Severe Hallux Valgus Deformity Research Articles

Investigation of the relationship between hallux valgus, quadriceps angle, and body image perception in young adults

Purpose: Our study aimed to identify the presence and severity of hallux valgus deformity in young adults, using both by the Manchester classification and goniometry, to evaluate the Quadriceps angle (Q angle), and to examine the relationship between some anatomical parameters and body image perception. Materials and Methods: A total of 158 individuals aged 18-30 (111 females, 47 males) who voluntarily agreed to participate in the study were included. Demographic characteristics, Quadriceps angle, and hallux valgus angle were measured. Hallux valgus and Quadriceps angles were determined using a goniometer, while the Manchester scale was employed to evaluate the level of Hallux valgus deformity. The Golden Ratio for the lower extremity was calculated by taking the ratio of lower extremity length to leg length, and the body image perception score was determined. Results: Body weight, height and body mass index showed statistically significant differences in terms of gender, while age parameter did not show statistically significant difference between genders. Also, no significant difference in Quadriceps angle was observed between genders for both right and left sides, while a significant difference in Hallux valgus angle was noted. A high, positive, and significant relationship was found between Manchester classification and hallux valgus, while Golden ratio values did not significantly differ by gender. Additionally, body image perception scores were higher in males (162.60±25.45 points) than in females (153.51±25.89 points). Conclusion: Deviations from their normal values of the hallux valgus and quadriceps angle which affect the musculoskeletal system, may lead to some health problems, as well as difficulties in performing daily life activities, and concerns about aesthetics. Failure to fulfil one’s normal functions or not to find oneself aesthetically insufficient will also make it likely that the body image perception will deteriorate.

Outcome comparison of minimally invasive proximal and distal chevron Akin osteotomies in patients with severe hallux valgus deformity: A randomized prospective study.

To date, the surgical treatment of severe hallux valgus deformity remains challenging despite the various methods presented. This study aimed to compare the effectiveness of minimally invasive distal chevron Akin osteotomies (d-MICA) and minimally invasive proximal chevron Akin osteotomies (p-MICA) in correcting severe hallux valgus deformities. This prospective follow-up study included patients randomly assigned to undergo p-MICA or d-MICA for hallux valgus deformities with a preoperative hallux valgus angle (HVA) ≥ 40° and/or a first to second intermetatarsal angle (IMA) ≥ 16°. After a minimum follow-up period of twoyears, we compared various clinico-radiographic parameters of patients whose HVA exceeded 15° at the final follow-up. In the p-MICA and d-MICA groups, seven of 40 cases (17.5%) and 16 of 41 cases (39.0%), respectively, exhibited HVA > 15° at the final follow-up (P = 0.048). The preoperative parameters showed no significant differences. However, at the first weight-bearing assessment, the HVA, IMA, and relative second metatarsal length were significantly smaller, and the distal metatarsal articular angle (DMAA) was greater in the p-MICA group (all P < 0.05) compared with the d-MICA group. Postoperatively, both groups exhibited significant decreases in HVA and IMA at the final follow-up (P < 0.001 for all parameters). The p-MICA group showed no significant changes in DMAA and the relative length of the second metatarsal (P = 0.253 and 0.185, respectively). However, the d-MICA group showed a significant decrease in DMAA (P < 0.001) and an increase in the relative length of the second metatarsal at the final follow-up (P = 0.01). p-MICA and d-MICA procedures demonstrated effective correction potential for severe hallux valgus deformities; however, the d-MICA procedure exhibited a notably higher incidence of unsatisfactory correction at the final follow-up than p-MICA. Therefore, d-MICA may be less predictable in achieving successful outcomes than p-MICA in treating severe hallux valgus deformities.

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

Radiologic and Clinical Outcomes of the Dovetailed Notch Scarf Osteotomy for Correcting the First Metatarsal Pronation in Moderate to Severe Hallux Valgus Deformity: A Comparative Study.

