Recurrence Of Hallux Valgus Research Articles

Recurrence rates with long-term follow-up after hallux valgus surgical treatment using shaft metatarsal osteotomies: a systematic review and meta-analysis.

Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to synthesize and critically appraise the literature on the long-term outcomes of shaft osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess the long-term HV recurrence rates of studies with a minimum follow-up of 5 years. This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of shaft osteotomies of the M1 for non-inflammatory and non-degenerative HV having a minimum follow-up of 5 years were included. We found five eligible studies comprising six datasets, all assessed Scarf osteotomies with a mean follow-up that ranged from 8 to 14 years. The HV recurrence rate was 40%, considering the threshold of >15° hallux valgus angle (HVA), 30% having >20°, and 2% having >25°. At a minimum follow-up of 8 years following shaft osteotomies of M1, the HVA was 15.9°, the intermetatarsal angle (IMA) was 7.7°, and the DMAA was 8.3°. Furthermore, the recurrence rates considering the various thresholds of HVA were: 40% having >15°, 20% having >20°, and 2% having >25°. Meta-analysis, Level IV.

First Cuneo-Metatarsal Arthrodesis (Modified Lapidus) with Plantar Plate for the Treatment of Hallux Valgus: Clinical and Radiological outcomes at One Year Follow-up

IntroductionThe modified Lapidus arthrodesis, involving the first cuneo-metatarsal joint, is a well-established surgical method and widely utilized for treating moderate to severe hallux valgus deformities with hypermobility in the first tarsometatarsal joint. The purpose of this study was to assess the rate of union following the Lapidus procedure using a plantar plate and an immediate full weight-bearing protocol. Secondary objectives included examining radiological corrections and potential associated complications. MethodsA retrospective study included 66 patients (80 feet) who underwent a modified Lapidus procedure for the treatment of hallux valgus associated with hypermobility of the first ray, performed by a single senior surgeon at our institution between May 2013 and November 2019. All patients had a minimum follow-up of 12 months. Patients were clinically assessed at 3 weeks, 3 months, and 1 year. Radiological measurements were taken on weight-bearing dorsoplantar views preoperatively, at 3 months, and at 12 months postoperatively. ResultsBone union was achieved in 79 cases (98.75%). There was one case of non-union, two wound complications (one infection and one dehiscence), two cases of symptomatic hardware requiring hardware removal, and one stress fracture associated with recurrence of hallux valgus that required revision. The mean hallux valgus angle (HVA) improved from 30.5 ° ±10.4 ° to 10.1 ° ±6.6 ° (p < .001), the mean intermetatarsal angle (IMA) improved from 13.4 ° ±3.6 ° to 5.6 ° ±2.9 (p < .001), The average sesamoid position improved from stage 5.9 ± 1.6 to stage 2.6 ± 1.2 (p < .001). The mean shortening of the first metatarsal was 3.6 mm ± 1.8. There was no significant difference between measurements at 3 and 12 months postoperatively. ConclusionModified Lapidus with a planter plate and compression screw is a reliable method of fixation with a high union rate, permit an immediate protected weight bearing and a low complications rate. Level of evidenceIV; Retrospective study

Developing Machine Learning-Based Predictive Models for Hallux Valgus Recurrence Based on Measurements From Radiographs.

Machine learning (ML) is increasingly used to predict the prognosis of numerous diseases. This retrospective analysis aimed to develop a prediction model using ML algorithms and to identify predictors associated with the recurrence of hallux valgus (HV) following surgery. A total of 198 symptomatic feet that underwent chevron osteotomy combined with a distal soft tissue procedure were enrolled and analyzed from 2 independent medical centers. The feet were grouped according to nonrecurrence or recurrence based on 1-year follow-up outcomes. Preoperative weightbearing radiographs and immediate postoperative nonweightbearing radiographs were obtained for each HV foot. Radiographic measurements (eg, HV angle and intermetatarsal angle) were acquired and used for ML model training. A total of 9 commonly used ML models were trained on the data obtained from one institute (108 feet), and tested on the other data set from another independent institute (90 feet) for external validation. Optimal feature sets for each model were identified based on a 2000-resample bootstrap-based internal validation via an exhaustive search. The performance of each model was then tested on the external validation set. The area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model were calculated to evaluate the performance of each model. The support vector machine (SVM) model showed the highest predictive accuracy compared to other methods, with an AUC of 0.88 and an accuracy of 75.6%. Preoperative hallux valgus angle, tibial sesamoid position, postoperative intermetatarsal angle, and postoperative tibial sesamoid position were identified as the most selected features by several ML models. ML classifiers such as SVM could predict the recurrence of HV (an HVA >20 degrees) at a 1-year follow-up while identifying associated predictors in a multivariate manner. This study holds the potential for foot and ankle surgeons to effectively identify individuals at higher risk of HV recurrence postsurgery.

