Recurrence Of Hallux Valgus Research Articles

Analysis of risk factors and progress on revision surgery for postoperative recurrence of hallux valgus

Recurrence of hallux valgus is one of the most common and difficult complications after surgery. Due to the lack of understanding of 3D deformity of hallux valgus and risk factors for recurrence, the overall recurrence rate is still high, and the choice of treatment is still controversial. Improper operation and severe deformity are known risk factors for recurrence, while the role of unstable of the first plantar train and combined flat foot deformity in the recurrence has been paid more attention by scholars at home and abroad. In addition to the first metatarsophalangeal fusion, modified Lapidus osteotomy and proximal metatarsal osteotomy have been proven to be reliable revision procedures. The purpose of this study is to summarize risk factors for recurrence of hallux valgus after surgery, and to explore the choice of revision surgery after recurrence, in order to provide guidance for prevention and management of recurrence of hallux valgus.

علاج الابهام الأروح عند البالغين: دراسة مقارنة بين نتائج خزع عظم المشط الأول بطريقة الاسفين المغلق والخزع بطريقة سكارف

Objective: The aim of this study is to evaluate the results of surgical treatments of hallux valgus by a scarf or closing wedge osteotomy of the first metatarsal. In addition to, detection complications resulting from the surgery. Patients and Methods: Descriptive comparative study was conducted for the period of one year (June2020 – June2021) at Tishreen University Hospital in Lattakia- Syria. The study included two groups of patients that were compared: group1 consisted of 19 patients (57.6%) who underwent closing wedge osteotomy, whereas group 2 consisted of 14 patients (42.4%) who underwent scarf procedure. Results: The mean hallux valgus angle (HVA) decreased from (31.43 º ±3.1) preoperatively to (9.15 º ±0.1) at postoperative in closing wedge group (group. 1), and from (29.45 º ±2.7) preoperatively to (10.10 º ±3.7) at postoperative in scarf group (group. 2), p:0.0001. The Foot and Ankle Disability Index (FADI) score increased significantly in the two groups during follow- up periods. Complications developed in the two groups, more frequently in the scarf group which included: wound healing after 8 weeks (35.7% vs 22.2%), operation site infection (21.4) % vs (11.1%), sudeck's disease (14.3% vs 5.6%), impaired wound healing (14.3% vs 5.6%) and recurrence of hallux valgus (7.1% vs 5.6%), without any case of the non- healing wound in the two groups. Satisfaction of the patients was complete in 84.8%, moderate in 9.1%, and 6.1% of the patients were unsatisfied. Conclusion: The current study demonstrated favorable results in correction deformity with two techniques, with fewer complications in closing wedge compared with the scarf method.

Effect of the Reversed L-Shaped Osteotomy on the Round Sign: Not All Hallux Valgus Deformities May Need Proximal Derotation to Correct the Radiographic Appearance of Metatarsal Pronation.

Background:Metatarsal pronation has been claimed to be a risk factor for hallux valgus recurrence. A rounded shape of the lateral aspect of the first metatarsal head has been identified as a sign of persistent metatarsal pronation after hallux valgus correction. This study investigated the derotational effect of a reversed L-shaped (ReveL) osteotomy combined with a lateral release to correct metatarsal pronation. The primary hypothesis was that most cases showing a positive round sign are corrected by rebalancing the metatarsal-sesamoid complex. We further assumed that the inability to correct the round sign might be a risk factor for hallux valgus recurrence.Methods:We retrospectively evaluated 266 cases treated with a ReveL osteotomy for hallux valgus deformity. The radiologic measurements were performed on weightbearing foot radiographs preoperatively, at an early follow-up (median, 6.2 weeks), and the most recent follow-up (median, 13 months). Univariate and multivariate logistic regression analyses identified risk factors for hallux valgus recurrence (hallux valgus angle [HVA] ≥ 20 degrees).Results:A preoperative positive radiographic round sign was present in 40.2% of the cases, of which 58.9% turned negative after the ReveL osteotomy (P < .001). Hallux valgus recurred in 8.6%. Risk factors for recurrence were a preoperative HVA >30 degrees (odds ratio [OR] = 5.3, P < .001), metatarsus adductus (OR = 4.0, P = .004), preoperative positive round sign (OR = 3.3, P = .02), postoperative HVA >15 degrees (OR = 74.9; P < .001), and postoperative positive round sign (OR = 5.3, P = .008). Cases with a positive round sign at the most recent follow-up had a significantly higher recurrence rate than those with a negative round sign (22.7% vs 5.9%, P < .001).Conclusion:The ReveL osteotomy corrected a positive round sign in 58.9%, suggesting that not all hallux valgus deformities may need proximal derotation to negate the radiographic appearance of the round sign. A positive round sign was found to be an independent risk factor for hallux valgus recurrence. Further 3-dimensional analyses are necessary to better understand the effects and limitations of distal translational osteotomies to correct metatarsal pronation.Level of Evidence:Level IV, case series.

