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Foot & Ankle Orthopaedics Apr 2024
PubMed: 38726324
DOI: 10.1177/24730114241247820 -
World Journal of Orthopedics Mar 2024Hallux valgus (HV) is a common foot deformity that manifests with increasing age, especially in women. The associated foot pain causes impaired gait and decreases... (Clinical Trial)
Clinical Trial
BACKGROUND
Hallux valgus (HV) is a common foot deformity that manifests with increasing age, especially in women. The associated foot pain causes impaired gait and decreases quality of life. Moderate and severe HV is a deformity that is characterized by the involvement of lesser rays and requires complex surgical treatment. In this study, we attempted to develop a procedure for this condition.
AIM
To analyse the treatment results of patients who underwent simultaneous surgical correction of all parts of a static forefoot deformity.
METHODS
We conducted a prospective clinical trial between 2016 and 2021 in which 30 feet with moderate or severe HV associated with Tailor's bunion and metatarsalgia were surgically treated a new method involving surgical correction of all associated problems. This method included a modified Lapidus procedure, M2M3 tarsometatarsal arthrodesis, intermetatarsal fusion of the M4 and M5 bases, and the use of an original external fixation apparatus to enhance correction power. Preoperative, postoperative, and final follow-up radiographic data and American Orthopaedic Foot and Ankle Society (AOFAS) scores were compared, and values < 0.05 were considered to indicate statistical significance.
RESULTS
The study included 28 females (93.3%) and 2 males feet (6.7%), 20 (66.7%) of whom had a moderate degree of HV and 10 (33.3%) of whom had severe deformity. M2 and M3 metatarsalgia was observed in 21 feet, and 9 feet experienced pain only at M2. The mean follow-up duration was 11 months. All patients had good correction of the HV angle [preoperative median, 36.5 degrees, interquartile range (IQR): 30-45; postoperative median, 10 degrees, IQR: 8.8-10; follow-up median, 11.5 degrees, IQR: 10-14; < 0.01]. At follow-up, metatarsalgia was resolved in most patients (30 5). There was a clinically negligible decrease in the corrected angles at the final follow-up, and the overall AOFAS score was significantly better (median, 65 points, IQR: 53.8-70; 80 points, IQR: 75-85; < 0.01).
CONCLUSION
The developed method showed good sustainability of correction power in a small sample of patients at the one-year follow-up. Randomized clinical trials with larger samples, as well as long-term outcome assessments, are needed in the future.
PubMed: 38596187
DOI: 10.5312/wjo.v15.i3.238 -
Journal of Orthopaedic Surgery (Hong... 2024The hallux valgus deformity is made up of misaligned first metatarsal, hallux, and sesamoids. Their angular deformities are well-studied, but not their positional...
BACKGROUND
The hallux valgus deformity is made up of misaligned first metatarsal, hallux, and sesamoids. Their angular deformities are well-studied, but not their positional displacements. A few available reports claimed the proximal end of the proximal phalanx and sesamoids were not shifted medially along with the first metatarsal head. However, the general observation is otherwise. This study revisits the issue.
METHODS
A radiological study of 189 feet with and without the hallux valgus deformity was carried out to analyze the first metatarsal, hallux, and sesamoid positional changes in relation to the second metatarsal and among themselves. A total of 194 X-ray images with all relevant measurements that formed the raw database for this study were submitted for online viewing and reference.
RESULTS
There was a statistically significant change in the first metatarsal, hallux, and sesamoid positions of feet with hallux valgus deformity compared to normal feet. All have migrated medially but to different degrees. It was contrary to the past findings of no change in sesamoid and hallux positions.
CONCLUSIONS
We agree with past findings that the metatarsus primus varus deformity is directly related to the failed medial metatarsosesamoid ligament. We also believe in the failure of the deep 1-2 transverse metatarsal ligament responsible for the sesamoid migration.
Topics: Humans; Hallux Valgus; Hallux Varus; Foot; Radiography; Hallux; Metatarsal Bones
PubMed: 38369475
DOI: 10.1177/10225536241233474 -
BMC Musculoskeletal Disorders Feb 2024Hallux Valgus (HV) deformity is associated with misalignment in the sagittal plane that affects the first toe. However, the repercussions of the first toe hyperextension...
BACKGROUND
Hallux Valgus (HV) deformity is associated with misalignment in the sagittal plane that affects the first toe. However, the repercussions of the first toe hyperextension in HV have been scarcely considered. The purpose of this study was to provide evidence of the association between first-toe hyperextension and the risk of first toenail onycholysis in HV.
METHODS
A total of 248 HV from 129 females were included. The extension of 1st MTP joint was measured while the patient was in the neutral position of the hallux using a two-branch goniometer. The classification of the HV severity stage was determined by the Manchester visual scale, and the height of the first toe in the standing position was measured using a digital meter. An interview and clinical examination were performed to collect information on the presence of onycholysis of the first toe.