Improvement of Valgus Deviation of the Lesser Toes of Moderate to Severe Hallux Valgus After Proximal Chevron Metatarsal Osteotomy and Akin Osteotomy.

This study examines the correction of lesser toe valgus deviation following proximal chevron metatarsal osteotomy (PCMO) and Akin osteotomy in moderate to severe hallux valgus patients, while identifying influencing factors. Among 89 patients (116 feet), those with moderate to severe hallux valgus underwent PCMO and Akin osteotomy. Radiologic assessments included preoperative metatarsus adductus angle (MAA), hallux valgus angle (HVA), intermetatarsal angle (IMA), valgus angles of the second to fourth metatarsophalangeal joints, and hallux valgus recurrence. Assessments included visual analog scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient satisfaction over an average follow-up of 30.6 ± 21.2 (range, 12-99) months. The mean preoperative HVA of 34.4 degrees decreased to 8.7 degrees at final follow-up. The valgus angles of the second, third, and fourth toes improved by 37.1%, 27%, and 44.5%, respectively. In metatarsus adductus patients, lesser toe valgus angles were significantly higher both preoperatively and at final follow-up. Hallux valgus recurrence patients had higher preoperative and final follow-up IMA and valgus angles in the second and third toes. Nonrecurrence patients showed greater decreases in these angles. A larger HVA correction corresponded to a greater decrease in lesser toe valgus deviation. VAS and AOFAS scores improved significantly at the last follow-up. The study found a significant reduction in the valgus angle of the second, third, and fourth toes after PCMO and Akin osteotomy in moderate to severe hallux valgus cases, without additional surgeries on lesser toes. The lesser toe angular reductions were less pronounced in patients with metatarsus adductus or with hallux valgus recurrence. Level IV, case series.

Long-Term Results After Hallux Valgus Correction with Distal Metatarsal Reversed-L (ReveL) Osteotomy: Factors That Influence Recurrence and the Clinical Outcome.

This study aimed to evaluate the long-term results of hallux valgus correction with a distal metatarsal reversed-L (ReveL) osteotomy. Eighty-eight patients (131 feet) were evaluated after a mean follow-up of 14.2 years (range, 10 to 18 years). Weight-bearing foot radiographs were analyzed preoperatively, at 6 weeks postoperatively, and at the final follow-up for the following parameters: hallux valgus angle (HVA), intermetatarsal angle (IMA), first metatarsophalangeal joint (MTPJ) congruence angle, sesamoid position, presence of the round sign, and first MTPJ arthritis. The visual analog scale (VAS) and the Foot and Ankle Outcome Score (FAOS) assessed postoperative pain and function. Univariate and multivariable logistic regression analyses identified risk factors for hallux valgus recurrence and an inferior clinical outcome. All radiographic parameters significantly improved at the 6-week follow-up and the final follow-up (p < 0.001). The recurrence rate (HVA >20°) was 14%. A preoperative HVA of >28° (odds ratio [OR], 9.1; p = 0.02) and a 6-week postoperative HVA of >15° (OR, 4.6; p = 0.03) were independent risk factors for recurrence. At the final follow-up, all FAOS subscales resembled high postoperative function (median, 100 points [range of the interquartile range (IQR), 81 to 100 points]). A preoperative body mass index of >30 kg/m2 was associated with lower FAOS quality of life (QOL) (p = 0.04), and postoperative hallux varus was associated with lower FAOS activities of daily living (p = 0.048). Patients with first MTPJ arthritis of grade 2 or higher at the final follow-up had significantly lower FAOS subscales (p < 0.01) except for QOL. Hallux valgus recurrence did not influence the long-term outcome. A symptomatic implant was the main cause of revision (15%). In 94% of cases, the patients were satisfied with the hallux appearance and, in 92% of cases, the patients were satisfied with postoperative pain reduction. Hallux valgus correction with a ReveL osteotomy led to high long-term satisfaction rates. A preoperative HVA of >28° and a 6-week postoperative HVA of >15° increased the risk of hallux valgus recurrence. First MTPJ arthritis was the leading cause of inferior clinical results, whereas radiographic hallux valgus recurrence had no impact on the clinical results. First MTPJ arthritis at the final follow-up was associated with an inferior clinical outcome, whereas radiographic hallux valgus recurrence had no impact on the long-term clinical results. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Joint-Preserving Surgery for Hallux Valgus Deformity in Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that frequently causes forefoot deformities. Arthrodesis of the first metatarsophalangeal joint is a common surgery for severe hallux valgus. However, joint-preserving surgery can maintain the mobility of the joint. This study aimed to investigate the clinical and radiographic outcomes of distal chevron metatarsal osteotomy (DCMO) for correcting hallux valgus deformity associated with RA. Between August 2000 and December 2018, 18 consecutive patients with rheumatoid forefoot deformities (24 feet) underwent DCMO for hallux valgus with/without lesser toe surgery. Radiological evaluations were conducted, assessing the hallux valgus angle, the intermetatarsal angle between the first and second metatarsals, and the Sharp/van der Heijde score for erosion and joint space narrowing. Clinical outcomes were quantified using a visual analog scale for pain and the American Orthopaedic Foot and Ankle Society forefoot scores to measure function and alignment. The mean hallux valgus angle decreased from 38.0° (range, 25°-65°) preoperatively to 3.5° (range, 0°-17°) at the final follow-up (p < 0.05). The mean intermetatarsal angle decreased from 14.9° (range, 5°-22°) preoperatively to 4.3° (range, 2°-11°) at the final follow-up. (p < 0.05). Regarding the Sharp/van der Heijde score, the mean erosion score (0-10) showed no significant change, decreasing from 3.83 (range, 0-6) preoperatively to 3.54 (range, 0-4) at the final follow-up (p = 0.12). Recurrent hallux valgus was observed in 1 patient and postoperative hallux varus deformity was observed in 2 feet. Spontaneous fusion of the metatarsophalangeal joint developed in 1 case. DCMO resulted in satisfactory clinical and radiographic outcomes for correcting RA-associated hallux valgus deformity.