Characteristics of Intermetatarsal Angle Between the Second and Fifth Metatarsals (M2-M5A) in the Rheumatoid Foot.

Background: Increasing of intermetatarsal angle between the first and second metatarsals (M1-M2A) has been reported as a risk factor for recurrence of hallux valgus (HV) deformity, on the other hand, increasing of intermetatarsal angle between the second and fifth metatarsals (M2-M5A) has been reported as a risk factor for resubluxation of the metatarsophalangeal (MTP) joint of the lesser toe after rheumatoid forefoot surgery. In this study, parameters related to increasing M2-M5A were investigated, as compared with M1-M2A and M1-M5A.Methods: Radiographic parameters including M1-M2A, M1-M5A, and M2-M5A were retrospectively evaluated for 119 lower limbs from 68 patients with rheumatoid arthritis (RA). To clarify the clinical importance of these intermetatarsal angles, relationships with results from the timed up-and-go (TUG) test were also investigated.Results: M1-M5A showed no correlation with mid-hind foot parameters, whereas M1-M2A and M2-M5A correlated with valgus/varus parameters. An increased M1-M2A was associated with lateral shift of the loading axis in the tibial plafond, whereas an increased M2-M5A was associated with medial shift, but M1-M5A showed no associations. M2-M5A/M1-M2A was significantly lower (1.7) in the normal TUG group than in the delayed TUG group (2.8) (p=0.045).Conclusions: Different patterns of spread are seen for the forefoot. One has a predominantly increased M1-M2A with lateral shift of the loading point in the tibial plafond, whereas the other has a predominantly increased M2-M5A with medial shift of the loading point in the tibial plafond. M2-M5A also should be calculated, and M2-M5A/M1-M2A might be meaningful in understanding physical mobility in RA patients.

Intra-articular pressure measurement of the first metatarsophalangeal joint of the foot

Objective: To measure the metatarsophalangeal (MTP) intra-articular pressure of the first ray before surgical intervention for hallux valgus (HV), recurrent HV, and hallux rigidus (HR). Methods: This is a cross-sectional study including a consecutive sample of patients obtained from 1/1/2009 and 8/30/2015 in a center in Argentina. Measurements were made with a Stryker® pressure gauge, and results were expressed in mmHg. Descriptive and comparative statistics (Mann-Whitney test) were performed. Results: A total of 166 feet were included, 120 cases with HV, 20 with HR, and 26 with recurrent HV; the sample consisted of men and women aged 15 to 90 years. The greater HV deformity, the higher intra-articular pressure at rest and during maximal dorsiflexion and maximal plantar flexion. Conversely, an inverse situation is observed in HR: the greater the deformity, the lower intra-articular pressure. Median resting intra-articular pressure of the first MTP joint of the foot was 3 mmHg in mild HV, compared to 23 mmHg in early-stage HR (p=0.001). Conclusions: The measurement of intra-articular pressure could be a useful tool to differentiate early stages of joint diseases of the first ray of the foot. Level of Evidence II; Prognostic Studies; Retrospective Study.

