Proximal Crescentic Osteotomy Research Articles

Pin fixation is an effective method for fixation of bunion osteotomy with various procedures: a retrospective cohort study

BackgroundVarious fixation devices are available for bunion osteotomy. In this study, we evaluated the radiographic outcomes, postoperative complications, and recurrence rate in a series of hallux valgus deformities treated with various osteotomy procedures using a pin for the fixation of the osteotomy.MethodsTwo-hundred forty-seven patients with hallux valgus deformity managed with a Simple, Effective, Rapid and Inexpensive (SERI) osteotomy, distal chevron osteotomy, or proximal crescentic osteotomy and K-wire fixation were included. The mean follow-up of the patients was 53.9 ± 8.9 months. Radiographic evaluations included the assessment of the Hallux valgus angle (HVA), intermetatarsal angle (IMA), and union. Clinical evaluations included the assessment of the range of motion, pain in the first metatarsophalangeal joint, and patient satisfaction.ResultsIn the last visit, the mean improvement of HVA was 23.9 ± 9.1º (P < 0.001). The mean IMA improvement was 6.1 ± 6º (P < 0.001). The mean metatarsophalangeal flexion and extension were 33 ± 10.7º and 34.6 ± 9.2º, respectively. Postoperative complications included pin tract infection in eight (3.2%) patients, deep infection in five (2%) patients, and early pin complication in four (1.6%) patients. Recurrence was observed in five (2%) patients. Twenty-three (9.3%) patients had slight pain in the last follow-up. The mean surgical time was smaller in the SERI osteotomy (P < 0.001). The mean hospitalization period was longer in the proximal osteotomy group (P = 0.039). The mean metatarsophalangeal flexion and extension were significantly smaller in the distal chevron osteotomy (P = 0.046 and P = 0.037, respectively). 90% of patients were satisfied or very satisfied with the surgical outcomes.ConclusionK-wire fixation is a safe and effective device for the fixation of bunion osteotomy, and this effectiveness is even higher with SERI and proximal crescentic osteotomy.

Plantar pressure distribution in hallux valgus feet after a first metatarsal proximal crescentic osteotomy with a lesser metatarsal proximal shortening osteotomy

BackgroundPlantar pressure distribution after the first metatarsal proximal crescentic osteotomy (FMPCO) with lesser metatarsal proximal shortening osteotomy (LMPSO) for hallux valgus with metatarsalgia has not been previously described. MethodsThe pre- (Pre) and postoperative (Post) groups comprised of 18 patients who underwent unilateral FMPCO with LMPSO; fifteen healthy volunteers constituted the control (C) group. For each of the 10 regions, peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force-time integral (FTI) were measured. ResultsThe mean Peak-P of the second metatarsal head was significantly lower in the Post group than the Pre group. The mean Peak-P, Max-F, Con-T, and FTI were not significantly different between the Post and C groups. The mean Con-A was significantly lower in the Post group than the C group. ConclusionFMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.

Proximal Crescentic Osteotomy Versus Proximal Opening Wedge Osteotomy of the First Metatarsal Bone in the Treatment of Moderate to Severe Hallux Valgus

Objectives: To compare the therapeutic outcomes of proximal crescentic osteotomy (PCO) versus proximal opening wedge osteotomy (POWO). Methods: In this retrospective analytical study, 88 patients with moderate to severe unilateral hallux valgus (HV) were enrolled. HV severity and angle, intermetatarsal angle, MTPJ status, and AOFAS score were collected. Results: The AOFAS score, HV and intermetatarsal angles, and MTPJ status improved in all patients with no significant differences between the two groups. The POWO group showed significantly higher satisfaction score at the 3rd month post-operation. Conclusions: Both osteotomies demonstrated acceptable outcomes; however, short term patient satisfaction was greater in the POWO technique.

Rigid Internal Fixation of Proximal Crescentic Metatarsal Osteotomy in Hallux Valgus Correction.