The traditional scarf osteotomy (TSO) has limited ability to correct the first metatarsal pronation. A novel modification that we refer to as a "dovetailed notch scarf osteotomy" (DNSO) has been developed to enhance the ability to correct coronal plane pronation. The study aimed to observe and compare TSO to DNSO in the treatment of moderate to severe hallux valgus deformity. This retrospective study included 78 feet that had a TSO and 105 feet that had a DNSO. Minimum follow-up was 24 months. Weightbearing computed tomography (WBCT) and weightbearing anterior-posterior (AP) radiographs were taken preoperatively and at the last follow-up. We measured the intermetatarsal angle (IMA), hallux valgus angle, distal metatarsal articular surface angle on AP radiographs and first metatarsal coronal pronation angle (α angle), tibial sesamoid coronal grading, and first metatarsal length on WBCT. Clinical assessment was done using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, Foot and Ankle Ability Measure (FAAM), and the 36-Item Short Form Health Survey (SF-36). The occurrence of postoperative complications was also documented. The DNSO group exhibited a significantly higher correction amount of α angle and IMA (14.3 ± 9.9 and 10.3 ± 4.6 degrees) than the TSO group (8.6 ± 5.9 and 5.4 ± 5.9 degrees) during the final follow-up assessment (P < .05).The DNSO group (10.1 [8.0-12.0] degrees and 4.8 [3.9-5.6] degrees) demonstrated significantly smaller α angle and IMA compared with the TSO group (4.8 [3.9-5.6] degrees and 9.5 [7.5-11.5] degrees) at 24 months postsurgery (P < .05). The postoperative FAAM activities of daily living and SF-36 physical functioning scores were significantly higher in the DNSO group (97.2 ± 3.3 and 95.7 ± 4.4 points) compared with the TSO group (92.3 ± 3.3 and 87.7 ± 8.7 points) (P < .05). Additionally, hallux varus occurred in 1 case in the DNSO group, whereas 4 cases were observed in the TSO group. Two osteotomy methods can effectively correct moderate to severe hallux valgus deformity. Compared with the TSO, the DNSO has stronger correction ability. The most crucial aspect lies in its controllability when correcting first metatarsal pronation and addressing IMA. Level III, retrospective comparative study.

Percutaneous distal chevron osteotomy is associated with lower immediate postoperative pain and a greater range of motion than the open technique: A prospective randomized study.

The results of past studies comparing percutaneous techniques with traditional open techniques for hallux valgus are controversial. Therefore, this study aimed to compare the radiologic and clinical outcomes of percutaneous and open distal chevron osteotomies. Seventy-one patients with mild to severe hallux valgus deformity were randomized to undergo percutaneous distal chevron osteotomy (percutaneous group, n = 36) or open distal chevron osteotomy (open group, n = 35) between October 2019 and September 2020. Radiological and clinical outcomes were assessed preoperatively and postoperatively. Outcome measures included the foot and ankle outcome score, foot functional index, visual analogue scale (VAS) scores for pain, range of motion (ROM) of the first metatarsophalangeal (MTP) joint, hallux valgus angle, intermetatarsal angle, and first metatarsal shortening. Additionally, the first metatarsal declination angle was measured to evaluate sagittal malunion. The mean first metatarsal declination angle decreased significantly at 12 months postoperatively in both groups (p = 0.021 and p < 0.001 in the percutaneous and open groups, respectively), and the decrement was significantly greater in the open group (p = 0.033). The mean VAS score for pain on postoperative day one was 4.2 ± 1.9 and 5.3 ± 1.7 in the percutaneous and open groups, respectively (p = 0.019). The mean ROM of the first MTP joint did not change significantly after surgery, from 72.5 ± 7.5 preoperatively to 71.0 ± 9.5 at 12 months postoperatively in the percutaneous group (p = 0.215); however, it decreased significantly from 70.6 ± 7.3 preoperatively to 63.4 ± 10.4 at 12 months postoperatively in the open group (p < 0.001). There were no significant differences between the groups regarding other clinical outcomes. The percutaneous group showed a lower immediate pain level at postoperative day 1 and better ROM of the first MTP joint at 12 months postoperatively.

