Underwent Hallux Valgus Correction Research Articles

Impact of Social Deprivation on Forefoot Surgical Outcomes

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: The impact of social environment on specific health outcomes is a topic of increasing interest in orthopedics. Conflicting lines of research suggest that social deprivation may impact orthopedic outcomes. There are limited reports on the influence of social deprivation on orthopedic foot and ankle procedures. The purpose of this study was to examine the effect of social deprivation on patient reported outcomes for patients undergoing forefoot surgery. Methods: This retrospective cohort study included 477 patients who underwent hallux valgus correction or hallux rigidus procedures between 2015 and 2022. Patient social deprivation was defined using the Area Deprivation Index (ADI), a validated metric of deprivation discretized geographically by zip code and defined by factors including education, income, employment, and housing quality. Patients meeting inclusion criteria were categorized into either a high or low social deprivation group based on the national median ADI of 50. PROMIS (Patient-Reported Outcomes Measurement Information System) Physical Function (PF) and Pain Interference (PI) scores were collected pre-operatively and then at 6 weeks and 6 months post-operatively. We compared high and low social deprivation groups at baseline and then longitudinally at 6 weeks and 6 months post-operatively, adjusting for demographic covariates including age, gender, race/ethnicity, marital status, and employment status. Statistical significance was defined as p < 0.05. Results: At baseline before surgery, PROMIS-PF and PROMIS-PI scores were similar between high and low social deprivation groups. At 6 weeks and 6 months after surgery, there were also no significant differences between high and low deprivation groups for either PROMIS-PF or PROMIS-PI. The only variable that delineated outcomes was employment status, with disabled and unemployed patients exhibiting greater pain (p < 0.001, p = 0.006, respectively) and less function (p < 0.001, p = 0.010, respectively) before surgery. When adjusting for baseline pain score, disabled patients also had greater pain on average after surgery (p = 0.031). Both groups (high and low social deprivation) demonstrated similar improvements in pain and function at 6 months after surgery. Conclusion: Patients undergoing forefoot surgery with greater social deprivation reported similar pain and physical function outcomes as patients with low deprivation before and after surgery. These findings suggest that patients with higher social deprivation can achieve equivalent post-surgical outcomes after forefoot surgery as compared to patients with lower social deprivation. Further investigations are needed to explore these relationships at longer-term follow-up as well with other common foot and ankle surgeries.

Minimally invasive Chevron-Akin (MICA) osteotomies without Akin fixation in hallux valgus correction: a case series with 2-year follow-up.

The minimally invasive Chevron-Akin (MICA) is considered the third generation of minimally invasive hallux valgus (HV) surgery, and its original description included fixation of the Akin osteotomy with a screw. The aim of this study is to evaluate a series of patients undergoing HV correction using the MICA technique without screw fixation of the Akin osteotomy. We retrospectively evaluated 58 consecutive patients who underwent surgical correction for HV between August 2018 and March 2020. A total of 69 feet were evaluated with a minimum follow-up of 2years. Clinical outcomes such as pain (VAS), function (AOFAS), range of movement, criteria personal satisfaction and complications were evaluated. The AOFAS score (mean ± standard deviation) significantly improved from 57.0 ± 8.6 preoperatively to 93.9 ± 8.7 postoperatively (p < .001) with a minimum follow-up of 2years. The VAS score improved from 6.0 ± 1.8 preoperatively to 0.6 ± 1.4 at 2-year follow-up (p < .001), and the hallux valgus angle reduced from 39.7 ± 6.9 to 8.9 ± 9.0 (p < .001). The majority of patients (95.6%) reported the result as excellent or good, and the most common complication was the need to remove the screw (7.2%). The use of MICA without Akin osteotomy fixation resulted in successful correction of hallux valgus with improvements in clinical and radiographic parameters. IV, case series.

Minimally Invasive Distal Metatarsal Osteotomy for Juvenile Hallux Valgus Correction: A Retrospective Radiographic Evaluation