The purpose of this study was to evaluate outcomes utilizing a low-profile titanium plate and screw construct for rigid fixation of first ray proximal crescentic osteotomies in the treatment of hallux valgus. Forty-eight patients (53 feet) with mild to severe hallux valgus were prospectively enrolled and completed 12-month follow-up. All were treated with a proximal crescentic osteotomy, fixed with a low-profile titanium plate, distal soft tissue correction, with or without an Akin osteotomy. Recorded outcomes included change in first ray dorsiflexion angles, need for hardware removal, radiographic and clinical evaluation, pain, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. All patients achieved radiographic union of their osteotomy. An Akin osteotomy was performed in 83% of patients. Seventeen feet (32%) had hardware removed. First ray dorsiflexion angles increased from a mean of 1.6 degrees preoperatively to 5.0 degrees postoperatively (P < .001). Dorsal malunion, defined as change in dorsiflexion angle greater than 1 standard deviation above the mean, occurred in 7 feet. The mean hallux valgus angle improved from 29 to 9 degrees (P < .001). The mean 1-2 intermetatarsal angle decreased from 14 to 6 degrees (P < .001). The first metatarsophalangeal joint range of motion decreased from 77 to 59 degrees (P < .001). The mean visual analog scale score improved from 4 to 0.7 (P < .0001). The mean AOFAS score improved from 55 to 89 points (P < .001). Proximal crescentic metatarsal osteotomy, fixed with a low-profile titanium plate and screw construct, with distal soft tissue repair, and Akin osteotomy as indicated, was a safe and reliable method for operative treatment of hallux valgus. Level IV, retrospective case series.

Operative Treatment for Hallux Valgus With Moderate to Severe Metatarsus Adductus.

Operative treatment is indicated for patients who have symptomatic hallux valgus (HV) with moderate to severe metatarsus adductus (MA). However, there is limited information available on the operative procedures and outcomes for the treatment of HV with MA. We aimed to investigate the average 10-year follow-up clinical and radiologic outcomes. Seventeen patients (21 feet, average age: 60.1 years) with symptomatic HV with moderate to severe MA were operatively treated. Mean postoperative follow-up duration was 114.4 (24-246) months. All feet had metatarsus adductus angle ≥20 degrees on dorsoplantar weight-bearing radiograph. The procedure included a proximal crescentic osteotomy of the first metatarsal and abduction osteotomy of the proximal third of the second and third metatarsals. The mean American Orthopaedic Foot & Ankle Society scale score improved significantly postoperatively ( P < .001). The mean postoperative visual analog scale score (17 feet) was 2.0 (0-6). Preoperative metatarsalgia was severe in 2 feet, moderate in 17, and mild in 2. At the most recent follow-up evaluation, 11 feet had no pain, 9 had mild pain, and 1 had moderate pain. The mean hallux valgus angle, intermetatarsal angle, and metatarsus adductus angle significantly decreased postoperatively ( P < .001 for all). Recurrence of HV (HV angle ≥ 20 degrees) was observed in 4 feet. The clinical and radiologic results indicated that our novel operative treatment for HV with moderate to severe MA can achieve significant correction of HV with MA deformities and significant improvement in pain and function. Level IV, retrospective case series.

Comparison of Plantar Pressure Distribution Between Postoperative Hallux Valgus Feet and Healthy Feet

Proximal crescentic osteotomy (PCO) in patients with moderate-to-severe hallux valgus (HV) is a well-established and effective procedure for correcting the deformity. However, there are no published studies comparing plantar pressure in postoperative HV feet with healthy feet. This study aimed to compare the plantar pressure distribution in postoperative HV feet with healthy feet. Twenty-six patients were included in the HV group, and 24 healthy participants were included in the control (C) group. All patients in the HV group underwent unilateral PCO. After undergoing PCO, this group was defined as the OP group. All subjects were women with no significant differences in age, height, weight, and body mass index. There were no significant differences in demographic characteristics between patients in each group. We divided the subjects' feet into 8 regions and measured the peak pressure (Peak-P), maximum force (Max-F), contact time, contact area, and the force-time integral in each region. All parameters of the great toe were significantly higher in the OP group than in the HV group. All forefoot parameters were not significantly different between the 2 groups. No parameter of the great toe was significantly different between the OP and C groups. However, mean Peak-P and Max-F of the central forefoot were significantly higher in the OP group than in the C group. PCO can improve the plantar pressure of the great toe in patients with moderate-to-severe HV to a level similar to that in healthy subjects. Level III, comparative study.