Relationship Between Hallux Valgus Recurrence and Sesamoid Position on AP Standing Radiographs After Distal Chevron Metatarsal Osteotomy

Category: Midfoot/Forefoot; Bunion Introduction/ Purpose: Recurrence of the hallux valgus deformity has various causes, and the incomplete reduction of sesamoids may be one of the important issues. However, we have seen several patients with postoperative lateral sesamoid displacement on AP standing radiographs who did not experience hallux valgus recurrence. Therefore, we hypothesized that lateral displacement of the sesamoid on AP standing radiographs does not cause hallux valgus recurrence. Methods: The study included 269 feet (185 patients) with hallux valgus treated with distal chevron metatarsal osteotomy. Mean patient age was 64.26 (range, 15–80) years. Patients were followed-up for an average of 33.85 (range, 12–228) months between April 2002 and December 2019. The patients were divided into four groups, according to the presence or absence of hallux valgus recurrence and sesamoid reduction. Results: During outpatient follow-up, we discovered 99 feet (42.1%) in which hallux valgus did not recur despite lateral sesamoid displacement (grade IV–VII) on AP standing radiographs. HVA, IMA, sesamoid grades all deteriorated over time after surgery, and each indicator was statistically significantly altered, and changes in the three indicators had a statistically significant positive correlation. Changes in HVA and IMA between feet with and without sesamoid reduction on AP standing radiographs increased over time, with the differences in HVA and IMA being significant at final follow-up. Regardless of whether sesamoid reduction was achieved on AP standing radiographs, the final analysis showed that HVA and IMA in both groups worsened over time. There were no differences between the two groups in the patterns of change over time. Conclusion: In our cohort postoperative sesamoid position on on AP standing radiographs was not associated with hallux valgus recurrence based on radiographic criteria.

Long Hallucal Tendon Force Vectors and First Metatarsophalangeal Deformity After Hallux Valgus Surgery

