Severe Hallux Valgus Deformity Research Articles

Scarf Osteotomy for Hallux Valgus Deformity: An Intermediate Followup of Clinical and Radiographic Outcomes

The scarf osteotomy is a versatile and reproducible procedure for the correction of moderate to severe hallux valgus deformity (intermetatarsal angle 12 to 20 degrees hallux valgus angle 20 to 46 degrees). We evaluated the results of 27 consecutive scarf osteotomies at an average followup of 16.1 months. Radiographic parameters, foot pressure analysis, and AOFAS scores were analyzed before and after surgery. Hallux valgus angles improved from 34.5 to 16.9 degrees, intermetatarsal angles improved from 15.4 to 10.1 degrees, AOFAS scores improved from 54.5 to 86.5. There was no change between the preoperative and postoperative relative lengths of the first and second metatarsals, defined as the difference between the first and second metatarsal lengths. The measurement was based on the anteroposterior standing radiographs and measured by a line intersecting the midway point at the diaphyseal-metaphyseal junction of the metatarsal and extending from the most proximal to distal aspects of the bone. The angle of Meary (talo-first metatarsal angle) did not change, except in one patient. Foot pressure analysis showed no evidence of transfer metatarsal lesions. The complication rate was 1.1% including superficial infection and recurrence. The scarf osteotomy provides a predictable and effective correction of moderate to severe hallux valgus deformities.

Foot and Ankle Risk Factors for Falls in Older People: A Prospective Study

Foot problems are common in older people and are associated with impaired balance and functional ability. Few prospective studies, however, have been undertaken to determine whether foot problems are a risk factor for falls. One hundred seventy-six people (56 men and 120 women, mean age 80.1, standard deviation 6.4 years) residing in a retirement village underwent tests of foot and ankle characteristics (including foot posture, range of motion, strength, and deformity) and physiological falls risk factors (including vision, sensation, strength, reaction time, and balance) and were followed for 12 months to determine the incidence of falls. Seventy-one participants (41%) reported falling during the follow-up period. Compared to those who did not fall, fallers exhibited decreased ankle flexibility, more severe hallux valgus deformity, decreased plantar tactile sensitivity, and decreased toe plantarflexor strength; they were also more likely to have disabling foot pain. Discriminant function analysis revealed that decreased toe plantarflexor strength and disabling foot pain were significantly and independently associated with falls after accounting for physiological falls risk factors and age. Foot and ankle problems increase the risk of falls in older people. Interventions to address these factors may hold some promise as a falls prevention strategy.

Correction of Moderate to Severe Hallux Valgus Deformity by a Modified Chevron Shaft Osteotomy

Hallux valgus is one of the most common foot deformities in women. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use, especially for severe deformities. Proximal osteotomies have long been done for severe deformities; however, diaphyseal osteotomies have gained popularity because of the greater degree of correction and stability obtained. This study retrospectively assessed the radiographic and clinical outcomes in 50 feet (34 patients) that had a modified chevron shaft osteotomy for moderate to severe hallux valgus. Additionally, an Akin medial closing wedge osteotomy of the proximal phalanx was done in most patients. Mean followup was 30 months (minimum 13 months). All patients in the study had either moderate or severe deformities. Patients with mild deformities had correction by other techniques. There was a mean AOFAS score improvement of 39.6 (44.5 to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and 10.4 degrees, respectively. Hallux valgus persisted in one foot; however, the patient was not dissatisfied. Two feet developed hallux varus. Revision was necessary in two patients; one needed revision because of loss of fixation and the other because of symptomatic hallux varus. Based on radiographic correction and clinical outcomes, this procedure is indicated for the treatment of moderate to severe hallux valgus deformities.

First Metatarsophalangeal Fusion with Ball-and-Socket Bone Preparation and a Dorsal Plate Fixation

The first metatarsophalangeal joint fusion is an accepted technique for hallux rigidus, severe hallux valgus deformity, and revision for failed hallux valgus surgery. In this article, the use of reamers for congruent convex concave surfaces is described. Together with a dorsal plate and an interfragmentary compression screw, this combination of the ball-and-socket bone preparation has operative advantages over other metatarsophalangeal fusion techniques. It is, on the one hand, technically simple to achieve congruent joint surfaces which is a requirement for good bone healing, and on the other hand, the prebent plate limits the risk for major malalignment of arthrodesis.