Rigid Internal Fixation of Proximal Crescentic Metatarsal Osteotomy in Hallux Valgus Correction

Category: Bunion Introduction/Purpose: Proximal first metatarsal crescentic osteotomies are an effective means for correction of moderate to severe hallux valgus deformities. The originally described fixation construct included an intramedullary screw and a Kirschner wire which crossed the joint and required removal at 6 weeks. Elevation malunion of the first ray was also frequently noted postoperatively. The purpose of this study was to evaluate the outcomes of utilizing a low-profile titanium plate and screw construct for rigid fixation of proximal crescentic osteotomies. Methods: There were 53 patients (60 feet, 7 bilateral) with hallux valgus deformities enrolled in the study. They were all treated operatively with a proximal crescentic osteotomy and distal soft tissue correction with or without an Akin osteotomy. The crescentic osteotomy was fixed with a low-profile titanium plate and screws. Postoperatively patients were assessed at 3 months, 6 months and 1 year. Outcomes assessed included the need for hardware removal, change in elevatus of the first ray, as well as pre- and post-op VAS pain scores, radiographic evaluation, AOFAS score, MTP joint range of motion, and complications. Results: Of the 60 hallux valgus cases enrolled, 56 have completed their final follow-up (93%). At 1 year 55/56 patients had achieved radiographic union of their osteotomy. Nine patients had their hardware removed (16%). Range of motion at the 1st MTP joint decreased from 76.5 to 59.6 degrees. Hallux valgus angle improved from a mean of 28.8 to 9.6 degrees. The mean 1-2 intermetatarsal angle decreased from 14.1 to 6.4 degrees. Elevatus of the first ray increased from a mean of 2.5 mm pre-op to 3.2 mm (&lt;1 mm) post-op. Mean VAS score improved from 4.43 to 0.68 (3.75 points). AOFAS score improved from 54.7 to 88.5 points. Complications included 4 superficial infections, 2 delayed wound healing cases and one DVT. Conclusion: Proximal crescentic metatarsal osteotomy with distal soft tissue repair is a safe and reliable method for operative treatment of hallux valgus. Utilization of a low-profile titanium plate and screw construct to rigidly fix the osteotomy yields a high rate of union and deformity correction with a low incidence of hardware removal and minimal increase in elevation of the first ray at final follow up.

A randomized comparison of the proximal crescentic osteotomy and rotational scarf osteotomy in the treatment of hallux valgus