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The minimally invasive distal metatarsal osteotomy (MIDMO) is an increasingly popular technique for hallux valgus (HV) correction in the adult population. In juveniles, however, the use of minimally invasive methods to surgically resolve HV remains a comparatively new and under-reported concept. The primary objectives of this retrospective review are to provide radiographic findings of pediatric patients who underwent surgical correction of HV via the minimally invasive distal metatarsal osteotomy (MIDMO). Secondary objectives are the utilization of the mechanical axis of the first metatarsal to measure pre- and postoperative radiographic outcomes and time to osseous consolidation. Methods: A multi-center retrospective review was performed of two institution system’s records was conducted for consecutive patients who underwent surgical correction for HV between January 2012 and June 2022. Patients were included if they underwent HV correction using MIDMO, were aged &lt; 18 years, had ≥ 3 months of clinical and radiographic follow-up, and had radiographs on file of both pre- and postoperative anteroposterior (AP) and lateral views. The first IMA (anatomic and mechanical axes), hallux abductus angle (HAA), distal metatarsal articular angle (DMAA), and tibial sesamoid position (TSP) were measured in pre- and postoperative AP and lateral views. A paired sample t-test was used to compare pre- and postoperative absolute radiographic measured angles. Results were considered statistically significant at the 5% (P &lt; 0.05) level. Results: Forty-two feet amongst 30 patients met the inclusion criteria. Twenty seven were female (90%) and 3 of whom were male (10%). Temporary pin fixation (23.8%) or screw fixation (76.2%). Mean patient age was 15.2 years. Mean follow-up was 13.7 months. Mean time to osseous consolidation was 6.7 weeks. A statistically significant reduction was noted in all the radiographic values of every angle measured from preoperative to postoperative. The mean first anatomic IMA changed from 14.52° to 3.53° postoperatively and the first mechanical IMA changed from 14.24° to 4.64° postoperatively. The mean HAA was reduced from 32.98° to 12.83° postoperatively, the mean DMAA shifted from 12.40° to 2.93° postoperatively, and the mean TSP was revised from 3.60° preoperatively to 1.07° postoperatively. Conclusion: This is the first retrospective North American radiographic review in the known literature that evaluates short-term results of juvenile HV correction utilizing the MIDMO. Our results support the conclusion that the MIDMO is an effective method for pediatric patients with HV and provides statistically significant radiographic correction. Additionally, our results support the versatility of the mechanical axis in evaluating pre- and postoperative radiographic outcomes of the first IMA. We recommend future larger efforts with greater patient populations and longer follow-up times for further investigation.

Does use of Allograft Affect Union Rates in Minimally Invasive Hallux Valgus Surgery?

Category: Bunion; Basic Sciences/Biologics Introduction/Purpose: Hallux valgus is a common foot deformity that can cause significant discomfort. Surgical correction of hallux valgus can be achieved through various techniques with minimally invasive surgery (MIS) gaining popularity amongst surgeons. The use of allograft in traditional open approaches has been proposed to improve the outcomes of hallux valgus repair by expediting time to union. We performed a retrospective analysis of patients undergoing MIS hallux valgus correction with and without the allograft at time of surgery. The primary aim of our study was to determine if use of allograft in hallux valgus MIS correction led to different time to union as well as rate of unions. Methods: A retrospective analysis was conducted to compare outcomes of patients who underwent hallux valgus correction with or without allograft. Patients included in the analysis underwent primary hallux valgus correction using third generation minimally invasive techniques and had postoperative weightbearing x-rays. Exclusion criteria included revision surgery, open surgeries, and loss-to-follow up. All surgeries were performed by three fellowship trained Foot and Ankle Orthopaedic surgeons at a single center from September 2019 to December 2022. All patients had similar post operative protocols. The allograft group received 2- 5 cc’s of a demineralized bone matrix (DBM) gel. Radiographs were evaluated by two independent orthopedic surgeons who were blinded to the patient's group allocation. The primary outcome of this study was time to radiographic union and rate of union. The data was analyzed using the independent t- test for continuous variables and the Fisher Exact test for categorical variables. Results: Seventy-two patients (77 feet) met inclusion criteria: allograft group (n=25) and a control group (n=52). Demographics between both groups were similar; the overall demographics can be found in Table 1. In our study, all 77 feet obtained complete union and no malunions or non-unions were observed in either group. The average time to complete union for the allograft group was 3.52 months (± 1.58) and the control group was 4.36 months (± 2.20); union times between groups did not reach statistical significance (p = 0.09) but did demonstrate a trend towards significance (Figure 1.) Maintenance of surgical correction was observed in all patients. Conclusion: While there was no statistically significant difference in union time and/or rates between the allograft group and control group, the allograft recipients had a reduction in the average time to union post MIS hallux valgus correction. No differences were observed with regards to radiographic recurrence nor complications between the two groups. This study suggests that demineralized bone matrix allograft may potentially decrease time to union but further studies are needed to confirm this.

Republication of "Treatment of Hallux Valgus Deformity Using a Suture Button Device: A Preliminary Report".