RESULTS
Of the 248 HV studied, 100 (40.3%) had onycholysis. A neutral extension > 30 degrees was noted in 110 (44.3%) HV. The incidence of onycholysis was higher in HV type C than in type B (p = 0.044). The probability of suffering onycholysis in the right foot was 2.3 times greater when the neutral position was higher than 30 degrees (OR = 2.3; p = 0.004). However, this was not observed in the left foot (p = 0.171). Onycholysis was more frequent in HV with more than 2 cm height of the first toe (p < 0.001). For both feet, the probability of suffering onycholysis was greater for each unit increase in hallux height (right foot OR = 9.0402, p = 0.005; left foot OR = 7.6633, p = 0.010).
CONCLUSIONS
The incidence of onycholysis appears to be significantly associated with HV showing more than 30º extension, and more than 2 cm height of the first toe. Height and hyperextension of the first toe together with first toenail pathology should be mandatory in the evaluation of HV.
Topics: Humans; Female; Hallux Valgus; Hallux; Cross-Sectional Studies; Prevalence; Onycholysis; Bunion; Metatarsophalangeal Joint
PubMed: 38317173
DOI: 10.1186/s12891-024-07219-1 -
JBJS Essential Surgical Techniques 2024The minimally invasive chevron Akin osteotomy technique is indicated for the treatment of symptomatic mild to moderate hallux valgus deformities. The aim of the...
BACKGROUND
The minimally invasive chevron Akin osteotomy technique is indicated for the treatment of symptomatic mild to moderate hallux valgus deformities. The aim of the procedure is to restore alignment of the first ray while minimizing soft-tissue disruption.
DESCRIPTION
Prior to the procedure, radiographs are utilized to characterize the patient's hallux valgus deformity by determining the hallux valgus angle and intermetatarsal angle. The metatarsal rotation is also assessed via the lateral round sign and sesamoid view. To begin, a stab incision is made over the lateral aspect of the first metatarsophalangeal (MTP) joint and a lateral release is completed by percutaneous fenestration of the lateral capsule. Next, the chevron osteotomy of the first metatarsal is performed. To begin this step, a Kirschner wire is inserted in an anterograde fashion from the medial base of the first metatarsal to the lateral aspect of the metatarsal neck. The wire is then withdrawn just proximal to the osteotomy site. A stab incision is made at the medial aspect of the metatarsal neck, and periosteal elevation is utilized for soft-tissue dissection. A minimally invasive burr is utilized to complete the osteotomy cuts. With the osteotomy complete, the first metatarsal translator is utilized to lever the metatarsal head laterally. Once satisfactory alignment has been achieved, the Kirschner wire is advanced into the metatarsal head. A cannulated depth gauge is utilized to measure the length of the screw. The near cortex is drilled, and the screw is inserted over the Kirschner wire, which is then removed. The next step is the Akin osteotomy of the proximal phalanx. Again, a Kirschner wire is placed in an anterograde fashion from the medial base of the proximal phalanx to the lateral neck. The Kirschner wire is then withdrawn until the tip is just proximal to the osteotomy site. A stab incision is made over the medial aspect of the proximal phalangeal neck, and periosteal elevation is carried out. The burr is utilized to complete the osteotomy; however, care is taken not to cut the far cortex. The great toe is then rotated medially, collapsing on the osteotomy site and hinging on the intact far cortex. When satisfactory alignment has been achieved, the Kirschner wire is advanced across the osteotomy and far cortex. A cannulated depth gauge is utilized to measure the length of the screw, and the wire is then driven through the lateral skin and clamped. The near cortex is drilled, the cannulated screw is inserted, and the Kirschner wire is then removed. Final fluoroscopy is performed to assess adequate correction, alignment, and hardware placement. The stab incisions are closed with use of simple interrupted 3-0 nylon. A tongue-depressor bunion dressing is applied. The patient is discharged to home with this dressing, as well as with an offloading postoperative shoe.
ALTERNATIVES
Surgical alternatives include open distal chevron osteotomy, open Akin osteotomy, MTP joint arthrodesis, Lapidus fusion, and Scarf osteotomy. Nonsurgical alternatives include the use of insoles, nonsteroidal anti-inflammatory drugs, wide-toed footwear, bunion shields and/or toe spacers, and physical therapy.
RATIONALE
The minimally invasive chevron Akin technique for hallux valgus correction provides alignment restoration of the first ray with less soft-tissue trauma than conventional open surgical procedures. This technique utilizes dorsal and medial stab incisions, instead of a more extensive open dorsal incision. These smaller incisions minimize the soft-tissue disruption, which has been reported to improve postoperative range of motion and to reduce loss of postoperative dorsiflexion related to scar tissue formation. Even while minimizing soft-tissue disruption, this technique still enables adequate correction and reliably stable fixation.
