial sesamoid position (p < .001) and proximal articular set angle (p=.014) were found to be independently associated with the first intermetatarsal angle, while the hallux valgus angle (p=.712), Engel's angle (p=.646), first metatarsal inclination angle (p=.097), and sesamoid rotation angle (p=.099) were not. The tibial sesamoid position (p=.003), proximal articular set angle (p < .001), Engel's angle (p=.006), and sesamoid rotation angle (p=.003) were found to be independently associated with the hallux valgus angle, while the first intermetatarsal angle (p=.712) and first metatarsal inclination angle (p=.400) were not. The first intermetatarsal angle (p < .001), hallux valgus angle (p=.003), and proximal articular set angle (p=.015) were found to be independently associated with the tibial sesamoid position, while Engel's angle (p=.400), the first metatarsal inclination angle (p=.088), and the sesamoid rotation angle (p=.649) were not. These findings appear to question a direct relationship between the first intermetatarsal angle and hallux valgus angle, as well as potentially infer a relationship between the frontal plane with the hallux valgus angle.

Hallux Pronation in Hallux Valgus: Experimental and Radiographic Study

Toe pronation is a frequent sign in hallux valgus (HV), but it is difficult to assess and quantify. The aim of this study was to evaluate the relation between big toe pronation with both radiological and clinical findings and to determine if toe pronation is an influential factor in severity of HV. Six big toe donor proximal phalanges were used to create a radiographic calibrating system controlling their pronation at 0° to 60°. A linear regression model was used to predict proximal phalanx pronation in radiographs. Big toe pronation in HV was clinically evaluated with a prospective study using 132 patients from our surgical waiting list and a control group of 30 patients without HV. Patients standing barefoot on a rigid platform were used to obtain the nail-floor angle. We obtained the following angles: HV, intermetatarsal, interphalangeal, distal articular set angle, proximal articular set angle, first metatarsal pronation, proximal phalanx pronation, and sesamoid bones displacement. We obtained an equation to predict proximal phalanx pronation according to the proportion of the rotated phalanx (p < .001, r = 0.98), and used an intraclass reliability test to assess the intra-/interobserver reliability (p < .001, intraclass correlation [ICC] = 0.89/p < .001, ICC = 0.82). We found that the relation between HV severity and proximal phalanx pronation, nail-floor angle, and first metatarsal pronation was statistically significant (p < .0001, r = 0.64). Proximal phalanx pronation and nail-floor angle should be considered to classify the severity of HV. Using a mathematical formula, we can predict proximal phalanx pronation on radiographs. Clinical Level of Evidence.

Проблемы диагностики и хирургического лечения вальгусного отклонения первого пальца стопы (обзор литературы)

Treatment of valgus deformity of the first toe is today one of the intensively developing areas of modern orthopedics. The complexity of treatment of this pathology is predetermined, first of all, by its multicomponent nature. Forefoot deformities are often the main cause of a decreased quality of life, which makes the patient irritable, inactive, and also makes it impossible to use standard footwear, and sometimes even orthopedic one. The purpose of our study was the analysis of scientific literature devoted to the problems of diagnosis and surgical treatment of valgus deviation of the 1st toe (hallux valgus). The materials of the study were domestic and foreign articles, reviews and monographs on the surgical treatment of hallux valgus, with mandatory analysis of long-term treatment outcomes. The history of the development of treatment of this pathology is presented with the analysis of surgical treatment methods aimed at different links of pathogenesis, as well as complications arising from the use of different techniques. The article presents modern trends in development and ways to improve the methods of surgical treatment of valgus deviation of the first toe. The analysis of the literature data showed significant success in the surgical treatment of valgus deviation of the first toe. However the current percentage of relapses may be due to the lack of an accurate method for determining proximal articular set angle (PASA) in the preoperative period, as well as the lack of the hallux valgus treatment able to eliminate valgus deviation of the first toe and avoid recurrence of the disease due to a more accurate correction of PASA.