ObjectivesThe aim of this study was to compare clinical and radiological results of proximal crescentic osteotomy (PCO) and rotational scarf osteotomy performed in the treatment of hallux valgus. MethodsA total of 57 consecutive patients (60 feet) with symptomatic hallux valgus deformity were randomly assigned to one of two groups. The PCO group consisted of 22 women and 5 men (30 feet) and the mean age was 43(±14.5) years. The scarf group consisted of 23 women and 7 men (30 feet) and the mean age was 40.9(±12.6) years. Outcomes were assessed by using of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analogue scale (VAS). Weight bearing X-rays were used for radiological evaluation. ResultsThe mean AOFAS scores improved from 42(±16.2) to 66.7(±13.4) points in PCO group and from 36.2(±16.1) to 73.2(±13.5) points in scarf group. The mean pain score improved from 6.3(±1.3) to 2.4(±2) in PCO group and from 6.5(±1.9) to 2.5(±1.3) in scarf group. The mean hallux valgus angle (HVA) decreased from 38.1°(±7.1) preoperatively to 23.8°(±8.5) at postoperative first year in PCO group, and from 36.1°(±7.5) preoperatively to 22.2°(±7.5) at postoperative first year in scarf group. The mean intermetatarsal angle (IMA) decreased from 17.3°(±3.8) preoperatively to 11.8°(±3.3) at postoperative first year in PCO group, and from 16.2°(±2.6) preoperatively to 9.3°(±2.4) at postoperative first year in scarf group.When all the patients were assessed together, the relations between preoperative DMAA values and postoperative first year HVA (r = 0,327) and IMA (r = 0,399) values were positive but had low significance. The HVA and IMA values were increased in both groups at the end of the first year when compared to the postoperative sixth week values (p < 0.01 for both groups for both values). ConclusionThe PCO and the rotational scarf osteotomy in the treatment of hallux valgus deformity provides a satisfactory correction. The clinical and radiological results of both methods are similar. Especially in patients with high preoperative DMAA, an increase in the HVA and the IMA values may occur in the first postoperative year when compared to the postoperative sixth week values. Level of evidenceLevel II, therapeutic study.

Fixation of the Proximal Metatarsal Crescentic Osteotomy Using a Head Locking X-Plate

We present a new method to stabilize proximal crescentic osteotomies (PCOs) for the correction of moderate to severe hallux valgus. A single-center prospective study with a consecutive series of 72 patients (94 feet) with a PCO was performed using a head locking X-plate. The primary aim was to investigate the stability of the osteotomy, measuring the dorsal elevation of the first metatarsal head, first cuneiform height, talus-first metatarsal angle, and first metatarsal inclination pre- and postoperatively. A secondary outcome assessed weight distribution during gait, quality of life, and radiologically documented bone healing process. Ninety-three percent of the feet were within ±2 mm change for dorsal elevation of the first metatarsal head, and 72% for the medial cuneiform height. Eighty-nine percent were within ±4 degrees change for the first metatarsal inclination, 73% for the talus-first metatarsal angle, and 100% for the calcaneus pitch angle. The mean changes between pre- and 1-year postoperative were not significantly different for any of the stability measurements except for the first metatarsal inclination angle. The SF36 showed a significant improvement of physical function, general health, and decreased bodily pain. Harris mat footprints showed a decrease of 46% underneath the second and a pressure decrease of 40% underneath the third metatarsal head. This technique, of using a head locking X-plate to stabilize the PCO, showed satisfactory and reproducible results in terms of stability, clinical outcome, bone healing, and patient satisfaction. The plate provided substantial support for the PCO resulting in adequate and easy fixation. Level IV, retrospective case series.

The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction to treat severe hallux valgus

To explore the method of the treatment for hallux valgus with the proximal crescentic osteotomy of the first metatarsal bone, combining with distal lateral soft tissue release. From January 2008 to December 2012, 21 cases 21 hallux valgus feet were treated by operative procedure, included 1 male (1 foot) and 20 females (20 feet), with the mean age of 52 years (range, 36-68 years). Among all patients were followed up for 12 to 26 months, with the mean 16 months. The preoperative, post-operative and final follow-up X-ray films of all patients were collected. The hallux valgus angle, intermetatarsal angle and distal metatarsal articular angle were measured and analyzed. The surgical outcome was evaluated combined with the AOFAS score. The average hallux valgus angle decreased from 42.3° ± 1.8° preoperatively to 14.5° ± 1.8 postoperatively, the average intermetatarsal angle did from 21.9° ± 1.7 to 9.1° ± 1.8°, and the average distal metatarsal articular angle did from 14.9° ± 1.8 to 7.2° ± 1.5, respectively. There were significant differences between the preoperative and postoperative roentgenographic index. AOFAS score was improved from 44.0 ± 1.8 preoperatively to 83.9 ± 2.2 at the final follow-up. The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction obtained satisfactory results in severe hallux valgus patients with big intermetatarsal angle.