Clinical comparative study on resection and non-resection of the fifth metatarsal to rheumatoid forefoot deformity

To explore clinical effect of the fifth metatarsal head excision and non-excision in rheumatoid arthritis (RA) forefoot deformity reconstruction. Retrospective analysis was performed on 50 patients (76 feet) with moderate to severe forefoot deformity caused by RA treated from May 2015 to January 2019. According to degeneration of the fifth metatarsophalangeal joint,the fifth metatarsal head was retained or excised by wind-like forefoot reconstruction,and divided into the fifth metatarsal head preservation group (preservation group) and the fifth metatarsal head resection group (resection group). Twenty-four female patients in preservation group,aged from 47 to 81 years old with an average of (60.37±8.60) years old;the course of disease ranged from 13 to 22 years with an average of (19.00±3.06) years;body mass index (BMI) ranged from 21 to 28 kg·m-2 with an average of (23.53±2.47) kg·m-2;six patients (6 feet) with moderate hallux valgus deformity and 18 patients (30 feet) with severe hallux valgus deformity;treated with the first metatarsophalangeal joint fusion combined with the second th the fourth metatarsophalangeal joint arthroplasty and the fifth metatarsophalangeal joint cleanup. Twenty-six female patients in resection group were female,aged from 30 to 80 years old with an average of (58.53±13.70) years old;the course of disease ranged from 8 to 25 years with an average of (17.94±3.92) years;BMI raged from 20 to 28 kg·m-2 with an average of (24.60±2.03) kg·m-2;4 patients (4 feet) with moderate bunion valgus deformity and 22 patients (36 feet) with severe bunion valgus deformity;treated by the first metatarsophalangeal joint fusion combined with the second th the fifth metatarsophalangeal joint resection of the metatarsophalangeal head. Operation time and postoperative complications between two groups were observed,hallux valgus angle (HVA),intermetatarsal angles between the first and the second metatarsals (IMAFS),intermetatarsal angles between the first and fifth metatarsals (IMAFF),Japanese Society for Surgery of Foot (JSSF) score before surgery and at the latest follow-up were compared. Fifty patients were followed-up from 14 to 46(25.30±8.83) months in resection group and 12 to 48 with an average of (24.30±11.12) months in preservation group,while no significant difference between two groups (P>0.05). There were no significant difference in operation time and postoperative complications between two groups (P>0.05). JSSF scores,HVA,IMAFS and IMAFF in fesection group were improved from (45.09±3.35) points,(38.90±13.67) °,(12.88±1.72) °,(32.50±2.99) ° before operation to (81.60±3.27) points,(15.40±0.90),(9.06±2.27) °,(22.20±1.98) ° at the latest follow-up (P<0.05);preservation group were improved from (47.09±3.96) points,(43.30±12.65) °,(13.99±3.13) °,(33.20±6.14) ° to (83.10±3.66) points,(15.20±1.54) °,(8.99±1.02) °,(24.70±1.88) °,respectively. There were no significant difference in JSSF score,HVA,IMAFS and IMAFF between two groups before operation and the latest follow-up (P>0.05). At the latest follow-up,there were statistically significant differences in pain and deformity in JSSF scores between two groups (P<0.05). Both rheumatoid anterior foot reconstruction and anterior foot reconstruction fifth metatarsophalangeal joint debridement showed significant improvement in clinical efficacy and imaging results. Compared with rheumatoid prefoot reconstruction,the fifth metatarsophalangeal joint reconstruction for the treatment of moderate and severe deformity of rheumatoid prefoot showed better improvement in pain,but worse improvement in deformity. For the moderate to severe deformity of the forefoot caused by rheumatoid disease,patients with mild to moderate degenerative deformity of the articular surface of the fifth metatarsal phalanges may be considered for use.

Weightbearing Imaging Assessment of Midfoot Instability in Patients with Confirmed Hallux Valgus Deformity: A Systematic Review of the Literature.