Hallux valgus (HV) is commonly treated with proximal or distal first metatarsal osteotomy. Despite good correction, these procedures have inherent risks such as malunion, nonunion, metatarsal shortening, loss of fixation, and avascular necrosis. Suture button fixation has been used for HV treatment. It avoids the risks of corrective osteotomies while maintaining reduction of the intermetatarsal angle (IMA). The goal of this study was to assess the radiographic and functional outcomes of patients undergoing HV correction with a distal soft tissue procedure and proximal suture button fixation. The authors retrospectively reviewed the charts and radiographs of 22 patients who had undergone HV correction using a distal soft tissue correction and proximal fixation with a miniature suture button device (Mini TightRope; Arthrex, Inc, Naples, FL). Mean follow-up was 27.7 months. The IMA, hallux valgus angle (HVA), and sesamoid station were measured on radiographs obtained preoperatively as well as in the immediate postoperative period and at final follow-up. Preoperative and postoperative Short Form-36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were collected. Postoperative complications, and any additional operative procedures performed were also recorded. The mean preoperative IMA and HVA were 16.9 and 32.6 degrees, respectively. The mean immediate postoperative IMA was 5.2 degrees (P < .0001) and the mean HVA was 9.8 degrees (P < .0001). At final follow-up, the mean IMA was 8.2 degrees (P < .0001) and the mean HVA was 16.7 degrees (P < .0001). The average change in HVA from preoperative to final follow-up was 16.0 degrees and the average change in IMA from preoperative to final follow-up was 8.6 degrees (P < .0001). Sesamoid station assessment at the 2-week follow-up showed that 22 patients (100%) were in the normal position group; at final follow-up, 17 patients (77%) had normal position and 5 patients (23%) had displaced position. Although there were no clinically symptomatic recurrences, asymptomatic radiographic recurrence was noted in 5 patients (23%) who had a final HVA >20 degrees. All components of the FAAM and the SF-36 showed improvement from preoperative to final follow-up, although these changes were not statistically significant. Three patients experienced complications, including an intraoperative second metatarsal fracture, a postoperative second metatarsal stress fracture, and a postoperative deep vein thrombosis. The use of a distal soft tissue procedure in conjunction with proximal suture button fixation is a safe and effective procedure for treating symptomatic HV deformity. Our results show that this technique can correct the IMA, HVA, and sesamoid station without the need for osteotomy. Level IV.

Radiographic Outcomes of Hallux Valgus Deformity Correction With Chevron and Scarf Osteotomies

There is no gold standard in the treatment of hallux valgus deformity. The purpose of our study was to compare various aspects of radiographic assessment following scarf and chevron osteotomies and try to determine which technique helps achieve a more pronounced intermetatarsal angle (IMA) and hallux valgus angle (HVA) correction and produces lower rates of complications, including adjacent-joint arthritis. This study included patients who underwent hallux valgus correction with the scarf (n=32) or chevron (n=181) method with a follow-up period of over 3 years. We evaluated the following parameters: HVA, IMA, duration of hospital stay, complications, development of adjacent-joint arthritis. The scarf technique helped achieve a mean HVA and IMA correction of 18.3° and 3.6°, respectively, and the chevron technique helped achieve a mean correction of 13.1° and 3.7°, respectively. The achieved deformity correction in terms of both the HVA and IMA was statistically significant in both patient groups. The loss of correction assessed with the HVA was statistically significant only in the chevron group. Neither group showed a statistically significant loss of IMA correction. The duration of hospital stay, reoperation rates, and fixation instability rates were comparable in the 2 groups. Neither of the evaluated methods caused a significant increase in total arthritis scores in the evaluated joints. Our study showed good outcomes of hallux valgus deformity correction in both evaluated groups; however, scarf osteotomy yielded somewhat better radiographic outcomes in HVA correction and no loss of HVA correction at 3.5 years of follow-up.

Factors Affecting Patient Reported Outcomes after Surgical Fixation for a Lisfranc Injury

Category: Bunion; Other Introduction/Purpose: Hallux valgus is a common deformity the foot and ankle surgeon will encounter that tends to have a progressive nature with a predilection for females. There are many operative techniques to appropriately treat HV however, there is limited literature focused on patient-reported outcomes for these procedures. In particular, we intend to compare patient- reported outcomes for those who had early (2 weeks postoperatively) vs standard weight-bearing (SWB) (6 weeks postoperatively) postoperative protocols after hallux valgus correction via the Lapidus procedure. Methods: A retrospective analysis of patients that underwent hallux valgus correction at our facility from 2010-2021 was conducted. Patients were selected if they underwent this correction via the Lapidus procedure. Basic patient demographics, preoperative and post-operative hallux valgus angles and intermetatarsal angles were recorded, type of hardware used for fixation, postoperative weight bearing protocol, complication rate, deformity recurrence, duration of symptoms, and any adjunctive procedures were all recorded utilizing the electronic medical record. Early weight-bearing (EWB) was defined as beginning a protected weight-bearing protocol at the two week visit. To evaluate outcomes, we utilized the Foot and Ankle Ability Measure (FAAM) survey as well as the Patient Reported Outcomes Measurement Information System (PROMIS) survey. Results: A total of 77 patients met criteria for this study with 20 patients having completed both the FAAM and PROMIS score surveys. The average time point at which the outcomes were collected was 5.65 years postoperatively ranging from 2.43 to 11.5 years. There were 35 patients in the EWB cohort and 42 in the SWB protocol. The average PROMIS physical function, pain interference, and depression scores for the EWB population was 45.96, 54.66, and 47.48 respectively vs 47.10, 48.34, and 50.21 in the SWB group. Patients in the EWB group reported their average activities of daily living (ADLs) via the FAAM subscale to be at 57% vs 62% in the SWB group. For the FAAM Sports Subscale, both groups reported fairly low numbers at 44% and 36% respectively. In this study, 1 patient experienced wound infection, 3 patients experienced nonunion (2 EWB, 1 SWB), and 1 patient experienced deformity recurrence. Conclusion: Preliminary results suggest equivalent results for EWB and SWB postoperative protocol for patients undering the Lapidus procedure. We plan to increase the power of our study for a more thorough investigation as well as conduct a more intensive statistical analysis to gain more insight on patient related factors and their effect on outcomes. We expect a higher number of patients to complete the PROMIS and FAAM surveys as we continue to reach out to these patients.