APSC2015-1310 Synergic Effects of Levamlodipine and Bisoprolol on Blood Pressure Reduction, Organ Protection and Stroke Protection in Rats

Different techniques of proximal osteotomies have been introduced to correct severe hallux valgus. The open wedge osteotomy is a newly introduced method for proximal osteotomy. The aim of this prospective randomized study was to compare the radiological and clinical results after operation for severe hallux valgus, comparing the open wedge osteotomy to the crescentic osteotomy which is our traditional treatment.Forty-five patients with severe hallux valgus (hallux valgus angle >35̊, and intermetatarsal angle >15̊) were included in this study. The treatment was proximal open wedge osteotomy and fixation with plate (Hemax), group 1, or operation with proximal crescentic osteotomy and fixation with a 3 mm cannulated screw, group 2. The mean age was 52 years (19–71). Forty-one females and four males were included. Clinical and radiological follow-ups were performed 4 and 12 months after the operation.In group 1 the hallux valgus angle decreased from 39.0̊ to 24.1̊ after 4 months and 27.9̊ after 12 months. In group 2 the angle decreased from 38.3̊ to 21.4̊ after 4 months and 27.0̊ after 12 months. The intermetatarsal angle in group 1 was 19.0̊ preoperatively, 11.6̊ after 4 months and 12.6̊ after 12 months. In group 2 the mean intermetatarsal angle was 18.9̊ preoperatively, 12.0̊ after 4 months and 12.6̊ after 12 months. The AOFAS score improved from 59.3 to 81.5 in group 1 and from 61.8 to 84.8 in group 2 respectively measured 12 months postoperatively. The relative length of the 1 metatarsal compared to 2 metatarsal bone was 0.88 and 0.87 preoperatively and 0.88 and 0.86 for group 1 and 2 respectively measured after 12 months.Crescentic osteotomy and open wedge osteotomy improve AOFAS score and VAS scores on patients operated with severe hallux valgus. No significant difference was found in the two groups looking at the postoperative improvement of HVA and IMA measured 4 and 12 months postoperatively. The postoperative VAS score and AOFAS score were comparable for the two groups with no significant difference. An expected tendency to gain better length of the first metatarsal using the open wedge osteotomy compared to the crescentic osteotomy was not found. Even though the IMA and HVA reduction was only suboptimal the improvement in AOFAS score was comparable to other similar clinical trials.

Proximal supination osteotomy of the first metatarsal for hallux valgus.

Risk factors for hallux valgus recurrence include postoperative round-shaped lateral edge of the first metatarsal head and postoperative incomplete reduction of the sesamoids. To prevent the occurrence of such conditions, we developed a proximal supination osteotomy of the first metatarsal. Our aim was to describe this novel technique and report the outcomes in this report. Sixty-six patients (83 feet) underwent a distal soft tissue procedure combined with a proximal supination osteotomy. After the proximal crescentic osteotomy, the proximal fragment was pushed medially, and the distal fragment was abducted, and then the distal fragment of the first metatarsal was manually supinated. Outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiographic examinations. The average follow-up duration was 34 (range, 25 to 52) months. The mean AOFAS score improved significantly from 58.0 points preoperatively to 93.8 points postoperatively (P < .0001). The mean hallux valgus and intermetatarsal angle decreased significantly from 38.6 and 18.0 degrees preoperatively to 11.0 and 7.9 degrees postoperatively, respectively (both, P < .0001). Sixty-nine feet (69/83, 83%) had a positive round sign preoperatively, and 66 feet (66/83, 80%) had a negative round sign postoperatively. According to the Hardy's classification of position of the sesamoids, all feet were classified as grade V or greater preoperatively, and 49 feet (49/83, 59%) were classified as grade IV or less postoperatively. Three feet (3/83, 4%) had recurrence of hallux valgus, defined as a hallux valgus angle ≥ 25 degrees. The rates of occurrence of a positive round sign and incomplete reduction of the sesamoids significantly decreased postoperatively, which may have contributed to the low hallux valgus recurrence rates. We conclude that a proximal supination osteotomy was an effective procedure for correction of hallux valgus and can achieve a low rate of hallux valgus recurrence. Level IV, retrospective case series.