One- and Two-Year Analysis of a Five-Year Prospective Multicenter Study Assessing Radiographic and Patient-Reported Outcomes Following Triplanar First Tarsometatarsal Arthrodesis With Early Weightbearing for Symptomatic Hallux Valgus

We report one- and 2-year results of a prospective, 5-year, multicenter study of radiographic, clinical, and patient-reported outcomes following triplanar first tarsometatarsal arthrodesis with early weightbearing. One-hundred and seventeen patients were included with a mean (95% confidence interval [CI]) follow-up time of 16.6 (15.5, 17.7) months. Mean (95% CI) time to weightbearing in a boot walker was 7.8 (6.6, 9.1) days, mean time to return to athletic shoes was 45.0 (43.5, 46.6) days, and mean time to return to unrestricted activity was 121.0 (114.5, 127.5) days. There was a significant improvement in radiographic measures with a mean corrective change of -18.0° (-19.6, -16.4) for hallux valgus angle, -8.3° (-8.9, -7.8) for intermetatarsal angle and -2.9 (-3.2, -2.7) for tibial sesamoid position at 12 months (n = 108). Additionally, there was a significant improvement in patient-reported outcomes (Visual Analog Scale, Manchester-Oxford Foot Questionnaire, and Patient-Reported Outcomes Measurement Information System) and changes were maintained at 12 and 24 months postoperatively. There was 1/117 (0.9%) reported recurrence of hallux valgus at 12 months. There were 16/117 (13.7%) subjects who experienced clinical complications of which 10/117 (8.5%) were related to hardware. Of the 7/117 (6.0%) who underwent reoperation, only 1/117 (0.9%) underwent surgery for a nonunion. The results of the interim report of this prospective, multicenter study demonstrate favorable clinical and radiographic improvement of the HV deformity, early return to weightbearing, low recurrence, and low rate of complications.

Early outcomes of Minimally Invasive Percutaneous Chevron/Akin Osteotomy for Symptomatic Hallux Valgus Deformity

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:Hallux Valgus (HV) is a common progressive forefoot deformity. Although traditional open techniques have shown good outcomes, no technique has been shown to be superior to other techniques and 15% of patients have procedure related complications. This has significant functional restrictions, pain, and reduced quality of life. Minimally Invasive (MIS) percutaneous techniques became more popular in Orthopaedics. The current third generation of hallux valgus MIS technique developed by Vernois and Redfern features a percutaneous procedure with a stable internal fixation. The purpose of this study is to review the early outcomes of MIS hallux valgus operation by a single surgeon.Methods:Electronic health records were queried from January 1, 2015, through February 01, 2021, for patients who underwent MIS to treat HV deformity. Patients were treated by a single surgeon. The primary clinical outcomes assessed were visual analog pain score (VAS), rate of revision surgery, and recurrence. Additionally, radiographic outcomes were assessed including pre-and postoperative hallux valgus angle (HVA), inter-metatarsal angle (IMA), and foot width. The secondary outcomes included postoperative complications: infection, scar hypersensitivity, hardware irritation, hardware loosening, removal of hardware, and metatarsal fracture.Results:A total of 91 feet underwent MIS to correct symptomatic HV deformity. The mean age of this cohort was 53.63 +- 15.42 years, mean BMI of 26.81 +- 6.21, mean follow-up of 6.33 +- 6.39 months and 87 feet belonged to female patients. Patients showed a statistically significant (P < 0.001) improvement in VAS score after surgery. The radiographic outcomes showed significant (P < 0.001) improvement for all three variables at final follow up, with a mean improvement of 10.70° +- 6.42, 2.39° +- 3.55, and 5.30 mm +- 4.23 for the HVA, IMA, and foot width respectively. Two patients (2.2%) required revision surgery, one due to nonunion and one due to persistent pain. One patient had a hardware irritation that did not require hardware removal and one patient had a second metatarsal fracture. No feet had HV recurrence, hardware loosening, infection, or scar hypersensitivity.Conclusion:The current study showed that minimally invasive percutaneous Chevron/Akin for symptomatic hallux valgus correction is an effective and safe technique. In addition to a low complication rate, significant improvement in pain score and radiographic parameters at final follow up were demonstrated. Future randomized trials with long term follow up are needed to validate the outcomes of minimally invasive techniques.

Imaging Findings and First Metatarsal Rotation in Hallux Valgus.