Hallux Valgus with Increased DMAA Correction by Modified Lapidus Procedure

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Hallux valgus is one of the most common deformities treated by orthopedic foot and ankle surgeons. Hallux valgus can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to treating the hallux valgus deformity. Many surgical procedures can correct hallux valgus with an increased DMAA with varying levels of success. Thus, we investigate the efficacy of the modified Lapidus procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery. Methods: A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a modified Lapidus procedure between April 26th, 2018 and November 19th, 2020. Exclusion criteria included any patient undergoing hallux valgus correction not receiving a modified Lapidus procedure and patients with inadequate follow up. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre-operative, immediate post-operative and at final follow up weight bearing radiographs. Results: The study included a total of 99 cases of modified Lapidus procedure for hallux valgus on 85 subjects with an average follow up of 5.4 months. On radiologic assessment, the average DMAA decreased from 17.72 +- 6.18 degrees pre-operatively to 9.19 +- 5.19 degrees immediately post-operatively (p &lt; 0.0001) and 9.79 +- 4.62 degrees at the final follow up (p &lt; 0.0001). The average HVA decreased from 31.34 +- 10.39 degrees pre-operatively to 13.34 +- 6.16 degrees immediately post-operatively (p &lt; 0.0001) and 15.05 +- 7.43 degrees at final follow up (p &lt; 0.0001). Lastly, the IMA decreased from 14.99 +- 3.82 pre-operatively (p &lt; 0.0001) to 4.66 +- 2.59 immediately post-operative and 6.62 +- 3.46 degrees at final follow up (p &lt; 0.0001). The rate of recurrence was 3.03%. Conclusion: The modified Lapidus procedure is an effective procedure in correcting the HVA, IMA, and DMAA in hallux valgus surgery without the need for additional distal or proximal metatarsal osteotomies. Surgeons should consider this technique in patients with moderate to severe hallux valgus deformity who may require correction of their DMAA.

What Proportion of Active-duty Servicemembers Functionally Improve at 1 Year Post Hallux Valgus Correction?

When the symptoms of hallux valgus persist despite nonoperative management, surgical intervention may be considered to improve pain and restore function. Although most patients return to full or near-full activity after surgery, this is not always the case in higher-demand populations. In fact, little is known about the likelihood of a military servicemember returning to running or military duty, which is analogous to a recreationally active adult, after hallux valgus correction. (1) What percentage of military servicemembers are able to return to full duty, including the ability to run 1.5 to 2 miles, 1 year after hallux valgus surgery? (2) What demographic, radiographic, and surgical variables are associated with an increased likelihood of return to full duty? This was a retrospective study of all military servicemembers who underwent surgical correction of hallux valgus deformities at a single tertiary institution from January 2005 to December 2016. We considered military servicemembers who were treated by four fellowship-trained foot and ankle orthopaedic surgeons and who had at least 1 year time-in-service remaining as potentially eligible. A total of 229 people underwent hallux valgus correction during this timeframe, but only 28% (64 of 229) of patients remained eligible: 41% (93 of 229) were excluded because they were not military members, 28% (64 of 229) were ineligible because they had less than 1 year remaining in service, 2% (4 of 229) were excluded because of prior surgery on the ipsilateral extremity, and 2% (4 of 2292) had an incomplete dataset. Interventions included a modified McBride procedure (9% [6 of 64]), distal metatarsal osteotomies (51% [33 of 64]), proximal metatarsal osteotomies (13% [8 of 64]), and Lapidus procedures (27% [17 of 64]). No bilateral procedures were performed. The mean age of our patients was 40 ± 10 years, and the mean BMI was 28 ± 9 kg/m 2 . In addition, 23% (15 of 64) of patients were nicotine users, 38% (24 of 64) were officers, and 45% (29 of 64) were women. The indication for surgery was functionally limiting pain that persisted despite 4 to 6 months of activity modifications, accommodative footwear, and orthotics. Cosmesis was not an indication for surgery. Before surgery, all patients were unable to complete a 1.5- to 2-mile timed run due to pain. The primary outcome measure was the proportion of patients who returned to full duty, which was defined as the ability to complete a 1.5-mile to 2-mile run for a military fitness test in a fixed time allotment, which varies by age and gender, and the ability to perform military-specific physical tasks at 1 year postoperatively. A secondary analysis according to demographic, radiographic, and surgical variables sought to determine any differences between those who did and did not return to full duty; this was assessed using univariable statistical comparisons at a p value of less than 0.01. A total of 28% (18 of 64) of patients who underwent surgery returned to full duty by 1 year after surgery as determined by the ability to complete a time-allotted 1.5- to 2-mile fitness test run. Of the factors we explored, we did not identify any variables associated with return to full duty. We note that our analysis may have been underpowered to detect differences among factors that could be clinically important, like BMI, age, and comparisons of officers versus enlisted servicemembers. Although this study analyzed the functional outcomes of a group of military servicemembers after hallux valgus correction, we believe our findings may also apply to recreationally active adults in the general population. Only a minority of military servicemembers (28% [18 of 64]) returned to duty 1 year after hallux valgus correction, as determined by the ability to complete a timed 1.5- to 2-mile run. We believe surgeons can use the findings of this study to set realistic expectations for recreationally active adults, particularly runners, after hallux valgus correction. Level III, therapeutic study.