Comment on Schuh et al.: Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

To the Editor, In this meta-analysis, Schuh et al. [1] compared correction of intermetatarsal and hallux valgus angles and complications of proximal crescentic, Ludloff, proximal opening wedge, proximal closing wedge, proximal chevron and other proximal first metatarsal osteotomies. They found that there was a mean correction of hallux valgus angle of 20.1° [confidence interval (CI) 18.7–21.4] and of intermetatarsal angle of 8.1° (CI 7.7–8.9). The overall complication rate reached 18.7 %. It is a valuable study. Nevertheless, there are some comments we would like to raise related to this article. The authors included 62 primary studies eligible for meta-analysis. However, we found several repeated studies in the meta-analysis (Table 1). Coughlin et al. reported their studies about proximal crescentic osteotomy [2, 3] twice in 2005 and 2007. Lee et al. also reported their studies about proximal chevron osteotomy [4, 5] twice from 2007 to 2008, and Sammarco et al. reported about proximal chevron osteotomy [6, 7] twice in 1993 and 1995. Schuh et al. included all these studies in their meta-analysis. In our opinion, some repeated data might exist among their studies [2–7]. To solve these problems, we suggest that these studies [2, 4, 6] should be excluded from the meta-analysis. Publication language was limited to English and German in the meta-analysis. Therefore, the authors should mention the potential importance of language bias in the limitations of their meta-analysis. The authors described that “funnel plots were drawn to check for publication bias. Inspection of the funnel plots showed no sign of publication bias.” However, we cannot find the funnel plots in the paper. The author should provide us all the funnel plots. We agree with the following conclusions of the authors, i.e. the proximal crescentic osteotomy provided the highest amount of HVA correction. However, regarding angular correction as well as complications, the proximal chevron osteotomy revealed the most favourable results. Rigid fixation is mandatory in order to reduce complications, and further high-quality prospective comparative studies are required and might change the observed effects.

Response to the comment on Schuh et al.: Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