Category: Midfoot/Forefoot Introduction/Purpose: Recurrence is one of the most common complications following hallux valgus surgery. Moreover, hallux varus occurs in cases of overcorrection. We aimed to quantitatively measure, using radiographic examination, the dynamics of the soft tissues that act on deformities (recurrence of valgus and occurrence of varus) after the surgery. Methods: This retrospective single-institution study included 60 patients (98 feet) who underwent hallux valgus surgery between 2009 and 2018. According to radiographic findings of the foot under weightbearing conditions at postoperative month 1, we examined the tendons’ pathway and calculated the forces on the first metatarsophalangeal joint, which we termed the deformity force angle (DFA). We compared whether there was a significant difference in DFAs between the groups in which deformities occurred and those in which deformities did not occur after correction. In addition, the DFA was compared to known radiographic measurements of hallux valgus recurrence (hallux valgus angle, distal metatarsal articular angle, intermetatarsal angle, and sesamoid position) to assess association with recurrence. Results: We observed a significant difference in the DFA between patients with and without hallux valgus recurrence (P &lt; .001) and between those with and without hallux varus (P &lt; .001) based on standing radiographs taken at a minimum of 6 months postoperation. For predicting the deformities, the areas under the curve were 0.863 (hallux valgus recurrence) and 0.831 (hallux varus occurrence), respectively, which was greater than other factors evaluated. The DFA values greater than 9.5 degrees and less than 5.5 degrees were associated with the recurrence of valgus and occurrence of varus, respectively. Conclusion: In our study, DFA was associated with hallux valgus recurrence when it exceeded 9.5 degrees and hallux varus when it was less than 5.5 degrees. Moreover, in the hallux valgus surgery we performed, a DFA from 5.5 to 9.5 degrees appeared to be a “safe zone” for preventing early deformity after surgery.

Association between Postoperative Medial: Middle Intercuneiform Joint Gapping and Recurrence Rates in Hallux Valgus

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) is a triplanar deformity of the first metatarsal, which may extend beyond the first ray. Compared with normal feet, previous studies have found that HV patients have an increase in hypermobility of the joints along the medial column and at the medial – middle (MM) intercuneiform joint. Despite increased instability at the MM intercuneiform joint, no study has investigated its clinical significance. The primary purpose of this study was to determine if postoperative widening of the MM intercuneiform joint was associated with recurrence in HV patients who undergo a first tarsometatarsal fusion (modified Lapidus procedure). A secondary purpose was to investigate whether other HV imaging parameters were associated with a widening of the MM intercuneiform joint. Methods: This study included 52 consecutive HV patients who underwent a modified Lapidus procedure and had preoperative and at least 5-month postoperative weightbearing CT (WBCT) scans. Preoperative and postoperative measurements of HV deformity, including the intermetatarsal angle and hallux valgus angle (HVA) on plain radiographs and triplanar pronation angle and sesamoid station from WBCTs, were performed as previously described. MM intercuneiform distance was measured on the coronal multiplanar reconstructed WBCT scans after reorienting the axial and sagittal planes such that the coronal cuts were orthogonal to the intercuneiform joint (Figure 1A). Recurrence of the HV deformity was defined as a postoperative HVA ≥ 20°. Paired t-tests were used to compare preoperative and postoperative imaging parameters, and Mann-Whitney U tests were used to compare measurements between patients with and without HV recurrence. Pearson correlation coefficients were used to explore associations between preoperative and postoperative measurements and the change in MM intercuneiform distance. Results: Nine of 52 patients (17.3%) had recurrence of their HV deformity. For the entire cohort, the mean preoperative and postoperative MM intercuneiform distances were 0.73 mm (standard deviation (SD) 0.3) and 1.08 mm (SD 0.5), respectively. In patients with and without HV recurrence, the mean widening at the MM intercuneiform joint was 0.69 mm (95% confidence interval (CI) 0.52-0.86) and 0.27 mm (95% CI 0.17-0.38, P&lt; 0.001), respectively. Patients with recurrence had significantly greater widening of the MM intercuneiform joint than patients without recurrence (P=0.001, Figure 1B and Table 1). While no preoperative imaging parameters were associated with a change in the MM intercuneiform distance, increasing postoperative sesamoid position (r=0.32, P=0.022) and HVA (r=0.28, P=0.046) were correlated with a greater change MM intercuneiform joint gapping. Conclusion: In patients undergoing a modified Lapidus procedure for correction of their HV deformity, postoperative widening of the MM intercuneiform joint was associated with recurrence of the HV deformity. As understanding of the HV deformity continues to evolve, our study suggests that there is a complex interplay between deformity at the hallux metatarsophalangeal (MP) joint, reduction of the metatarsosesamoid joint complex, and the instability at the tarsometatarsal and intercuneiform joints. This may guide surgical correction as surgeons may need to address both intercuneiform instability and correction at the hallux MP joint in order to decrease HV recurrence rates.