Hallux valgus deformity (HVD) involves subluxation of the first metatarsophalangeal joint. While HVD is primarily considered a forefoot condition, midfoot instability may play a significant role in its development and severity. However, very few studies have placed a heavy emphasis on studying this phenomenon. Therefore, this review had a particular focus on understanding midfoot instability based on weightbearing imaging assessments of the TMT joint. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched five databases for studies on midfoot instability in HVD patients. The severity of HVD was defined by hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA). Data was extracted, and articles were graded using the Methodological Index for Non-Randomized Studies (MINORS). Of 547 initially retrieved articles, 23 met the inclusion criteria. Patients with HVD showed higher HVA and DMAA on weightbearing radiographs (WBRG) and weightbearing computed tomography (WBCT) compared to healthy individuals. Midfoot instability was assessed through intermetatarsal angle (IMA) and tarsometatarsal angle (TMT angle). Patients with HVD exhibited greater IMA and TMT angles on both WBRG and WBCT. This review highlights the importance of weightbearing imaging assessments for midfoot instability in HVD. IMA and TMT angles can differentiate between healthy individuals and HVD patients, emphasizing the significance of midfoot assessment in understanding HVD pathology. These findings validate the limited evidence thus far in the literature pertaining to consistent midfoot instability in HVD patients and are able to provide ample reasoning for physicians to place a larger emphasis on midfoot imaging when assessing HVD in its entirety.

Comparison of Radiographic and Clinical Outcomes between Distal and Proximal Minimally Invasive Chevron and Akin Osteotomy for Severe Hallux Valgus Deformity

Category: Midfoot/Forefoot; Midfoot/Forefoot Introduction/Purpose: The surgical treatment of severe hallux valgus (HV) deformity is challenging due to the difficulty in achieving sufficient reduction and the increased risk of complications such as recurrence, delayed or non-union. Minimally invasive surgery (MIS) has been increasingly used to treat HV deformity, with the third-generation minimally invasive Chevron and Akin osteotomies (MICA) technique being widely accepted. This retrospective cohort study aimed to compare the radiographic and clinical outcomes between the distal and proximal MICA techniques for severe hallux valgus deformity. It was hypothesized that the proximal MICA technique would provide better radiographic results due to the stronger deformity correction achieved by the proximal metatarsal osteotomy. Methods: Seventy-four feet with severe HV (defined as HVA [≥40 degrees] and/or IMA [≥20 degrees]) treated with distal MICA (40 feet) or proximal MICA (34 feet) were included in this study after at least one year of follow-up. Clinical assessment included the American Orthopaedic Foot &amp; Ankle Society (AOFAS) score, pain visual analog scale (VAS), patient satisfaction rating, and complications. Radiographic assessments included HV angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Results: There were no differences in the mean AOFAS score, pain VAS score, and patient satisfaction rate at the final follow-up between the two groups (all p &gt; .05). The mean postoperative HVA, IMA, and DMAA significantly improved at the final follow-up in both groups (all p &lt; .001). There was no significant difference in the improvement of radiographic values after surgery between the two groups (all p &gt; 0.05). Although not statistically significant, there was a trend toward a higher recurrence and delayed or nonunion rate in the distal MICA group (7.5% vs. 2.9%, P =.218 and 10% vs. 2.9%, P =.072). Conclusion: Both types of minimally invasive techniques resulted in satisfactory outcomes in terms of significant improvement in clinical values, large deformity correction, and reasonable complication rates. However, the proximal MICA technique appears to provide more stable maintenance of deformity correction than the distal technique.