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction

BackgroundPatients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Operative management of bunions with hammertoe can be more extensive; however, it is unclear whether this affects patient-reported outcomes. The aim of this study was to compare postoperative patient-reported outcome measures and radiographic outcomes between patients who underwent isolated bunion correction and patients who underwent simultaneous bunion and hammertoe correction. MethodsPreoperative, postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores were compared between patients who underwent isolated hallux valgus correction and those who underwent concomitant hammertoe correction. Radiographic measures including hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary’s angle were also compared. Targeted minimum-loss estimation (TMLE) was used for statistical analysis to control for confounders. ResultsA total of 221 feet (134 isolated bunion correction, 87 concomitant hammertoe correction) with a minimum of 12 months follow-up were included in this study. Both cohorts demonstrated significant improvements in the physical function, pain interference, pain intensity, and global physical health PROMIS domains (all p < 0.001). However, patients in the concomitant hammertoe cohort had significantly less improvements in pain interference and pain intensity (p < 0.01, p < 0.05 respectively). The concomitant hammertoe cohort also had significantly higher postoperative pain interference scores than the isolated bunion cohort (p < 0.01). Radiographic outcomes did not differ between the two groups. ConclusionWhile both isolated bunion correction and concomitant hammertoe correction yielded clinically significant improvements in patient reported outcomes and normalized radiographic parameters, patients undergoing simultaneous bunion and hammertoe correction experienced substantially less improvement in postoperative pain-related outcomes than those who underwent isolated bunion correction.

Bosch Osteotomy for Hallux Valgus Correction: Results at a Mean 10-Year Follow-Up

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Boesh osteotomy (BO) is a surgical option for the correction of hallux valgus (HV). The aim of this study was to assess the long-term clinical and radiographic results in a cohort of patients treated at our institution.Methods:In this retrospective cohort study, we included 58 HVs (28 right, 30 left) in 46 patients (42 females, 4 males; mean age and BMI at surgery 44 +- 15 (range, 15-64) years and 26 +- 4 (range, 22-38) points, respectively) who underwent HV correction by BO and were followed at a minimum of 7 years. The range of motion (ROM), the American Orthopaedic Foot & Ankle Society's Forefoot scale (AOFAS-FS) and the Visual Analogic Scale (VAS) for pain were recorded. On weightbearing radiographs, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), the Distal Metatarsal Articular Angle (DMAA) and the Sesamoid position were measured and compared with pre-operative values. The complication rate and first metatarsophalangeal joint stiffness were also assessed.Results:At a mean follow-up of 10+-2 (range, 7-17) years, mean+-standard deviation AOFAS-FS and VAS were 89+-11 (range, 67-93) and 2.1+-2.8 (range, 0-7) points, respectively. In 62% of patients there was no pain while in 38% an occasional pain was referred. In 42 (72%) cases there was no limitation in the choice of footwears. Radiographically, we found a significant improvement in the HVA (from 33.9°+-6.7 to 18.8°+-5.6, p<0.001), in the IMA (14.2°+-3.1 to 9.4°+-2.7, p<0.001), in the DMAA (from 30.3°+-6.8 to 11.5°+-5.1, p<0.001) and in the sesamoid position (median value from 3 to 1, p<0.001). In 36 (62%) cases the ROM was greater than 75° while in 22 (38%) it ranged between 30° and 75°. Complications occurred in 6 (10%) cases (3 superficial infections, 1 accidental removal of the K-wire, 1 metatarsal head necrosis and 1 development of osteoarthritis), which did not require any surgery at the longest follow-up.Conclusion:Boesh technique provided satisfactory clinical and radiographic outcomes in the correction of Hallux Valgus which persisted at a mean 10-year follow-up. The complication rate was not different from more recent techniques described in literature.