当院におけるＨａｍｍｏｎｄ変法を用いた外反母しの治療治績

From 1998 to 2004, 15 feet in 14 patients underwent the Hammond procedure alone or Hammond procedure with lateral soft tissue release to correct hallux valgus deformities. The average patient age at the time of the operation was 50.3 years, and the average follow-up was 7.6 months. The average preoperative hallux valgus angle was 34.6°, and the average intermetatarsal angle was 15.1°. After surgery, the feet were corrected to an average hallux valgus angle of 14.7°, and the average intermetatarsal angle was 7.7°. The results were also graded according to the Japanese Orthopaedic Association (JOA) score and Glynn's assessment. This modification of the Hammond procedure can serve as an effective means of managing severe hallux valgus deformities.

Determinants of Disabling Foot Pain in Retirement Village Residents

The aim of this study was to evaluate the relative contribution of structural foot characteristics and comorbidities to the presence of disabling foot pain in older people. One hundred seventy-two people (55 men and 117 women) aged 62 to 96 years (mean +/- SD, 80.1 +/- 6.4 years) who lived in a retirement village underwent tests of foot posture, range of motion, and deformity in addition to completing a medical history questionnaire. Disabling foot pain was determined using the Manchester Foot Pain and Disability Index. Thirty-eight subjects (22%) reported disabling foot pain. Subjects with disabling foot pain had a higher body mass index and were more likely to be female; to report osteoarthritis in the spine, hips, hands or wrists, and feet; and to report pain in the back, hips, and hands or wrists. The only significant difference between the groups regarding structural foot characteristics was that those with disabling foot pain exhibited more severe hallux valgus deformity. The strongest determinants of disabling foot pain revealed by a discriminant function analysis were foot osteoarthritis, pain in the hips, and pain in the hands or wrists. These findings indicate that disabling foot pain in older people is more closely related to pain and osteoarthritis in other body regions than to structural characteristics of the foot, and they suggest that more severe forms of foot pain in older people may be a component of a general chronic pain syndrome or a polyarticular form of osteoarthritis.

Arthrodesis of the First Metatarsophalangeal Joint for Idiopathic Hallux Valgus: Intermediate Results

Followup studies documenting the outcome of primary metatarsophalangeal (MTP) joint arthrodesis for treatment of hallux valgus deformities are rare. The purpose of this report was to evaluate the results of first MTP joint arthrodesis as treatment for moderate and severe hallux valgus deformities over a 22-year period in a single surgeon's practice. All living patients treated between 1979 and 2001, for moderate and severe idiopathic hallux valgus deformities with first MTP joint arthrodesis were contacted and asked to return for a followup examination. Outcomes were assessed by comparing preoperative and postoperative pain, function, and radiographic appearance. First ray mobility and ligamentous laxity also were assessed postoperatively. Eighteen of 21 of the first MTP joints had successfully fused with the primary procedure at an average followup of 8.2 years (range 24 to 271 months). The time to union averaged 10 (range 7 to 15) weeks. Two of the three nonunions, both in the same patient, were asymptomatic and were not revised. One required a revision to achieve fusion. The average corrections in the hallux valgus angle and 1-2 intermetatarsal (IM) angle were 21 degrees and 6 degrees, respectively, and the average postoperative dorsiflexion angle was 22 degrees. Subjective satisfaction was rated as excellent in seventeen of 21 cases (80%) and good in the remaining four (20%). There was significant reduction in postoperative pain (p < 0.001), complete resolution of lateral metatarsalgia, and the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores averaged 84 (range 72 to 90) at final followup. Major activity restrictions after surgery were uncommon, and all patients were able to wear conventional or comfort shoes. Interphalangeal (IP) joint arthritis progressed in seven of 21 feet (33%), but all of these changes were mild. In the present study, arthrodesis of the first MTP joint for idiopathic hallux valgus resulted in a high percentage of successful results at an average followup of over 8 years.