Biomechanical Evaluation of 4th Generation Minimally Invasive Distal First Metatarsal Osteotomy-Akin Osteotomy Technique on First Ray Articular Contact Properties

Category: Bunion; Basic Sciences/Biologics Introduction/Purpose: Hallux valgus is a common deformity encountered, but remains a complex clinical entity. Fourth generation minimally invasive (MIS) techniques consisting of a percutaneous distal metatarsal transverse osteotomy combined with an Akin osteotomy have been utilized to address mild to severe hallux valgus deformities. Benefits of a MIS approach include improved cosmesis, faster recovery, lower opiate requirement, immediate weightbearing, and favorable outcomes relative to a traditional, open procedure. An understudied area with respect to hallux valgus correction is the effect that osteotomies can have on the articular contact properties of the first ray following correction. Methods: Sixteen paired cadaveric specimens were dissected to include the first ray and tested in a customized apparatus. Specimens were randomized to receive a distal transverse osteotomy translated either 50% or 100% of the width of the first metatarsal shaft. The osteotomy was performed with either a 00or 200 distal angulation of the burr relative to the shaft in the axial plane. Specimens were tested in the intact state and following the distal first metatarsal osteotomy for peak pressure, contact area, contact force and center of pressure at the first metarsophalangeal joint (MTP) and first tarsometatarsal joint (TMT). An Akin osteotomy was then performed on each specimen and peak pressure, contact area, contact force and center of pressure were recalculated. Results: There was a notable decrease in peak pressure, contact area, and contact force across the TMT joint with greater shifts of the capital fragment. However, at 100% translation of the capital fragment, distal angulation of the osteotomy by 200 appears to improve loading across the TMT joint. Addition of the Akin osteotomy at 100% translation also aids in increasing the contact force across the TMT joint. The MTP joint is less sensitive to changes in shifts and angulation of the capital fragment. The Akin osteotomy also leads to increased contact force across the MTP joint when the capital fragment is translated 100%. Conclusion: While the clinical significance is unknown, larger shifts of the capital fragment lead to greater load alterations at the level of the TMT joint than the MTP joint. Distal angulation of the capital fragment and the addition of an Akin osteotomy can aid in reducing the size of those changes. The Akin can lead to increased contact forces at the MTP joint with 100% translation of the capital fragment.

Modified Endoscopic Distal Soft Tissue Procedure (mEDSTP) and Arthroscopic Lapidus Arthrodesis for Correction of Severe Hallux Valgus

Hallux valgus is one of the most common forefoot deformities faced by foot and ankle surgeons. Symptomatic deformity usually needs surgical correction. Endoscopic techniques of hallux valgus correction have been reported that are based on the same principle of the classic distal soft tissue procedure. Recently, the technique has been modified to include reconstruction of the medial metatarsosesamoid ligament and augmentation of the intermetatarsal ligament. In severe deformity or the presence of hypermobility or painful degeneration of the first tarsometatarsal joint, Lapidus arthrodesis of the joint is indicated. Arthroscopic Lapidus arthrodesis has been reported to reduce the complications associated with open procedure, including first metatarsal shortening, metatarsal elevatus, and nonunion. In this technical note, the technical details of a combined modified endoscopic distal soft tissue procedure and arthroscopic Lapidus arthrodesis is described. This is a minimally invasive approach for correction of severe hallux valgus deformity, especially that associated with ligamentous laxity.

Arthroscopic Sesamoidectomy and Plantar Metatarsal Head Bone Shaving in Management of First Metatarsal Head Metatarsalgia After First Metatarsophalangeal Fusion

First metatarsophalangeal arthrodesis has been used to treat end-stage arthritis of the great toe (e.g., gout, post-traumatic, infection), severe hallux valgus deformity, hallux valgus caused by neuromuscular disorders, rheumatoid forefoot deformity, primary hallux varus, and rigid plantarflexion deformities, as well as a salvage procedure for failed previous operation of the great toe. As with any arthrodesis procedure, proper positioning of the hallux in first metatarsophalangeal arthrodesis is of utmost importance for good clinical outcome. The chief problem tends to be sagittal alignment. In case of the significant dorsiflexion malunion of the fusion site with excessive plantar pressure of the first metatarsophalangeal joint and abutment of the hallux to the shoebox, corrective osteotomy is indicated. If there is isolated excessive plantar pressure of the first metatarsophalangeal joint without hallux problem, arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head is another surgical option. The purpose of this technical note is to describe the details of arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head.