Comparison of Mini Tightrope Intermetatarsal Fixation and Inter-Cuneiform Screw Fixation in Lapidus

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: First metatarso-cuneiform joint arthrodesis for treatment of metatarsus primus varus was originally introduced by Lapidus in 1934. In his technique, fixation was achieved using heavy chromic sutures between the first and second metatarsals to achieve parallel alignment. Since then, the indications and technique for Lapidus procedure have considerably evolved and many modifications have been introduced to Lapidus’s original description. Despite these modifications, recurrence of hallux valgus remains relatively common, either due to malunion at the TMT arthrodesis or through intercuneiform instability. This has informed the approach for additional fixation between the 1st and 2nd rays. This study aims to compare outcomes of inter-cuneiform screw fixation (ICS) and suspensory intermetatarsal fixation (SIM) using a mini-tightrope in terms of deformity correction and maintaining the correction over time. Methods: This was a retrospective comparative study of prospectively collected data for patients who have underwent a Lapidus procedure for hallux valgus between 2012-2022. The electronic medical records were reviewed for demographics, radiologic parameters, and operative data. Radiographic parameters were intermetatarsal angle (IMA), hallux valgus angle (HVA), and sesamoid station on preoperative, 3 months postoperatively and final follow-up. Hallux valgus station was graded from normal, mild, moderate, and severe based on the method used by Agrawal et al. Using a multivariate regression model, a comparison was conducted between suspensory intermetatarsal fixation(SIM) and inter-cuneiform screw fixation(ICS). Univariate linear regression analysis was conducted with the inclusion of covariates' age, smoking, diabetes, and BMI. Comparison of HVA and IMA was conducted using t-test. Results: 65 patients met the inclusion criteria; 20 had ICS, and 45 had SIM. The pre-op IMA improved from 13.57 (3.84) to 6.14 (2.41) degrees postoperatively in the ICS group (p), and from 13.37(3.84) to 6.16 (2.74) degrees postoperatively in the SIM group (p). The final follow-up IMA was 5.9 (2.1) in the ICS group and 6.84 (2.31) in the SIM group, with no difference from post-op values, p=0.123 and, respectively. There was no statistically significant difference between ICS and SIM groups in IMA at pre-op (p=0.41), post-op (p=0.49), and final follow up (p=0.62). There were no statistically significant differences between SIM and ICS groups in HVA preoperatively [37.47(12.21) vs. 40.38(13.59), p=0.19], postoperatively [18.2(10.82) vs. 18.95(10.1),p=0.36] or at final follow up [20.12(9.72) vs 19.33(9.16) ,p=0.38]. Conclusion: Lapidus procedure remains the procedure of choice for severe hallux valgus with predictable correction. Supplementing the first tarsometatarsal arthrodesis with suspensory intermetatarsal fixation using a mini-tightrope achieved similar deformity correction and preservation of correction to intercuneiform screw fixation.

Augmentation of the medial collateral ligament using suture tape reduces the recurrence after corrective surgery for severe hallux valgus

BackgroundThe severity of hallux valgus (HV) deformity is associated with recurrence after corrective surgery because of the degenerative change of the medial capsule including the medial collateral ligament (MCL) at the metatarsophalangeal joint. This study aimed to assess the effectiveness of the MCL augmentation using a suture tape anchor of the recurrence of HV and to evaluate the histological changes of the medial joint capsule in HV patients. MethodsThirty-four feet with severe hallux valgus were included and divided into 2 groups. Seventeen feet had the MCL reconstruction using suture tape anchor with a combination of the corrective osteotomy as the suture tape group (mean age, 64.0 years), and other seventeen feet had the corrective osteotomy without MCL reconstruction as the control group (mean age, 62.0 years). HV angle (HVA) and intermetatarsal angle (IMA) on the weight-bearing radiograms and the Japanese Society for Surgery of the Foot (JSSF) score in both groups were compared at the final follow-up. The medial capsule was harvested from other 20 feet with HV and the relationship between the severity of HV and the histological findings was analyzed. ResultsHVA, IMA, and JSSF scores in both groups were significantly improved from preoperatively to the final follow-up (P < 0.01). At the final follow-up, HVA in the suture tape group (9.2°) was significantly smaller than that in the control (15.4°) (P < 0.01). There were no significant differences in the IMA and the JSSF score at the final follow-up between both groups. Histological scores in HV with ≥40° HVA was significantly worse than those in <40°. ConclusionThe medial joint capsule in severe HV deformity showed the degenerative change and the MCL reconstruction using suture tape combined with osteotomy provides a strong medial constraint to prevent the recurrence of the deformity in severe hallux valgus. Level of Clinical Evidence3

Radiographic and Patient-Reported Outcomes of a Low-Cost Modified Lapidus Bunion Correction Technique.