Treatment of Moderate Hallux Valgus by Percutaneous, Extra-articular Reverse-l Chevron (PERC) Osteotomy

Category: Midfoot/Forefoot Introduction/Purpose: The purpose of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a Percutaneous Extra-articular Reverse-L Chevron (PERC) osteotomy. Methods: A total of 38 patients underwent 45 PERC procedures. A medial approach is used just proximal to the flare of the metatarsal head. The osteotomy is performed using a burr, the thickness of which is selected according to the planned correction and shortening. A second dorsolateral approach is then performed and the osteotomy is fixed using a self-drilling, self-tapping 3 mm diameter cannulated and headless compression screw. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. Results: The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. Conclusion: Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy. Its main asset is that it maintains an excellent range of movement; other advantages relate to the procedure being performed on an outpatient basis and the absence of tourniquet use.

ИСПОЛЬЗОВАНИЕ БИОДЕГРАДИРУЕМЫХ ВИНТОВ ПРИ ЛЕЧЕНИИ ПАЦИЕНТОВ С HALLUX VALGUS

The aim of the research was to assess using biodegradable screws in treatment of hallux valgus. We managed 40female patients (average age 50±2.51) with hallux valgus who where admitted to the orthopedic unit of Irkutsk Scientific Center of Surgery and Traumatology for operative treatment.All patients had X-ray, MRI and intraoperational examination of affected foot before the surgery and in postoperative period. All patients were operated using own surgical technique.Patients were divided into two groups: group1 (22patients) – osteosynthesis using biodegradable (PLGA) screws; group2 (18patients) – osteosynthesis using metal cannulated screws.In group1 postoperative values of M1P1 angle were within normal range (9.67±0.78°). According to MRI, proximal articular set angle (PASA) was corrected from 21.5±0.35 to 4.17±0.09°. 6patients of the group1 were complaining of pain and discomfort in the area of screw-head contacting soft tissues. The result of operative treatment in the group2 resulted in the correction of M1P1 angle from 34±1.63 to 7.67±0.75°. After the surgery intraoperative PASA was back to the normal range (4.33±0.34°).The comparison of the results of treatment of patients of groups1 and 2 didn’t reveal any statistically significant dif-ferences in the values of М1Р1, М1М2, М1М5 angles and PASA.The advantage of using biodegradable screws, compared to the metal ones, in the treatment of hallux valgus is the possibility of postoperative MRI of the foot with calculation of PASA to evaluate treatment results. The disadvantage of using biodegradable screws is engineering deficiency preventing screw-head from dipping into bone tissue and causing soft tissue traumatizing. Biodegradable and metal screws allow to obtain similar results of hallux valgus treatment.

The Mau-Reverdin Osteotomy: A Short-Term Retrospective Analysis

We reviewed 33 consecutive Mau-Reverdin osteotomies in 23 patients performed for correction of hallux abducto valgus from November 2010 to May 2013. All patients were followed up and evaluated for a mean of 401 days and median of 360 days after surgery. In each foot, the preoperative first intermetatarsal angle, hallux abductus angle, and proximal articular set angle were obtained. The mean correction of these angles was as follows: intermetatarsal angle 10.5° ± 3.31°, hallux abductus angle 24.4° ± 8.8°, and proximal articular set angle 28.39° ± 11.2°. Furthermore, we evaluated for metatarsus elevates, and no statistically significant first metatarsal elevation was present in any of the 33 feet (p < .0001). Additionally, 21 of the 33 feet (63.6%) were available for first metatarsophalangeal joint American Orthopaedic Foot and Ankle Society scale score evaluation. The mean preoperative score was 25.5 ± 16.7. After correction, the mean American Orthopaedic Foot and Ankle Society scale score had increased to 95.4 ± 5.7. All these differences were statistically significant (p < .0001), and the patients had a very high level of satisfaction. In all 33 feet, no deep infection, malunion, nonunion, avascular necrosis of the first metatarsal, or hardware failure developed. One patient developed hallux varus deformity. The Mau-Reverdin osteotomy is a very effective and reproducible procedure that successfully corrects large bunion deformities and provides patients with a high level of satisfaction and a low complication rate.

Radiological characteristics and anatomical risk factors in the evaluation of hallux valgus in chinese adults.