Indications and possible limitations using medio-plantar plate systems in tarsometatarsal 1 fusions – A cadaveric study

BackgroundThe tarsometatarsal 1 arthrodesis is an adequate treatment for moderate to severe hallux valgus deformity and instability of the first ray. Plantar plating arthrodesis has been shown to provide better mechanical stability and fewer postoperative complications than screw fixation or medial plating. The medio-plantar plate is a new plate design for Lapidus arthrodesis. It could combine the biomechanical advantages of the plantar plate and the anatomical overview of a medial plate. However, the implanted material can cause irritation of the tibialis anterior, which in some cases may require removal of the material. The purpose of this study was to examine the possibility of tendon irritation following medio-plantar first tarsometatarsal joint arthrodesis using cadaveric specimens. MethodsThe study involved the simulated surgical procedure of medio-plantar plate arthrodesis on 30 lower extremities. After the plates were fixed, a thorough examination of the feet was conducted to assess any tendon irritation and to determine a recommendation for placement of the medio-plantar plate based on the Olewnik classification. ResultsIrritation of the tibialis anterior tendon components with the medio-plantar plate depends mainly on the anatomic norm variant, classified according to Olewnik et al. A medio-plantar plate is particularly recommended in TA tendon Olewnik type 3 and type 5. The positioning of a medio-plantar plate in Olewnik type 1 and type 2 tendons depends on the anatomic fit of the medio-plantar plate and the bony configuration of the TMT 1 joint. A large portion of the TA tendon must be detached, so a different plate design may be preferred in these patients. ConclusionsTMT 1 arthrodesis with medio-plantar plating of the first tarsometatarsal joint should be performed considering the anatomic TA tendon variations. Level of evidenceLevel V, Expert Opinion includes Case Reports and Technique Tips.

Minimally Invasive Transverse Distal Metatarsal Osteotomy (MITO) for Hallux Valgus Correction: Early Outcomes of Mild to Moderate vs Severe Deformities.

We compared the radiological and clinical outcomes of mild to moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon. Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) >40 degrees or preoperative first-to-second intermetatarsal angle (1-2 IMA) >16 degrees; the mild to moderate group was defined as having an HVA <40 degrees and a 1-2 IMA <16 degrees. Pre- and postoperative measurements of the HVA, 1-2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The visual analog scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 physical component summary were used to assess clinical outcomes. A total of 116 feet were included in this study and median follow-up period of 29.0 months (range, 24-52 months). Both groups showed significant improvements in all radiologic parameters postoperatively, with the degrees of correction greater in the severe group than in the mild to moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups. This study showed that short-term radiographic results for patients with either mild to moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. In this series, we found MITO with screw fixation to be a satisfactory surgical option for patients with mild to severe HV deformities. Level III, retrospective comparative study.

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

Biomechanical Evaluation of Fourth Generation Minimally Invasive Distal First Metatarsal Osteotomy-Akin Osteotomy Technique on First Ray Articular Contact Properties.