Dear Prof. Pecina, We greatly appreciate the comments offered by Dr. He and Dr. Peng regarding the recent publication “Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity” [1]. To the raised claims I would like to comment as follows: He and Peng detected six studies included in our meta-analysis to be suspicious for double-counting patients [2–7]. I reviewed these publications once again and concluded that for the publications from Coughlin et al. [2, 3] this is not the case. Coughlin’s publication from 2005 entitled “Proximal metatarsal osteotomy and distal soft tissue reconstruction as treatment for hallux valgus deformity” was a review article which contains results of 27 juvenile patients (33 feet) with hallux valgus. These patients were operated over an 11-year period and were part of the patient cohort from Coughlin’s study concerning juvenile hallux valgus published in 1995 [8]. The 103 patients (122 feet) treated with proximal crescentic osteotomy whose results were presented in 2007 [3] were all operated between September 1999 and May 2002. Therefore, the authors did not include overlapping patient data from Coughlin et al. Sammarco et al. reported results of the proximal chevron osteotomy in 1993 and in 1998 [4, 5]. The first study comprised 43 patients (51 feet) with a mean age of 48 years (range 12–81) [4]. The second study included 55 patients (72 feet) with a mean age of 56 years (range 24–81) [5]. In this case there are perhaps some patients who were included in both studies. However, in the study cohort from 1998 they reviewed the case records of 69 patients and, due to the deaths of unrelated causes of two patients (two feet), the lack of adequate follow-up from six patients (eight feet) and the exclusion of six patients with adolescent bunion or rheumatoid arthritis (six feet), 55 patients with 72 operated feet remained. This demonstrates that not the whole patient cohort from the former published study was included in the later study. Lee at al. published a prospective randomized study comparing two axial K-wires with a supplementary transverse K-wire for proximal chevron osteotomy fixation [6]. The two cohorts contained 32 patients (41 feet) and 33 patients (44 feet), respectively. One year later Lee et al. published a retrospective comparative study with a patient group treated with unilateral and a group operated upon simultaneously for hallux valgus correction (52 patients, 69 feet) [7]. All patients in this study underwent the same surgical technique, in particular axial K-wire fixation with two K-wires. The apprehension of He and Peng could indeed be correct in that we included some of Lee’s patients in duplicate into meta-analysis. Concerning the publication language, the authors did not restrict our systemic search to any languages. During the review process all publications revealed by the online databases MEDLINE, EMBASE, CINAHIL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, using the MeSH terms “(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR ludloff) AND osteotomy” have been reviewed. Studies had to meet the inclusion criteria and a manual reference check of all accepted papers was performed to supplement the electronic search. Finally, only English- and German-language studies were eligible for meta-analysis We would like to provide the funnel plots for delta IMA (Fig. 1) and delta HVA (Fig. 2). In consequence of a limitation in figure submission and publication the authors renounced the attachment of the drawn funnel plots in our original paper. Fig. 1 Funnel plot for the delta intermetatarsal angle (IMA) meta-analysis Fig. 2 Funnel plot for the delta hallux valgus angle (HVA) meta-analysis He and Peng raised some legitimate thoughts regarding our publication “Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity” [1]. After careful reflection we concluded that the study from Sammarco et al. [4] and the axial K-wire fixation group from Lee et al. [6] should be excluded from meta-analysis. As already mentioned, further high-quality prospective comparative studies are required and might change the observed effects.

Radiographic Measurements in Patients with Hallux Valgus Before and After Proximal Crescentic Osteotomy

Radiographic measurements such as those of the hallux valgus angle and the intermetatarsal angle are essential parameters for assessing the severity of hallux valgus deformities and the extent of surgical correction required. However, to our knowledge, no study has investigated the reliability of the measurements that are made radiographically before and after a proximal crescentic osteotomy of the first metatarsal. The purpose of the present study was to investigate the intraobserver and interobserver reliability of different methods that are used to measure the angles and to determine the most reliable method. We selected twenty preoperative and twenty postoperative dorsoplantar weight-bearing radiographs for patients who had undergone a proximal crescentic osteotomy of the first metatarsal. Three foot and ankle surgeons measured the hallux valgus angle and the intermetatarsal angle with use of five different methods. We calculated the intraobserver and interobserver correlation coefficients and agreement to determine the most reliable method. Significant differences were observed among the methods with regard to the postoperative hallux valgus angle (p < 0.05) and the preoperative and postoperative intermetatarsal angles (p < 0.01 for both). The method in which a line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal was used to define the longitudinal axis of the first metatarsal yielded the highest intraobserver and interobserver correlation coefficients for the preoperative hallux valgus and intermetatarsal angles and the postoperative hallux valgus angle. For this method alone, the intraobserver and interobserver agreements for the angular measurements were found to be >80%. A line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal to define its longitudinal axis yields the best intraobserver and interobserver reliability for the measurement of the hallux valgus and intermetatarsal angles. Therefore, this method can be recommended for evaluating radiographs before and after a proximal crescentic osteotomy performed for the treatment of hallux valgus.