Comparing Open vs Minimally Invasive Techniques for the Correction of Hallux Valgus: Clinical and Patient Reported Outcomes

Category:BunionIntroduction/Purpose:Multiple operative techniques have been developed for hallux valgus with varying success. While correction has been traditionally achieved through open surgical approaches, there has been a growing interest in minimally invasive surgical (MIS) techniques. The purpose of this study was to compare clinical and patient-reported outcomes for patients undergoing hallux valgus correction with Lapidus, Scarf and MIS. Our hypothesis was that while a superior clinical correction would be achieved with open techniques there would be similar patient-reported outcomes among open and MIS techniques.Methods:A total of 257 patients who underwent Lapidus (n=82), Scarf (n=82) or MIS (n=93) hallux valgus correction between January 2017- January 2020 at one of two academic institutions by 1 of 9 foot and ankle-fellowship trained orthopedic surgeons were included in this study. Only 3 of 9 performed MIS correction. The average age at the time of surgery 55.4 (range 14-79). Patients were required to have a minimum baseline and 1-year postoperative Patient-Reported Outcomes Measurement Information Scores (PROMIS) and minimum 3-month clinical follow-up. Retrospective chart review was performed to assess the incidence of postoperative complications and reoperations, with an average clinical follow-up of 8 months.Results:All groups had statistically significant differences between pre- and post-operative measurements of HVA, IMA, DMAA, and tibial sesamoid position (<0.05). In addition, the Lapidus group demonstrated change in all parameters measured including Meary's angle, sagittal IMA and Seiberg index. All groups had statistically significant improvement in the PROMIS physical function, pain interference, and global health physical at 1 year (p<0.05). The Lapidus group had significant improvement in all 6 PROMIS domains measured. There were no significant differences in PROMIS score changes from pre to post-op for any PROMIS domain when comparing MIS vs Scarf vs Lapidus. Complications: Minor Complications were classified as infection, symptomatic hardware, delayed union, nerve irritation, transfer metatarsalgia (Lapidus n=14 (17.1%), Scarf n=2 (2.4%), MIS n=15 (16.1%)). Major complications were classified as nonunion, recurrence, hallux varus, recurrence (HVA >20) (Lapidus n=7 (8.5%), Scarf n=9 (11.0%), MIS n=9 (9.7%)).Conclusion:In the last decade, there has been a growing interest in the use of minimally invasive surgical MIS techniques for the treatment of hallux valgus. When compared with traditional open techniques using Lapidus and Scarf osteotomies MIS presents a safe and effective approach to treating hallux valgus.

Bösch osteotomy for hallux valgus correction: results at a mean 10-year follow-up.

Bösch osteotomy (BO), which is a first metatarsal subcapital osteotomy stabilised with a K-wire, is a surgical option to correct hallux valgus (HV). The aim of this study was to assess the long-term clinical and radiographic results in a cohort of patients treated at our institution with such osteotomy. In this retrospective monocentric single-surgeon cohort study, we included 58 HVs (46 patients) who underwent HV correction by BO and were followed at a minimum of 7years. The range of motion (ROM), the American Orthopaedic Foot and Ankle Society's Forefoot scale (AOFAS-FS) and the Visual Analogic Scale (VAS) for pain were recorded. On weightbearing radiographs, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), the Distal Metatarsal Articular Angle (DMAA), and the Lateral Sesamoid Position (LSP) were measured and compared with pre-operative values. The complication rate and first metatarsophalangeal joint stiffness were also assessed. At a mean follow-up of 10 ± 2 (7-17) years, mean ± standard deviation AOFAS-FS and VAS were 89 ± 11 (67-93) and 2.1 ± 2.8 (0-7) points, respectively. In 42 (72%) cases there was no limitation in the choice of footwears. Radiographically, we found a significant improvement in the HVA (from 33.9° ± 6.7 to 18.8° ± 5.6, p < 0.001), in the IMA (14.2° ± 3.1 to 9.4° ± 2.7, p < 0.001), in the DMAA (from 30.3° ± 6.8 to 11.5° ± 5.1, p < 0.001) and in LSP (median value from 3 to 1, p < 0.001). In 36 (62%) cases the ROM was greater than 75° while in 22 (38%) it ranged between 30° and 75°. Minor complications occurred in six (10%) cases, which did not require any further surgery at the longest follow-up. Bösch technique provided satisfactory clinical and radiographic outcomes in the treatment of hallux valgus which persisted at a mean 10-year follow-up. The complication rate did not differ from more recent techniques described in literature. Level IV, retrospective cohort study.

Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications

In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure.

Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs. Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ2 test, logistic regression, and a t test. A P value <.05 was considered statistically significant. There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls. The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction. Level III: Retrospective cohort study.

TL 18166 - Evaluation of quality of life and radiological parameters after hallux valgus correction

Introduction: The outcome of hallux valgus correction surgery is usually evaluated based on parameters of interest to the surgeon; however, the outcomes considered important by patients differ from those analyzed by physicians. Our objective is to evaluate the quality of life of patients undergoing hallux valgus correction and to assess the maintenance of radiographic parameters over time. Methods: The study included 38 patients who underwent hallux valgus correction surgery using different osteotomy techniques (scarf, chevron, arciform, proximal chevron and chevron-Akin) from January 2010 to December 2012. The patients were evaluated radiographically at 3 different times (preoperatively and 1 and 5 years postoperatively) and filled out the 36-Item Short Form Survey (SF-36) for the assessment of quality of life. Statistical analysis was performed using the paired Student’s t-test and the nonparametric Wilcoxon signed-rank and Friedman tests, with a maximum significance level of 5%. Results: Among the main findings of the SF-36 questionnaire, the sections on which the patients reported the best results were emotional role functioning, physical functioning and social role functioning, and the final mean score was 74.9. The metatarsophalangeal and intermetatarsal angles and medial eminence showed significant decreases during the postoperative period (p&lt;0.05), and only 1 patient presented loss of joint congruence. Conclusion: Different surgical osteotomy techniques used to correct moderate and severe hallux valgus improved the patients’ radiological parameters and quality of life.

Radiographic Outcomes after Fixation of Distal Metatarsal Osteotomy for Hallux Valgus Using a Tension Band Construct

Category:BunionIntroduction/Purpose:Hallux valgus is a common deformity of the forefoot. There are over 130 procedures described to correct hallux valgus. Classically, the treatment of mild to moderate hallux valgus is with a distal metatarsal osteotomy. A variety of fixation techniques have been described for use with this osteotomy most of which require partial or non-weight bearing until the osteotomy is healed. Tension Band fixation is a well-known principle in orthopedic surgery. The goal of the present study is to radiographically assess the maintenance of distal first metatarsal osteotomy fixation using a novel tension band device (Re+Line tension band bunion plate system, Nextremity Solutions) with immediate post-operative weight-bearing.Methods:The patient database for one surgeon was retrospectively reviewed for patients that underwent hallux valgus correction with the Re+Line tension band device between 2014 and 2017. Postoperative protocol included a soft dressing, firm surgical shoe, and weight-bearing as tolerated with a cane. Patients were excluded if fixation was achieved with something other than a tension band construct. Radiographs were obtained and reviewed retrospectively by 3 authors. Pre and postoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were measured as described previously in the literature, and the changes in correction compared. Maintenance of correction and hardware integrity were assessed at final follow-up after weight bearing as tolerated in a surgical shoe in the postoperative period. Statistical analysis was performed using a Wilcoxon signed-rank test for the changes in HVA and IMA.Results:There was a total of 72 patients and 76 toes that underwent hallux valgus correction with a tension band construct, at a mean follow-up of 4.36 months. 68 of 72 patients were female. The average age was 60.8 years old. The mean preoperative HVA was 27.1 degrees. The mean postoperative HVA was 6.14 degrees, with a mean correction of 20.22 degrees (p<0.001). The mean preoperative IMA was 14.14 degrees. The mean postoperative IMA was 6.10 degrees, with a mean correction of 7.98 degrees (p<0.001). There was loss of reduction found in 6 of 76 toes (7.89%).There were zero cases of hardware failure. All osteotomies healed at final follow-up.Conclusion:This study shows successful radiographic outcome after hallux valgus correction using a tension band construct and allowing immediate full weight-bearing in a surgical shoe in the postoperative period. Significant deformity correction was achieved and maintained and all osteotomies healed. The Re+Line tension band bunion correction system can be safely used as a successful option to fix distal first metatarsal osteotomies, while allowing patients to fully weight bear in a surgical shoe postoperatively and potentially return to activities faster than when using traditional fixation methods. Future studies are needed to assess functional outcomes and patient satisfaction with this novel technique.

Pretreatment of ankle nerve block provides better postoperative analgesia than peri-incisional local anesthetic infiltration in hallux valgus correction surgery.