Background:There are no unified theories as to the anatomical changes that occur with hallux valgus, we investigated the radiological characteristics and anatomical risk factors for hallux valgus deformity in Chinese adults.Methods:We reviewed 141 patients with hallux valgus (206 feet; 15 males, 126 females; mean age, 58.5 years). These patients attended Peking University People's Hospital from April 2008 to March 2014. All feet had intact radiological data, obtained using the Centricity RIS/PACS system. We measured hallux valgus angle (HVA), 1–2 intermetatarsal angle (IMA), proximal articular set angle (PASA), distal articular set angle, hallux interphalangeal angle, metatarsocuneiform angle, size of the medial eminence of the distal first metatarsal, tibial sesamoid position, and joint congruity of the first metatarsophalangeal joint (MTPJ).Results:We found positive correlations between the HVA and IMA (r = 0.279, P < 0.01) and HVA and PASA (r = 0.358, P < 0.01), but not for IMA and PASA (P > 0.05). Feet were divided into three groups based on HVA severity. IMA (P < 0.05) and PASA (P < 0.05) in the mild group were significantly lower than that in the moderate and severe groups, with no significant difference determined for IMA or PASA between the moderate and severe groups (P > 0.05). Feet were then grouped based on the shape of the first metatarsal head. Using this grouping, HVA was significant higher in the rounded shape (19.92°) than in a flat shape (17.66°). The size of the medial eminence of the distal first metatarsal was positively correlated with HVA (r = 0.185, P < 0.01). The medial eminence in the moderate and severe groups was significantly larger than that in the mild group; moderate and severe groups were not significantly different.Conclusions:PASA enlargement is an adaptive change during early hallux valgus formation, and decompensation leads to subdislocation in the first MTPJ. A rounded first metatarsal head would thus predispose a foot to hallux valgus. Furthermore, bone proliferation at the medial eminence may also lead to early hallux valgus development.

Observed Changes in Radiographic Measurements of the First Ray after Frontal Plane Rotation of the First Metatarsal in a Cadaveric Foot Model

We observed the changes in the angular measurements commonly used in the evaluation of the first metatarsal and first metatarsophalangeal joint in cadaveric specimens before and after frontal plane rotation of the first metatarsal. Measurements of the first and second intermetatarsal angle (IMA), hallux abductus angle, proximal articular set angle, and tibial sesamoid position (TSP) were taken after varying degrees of varus and valgus rotation of the first metatarsal. Standard dorsoplantar radiographs were taken at 0°, 10°, 20°, and 30° of valgus rotation of the first metatarsal and repeated at 10°, 20°, and 30° varus rotation of the first metatarsal. The data were analyzed using a mixed linear model to compare the change in each angle measurement over the range of valgus and varus rotation. The change in the TSP was significant in both valgus and varus rotations (p = .0004 and p = .028, respectively), an increase in valgus rotation causing an increase in the TSP and an increase in varus rotation causing a decrease in TSP. The change in the IMA was significant compared with valgus rotation (p = .028), showing that as the valgus rotation increased, the IMA also increased. However, compared with the varus rotation, the correlation was not significant (p = .18). The proximal articular set angle and hallux abductus angle measurements, compared with metatarsal rotation, showed positive trends but were not statistically significant. From our results and a review of the published data, we have hypothesized that frontal plane rotation of the first metatarsal is an integral component of hallux abducto valgus pathologic features, specifically in relation to the TSP and IMA.

The Endolog System for Moderate-to-Severe Hallux Valgus

To report the midterm outcome of the Endolog system for correction of moderate-to-severe hallux valgus. 23 women and 2 men (33 feet) aged 35 to 80 (mean, 52) years underwent minimally invasive surgery for moderate (n=25) and severe (n=8) hallux valgus using the Endolog system. The hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the proximal articular set angle (PASA) were measured on radiographs. The feet were also assessed based on the American Orthopaedic Foot and Ankle Society (AOFAS) scale. The mean follow-up duration was 18.2 (range, 12-36) months. The mean HVA, IMA, PASA, and the mean AOFAS score improved significantly after surgery (all p<0.0001). Periosteal reaction was noted by week 4, and callus formation after 3 months. There were no delayed or non-union or other complications. The Endolog system achieved good outcome for moderate-to-severe hallux valgus.

Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the Literature

Rotation of the first metatarsal, as a component of hallux abducto valgus, is rarely discussed and is not addressed as a component of most hallux valgus corrective procedures. We believe frontal plane rotation of the first metatarsal to be an integral component of hallux abducto valgus deformity (the “third plane of deformity”) and believe de-rotation is necessary for complete deformity correction. We observed the change in angular measurements commonly used in the evaluation of hallux valgus deformity in patients who underwent a modified lapidus procedure. We measured the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position on weightbearing radiographs of 25 feet in 24 patients who had undergone tarsal metatarsal corrective arthrodesis and lateral capsular release. Specific attention was given to reduction of the frontal plane rotation of the first metatarsal during correction. Our results showed a change in the angular measurements observed by 4 investigators as follows. The mean change in the intermetatarsal angle was 10.1° (p < .0001). The mean change in the hallux abductus angle was 17.8° (p < .0001). The mean change in the proximal articular set angle was 18.7° (p < .0001). The mean change in the tibial sesamoid position was 3.8 (p < .0001). Also, a consistent valgus, or everted position of the first metatarsal, was noted as a component of the hallux abducto valgus deformity in our patient population and was corrected by varus rotation or inversion of the metatarsal. We also reviewed the current literature related to anatomic changes in the first ray in the patient with hallux valgus deformity and reviewed our hypothesis regarding the reduction in the proximal articular set angle, which we believe to be related to frontal plane rotation of the first metatarsal, resulting in a radiographic artifact.

The clinical efficacy of treatment on the cases of severe hallux valgus by the first metatarsal basal osteotomy combined with Chevron-Gerbert operation

To evaluate the clinical efficacy of treatment on the cases of severe hallux valgus by the first metatarsal basal osteotomy combined with Chevron-Gerbert operation. From June 2004 to August 2008, 37 cases of severe hallux valgus (66 feet) underwent first metatarsal basal osteotomy combined with Chevron-Gerbert operation. There were 5 males (10 feet) and 21 females (38 feet), aged 21 - 76 years (mean 58 years). For all patients with follow-up, radiographic measurements of frontal and lateral position of foot were taken to measure the hallux valgus angle (HVA), the IMA (intermetatarsal angle) and the proximal articular set angle (PASA) preoperatively, postoperatively and in follow-up respectively. The measuring results were compared among the preoperative, the 6-week postoperative and the final follow-up. At the same time the patients were evaluated with the AOFAS Maryland score. Of the original 37 patients, 26 patients (48 feet) were followed up. The mean durations of follow-up was 2.3 years (range from 1 to 4 years). At final follow-up, HVA corrected 25.6° ± 3.8°, IMA corrected 8.6° ± 2.4°, and PASA corrected 4.7° ± 4.2°. According to AOFAS rating system, 91.7% patients were rated as excellent or good with excellent in 15 patients (28 feet), good in 8 patients (16 feet), and fair in 3 patients (4 feet). First metatarsal basal osteotomy combined with Chevron-Gerbert operation has good efficacy to the patients with severe hallux valgus. However there are disadvantages such as complexity relatively for multi-stage osteotomy and internal fixation.

Radiographic correlates of hallux valgus severity in older people

BackgroundThe severity of hallux valgus is easily appreciated by its clinical appearance, however x-ray measurements are also frequently used to evaluate the condition, particularly if surgery is being considered. There have been few large studies that have assessed the validity of these x-ray observations across a wide spectrum of the deformity. In addition, no studies have specifically focused on older people where the progression of the disorder has largely ceased. Therefore, this study aimed to explore relationships between relevant x-ray observations with respect to hallux valgus severity in older people.MethodsThis study utilised 402 x-rays of 201 participants (74 men and 127 women) aged 65 to 94 years. All participants were graded using the Manchester Scale - a simple, validated system to grade the severity of hallux valgus - prior to radiographic assessment. A total of 19 hallux valgus-related x-ray observations were performed on each set of x-rays. These measurements were then correlated with the Manchester Scale scores.ResultsStrong, positive correlations were identified between the severity of hallux valgus and the hallux abductus angle, the proximal articular set angle, the sesamoid position and congruency of the first metatarsophalangeal joint. As hallux valgus severity increased, so did the frequency of radiographic osteoarthritis of the first metatarsophalangeal joint and a round first metatarsal head. A strong linear relationship between increased relative length of the first metatarsal and increased severity of hallux valgus was also observed.ConclusionsStrong associations are evident between the clinical appearance of hallux valgus and a number of hallux valgus-related x-ray observations indicative of structural deformity and joint degeneration. As it is unlikely that metatarsal length increases as a result of hallux valgus deformity, increased length of the first metatarsal relative to the second metatarsal may be a contributing factor to the development and/or progression of hallux valgus.