Failure to identify and correct malrotation of the first metatarsal may lead to recurrent hallux valgus deformity. We aimed to identify the proportion of hallux valgus patients with increased first metatarsal pronation using weightbearing computed tomography (WBCT) and to identify the relationship with conventional radiographic measurements. WBCT scans were analyzed for 102 feet with a hallux valgus angle (HVA) and intermetatarsal angle (IMA) greater than or equal to 16 and 9 degrees, respectively. Metatarsal pronation angle (MPA), alpha angle, sesamoid rotation angle (SRA), and sesamoid position were measured on standardized coronal WBCT slices. Pronation was recorded as positive. Hindfoot alignment angle (HAA) was assessed using dedicated software. Pearson correlation and multiple regression analyses were used to assess differences between groups. Mean HVA was 29.8±9.4 degrees and mean IMA was 14.1±3.7 degrees. Mean MPA was 11.9±5.8 (range 0-26) degrees and mean alpha angle was 11.9±6.8 (range -3 to 29) degrees. In a previous study, we demonstrated the upper limit of normal MPA as 16 degrees and alpha angle as 18 degrees. Based on these criteria, we identified abnormal metatarsal pronation in 32 feet (31.4%). We found a strong positive correlation between SRA and HVA/IMA (R = 0.67/0.60, respectively, P < .001). IMA and HAA weakly correlated with MPA and alpha angle (IMA: R = 0.26/0.27, respectively, P < .01; HAA: R = 0.26/0.27, respectively, P < .01). Regression analyses suggested that increasing IMA was the most significant radiographic predictor of increased pronation. In this cohort, there was no correlation between HVA or sesamoid position and MPA / alpha angle (HVA: P = .36/.12, respectively, sesamoid position, P = .86/.77, respectively). In this cohort of 102 feet that met plain radiographic criteria for hallux valgus deformity, first metatarsal pronation was found abnormal in 31.4% of patients. We found a weak association between the IMA and hindfoot valgus, but not the HVA.

Moderate to Severe Hallux Valgus Deformities. Surgical treatment with SCARF Osteotomy Technique.

Introduction; Many procedures are described in the literature for the surgical management of hallux valgus. There are over 130 surgical procedures described. There is ever rising enthusiasm among orthopedic surgeons regarding diaphyseal osteotomy ever since Burutaran described the procedure in 1973. We report our experience of treating severe cases of Hallux Valgus deformity with a SCARF osteotomy at the last three years follow-up, at patients diagnosed and operated in the University Hospital of Trauma, from January 2015 - February 2018. The technique we are presenting, provides the correction of moderate to severe hallux valgus deformities.&#x0D; Material and Methods: Correction of hallux valgus deformities was achieved using a Z step osteotomy cut to realign the first metatarsal bone. A retrospective analysis was undertaken in 38 consecutive patients (54 feet). All results were analyzed by clinical examination, a questionnaire including the AOFAS forefoot score, modified, and plain roentgenograms.&#x0D; Results: Hallux valgus and intermetatarsal angle improved at mean 19.6° and 6.9°, respectively. Mean forefoot score improved from 50.1 to 91 points out of 100 possible points. Satisfactory healing time was expressed by an average return back to their attitude of 6-12 weeks, without including physiotherapy. Persistence or recurrence of hallux valgus was seen in 3 patients (8%). The complication rate was 5.4% including superficial wound infection, atrophy of the muscles, traumatic dislocation of the distal fragment.&#x0D; Conclusion: Scarf osteotomy is a powerful and versatile procedure to correct hallux valgus deformity, and provides a predictable and satisfying result. Scarfs are not considered as a single osteotomy but as a combination of several procedures and displacement in several planes are possible.