Hallux valgus is a common deformity encountered but remains a complex clinical entity. Fourth-generation minimally invasive surgery (MIS) techniques consisting of a percutaneous distal metatarsal transverse osteotomy combined with an Akin osteotomy have been used to address mild to severe hallux valgus deformities. The benefits of an MIS approach include improved cosmesis, faster recovery, lower opiate requirement, immediate weightbearing, and favorable outcomes relative to a traditional, open procedure. An understudied area with respect to hallux valgus correction is the effect that osteotomies can have on the articular contact properties of the first ray following correction. Sixteen paired cadaveric specimens were dissected to include the first ray and tested in a customized apparatus. Specimens were randomized to receive a distal transverse osteotomy translated either 50% or 100% of the width of the first metatarsal shaft. The osteotomy was performed with either a 0° or 20° distal angulation of the burr relative to the shaft in the axial plane. Specimens were tested in the intact state and following the distal first metatarsal osteotomy for peak pressure, contact area, contact force and center of pressure at the first metatarsophalangeal (MTP) and first tarsometatarsal (TMT) joints. An Akin osteotomy was then performed on each specimen, and peak pressure, contact area, contact force, and center of pressure were recalculated. There was a notable decrease in peak pressure, contact area, and contact force across the TMT joint with greater shifts of the capital fragment. However, at 100% translation of the capital fragment, distal angulation of the osteotomy by 20° appears to improve loading across the TMT joint. Addition of the Akin osteotomy at 100% translation also aids in increasing the contact force across the TMT joint. The MTP joint is less sensitive to changes in shifts and angulation of the capital fragment. The Akin osteotomy also leads to increased contact force across the MTP joint when the capital fragment is translated 100%. While the clinical significance is unknown, larger shifts of the capital fragment lead to greater load alterations at the level of the TMT joint than the MTP joint. Distal angulation of the capital fragment and the addition of an Akin osteotomy can aid in reducing the size of those changes. The Akin can lead to increased contact forces at the MTP joint with 100% translation of the capital fragment. Not applicable, Biomechanical study.

Arthroscopic Arthrodesis of the First Metatarsophalangeal Joint in Hallux Valgus Deformity Using Medial and Toe Web Portals

Arthrodesis of the first metatarsophalangeal joint is indicated for severe hallux valgus deformity. Open arthrodesis requires extensive soft-tissue dissection. Recently, a technique of arthroscopic first metatarsophalangeal arthrodesis in hallux valgus deformity has been reported. This approach includes endoscopic lateral release of the first metatarsophalangeal joint via the plantar and toe web portals, followed by arthroscopic arthrodesis of the joint via the medial and dorsolateral portals. Endoscopic lateral release of the first metatarsophalangeal joint can convert the fixed hallux valgus deformity into a flexible one and reduce the stress over the screws and risk of loss of reduction and nonunion. The purpose of this Technical Note is to report a modified technique of arthroscopic first metatarsophalangeal arthrodesis in hallux valgus deformity. In this modified technique, the arthrodesis is performed via the medial and toe web portals and creation of the dorsolateral portal is not needed. A 2.7-mm arthroscope is used for the arthrodesis procedure instead of a 1.9-mm arthroscope. This can improve fluid inflow and visualization.

The distal metatarsal articular angle in hallux valgus deformities. Comparisons of radiographic and weightbearing CT scan measurements with variations in hindfoot position

BackgroundWhen evaluating hallux valgus (HV) deformity with anteroposterior (AP) foot radiographs, the distal metatarsal articular angle (DMAA) has been the subject of frequent debate. Although a straightforward indicator of structural alignment of the distal first metatarsal articular surface, inter- and intraobserver measurements can vary widely. Alterations in the radiographic appearance of bony “structure” with positional changes of the foot/foot bones in HV deformities in no small part contributes to these inaccuracies. The aim of this study was to determine the effect of hindfoot position on the DMAA. MethodsFour different radiologic images were obtained for 15 subjects with HV: three AP foot radiographs (standard weightbearing, foot supinated, foot pronated) and one weightbearing CT (WBCT) scan. For each image, five investigators measured the DMAA in order to assess reliability. ResultsMean DMAA values measured from the images indicated that the angle was highest with the pronated foot (15.3 (95% CI, 10.3–20.3) degrees) and lowest when measured from the CT image (11.6 (95% CI, 7.3–16.0) degrees). For all image types, the intraclass correlation coefficient was greater than 0.9 and statistically significant (P < 0.0005). ConclusionHindfoot positions affected radiographic DMAA/mean DMAA values, with values highest with feet in pronated attitudes. Unlike radiographic projections, the WBCT appears less likely to overestimate DMAA and is not subject to variations in foot positioning. In the preoperative evaluation of HV deformities, this points to the potential use of WBCT as a reference standard. For markedly severe HV deformities that may present with AP radiographs with marked first metatarsal head “roundness,” the use of WBCT is the intuitive choice.The results indicate excellent reliability in measurements of DMAA between all five investigators. As such, the measurement method used to determine DMAA in this study was dependable and reproducible. Level of evidenceLevel II