The Modified Mau-Reverdin Double Osteotomy for Correction of Hallux Valgus: A Retrospective Study

The deformity of hallux valgus is multifactorial, albeit primarily in the transverse plane. In order to achieve an anatomic correction, a surgical technique must be able to address the deformity with consistent outcomes. The purpose of the present study was to evaluate a technique designed to reposition the first metatarsal bone, metatarsophalangeal joint, and sesamoid apparatus in an anatomic and biomechanical corrected position for correction of hallux valgus deformity. This article is a retrospective analysis of 36 operations performed in 28 individuals between January 1995 and December 2005. Each case involved the use of a modified-Mau osteotomy combined with a Reverdin osteotomy to correct the first intermetatarsal and proximal articular set angles. Comparisons were made between the preoperative and postoperative first IM angle, proximal articular set angle, tibial sesamoid position, and hallux valgus angle. The median follow-up period was 48 (range 12-121) months from the date of surgery. The median reduction of the 1-2 intermetatarsal angle was 12 degrees (range 5-19 degrees). The median decrease for the hallux valgus angle was 20.5 degrees (range 0-63 degrees). The median reduction in the PASA was 16 degrees (range 4-69 degrees). The median decrease in the tibial sesamoid position was 5 (range 2-6). These differences were all highly statistically significant (P < .001), and all of the patients experienced a high rate of satisfaction (median AOFAS score 95 [range 70-95]) following the intervention. The Mau-Reverdin double osteotomy appears to be an effective intervention for the radiographic and clinical correction of hallux valgus. 4.

Les lésions cartilagineuses métatarsosésamoïdiennes dans les résultats de l’ostéotomie Scarf: À propos d’une série prospective de 100 cas

Sesamoid bones of the hallux play a major role in the biomechanics of the metatarsophalangeal complex. Due to the deformations resulting from hallux valgus, the sesamoid system is exposed to abnormal stress forces. Mapping the degenerative cartilage shows the significant prevalence of these lesions and their relation with the anatomic deformation. The purpose of this work was to determine the impact of these metatarsosesamoidal joint changes on the results of Scarf procedure for hallux valgus. This series included 89 patients (100 feet) who underwent Scarf osteotomy with complementary phalangeal osteotomy. We distinguished two groups in this cohort: 78 cases of surgery not involving the lateral metatarsals (group A), and 22 cases with associated lateral metatarsal osteotomy (group B). Mean follow-up was 2.3 years; minimal follow-up 16 months. The study protocol was prospective, with preoperative and last follow-up radiological and clinical assessment by an independent operator. Joint lesions noted intraoperatively by one senior operator were noted. The clinical work-up included the AOFAS score. A 15 degrees anteroposterior weight-bearing view was used to determine the degree of sesamoid dislocation and measure the following angles: first metatarsophalangeal angle (M1P1), first intermetatarsal space (M1M2), proximal articular set angle (PASA). Eleven zones were described to map the joint surfaces. The statistical analysis was used to search for links between joint lesions and the radiographic and clinical findings. The joint cartilage analysis revealed lesions involving the sesamoid bones in 72 cases, with a preferential involvement of the medial sesamoid bone (67%). The plantar joint surface of the first metatarsal presented lesions in the medial gutter in 72 cases, and in the lateral gutter in 68. Complete absence of the intersesamoid crest was noted in 38%. The metatarsophalangeal compartment presented degenerative lesions in 15 cases. The preoperative assessment noted a positive significant correlation between the AOFAS overall score and the absence of lesions involving the lateral sesamoid bone (p=0.015), between the AOFAS pain score and the absence of lesions involving the lateral sesamoid bone (p=0.022), between the AOFAS pain score and the complete absence of the intersesamoid crest (p=0.001), between the AOFAS deviation score and the absence of lesion involving the lateral gutter (p=0.001), between the M1P1 angle and the absence of an intersesamoid crest (p=0.001). At last follow-up, there was a positive significant correlation between the absence of lesions involving the medial sesamoid bone and a better overall AOFAS score (p=0.014), between absence of a lateral sesamoid lesion and better postoperative sentering of the sesamoids (p=0.014), between the absence of lesion in the medial gutter and a higher postoperative M1P1 angle (p=0.002), between the absence of lesions involving the lateral gutter and more favorable overall AOFAS score (p=0.005) for function (p=0.022), and deviation (p=0.018), between the absence of intersesamoid crest lesions and better radiographic sesamoid recentering (p=0.020). Distinct analysis of groups A and B did not demonstrate a significant difference compared with the overall cohort. Comparison of the two groups only demonstrated three significant differences involving radioclinical parameters. Hallux valgus is associated with very frequent metatarsosesamoid lesions. The distribution of these lesions is a function of the anatomic and biomechanical features of the metatarsosesamoid joint surfaces. Lesions to the lateral compartment would be a poor prognostic factor for Scarf procedure.