Clinical and Radiological Outcomes of Modified Lapidus Procedures Using 2 Compression Cannulated Screws in Hallux Valgus Deformity

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:Hallux valgus is common disease. Surgical correction is usually required because, conservative treatment can not correct deformity and lacks evidence for prevention of progression of deformity. Among the various methods for the correction of hallux valgus deformity, the modified Lapidus procedure is known to be performed in less than 10%. The purpose of this study is to investigate the clinical and radiological outcomes of patients who underwent the modified Lapidus method.Methods:From January 2010 to December 2019, 34 cases of patients who underwent the modified Lapidus procedure and followed up for at least 6 months were included in the study. For clinical evaluation, VAS score, AOFAS score, and patient satisfaction (very satisfied, satisfied, dissatisfied, very dissatisfied) were used. For radiological evaluation, hallux angle and 1-2 metatarsal angle on anterior and posterior foot x-ray of the weight-bearing were used. Furthermore, rate of bone union and the period until bone union were also evaluated.Results:The mean follow-up period was 21.0 (6~108) months. The indications for surgery were: Severe hallux valgus in 30 cases, metatarsus adductus in 17 cases, recurrent hallux valgus in 4 cases, and hypermobility of the first tarso-metatarsal joint in 10 cases. In terms of VAS score, between pre-operation and the last follow-up was significantly improved from 5.8+-2.1 to 1.1+-1.4 (p<0.05), and the AOFAS score from 52.8+-15.0 to 92.3+-9.8 (p<0.05). In terms of patient satisfaction, 33 patients (97.1%) showed overall satisfaction (very satisfied and satisfied). Complications were nonunion in 3 cases (8.8%), incomplete union in 1 case, delayed union in 1 case, and hallux varus in 1 case. There was no additional surgery for these complications. At preoperative and last follow-up, the hallux angle improved from 46.0°+-10.7° to 5.9°+-11.7°, and the 1-2 IMA improved from 18.2°+-5.1° to 5.5°+-4.5°. In the cases excluding complications, the average period to bone union was 3.9(3-8) months.Conclusion:In our study, the modified Lapidus method using 2 compression cannulated screws was showed satisfactory clinical, radiological outcomes and relatively satisfactory bone union (91.2%) in a short follow-up. The modified Lapidus method using 2 compression cannulated screws is a considerable option for severe hallux valgus deformity.

Percutaneous Modified Lapidus Procedure with Early Weightbearing: Technique and Early Outcomes of the First 30 Cases

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Minimally invasive techniques (MIS) have focused on first metatarsal osteotomies in hallux valgus correction. Concurrently, new fixation methods allow early weightbearing protocols with the open Lapidus procedure, with nonunion rates comparable to those of more traditional protocols requiring nonweightbearing. We aimed to assess clinical and radiographic results of an MIS-modified Lapidus technique with axial nail fixation (Phantom Lapidus Intramedullary Nail: Paragon28, Englewood, CO USA) and early weightbearing.Methods:After institutional review board approval, the first 30 consecutive percutaneous MIS-modified Lapidus procedures by a single surgeon were retrospectively reviewed. Indications for surgery included moderate to severe hallux valgus deformity with or without first tarsometatarsal joint (TMT) instability, first TMT arthritis, adolescent bunion, and failed prior surgery. All patients initiated weightbearing within 12 days and returned to regular footwear by 6 weeks postoperatively. Patients had a minimum follow-up period of 3 months (average 8.3 months). The pre- and postoperative visual analog scale (VAS) pain scores, intra- and postoperative complications, and need for revision surgery were recorded. Pre- and postoperative radiographs were used to evaluate the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and sesamoid station. Postoperative radiographs were evaluated for signs of hardware loosening and union of the first TMT arthrodesis site. A postoperative CT scan was obtained if nonunion was suspected.Results:Thirty consecutive percutaneous modified Lapidus procedures were performed in 28 patients. VAS scores improved from 4.1 preoperatively to 1.8 at final follow-up. The IMA decreased 8.3 degrees to an average of 5.9 degrees. The HVA decreased 19.2 degrees to 11.7 degrees. The medial column was shortened by 0.6%. There were no intraoperative complications. There were two reoperations, including one nonunion requiring revision first TMT fusion with autograft and one hallux valgus recurrence requiring a distal chevron osteotomy. There were no wound complications, surgical site infections, hardware complications, postoperative transfer metatarsalgia, or nerve-related problems.Conclusion:The current study provides clinical evidence that the intramedullary nail is a biomechanically stable construct evidenced by the high union rate, lack of hardware failure, and tolerance for early weightbearing. This percutaneous modified Lapidus technique may allow for a low rate of wound complications, accelerated rehabilitaion, and improved cosmesis.