Adequate postoperative analgesia after hallux valgus (HV) correction surgery improves early mobilization and decreases hospital stay. Peripheral nerve block and peri-incisional local anesthetic (LA) infiltration are both widely used for pain management in orthopedic surgeries. The aim of this study was to compare the analgesic effects between the ankle block and peri-incisional infiltration technique in patients undergoing HV correction surgery. Ninety patients scheduled for hallux valgus correction surgery were randomly allocated into three groups. In group N, patients were pretreated with tibial and peroneal nerve blocks with 8-10 mL of 0.25% bupivacaine before surgery. In group P, patients received the same LA for peri-incisional infiltration preoperatively. In group C, patients underwent surgery without regional analgesic pretreatment. All patients had intravenous fentanyl patient control analgesia as part of multimodal postoperative pain management. Fentanyl consumption, rest and moving pain scale, and adverse effects were evaluated at postoperative 6 h (Poh6), Poh12, Poh 24, and Poh36, respectively. Patients receiving bilateral feet surgeries were excluded in this study. Seventy-five patients were enrolled into final analysis. The patients in group N expressed lower resting and moving pain scores at Poh6, but the pain scores turned similarly among the three groups following Poh12 and then. The total fentanyl consumption was significantly less in group N than in group P. The postoperative activities and mood disturbance were not significantly different between groups after Poh12 and then. We conclude that ankle block is better than peri-incisional LA infiltration in HV correction surgery in pain relief and fentanyl consumption.

Evaluation of quality of life and radiological parameters after hallux valgus correction

Objective: To evaluate the quality of life of patients undergoing hallux valgus correction and maintenance of radiographic parameters over time. Methods: The study included 38 patients who underwent hallux valgus correction surgery using different osteotomy techniques (Scarf, Chevron, Arciform, Proximal Chevron and Chevron-Akin) between January 2010 and December 2012. The patients were evaluated radiographically at 3 different periods (preoperatively and 1 year and 5 years postoperatively) and completed the SF-36 quality-of life questionnaire. Statistical analysis was performed using Student’s t-test and the nonparametric Wilcoxon and Friedman tests at a maximum significance level of 5%. Results: Among the main results obtained for the SF-36 questionnaire, the domain patients felt better about emotional aspects, physical limitations and social aspects, with a final mean of 74.9. The metatarsophalangeal and intermetatarsal angles and medial eminence exhibited significant reductions in the postoperative period (p&lt;0.05), and only 1 patient presented with the loss of joint congruence. Conclusion: Different surgical osteotomy techniques used to correct moderate and severe hallux valgus provide improvements in the radiological parameters and quality of life of patients. Level of Evidence IV; Therapeutic Studies; Case Series.

Treatment of Hallux Valgus Deformity Using a Suture Button Device: A Preliminary Report

Background: Hallux valgus (HV) is commonly treated with proximal or distal first metatarsal osteotomy. Despite good correction, these procedures have inherent risks such as malunion, nonunion, metatarsal shortening, loss of fixation, and avascular necrosis. Suture button fixation has been used for HV treatment. It avoids the risks of corrective osteotomies while maintaining reduction of the intermetatarsal angle (IMA). The goal of this study was to assess the radiographic and functional outcomes of patients undergoing HV correction with a distal soft tissue procedure and proximal suture button fixation. Methods: The authors retrospectively reviewed the charts and radiographs of 22 patients who had undergone HV correction using a distal soft tissue correction and proximal fixation with a miniature suture button device (Mini TightRope; Arthrex, Inc, Naples, FL). Mean follow-up was 27.7 months. The IMA, hallux valgus angle (HVA), and sesamoid station were measured on radiographs obtained preoperatively as well as in the immediate postoperative period and at final follow-up. Preoperative and postoperative Short Form-36 (SF-36) and Foot and Ankle Ability Measure (FAAM) scores were collected. Postoperative complications, and any additional operative procedures performed were also recorded. Results: The mean preoperative IMA and HVA were 16.9 and 32.6 degrees, respectively. The mean immediate postoperative IMA was 5.2 degrees ( P &lt; .0001) and the mean HVA was 9.8 degrees ( P &lt; .0001). At final follow-up, the mean IMA was 8.2 degrees ( P &lt; .0001) and the mean HVA was 16.7 degrees ( P &lt; .0001). The average change in HVA from preoperative to final follow-up was 16.0 degrees and the average change in IMA from preoperative to final follow-up was 8.6 degrees ( P &lt; .0001). Sesamoid station assessment at the 2-week follow-up showed that 22 patients (100%) were in the normal position group; at final follow-up, 17 patients (77%) had normal position and 5 patients (23%) had displaced position. Although there were no clinically symptomatic recurrences, asymptomatic radiographic recurrence was noted in 5 patients (23%) who had a final HVA &gt;20 degrees. All components of the FAAM and the SF-36 showed improvement from preoperative to final follow-up, although these changes were not statistically significant. Three patients experienced complications, including an intraoperative second metatarsal fracture, a postoperative second metatarsal stress fracture, and a postoperative deep vein thrombosis. Conclusion: The use of a distal soft tissue procedure in conjunction with proximal suture button fixation is a safe and effective procedure for treating symptomatic HV deformity. Our results show that this technique can correct the IMA, HVA, and sesamoid station without the need for osteotomy. Level of evidence: Level IV.