EXPECTED OUTCOMES
The expected outcome of this procedure is a return to normal activities following the recovery period. Prior to correction, the patient is counseled regarding the risk of persistent or recurrent deformity postoperatively. The patient is also informed regarding potential postoperative stiffness. According to the literature, outcomes following minimally invasive chevron Akin hallux valgus correction have been shown to be equivalent to traditional open correction, with reported recurrence rates of <1% and excellent or good patient satisfaction in >90% of patients. Function, as measured with use of the Manchester-Oxford Foot Questionnaire, has been shown to improve significantly from preoperatively (58.5 ± 15.9) to postoperatively (9.6 ± 9.2). Lastly, reported complication rates have varied according to the author's definition of complications, but typically range from 10% to 22%.
IMPORTANT TIPS
If the chevron osteotomy cut accidentally turns into a transverse cut, then add a second screw to provide rotational stability.Obtain a perfect lateral view after placing the Kirschner wire in order to ensure satisfactory trajectory of the Kirschner wire in all planes.Drive the Akin Kirschner wire through the skin distally and clamp with a mosquito to prevent pullout after drilling.If the Akin Kirschner wire is too flimsy to get a good starting point and trajectory, exchange it for the chevron Kirschner wire and use the drill to exchange back just prior to screw insertion.Subtract approximately 4 mm from the measured screw length in order to ensure that the screw is not too long; otherwise, it may create a gap in the osteotomy site.
ACRONYMS AND ABBREVIATIONS
NSAIDs = nonsteroidal anti-inflammatory drugsK-wire = Kirschner wireHVA = hallux valgus angleIMA = intermetatarsal angleMIS = minimally invasive surgeryAP = anteroposteriorOR = operating roomMTP = metatarsophalangealVAS = visual analog scaleMOXFQ = Manchester-Oxford Foot Questionnaire.
PubMed: 38268770
DOI: 10.2106/JBJS.ST.22.00021 -
BMC Musculoskeletal Disorders Jan 2024Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of...
BACKGROUND
Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of TSO, Modified Rotary Scarf osteotomy (MRSO) was introduced in this study, which aimed to compare the clinical and radiological outcome in the patients treated with MRSO or TSO.
METHODS
Of 175 patients (247 feet) with MSHV, 100 patients (138 feet) treated with MRSO and 75 patients (109 feet) treated with TSO were evaluated according to relevant indicators in twenty-four months follow-up. Pre-surgical and post-surgical HVA, IMA, DMAA, MTP-1 ROM, sesamoid grade and AOFAS (American Orthopaedic Foot and Ankle Society) scores and postsurgical complications were evaluated.
RESULTS
Both groups manifested similar baseline characters. The mean follow-up was of 25.9 (range, 22-37) months. Significantly lower IMA, lower Sesamoid grade and higher DMAA at six months, twelve months and twenty-four months post-surgically had been showed in MRSO group compared to TSO group. There was no significant difference in HVA, MTP-1 ROM and AOFAS data at each follow-up time point post-surgically between the two groups. No major complications occurred in either group.
CONCLUSION
MRSO showed comparable results to TSO, and improved IMA and sesamoid grade to a greater extent, with a lower probability of throughing effect. Although DMAA could be increased by MRSO, MRSO could still be a reproducible, non-dangerous and efficacious alternative procedure for treating HV patients which do not have severe DMAA.
Topics: Humans; Hallux Valgus; Retrospective Studies; Treatment Outcome; Bunion; Osteotomy; Metatarsal Bones
PubMed: 38216881
DOI: 10.1186/s12891-023-07156-5 -
The American Journal of Case Reports Dec 2023BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing...
A 28-Year-Old Woman with Down Syndrome, Congenital Heart Disease, and a History of Knee Surgery and Plantar Fasciitis, with Hallux Abducto Valgus (Bunion) and Lapiplasty Three-Dimensional Correction Surgery.
BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. CASE REPORT Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. CONCLUSIONS The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays.
Topics: Female; Humans; Adult; Hallux; Down Syndrome; Flatfoot; Fasciitis, Plantar; Bunion; Hallux Valgus; Joint Instability; Heart Defects, Congenital; Metatarsal Bones
PubMed: 38091276
DOI: 10.12659/AJCR.940879 -
The Journal of Foot and Ankle Surgery :... 2024Hallux valgus (HV) is a common deformity of the foot. Its postoperative recurrence is not uncommon and is closely related to the recurrence of its underlying metatarsus...