Prevalence and Predisposing Factors for Recurrence after Hallux Valgus Surgery: A Systematic Review and Meta-Analysis.

Recurrence is a frequent and undesirable outcome after hallux valgus (HV) surgery. However, the prevalence of HV recurrence and the pre- and postoperatory factors associated with it have not been adequately studied. This study aimed to quantify the prevalence rate of HV recurrence and to analyze its predisposing factors. MEDLINE and EMBASE databases were systematically searched for observational studies including individuals undergoing HV surgical correction. The random-effects restricted maximum likelihood model was used to estimate the pooled effect size (correlation coefficient (r)). Twenty-three studies were included, yielding a total of 2914 individuals. Pooled prevalence of HV recurrence was 24.86% (95% confidence interval (CI), 19.15 to 30.57, I2 = 91.92%, p = 0.00). Preoperative HV angle (HVA) (r = 0.29; 95% CI, 0.14 to 0.43) and preoperative intermetatarsal angle (IMA) (r = 0.13; 95% CI, 0.00 to 0.27) showed a moderate positive relationship with recurrence. Postoperative HVA (r = 0.57; 95% CI, 0.21 to 0.94) and sesamoid position (r = 0.46; 95% CI, 0.31 to 0.60) showed strong relationships with recurrence. In conclusion, preoperative HVA, IMA, and postoperative HVA and sesamoid position are significant risk factors for HV recurrence, and the association of these factors with recurrence is affected by age.

Forefoot Deformities in Patients with Rheumatoid Arthritis: Mid- to Long-Term Result of Joint-Preserving Surgery in Comparison with Resection Arthroplasty.

Background: Joint-preserving surgery for the forefoot has been increasingly performed for rheumatoid arthritis (RA). We compared joint-preserving surgeries with resection arthroplasty for RA in the forefoot. Methods: Forefoot surgeries were performed on 62 toes in 42 patients with RA (men: 2; women: 40) between 2002 and 2018. Three groups were compared: PP—31 toes treated with joint-preserving surgery involving the modified Mann method for the big toe and offset osteotomy for lesser toes, PR—15 toes treated with joint-preserving surgery for the big toe and resection arthroplasty for lesser toes, and RR—16 toes treated with resection arthroplasty for all the toes. Results: The PP group had significantly higher mean scores on a scale for RA in the foot and ankle at the latest follow-up than the RR group (86 vs. 75 points; p < 0.05). Hallux valgus (angle > 20°) of the big toe at the latest follow-up recurred in 10 (32%), 9 (60%), and 16 (100%) patients in the PP, PR, and RR groups, respectively. A revision surgery was performed in one patient each in the PP and PR groups. Conclusions: Joint-preserving surgery is superior to resection arthroplasty in preventing function loss and the recurrence of hallux valgus.

Combination of Modified Scarf Osteotomy and Metatarsal Shortening Offset Osteotomy for Rheumatoid Forefoot Deformity.

With the progress of medical treatment for rheumatoid arthritis (RA), several joint-preserving forefoot surgical procedures have been established and performed. In this situation, we have been choosing the combined surgery: modified scarf osteotomy for the great toe and metatarsal shortening offset osteotomy for the lesser toes in RA cases. A retrospective observational study of 53 RA patients (mean follow-up period: 4.6 years) who underwent the surgery was completed. RA foot ankle scores were assessed, using the Japanese Society for Surgery of the Foot (JSSF) standard rating system, and a self-administered foot evaluation questionnaire (SAFE-Q) was also checked to evaluate clinical outcomes. For radiological evaluations, deformity parameters were measured using radiographs of the feet with weight-bearing. JSSF hallux and lesser toes scores and the SAFE-Q score showed significant improvement in all indices. HVA, M1-M2A, M1-M5A, M2-M5A, and sesamoid position were significantly improved after surgery. At the final follow-up, the hallux valgus deformity had recurred in 4 feet (7.5%), and hallux varus deformity had developed in 8 feet (15.1%). No case of recurrent hallux valgus deformity required revision surgery. Recurrence of dorsal dislocation/subluxation of the lesser toe MTP joint was seen in 6 feet (11.3%) after surgery. A combination of modified scarf osteotomy for the great toe and modified metatarsal shortening offset osteotomy for the lesser toes is one of the novel surgical procedures for rheumatoid forefoot deformity. Preoperative disease activity of RA negatively affected the clinical score of the hallux. The spread of M2-M5A was a risk factor for resubluxation of the lesser toe MTP joint.