Predicting articular erosion in hallux valgus: Clinical, radiographic, and intraoperative analysis

The authors present a prospective intraoperative evaluation of the articular wear pattern of the first metatarsal, tibial and fibular sesamoids, and base of the proximal phalanx of 166 feet undergoing hallux valgus surgery. The collected data were compared with various clinical parameters and radiographic measurements to determine if any of these variables can predict the incidence and location of articular erosion. The incidence and predictability of the location of the articular erosion increased significantly as the patient's age ( P = .000), intermetatarsal angle 1-2 ( P = .004), hallux abductus angle ( P = .000), tibial sesamoid position ( P = .016), and proximal articular set angle ( P = .02) increased. The association of foot type (ie, digital length pattern), metatarsal protrusion distance, metatarsal head shape, and hallux abductus interphalangeus was not significant. Therefore, preoperative clinical parameters (ie, age) and radiographic measurements (ie, intermetatarsal angle 1-2, hallux abductus angle, tibial sesamoid position, and proximal articular set angle) can directly define the incidence and location of articular erosion and are helpful in the preoperative assessment of the hallux valgus deformity. In addition, nearly every first metatarsophalangeal joint evaluated had some degree of articular erosion and, in certain circumstances (ie, advanced age and increased proximal articular set angle), it was universal and extensive.

Effect of a sequential plantar fasciotomy on the width of the forefoot

Abstract The effect of a sequential proximal fascial release on the width of the forefoot was studied in 6 cadaveric feet. Six adult below knee cadaver specimens were axially loaded to 900N. The plantar fascia was sectioned sequentially (a third, half, complete release) from medial to lateral. After each sectioning a radiographic dorsoplantar view of the forefoot was obtained and radiologic parameters were determined. No significant change of values was seen in the hallux valgus angle, the proximal articular set angle and the intermetatarsal angle 1/5. However, a progressive increase of the intermetatarsal angle was determined during sequential sectioning of the fascia ( p =0.56). The increase of the IM angle for a static test indicates a stronger stabilizing effect on the plantar plate of the first two rays compared to the lateral forefoot. However, the overall effect of the plantar fascial release on the structure of the forefoot is not significant.

Revisional hallux abducto valgus surgery using tricorrectional bunionectomy.

We present a radiographic analysis of 91 failed hallux abducto valgus surgeries. Patients were categorized by type of postoperative complication: hallux varus, hallux limitus, or recurrent hallux abducto valgus deformities. All deformities were radiographically evaluated preoperatively and after correction using tricorrectional bunionectomy. Analysis of the surgical revisions showed improvement in radiographic parameters, including the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position. We conclude that tricorrectional bunionectomy is a versatile procedure that can be used when addressing a residual deformity after failed hallux abducto valgus surgery.