The chevron bunionectomy for moderate to severe hallux valgus deformity: Effects of procedural factors on hallux valgus correction

BackgroundEffects of procedural factors on chevron bunionectomy outcomes were studied. MethodsIncluded were 109 feet with distal chevron osteotomy and preoperative intermetatarsal angle (IMA) greater than 15 degrees. IMA and hallux valgus angles (HVA), release type, fixation, second-digit procedures, and risk factors were evaluated. ResultsEighty-three percent (91/109 feet) had satisfactory outcomes; nine had moderate pain. From preoperative, IMA improved 7.2 and HVA 20.5 degrees. Risk factors or second-digit procedures had no effect. Lateral release improved IMA (p < 0.01), with no difference between open lateral and transarticular release; 86% percent (64/74) were satisfied with open lateral release compared with 83% (19/23) and 66% (8/12) with no release and transarticular release, respectively. Fixation did not affect outcomes. ConclusionChevron bunionectomy corrected IMA and HVA to normal with few complications. Lateral release increased IMA correction. Transarticular release had lower satisfaction than open lateral release or no release. Level of EvidenceLevel III, retrospective

The Radiological Outcome of Surgical Correction of Hallux Valgus with Combined Scarf and Akin Osteotomies

Background: Hallux valgus deformity is one of the most common chronic and progressive foot deformities. Surgical correction of the deformity plays a central role in the treatment of symptomatic hallux valgus. However, more than one hundred different surgical techniques have been described. Objective: To assess the radiological outcome of hallux valgus surgical correction using a scarf and akin osteotomies. Materials and methods: A cross-sectional hospital-based study was conducted on 25 adult patients (36 feet). Twenty-two females and two males with hallux valgus were treated with surgical correction using a scarf and akin osteotomies. All candidates were kept on regular postoperative, scheduled clinical follow-up programs for one year and assessed radiologically. Results: Twenty-five patients (36 feet) were included in this study. The hallux valgus angle significantly shifted to the normal range (less than 15°) after surgery, and the inter-metatarsal angle also improved to the normal range (less than 9°). Conclusion: Using scarf and akin osteotomies in treating moderate and severe hallux valgus deformity provides the satisfactory radiological outcomes in form of decreasing hallux valgus angle and inter-metatarsal angle.

The distal metatarsal screw is not always necessary in third-generation MICA: a case-control study.

To evaluate the clinical and radiological results after fixation of the first metatarsal head (MTH) with one or two screws as part of the third-generation minimally invasive Chevron-Akin osteotomy (MICA) for hallux valgus deformities. Between August 2020 and November 2021, 55 MICA procedures (50 patients, male:female = 7:43), 22 with two (MICA2), 33 with one screw (MICA1) were performed for mild to severe hallux valgus deformities. Exclusion criteria were a concomitant pes adductus (Sgarlato angle > 20°) or hindfoot/midfoot deformities requiring treatment. In 27 cases, additional procedures on the forefoot (small toe corrections or metatarsal osteotomies II-V) were necessary. Pre- and post-operatively, hallux valgus angle (HVA) and intermetatarsal I/II angle (IMA) were measured. Clinically, subjective satisfaction, range of motion (ROM) of the first metatarsophalangeal joint (MTPJ), and pain level (NRS score) were evaluated. The minimum follow-up was 12months. Displacement of MTH was 70-90% on average, all osteotomies showed full consolidation at latest follow-up. In one case of either group, a slight subsidence of MTH was documented. The radiological and clinical parameters showed no differences between the groups. The pain level improved by an average of three points. The mobility of the MTPJ showed a slight reduction in nine casesafter threemonths (4 MICA2, 5 MICA1)which persisted in three cases. Fifty-two of 55 patients (95%) would opt again for the operation. Fixation of the first MTH with a single bicortical screw in MICA with moderate lateralization of MTH shows stable anchoring and good clinical results. The routine use of a second metatarsal screw can be omitted.