Clinical and radiological outcomes of modified Mitchell's osteotomy using three-point fixation for hallux valgus.

This study examined the clinical and radiographic outcomes of modified Mitchell's osteotomy using three-point fixation with a full-thread headless screw. This technique was described to resolve the problem of excessive shortening and overshifting of the metatarsal. A total of 33 feet of 26 patients underwent modified Mitchell's osteotomy with three-point fixation for hallux valgus. Clinical and radiographic outcomes were assessed preoperatively and at specific time points of follow-up by using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, hallux valgus angle (HVA), and intermetatarsal angle (IMA). The global AOFAS scale score (0-100) significantly improved from 50.7 ± 9.9 preoperatively to 84.4 ± 8.7 at the final follow-up. The HVA significantly improved from 30.2 [Formula: see text]± 6.0 [Formula: see text] to 9.0 [Formula: see text] ± 5.0 [Formula: see text], and the IMA significantly improved from 14.2 [Formula: see text] ± 2.6 [Formula: see text] to 5.1 [Formula: see text] ± 2.0 [Formula: see text]. None of the patients experienced nonunion and transfer metatarsalgia. Complications were observed in two feet, and one foot had recurrence of hallux valgus. Modified Mitchell's osteotomy using three-point fixation with a full-thread headless screw is a reliable alternative treatment for hallux valgus, even in patients with severe deformities.

A Novel Manipulation Technique for Lapidus Fusion in Correction of Hallux Valgus Deformity With Underlying Metatarsus Adductus: A Case Series

Underlying metatarsus adductus (MA) is commonly seen in patients with hallux valgus (HV) deformity, with implications regarding procedure selection and hallux valgus recurrence. Lapidus, or first tarsometatarsal fusion, is commonly performed allowing reduction in intermetatarsal angle (IMA) but this procedure has not been established as an approach to provide partial correction of MA deformity. Retrospective assessment of preoperative and postoperative metatarsus adductus angle (MAA), IMA and hallux abductus angle (HAA) in patients treated with Lapidus fusion for HV. Significance was determined via paired t test with a p value of <.05. All cases involved manual transverse plane manipulation to reduce both IMA and MAA during screw insertion. Intermetatarsal angle and Engel's angle were measured on preoperative AP radiographs to determine the presence of underlying MA in patients undergoing Lapidus fusion for HV. Ten weeks and 1 year postoperative radiographs were measured to determine degree of correction of IMA, HAA, and MAA. Thirty-four patients met inclusion criteria, which is approximately 46% of our sample population. The average preoperative IMA was 19.4˚ (range 12-32) and the average postoperative IMA was 9.7˚ (range 6-14). The average preoperative Engel's angle was 27.4˚ (range 24-34) and the average postoperative Engel's angle was 22.6˚ (range 15-28) with mean improvement in MA of 6.6˚. Of the 34, 27 (79.4%) patients had a normal Engel's angle at 10 weeks postoperatively. All measures of change met level of significance (p < .05). Of the 34 patients, 21 had radiographs taken beyond the 1 year mark (average 53 weeks). These patients were found to have an average Engel's angle of 23.0˚, which is not statistically significantly different from their 10 week measurements. Of the 21 patients, 17 (81%) maintained normal Engel's angle past 1 year. Metatarsus adductus varies regarding degree of reducibility and complicates preoperative angular measurement and correction of HV. Based on these findings, we recommend Lapidus fusion using this specified manipulation technique to obtain comprehensive transverse plane correction.

Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up.

Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known. A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction. Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%. Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence. Level IV, case series.

Recurrence of Hallux Valgus After Modified Lapidus Procedure With Successful Fusion of the Intermetatarsal and Intercuneiform Joints.