The modified Lapidus (ML) is a powerful procedure for correction of hallux valgus (HV) with emerging techniques. Studies considering patient-reported outcomes, radiographic measures, complications, and implant costs are currently limited. Retrospective cohort with prospectively collected Patient Reported Outcome Information System Physical Function (PROMIS-PF) Computerized Adaptive Test (CAT) scores, radiographic parameters (intermetatarsal angle, IMA; hallux valgus angle, HVA; and tibial sesamoid position, TSP), complications, and total operative time and implant costs were reviewed from 2014 to 2019. Seventy-three feet (68 patients) underwent bunion correction by ML with lag-screw fixation. Median age was 55.8 years (IQR 45.6, 53.9), 4 of 73 (5.5%) were male, 11 of 73 (15.1%) were smokers, and 15 of 73 (20.6%) were diabetic (median HbA1c 6.4% [IQR 6.0, 7.4], none insulin dependent, 5 of 15 with neuropathy). Complications included 6 of 73 (8.2%) wound issues resolved with topical or oral treatment, 9 of 73 (12.3%) painful or broken hardware requiring hardware removal. Two of 73 (2.7%) had persistent pain despite union. One of 73 (1.4%) was overcorrected and required first MTP arthrodesis. Of 3 nonunions (2.7%), 1 resolved with corrected hypothyroidism, 1 was asymptomatic and required no treatment, 1 had a hallux valgus recurrence and sought revision surgery elsewhere. Preoperative radiographic angles were HVA 35 degrees, IMA 14 degrees which improved at final postoperative follow up to HVA 10 degrees, IMA 6 degrees. Tibial sesamoid position improved from 6.05 ± 1.00 to 2.22 ± 1.38. Thirty-two patients had preoperative and 42 had 1-year postoperative outcomes. PROMIS-PF (51% collection rate) was 43 (IQR 37,52) preoperatively, 37 (31, 39) at 6 weeks, 46 (42, 51) at 3 months, and 49 (41, 53) at >360 days postoperatively. The drop in PROMIS-PF between preoperative and 6 weeks and the rise from 6 weeks to 3 months were statistically significant. Pre- and postoperative PROMIS-PF scores were not significantly different. Implant cost averaged US$146. We report low complication rates and costs with high patient postoperative functional and radiographic outcomes. PROMIS-PF decreased acutely postoperatively but recovered and maintained high levels by 3 months postoperatively. Level IV, case series.

Medial Reduction in Sesamoid Position after Hallux Valgus Correction Surgery Showed Better Outcome in S.E.R.I. Osteotomy than DCMO

Background: The purpose of the present study was to compare the degree of sesamoid reduction after hallux valgus correction between distal chevron metatarsal osteotomy (DCMO) and S.E.R.I. (simple, effective, rapid, and inexpensive) osteotomy, and to analyze the effects on the recurrence of hallux valgus. Methods: We retrospectively analyzed the foot radiographs of 60 feet (30 DCMO and 30 SERI) treated for hallux valgus from August 2013 to July 2017. Radiographic assessments were performed preoperatively, at early follow-up (at a mean of 3.1 months) and at the most recent follow-up (at a mean of 16.7 months). The location of the medial sesamoid was classified into seven stages, in accordance with the method described by Hardy and Clapham; stage IV or less was defined as the normal position for the medial sesamoid, and stage V or greater was defined as lateral displacement of the sesamoid. The pre- and post-operative hallux valgus angle, 1–2 intermetatarsal angle, and sesamoid position were compared between the two groups. Results: The mean follow-up period was 18.4 (12–36) months in the DCMO group and 15.0 (12–36) months in the S.E.R.I. group (p = 0.108). The radiologic results showed that the hallux valgus angles were not significantly different between the two groups preoperatively and at the early follow-up: preoperatively, they were 28.8 ± 7.7 in the DCMO group and 32.6 ± 9.5 in the S.E.R.I. group (p = 0.101), and they were 10.4 ± 4.0 and 8.7 ± 5.0 (p = 0.148) at the early follow-up, respectively. However, at the most recent follow-up, the DCMO group (13.9 ± 5.6) showed significantly higher hallux valgus angles than the S.E.R.I. group (10.4 ± 6.4, p = 0.030), and there were no differences between the recurrence of hallux valgus in the DCMO group (13%)and that in the S.E.R.I. group (10%) (p = 0.553). There were no significant differences in the 1–2 intermetatarsal angles between the two groups at the early follow-up (6.1 ± 2.5 vs. 4.8 ± 3.1, p = 0.082) and at the most recent follow-up (7.3 ± 2.9 vs. 6.6 ± 3.5, p = 0.408). After hallux-valgus-correction surgery, the stage change of the tibia sesamoid position from the preoperative stage to the initial follow-up was significantly larger in the S.E.R.I. group (−4.4 ± 1.4) than in the DCMO group (−3.4 ± 1.1) (p = 0.003); the changes from the preoperative stage to the last follow-up were also significantly larger in the SERI group (−3.3 ± 1.7) than in the DCMO group (−2.4 ± 1.5) (p = 0.028); however, the changes from the initial follow-up to the last follow-up showed no significant differences between the two groups (+1.0 ± 1.1 in the DCMO group vs. +1.1 ± 1.2 in the S.E.R.I. group) (p = 0.822). The medial sesamoid was laterally subluxated in all the preoperative cases in the DCMO and S.E.R.I. groups. The lateral subluxation of the tibia sesamoid was more frequently observed in the DCMO group (four cases, 13%) than in the S.E.R.I. group (0 cases, 0%) (p = 0.038) at the early follow-up. Conclusion: In conclusion, our results demonstrated that the S.E.R.I. procedure is superior to DCMO in decreasing the hallux valgus angle and showed that the early post-operative reduction in the sesamoids can be a risk factor for the recurrence of hallux valgus.