Correction of hallux valgus deformity with distal soft tissue realignment and proximal metatarsal osteotomy

Fifty moderate to severe hallux valgus deformities were corrected with a distal soft tissue realignment and proximal crescentic metatarsal osteotomy. With an average follow-up of 5.6 years, 40 feet (80%) were pain free and 42 (84%) caused no functional limitation. The average hallux valgus angle improved from 38.2° preoperatively to 12.4° at follow-up. The average intermetatarsal angle improved from 15.4° to 6.8°. The arch of motion of the first metatarsophalangeal joint was 75° preoperatively and 62° at follow-up. According to the AOFAS scoring system, 29 results (58%) were excellent, 14 (28%) good, 2 (4%) fair and 5 (10%) poor. The 5 poor results were attributed to recurrence of hallux valgus (2 cases), stiffness (1), hallux varus (1) and malunion of the osteotomy in dorsiflexion (1). The incidences of hallux varus and malunion in dorsiflexion were 8% and 14%, respectively. This technique is valuable in correction of moderate to severe hallux valgus deformities.

Mechanical Comparison of Two Types of Fixation for Proximal First Metatarsal Crescentic Osteotomy

The proximal crescentic osteotomy is an effective technique for correcting a widened 1-2 intermetatarsal angle associated with moderate to severe hallux valgus deformities. However, postoperative dorsal malunion at the osteotomy site from loss of fixation has been reported. The purpose of this study was to evaluate the biomechanical characteristics of a new custom-designed plate and compare it to the traditional screw and Kirschner wire construct. Twenty identical Sawbone (Pacific Research Laboratories, Vashon, WA) models were used for the study. A proximal crescentic osteotomy was done on each specimen, and 10 were secured with a dorsomedial plate (group I). The remaining 10 models were fixed with a screw and Kirschner wire combination (group II). Physiologic cyclical testing was done using a mechanical testing machine to evaluate dorsal displacement of the metatarsal. Load-to-failure testing was then done on each specimen to evaluate ultimate failure and stiffness of the constructs. Groups I and II were statistically compared using paired t-testing. The mean dorsal displacement of the first metatarsal head after 1000 cycles was 0.19 mm (SD = 0.09 mm) for group I and 0.28 mm (SD = 0.15) for group II, and the difference was not statistically significant (p = 0.08). Group I demonstrated statistically superior ultimate failure strength (95.2 N) and stiffness (26.8 N/mm) compared to group II (73.7 N, 19.4 N/mm). Based on Sawbone models, dorsal plate fixation of proximal crescentic osteotomy provides a stronger construct than the traditional screw and Kirschner wire construct. The clinical use of the specially-designed plate described in this study may lower the incidence of dorsal malunions that occur postoperatively and may decrease the occurrence of transfer metatarsalgia. Its application may be particularly helpful in patients with poor bone quality.

Clinical results with the Ludloff osteotomy for correction of adult hallux valgus.

Biomechanically, the Ludloff osteotomy fixed with lag screw compression has been shown to be more rigid than proximal crescentic and other proximal first metatarsal osteotomies for correction of symptomatic hallux valgus with a moderate to severe increase in the first intermetatarsal angle. The Ludloff osteotomy may, therefore, have a lower incidence of dorsal malunion and transfer metatarsalgia than other proximal first metatarsal osteotomies, such as the crescentic or chevron. We reviewed the results of 82 consecutive cases of moderate to severe hallux valgus deformities corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. Follow-up was possible in 70 cases (85%) at an average of 30 months (range, 18 to 42 months). Preoperatively, the mean hallux valgus and first intermetatarsal angles were 31 degrees and 16 degrees, respectively. Postoperatively, these values improved to an average of 11 degrees and 7 degrees. In the sagittal plane, the first metatarsal was plantarflexed by an average of 1 mm, and there were no symptomatic transfer lesions of the second metatarsal. The mean AOFAS hindfoot score improved from 54 to 91 points. Complications included prominent hardware requiring removal (5), hallux varus (4), delayed union (3), superficial infection (3), and neuralgia (3). The use of the Ludloff oblique first metatarsal osteotomy resulted in excellent correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. With the plane of the osteotomy and rigidity of fixation, immediate ambulation was possible with minimal risk of dorsiflexion malunion of the first metatarsal.

Mathematical model for pre-operative planning of linear and closing-wedge metatarsal osteotomies for the correction of hallux valgus.