BackgroundThe Lapidus procedure has become a popular procedure in correcting hallux valgus deformities and has undergone several modifications in an effort to improve the efficacy of the procedure. The senior author modifies this procedure with the addition of an intermetatarsal and intercuneiform fusion. Our hypothesis is that this will improve the procedure outcomes and decrease deformity recurrence.MethodsWe reviewed patient charts who underwent the procedure between 2014 and 2017 performed by the senior author. This yielded 47 reviewable cases, with 34 meeting study criteria. The cases were analyzed for standard hallux valgus measurements (intermetatarsal angle [IMA], hallux valgus angle [HVA]) and fusion on X-ray.ResultsThe results of the study showed partial intermetatarsal and intercuneiform fusion failure in seven (20%) cases, and one case where the great toe fell into varus. These cases were excluded. In the remaining cases, there was a statistically significant improvement in the HVA and IMA between the preoperative X-ray and first postoperative X-ray. Additionally, there was no significant difference between HVA and IMA between first and final postoperative radiographs. There was a significant increase in IMA for the fusion failure cases (p=0.001).ConclusionClinically, our findings demonstrate that successful union is possible with low recurrence and complication rates when using this modification of the Lapidus procedure in patients with hallux valgus deformity.

753 Sesamoid Alignment After MIS Chevron Osteotomy and Its Role to Prevent Hallux Valgus Recurrence

Abstract Introduction Incomplete correction of the sesamoid position after corrective osteotomy is a risk factor for recurrence of the hallux valgus deformity. This study was done to report the results of sesamoid alignment after chevron osteotomy. Method 92 patients (111 feet) had minimally invasive (MIS) distal chevron osteotomy and release of fibular sesamoid ligaments done, sesamoid position was assessed in the weight-bearing views of the foot, tibial sesamoid position in relation to the mechanical axis of the first metatarsal was classified as grades 0-3 where the normal position was graded (0) and the most lateral sublaxation was graded (3). There were 2 groups; the reduced (grade 0-1) &amp; the dislocated (grade 2,3) groups. Preoperative and post-operative radiographs were compared. Postoperative images were done 6-8 weeks post-operatively to ensure osteotomy healing. Results Sesamoids alignment was corrected following the MIS chevron osteotomy; 84 feet (75.7%) were from the dislocated group and 27 feet (24.3%) were from the reduced group pre-operatively improved to 102 feet (91.9%) reduced and only 9 feet (8.1%) dislocated following the procedure with P-value &amp;lt; 0.00001. To ensure inter-observer reliability, images were assessed by 2 observers with Cohen’s Kappa coefficient 0.477. Conclusions MIS chevron osteotomy can produce significant improvement of sesamoid position which is crucial to prevent recurrence of hallux valgus.

Reconstruction of the plantar plate of the metatarsophalangeal joint using adorsal transarticular approach

Reconstruction of the plantar plate to stabilize adislocated or instable lesser metatarsophalangeal joint using adorsal approach in combination with aWeil osteotomy. Dislocated or instable lesser metatarsophalangeal joint with rupture of the plantar plate. Infection, circulatory disorders, symptomatic degenerative arthritis lesser metatarsophalangeal joint. Weil osteotomy using adorsal approach. Temporary dislocation of the metatarsal head as proximal as possible. Inspection of the plantar plate. Assessment and classification of type and extent of the rupture. Suturing of the plantar plate to the plantar bases of the proximal phalanx. Fixation of the Weil osteotomy with correction of the metatarsal alignment. Weight bearing in apostoperative shoe as tolerated. X‑ray control 6weeks postoperative. Full weight bearing in aconventional shoe after bony consolidation. A total of 23surgical reconstructions of the plantar plate (complete plantar plate repair) between 12/2012 and 10/2014 were performed. The mean follow-up was 18.6 (12-30) months. Five secondary dislocations were observed: onedeep postoperative infection, one early dislocation of unknown cause, one secondary dislocation caused by severe hallux valgus recurrence, onemassive foreign body reaction to the non-resorbable sutures, and one late secondary dislocation occurred between 6weeks and 1year postoperative. Normal function of the reconstructed joint was achieved in 13 of the 23reconstructions (57%). Areduced toe purchase was observed in 3reconstructions (13%). Afloating-toe resulted after 7reconstructions (30%).