Recurrence Rates With Longer-Term Follow-up After Hallux Valgus Surgical Treatment With Distal Metatarsal Osteotomies: A Systematic Review and Meta-analysis.

Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years. This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years. We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and "others." The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees. At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques. Level IV, meta-analysis.

Long Hallucal Tendon Force Vectors and First Metatarsophalangeal Deformity After Hallux Valgus Surgery.

Recurrence is one of the most common complications following hallux valgus surgery. Moreover, hallux varus occurs in cases of overcorrection. We aimed to quantitatively measure, using radiographic examination, the dynamics of the soft tissues that act on deformities (recurrence of valgus and occurrence of varus) after the surgery. This retrospective single-institution study included 60 patients (98 feet) who underwent hallux valgus surgery between 2009 and 2018. According to radiographic findings of the foot under weightbearing conditions at postoperative month 1, we examined the tendons' pathway and calculated the forces on the first metatarsophalangeal joint, which we termed the deformity force angle (DFA). We compared whether there was a significant difference in DFAs between the groups in which deformities occurred and those in which deformities did not occur after correction. In addition, the DFA was compared to known radiographic measurements of hallux valgus recurrence (hallux valgus angle, distal metatarsal articular angle, intermetatarsal angle, and sesamoid position) to assess association with recurrence. We observed a significant difference in the DFA between patients with and without hallux valgus recurrence (P < .001) and between those with and without hallux varus (P < .001) based on standing radiographs taken at a minimum of 6 months postoperation. For predicting the deformities, the areas under the curve were 0.863 (hallux valgus recurrence) and 0.831 (hallux varus occurrence), respectively, which was greater than other factors evaluated. The DFA values greater than 9.5 degrees and less than 5.5 degrees were associated with the recurrence of valgus and occurrence of varus, respectively. In our study, DFA was associated with hallux valgus recurrence when it exceeded 9.5 degrees and hallux varus when it was less than 5.5 degrees. Moreover, in the hallux valgus surgery we performed, a DFA from 5.5 to 9.5 degrees appeared to be a "safe zone" for preventing early deformity after surgery. Level III, prognostic.

Relationship Between Hallux Valgus Recurrence and Sesamoid Position on Anteroposterior Standing Radiographs After Distal Chevron Metatarsal Osteotomy.

Recurrence of the hallux valgus deformity has various causes, and the incomplete reduction of sesamoids may be one of the important issues. However, we have seen several patients with postoperative lateral sesamoid displacement on anteroposterior (AP) standing radiographs who did not experience hallux valgus recurrence. Therefore, we hypothesized that lateral displacement of the sesamoid on AP standing radiographs does not cause hallux valgus recurrence. The study included 269 feet (185 patients) with hallux valgus treated with distal chevron metatarsal osteotomy. Mean patient age was 64.26 (range, 15-80) years. Patients were followed up for an average of 33.85 (range, 12-228) months between April 2002 and December 2019. The patients were divided into 4 groups, according to the presence or absence of hallux valgus recurrence and sesamoid reduction. During outpatient follow-up, we discovered 99 feet (42.1%) in which hallux valgus did not recur despite lateral sesamoid displacement (grade IV-VII) on AP standing radiographs. Hallux valgus angle (HVA, 2.7 to 7.9 degrees), intermetatarsal angle (IMA, 4.6 to 6.2 degrees), and sesamoid grades (2.1 to 3.5) all deteriorated over time after surgery, and each indicator was statistically significantly altered, and changes in the 3 indicators had a statistically significant positive correlation. Changes in HVA and IMA between feet with and without sesamoid reduction on AP standing radiographs increased over time, with the differences in HVA (2.9 degrees) and IMA (0.9 degrees) being significant at final follow-up (P < .05 for each). Regardless of whether sesamoid reduction was achieved on AP standing radiographs, the final analysis showed that HVA and IMA in both groups worsened over time. Further, there were no differences between the 2 groups in the patterns of change over time. In our cohort, postoperative sesamoid position on AP standing radiographs was not associated with hallux valgus recurrence based on radiographic criteria. Level III, retrospective comparative study.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints

BackgroundHallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint. MethodsFifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft. ResultsThe mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0–3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints). ConclusionsThe clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates. Level of evidenceLevel IV, retrospective case series.

Indication and Consideration of Minimally Invasive Bosh Akin (MIBA) for Salvage in Recurrence of Hallux Valgus

Category: Bunion Introduction/Purpose: Hallux valgus recurrence is a common complication to consider, depending on the different series it has an incidence of between 5-15%, being one of the most frequent complications reported after surgical surgery, however, not all of them require surgical treatment. This has a multifactorial origin with factors depending on the surgeon, the chosen surgical technique and some components of the deformity not completely corrected during the initial surgery. In cases where this recurrence requires surgical correction, it is a challenge for both the patient and the surgical team, and the success of the treatment depends on correct identification of the cause of failure after primary surgery and correct surgical planning. We present some technical considerations for choosing a minimally invasive osteotomy in this cases. Methods: The inappropriate selection of the technique in a patient with a recurrence of hallux valgus has a high rate of failure. In this sense, we must carry out a precise preoperative evaluation of the patients, both clinical and radiological, using weight-bearing X-rays or even a Weight-bearing CT scan that allows Adequate planning to evaluate rotation and pronation of the metatarsal more reliably, associated with an evaluation of sesamoid subluxation, possible signs of cuneometatarsal instability, such as plantar gap, articular facet obliquity, cortical thickening of the 2nd metatarsal. This also allows us to confirm the presence of metatarsophalangeal arthrosis, or sesamoid metatarsal arthritis that could influence our decision algorithm. Results: Similar to a primary hallux valgus, an asymptomatic deformity should only be observed and if it becomes symptomatic or has a considerable rate of progression, it should be treated surgically. In cases of symptomatic deformities we should always consider the presence of metatarsophalangeal osteoarthritis, medial column instability, if these are not present as indicated by Raikin in his algorithm proposed in 2014, we consider an osteotomy as a revision procedure in a recurrent hallux. In this scenario, we have considered this alternative for selected cases, using the minimally invasive Bosh Akin (MIBA) technique, as a salvage alternative in surgery for recurrences of Hallux valgus. We present a series of 4 feet successfully treated with MIBA osteotomy Conclusion: The application of the miba osteotomy is an effective alternative for the treatment of recurrence of Hallux valgus, which achieves results similar to other open rescue techniques with less aggression of soft tissue

A Systematic Review of Open and Minimally Invasive Surgery for Treating Recurrent Hallux Valgus.

Background Despite advancements in primary correction of hallux valgus (HV), significant rates of reoperation remain across common techniques, with complications following primary correction up to 50% according to some studies. 1 This study explored different methods of surgery currently used in treating HV recurrence specifically (for which literature on the subject has been limited), evaluating open and adapted minimally invasive surgical (MIS) primary techniques used for revision. Methods In December 2020, literature search for both open and MIS surgical techniques in HV revision was conducted using PubMed, EMBASE, and MEDLINE library databases. Results and Conclusion Of initial 143 publications, 10 were finally included for data synthesis including 273 patients and 301 feet. Out of 301 feet, 80 (26.6%) underwent revision with MIS techniques (involving distal metatarsal osteotomies). Those undergoing grouped MIS revisions had an average improvement of 38.3 in their American Orthopaedic Foot and Ankle Society score, compared to 26.8 in those using open techniques. Revision approaches using grouped MIS techniques showed a postoperative reduction in intermetatarsal angle and HV angle of 5.6 and 18.4 degrees, respectively, compared to 15.5 and 4.4 degrees, respectively, for open techniques. There are, however, limitations in the current literature on MIS techniques in revision HV surgery specifically. MIS techniques grouped did not show worse outcomes or safety concerns compared to open techniques.

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.