First-metatarsal osteotomy is performed for an abnormal intermetatarsal angle and severe hallux valgus deformity. The metatarsal head is slid along the osteotomy and fixed with a Kirschner wire to achieve angular and linear realignment with respect to the other metatarsals. When reduction of joint subluxation is also sought, a bone wedge is removed. A mathematical model and a corresponding computer-based tool were developed for pre-operative planning of the optimum surgical solution. Standard intermetatarsal angle correction, head-to-sesamoids re-alignment, joint subluxation reduction and metatarsal length adjustment were all pursued. A standard pre-surgical dorso-plantar radiograph of the patient, with an additional metal ball for calculation of X-ray magnification, was necessary to analyse the original and final geometrical configurations. For the first time, expected bone loss and wire diameter were also considered. The angles of bone cuts and the amount of sliding along these cuts were calculated by the model according to the surgical goal. All the resulting geometrical parameters, both in the pre- and planned post- operative configuration, were provided in graphical and tabular form. In a change from former qualitative analysis of radiograms, the surgeon can now enter the operating theatre with a detailed plan of the goal to be achieved.

The SCARF osteotomy for the correction of hallux valgus deformities.

The authors report their experience with a modified SCARF osteotomy with three years follow-up. Correction of moderate to severe hallux valgus deformities was achieved using a Z step osteotomy cut to realign the first metatarsal bone. A retrospective analysis was undertaken in 89 consecutive patients (111 feet). Results were analyzed by clinical examination, a questionnaire including the AOFAS forefoot score, and plain roentgenograms. Hallux valgus and intermetatarsal angle improved at mean 19.1 degrees and 6.6 degrees, 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 work of 5.8 weeks and back to sport of 8.3 weeks. Persistence or recurrence of hallux valgus was seen in seven patients (6%). The complication rate was 5.4% including superficial wound infection, traumatic dislocation of the distal fragment, and hallux limitus. The presented technique provides predictable correction of moderate to severe hallux valgus deformities.

Compression screw fixation for first metatarsal basal osteotomy.

Proximal osteotomy and distal soft tissue correction is recommended for correction of severe hallux valgus deformity. Basal closing wedge osteotomy is inherently unstable, and there is a tendency for dorsal displacement of the distal fragment. This has led many surgeons to attempt a variety of fixation techniques to counteract this instability, including AO-cortical and cancellous screws, K-wires, and shape-memory staples. 1 – 3 The Acutrak® screw (Acumed. Inc., Beaverton, Oregon) has been used to fix tibial spine avulsions and scaphoid fractures 5 but was not previously reported in hallux valgus surgery. We used a modified closing wedge basal osteotomy technique with Acutrak cannulated compression screw in order to add stability to the osteotomy.

Correlation of Correction Angle with Pain at First Metatarsophalangeal Joint in the Treatment of Hallux Valgus

Purpose : We evaluated the correlation between correction angle and pain of the first metatarsophalangeal joint in the treatment of hallux valgus. Materials and Methods : The 28 cases (20 patients) with moderate to severe hallux valgus deformity and pain of the first metatarsophalangeal joint who underwent the distal soft tissue procedure and proximal metatarsal closing wedge osteotomy, were divided into two groups, Group I: no pain of the first metatarsophalangeal joint after surgery, and Group II: with persisting pain. We analyzed the correction angle and pain of the first metatarsophalangeal joint in each group, preoperatively and at the last follow-up. All of the patients were women and their mean age was 58 years old. The average follow-up time was 18months. Results : At the last follow-up, the 21 feet (75%) were free of pain of the first metatarsophalangeal joint. In 7 feet (25%) pain persisted. In group I, sufficient deformity correction was obtained, but in group II, the deformity was corrected insufficiently. A high correlation was observed between correction angle and pain relief. Conclusion : A high correlation was obtained between correction angle and pain of the first metatarsophalangeal joint in the treatment of hallux valgus deformity. Therefore, in view of the patient’s expectation of pain relief, meticulous attention should be paid to the correction of hallux valgus deformity.

The grading of hallux valgus. The Manchester Scale.

This article describes a new, noninvasive method of assessing the severity of hallux valgus deformity by means of a set of standardized photographs. Six podiatrists were independently asked to grade the level of deformity of 13 subjects (26 feet) on a scale of 1 (no deformity) to 4 (severe deformity). The reliability of the four-point scale for the severity of hallux valgus was investigated by means of kappa-type statistics for more than two raters. The results showed that the grading method had excellent interobserver repeatability with a combined kappa-type statistic of 0.86, making it a suitable instrument for clinical and research purposes.