Screw Versus Plate Fixation of Proximal First Metatarsal Crescentic Osteotomy

Hallux valgus associated with metatarus primus varus is a deformity that disrupts normal foot function. Standard treatment has often included distal or proximal metatarsal osteotomy with or without a distal soft tissue procedure. The intrinsically unstable proximal crescentic osteotomy relies on operative fixation for stability. This study examined the strength of fixation of a single screw versus a plate for stabilization of proximal first metatarsal crescentic osteotomies for correction of hallux valgus. A crescentic osteotomy was performed on nine pairs of fresh/frozen cadaveric feet. The distal fragment was rotated laterally and the osteotomy was temporarily stabilized with a Kirschner wire. The osteotomized metatarsal fragments were fixed with a cancellous screw on one side and single plate on the contralateral side. Each specimen was loaded in a mechanical testing machine, and its response was measured by monitoring the opening of the osteotomy and change in alignment of the fragments. Position and alignment of the proximal and distal fragments were calculated. All of the measures of fixation strength were statistically greater in specimens treated with a plate rather than with screw fixation. Plate fixation provided approximately twice the resistance to disruption of the osteotomy under cyclic loading conditions. The dorsal plate is biomechanically more stable than a single cancellous screw when applied to proximal crescentic osteotomies. The greater stability of the plate construct may be helpful in selecting the fixation device for these osteotomies.

Screw Versus Plate Fixation of Proximal First Metatarsal Crescentic Osteotomy

Hallux valgus associated with metatarus primus varus is a deformity that disrupts normal foot function. Standard treatment has often included distal or proximal metatarsal osteotomy with or without a distal soft tissue procedure. The intrinsically unstable proximal crescentic osteotomy relies on operative fixation for stability. This study examined the strength of fixation of a single screw versus a plate for stabilization of proximal first metatarsal crescentic osteotomies for correction of hallux valgus.A crescentic osteotomy was performed on nine pairs of fresh/frozen cadaveric feet. The distal fragment was rotated laterally and the osteotomy was temporarily stabilized with a Kirschner wire. The osteotomized metatarsal fragments were fixed with a cancellous screw on one side and single plate on the contralateral side. Each specimen was loaded in a mechanical testing machine, and its response was measured by monitoring the opening of the osteotomy and change in alignment of the fragments. Position and alignment of the proximal and distal fragments were calculated.All of the measures of fixation strength were statistically greater in specimens treated with a plate rather than with screw fixation. Plate fixation provided approximately twice the resistance to disruption of the osteotomy under cyclic loading conditions.The dorsal plate is biomechanically more stable than a single cancellous screw when applied to proximal crescentic osteotomies.The greater stability of the plate construct may be helpful in selecting the fixation device for these osteotomies.

Hallux Valgus and First Ray Mobility

There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the postoperative hallux valgus deformity, or the magnitude of hallux valgus correction. A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.

Proximal Metatarsal Osteotomy for Hallux Valgus: Comparison of Outcome for Moderate and Severe Deformities

We compared the results of a distal soft-tissue procedure with a proximal crescentic osteotomy of the first metatarsal for moderate and severe hallux valgus. The series consisted of 54 feet treated with this procedure. The average followup was 30 months. Fifty-four feet were divided into two groups including Group M (moderate) (24 feet, preoperative hallux valgus angle of 40 degrees or less and preoperative intermetatarsal angle of less than 18 degrees) and Group S (severe) (30 feet, preoperative hallux valgus angle of greater than 40 degrees or preoperative intermetatarsal angle of 18 degrees or greater). The difference between Group M and S was not significant with regard to the age of patients, duration of followup, or postoperative pain and function scores on the American Orthopaedic Foot and Ankle Society scale. However, postoperative alignment score in Group M was significantly greater than that in Group S (p = 0.038). Postoperative hallux valgus and intermetatarsal angles in Group S were significantly greater than those in Group M, respectively (p = 0.025, p = 0.001). The prevalence of recurrent hallux valgus (hallux valgus angle of 20 degrees or greater) in Group S was significantly higher than that in Group M (p = 0.013). This procedure is an effective method for relieving pain and improving function regardless of the severity of hallux valgus. However, the correction of moderate hallux valgus is likely to be better than that of severe hallux valgus.

Hallux Valgus and First Ray Mobility

There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the post-operative hallux valgus deformity, or the magnitude of hallux valgus correction. A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.