A comparison between the Regnauld arthroplasty and osteotomies of the first ray for the treatment of hallux valgus

This article is a retrospective study comparing the efficacy of Regnauld arthroplasty to first ray osteotomies for the treatment of hallux valgus. One hundred consecutive cases of Regnauld arthroplasties were compared with 100 consecutive first ray osteotomies. One hundred fourty-one patients were available for follow-up, and based on clinical/radiographic examinations, 72 were treated with the osteotomy protocol (group A) and 69 with Regnauld arthroplasty (group B). Age at surgery, clinical symptoms, and preoperative radiologic findings were similar for the 2 groups; there was a preponderance of female patients (90%). The average follow-up was 49 months in group A and 51 months in group B. Clinical evaluation showed in the osteotomy group a more stable correction (79% v 49%), greater pain reduction (measured in a visual analog scale from 0 = pain free to 10 = deep intolerable pain), increased residual articular excursion of the first metatarsophalangeal joint (27° of active dorsiflexion from neutral position v 8°), and less presence of central metatarsalgia (15% v 34%) ( P < .05). The radiographic evaluation expressed more stable correction values in group A for the following parameters: joint preservation, sesamoid position, intermetatarsal angle (7° v 12°), abduction angle of the hallux (14° v 20°), and proximal articular set angle (8° v 18°) ( P < .05). (The Journal of Foot & Ankle Surgery 42(3):155-160, 2003)

First metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy for treatment of hallux valgus: An intermediate-term retrospective outcomes study

The authors present a retrospective study of 14 patients (20 feet) treated with first metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy and distal soft tissue alignment for hallux valgus associated with hypermobility of the first ray and an increased proximal articular set angle. The purpose of this study was 3-fold: (1) to determine clinical outcome of this procedure combination, (2) to evaluate the effect of this procedure on the radiographic parameters of hallux valgus, and (3) to determine the degree of first ray shortening. At a mean 50.1 months postoperatively, patients were evaluated according to the American Orthopedic Foot and Ankle Society's Hallux-First Metatarsophalangeal-Interphalangeal Clinical Rating Scale. Preoperative and follow-up radiographs were compared for changes in the following measurements: 1-2 intermetatarsal angle (IMA), hallux abduction angle (HAA), proximal articular-set angle (PASA), and metatarsal protrusion distance (MPD). Statistical analysis using the Student t test showed a significant increase in total scores from a mean 43.6 to 92.6 of 100. A significant decrease was found in the IMA from a mean 16.9° to 7.1°, in the HAA from a mean 37.1° to 5.2°, in the PASA from a mean 20.3 ° to 3.4°( P < .001), and a significant change in the was found in the MPD of 7.7 mm ( P < .001). Given the high rating scale scores, first ray shortening did not appear to hamper our patients' clinical outcome. (The Journal of foot & Ankle Surgery 42(2):77-85, 2003)

Effect of proximal articular set angle-correcting osteotomies on the hallucal sesamoid apparatus: A cadaveric and radiographic investigation

A cadaveric and radiographic study was undertaken to demonstrate the change in intersesamoidal crista architecture after an osteotomy that corrects the proximal articular set angle (PASA). Three cadaveric first metatarsals with hallux valgus deformity were utilized. Separate Kirschner wires representing the longitudinal axis bisection, PASA, and the long axis of the crista were placed into each specimen. After osteotomy, the metatarsal heads were translated laterally, rotated parallel to the transverse plane to correct PASA, and impacted. The relationship between the crista and the long axis of the metatarsal was determined. A deviation in the alignment between the intersesamoidal crista and the long axis of the metatarsal following the osteotomy was observed. The radiographic portion of this study correlated intermetatarsal angle, PASA, and tibial sesamoid position with intersesamoidal crista appearance on sesamoidal axial radiographs. Radiographic parameters in 19 patients (34 feet) were compared and two distinct patterns were evident: 1) A proximal articular set angle greater than 15 degrees was associated with complete crista erosion in 10 feet (91% of this subgroup); 2) a tibial sesamoid position greater than three was associated with partial or complete erosion in 17 feet (100% of this subgroup). A higher deviation of PASA and increased displacement of the sesamoidal apparatus correlated with crista erosion. These findings suggest that the crista fails to adapt with PASA as hallux valgus progresses and undergoes erosion instead. This study suggests that when correcting the PASA, misalignment of the sesamoid apparatus may lead to sub-first metatarsal arthrosis.