Retrospective analysis of the Ludloff osteotomy for correction of severe hallux valugs deformity

The purpose of this study was to evaluate retrospectively the outcomes of the Ludloff osteotomy for severe hallux valgus. Thirty cases in 23 patients, with an average clinical follow-up of 29.5 months, are reported. The hallux valgus angle improved on average 22°, from a preoperative average of 33.8° to 11.8° at follow-up. The intermetatarsal (IM)1–2 angle improved on average 12.8°, from 19.6° preoperatively to 7.7° at follow-up. The lateral plantar first metatarsal angle did not change; union occurred at an average of 6 weeks. Tibial sesamoid position improved from a preoperative average position of 2.8 to an average position of 0.6. The AOFAS Rating Score improved from a preoperative average of 48.8/100 to an average of 90.1/100 at follow-up. There were four patients with complications, including three cases with delayed unions and one with superficial wound infection. We found a significantly favourable correlation in the amount of IM 1–2 angle, hallux valgus and tibial sesamoid position correction when compared with an increased postoperative foot score. This is an important finding because there is a direct correlation here between improved measurable radiographical findings and an improved subjective evaluation. Furthermore, we found a trend for a longer follow-up period to be correlated with a better postoperative foot score. Based on our results and on the review of the literature, we conclude that Ludloff osteotomy provides reliable successful long-term results for the treatment of severe symptomatic hallux valgus and metatarsus primus adductus deformity.

Tibiotalocalcaneal arthrodesis

The purpose of this study was to evaluate retrospectively the outcomes of the Ludloff osteotomy for severe hallux valgus. Thirty cases in 23 patients, with an average clinical follow-up of 29.5 months, are reported. The hallux valgus angle improved on average 22°, from a preoperative average of 33.8° to 11.8° at follow-up. The intermetatarsal (IM)1–2 angle improved on average 12.8°, from 19.6° preoperatively to 7.7° at follow-up. The lateral plantar first metatarsal angle did not change; union occurred at an average of 6 weeks. Tibial sesamoid position improved from a preoperative average position of 2.8 to an average position of 0.6. The AOFAS Rating Score improved from a preoperative average of 48.8/100 to an average of 90.1/100 at follow-up. There were four patients with complications, including three cases with delayed unions and one with superficial wound infection. We found a significantly favourable correlation in the amount of IM 1–2 angle, hallux valgus and tibial sesamoid position correction when compared with an increased postoperative foot score. This is an important finding because there is a direct correlation here between improved measurable radiographical findings and an improved subjective evaluation. Furthermore, we found a trend for a longer follow-up period to be correlated with a better postoperative foot score. Based on our results and on the review of the literature, we conclude that Ludloff osteotomy provides reliable successful long-term results for the treatment of severe symptomatic hallux valgus and metatarsus primus adductus deformity.

Long-term results of first metatarsophalangeal joint fusion for severe hallux valgus deformity

To evaluate the long-term results of a first metatarsophalangeal joint (MTPJ) fusion a series of 70 arthrodeses in 42 patients was reviewed. Thirty-seven out of 42 patients (62 fusions) were available for clinical and radiological evaluation, 2–31 years postoperatively (average: 21.5 years). The surgical technique was identical in all patients and based on a cone shaped ‘ball and socket’ configuration of the first MTPJ. Fixation was achieved with a screw. The study showed that the first MTPJ fusion is a consistently successful operation that relieves pain and corrects deformity and its good results remain unchanged for up to 31 years.

A Biomechanical Comparison of the Z Step-cut and Basilar Crescentic Osteotomies of the First Metatarsal

The basilar crescentic osteotomy is a popular procedure for the correction of moderate to severe hallux valgus deformity. Dorsiflexion due to malposition of the osteotomy, fixation failure, or late contracture of the soft tissues can lead to lateral metatarsalgia. This study compares the mechanical properties of the Z step cut osteotomy Scarff to those of the crescentic osteotomy in cantilever-bending. The ultimate load, maximum bending moment and energy absorbed were significantly greater for the Scarff osteotomy compared to those in the crescentic osteotomy (p < 0.001). Values for stiffness did not differ between the two osteotomies. Failure of the cortical bone-bridge between the screw-hole and the osteotomy was observed in all crescentic osteotomies, while fracture of the proximal dorsal bridge was seen in all Scarff osteotomies.

Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release.

Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15 degrees, or hallux valgus (HV) angle > 30 degrees]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1 degrees preoperatively and 14.6 degrees postoperatively. The respective values for the IM angle were 17.8 degrees and 7.8 degrees. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15 degrees or HV angle > 30 degrees).