Hallux valgus (HV) is a common deformity of the foot. Its postoperative recurrence is not uncommon and is closely related to the recurrence of its underlying metatarsus primus varus (MPV) deformity. The syndesmosis procedure uses 1 to 2 intermetatarsal cerclage sutures to realign the first metatarsal and then induces a biological bonding between the 2 metatarsals to prevent the MPV deformity from recurring. This radiological study aimed to assess its effectiveness in long-term MPV and HV deformities recurrence prevention. Ninety-two feet of 51 consecutive patients had syndesmosis procedures that were prospectively followed up for more than 1 y and up to 14 y, averaging 100.5 (SD 45.2) months. Patients underwent X-ray examinations regularly at fixed intervals of their feet. We used Hardy's methods in measuring the intermetatarsal angle (IMA), hallux valgus angle (HVA), and medial sesamoid position from standing foot X-rays. More than 450 relevant X-ray and photo images were submitted as Supplementary Material for online viewing and reference. There was a significant final correction of IMA from 14.30° (SD 2.70) to 6.70° (SD 1.75) (p < .0001). There was no significant increase in IMA after the sixth postoperative month to their final follow-up endpoints, regardless of their lengths. There was a significant final correction of HVA from 31.95° (SD 7.45) to 19.1° (SD 7.45) (p < .0001). This study reconfirmed past findings that the MPV deformity could be corrected without osteotomies. Creating a syndesmosis-like intermetatarsal bonding was effective for long-term MPV recurrence prevention. Three feet had postoperative stress fracture of the second metatarsal. However, the HV deformity correction was less satisfactory, and the reasons were explained.
Topics: Humans; Hallux Valgus; Hallux Varus; Treatment Outcome; Metatarsal Bones; Bunion; Osteotomy; Retrospective Studies; Metatarsus Varus
PubMed: 38056554
DOI: 10.1053/j.jfas.2023.11.014 -
Journal of Children's Orthopaedics Dec 2023We compared the outcomes of arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in 31 adolescents with cerebral palsy, using three different...
Arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in adolescents with cerebral palsy: A retrospective comparison study of three surgical techniques.
PURPOSE
We compared the outcomes of arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in 31 adolescents with cerebral palsy, using three different methods of fixation: K-wires, non-locking plates, and locking plates.
METHODS
Clinical outcomes included time to weight-bearing, fusion rates and surgical complications. Radiographic assessment included comparing pre- and post-operative hallux valgus angles, intermetatarsal angles, interphalangeal angles, and lateral metatarsophalangeal angles. Patient-reported outcomes included pre- and post-operative visual analogue scales addressing bunion pain and concerns, difficulties with wearing shoes and braces, and difficulties with foot hygiene.
RESULTS
Of the 31 adolescents (16 male), 10 patients had K-wire fixation, 11 had a non-locking dorsal plate, and 10 had fixation with a dorsal locking plate. Mean age at surgery was 16 years (12-18 years) and mean follow-up was 4 years (2.7-6.5 years). Patients with K-wire fixation had delayed weight-bearing and had more complications than those managed by dorsal plating. There were significant improvements in radiographic parameters (except interphalangeal angle) and in patient-reported outcomes, in all groups ( < 0.001). However, radiographic and clinical outcomes were better in the dorsal plating groups compared to the K-wire group.
CONCLUSION
Arthrodesis of the first metatarsophalangeal joint gave good correction of deformity with improvements in symptoms and radiographic parameters in adolescents with cerebral palsy. We recommend dorsal plating that allowed early weight-bearing and had fewer complications with better clinical and radiographic outcomes, than K-wire fixation.
LEVEL OF EVIDENCE
IV: Retrospective case series.
PubMed: 38050598
DOI: 10.1177/18632521231200060 -
Foot & Ankle Orthopaedics Jul 2023The modified Lapidus (ML) is a powerful procedure for correction of hallux valgus (HV) with emerging techniques. Studies considering patient-reported outcomes,...
BACKGROUND
The modified Lapidus (ML) is a powerful procedure for correction of hallux valgus (HV) with emerging techniques. Studies considering patient-reported outcomes, radiographic measures, complications, and implant costs are currently limited.
METHODS
Retrospective cohort with prospectively collected Patient Reported Outcome Information System Physical Function (PROMIS-PF) Computerized Adaptive Test (CAT) scores, radiographic parameters (intermetatarsal angle, IMA; hallux valgus angle, HVA; and tibial sesamoid position, TSP), complications, and total operative time and implant costs were reviewed from 2014 to 2019.
RESULTS
Seventy-three feet (68 patients) underwent bunion correction by ML with lag-screw fixation. Median age was 55.8 years (IQR 45.6, 53.9), 4 of 73 (5.5%) were male, 11 of 73 (15.1%) were smokers, and 15 of 73 (20.6%) were diabetic (median HbA1c 6.4% [IQR 6.0, 7.4], none insulin dependent, 5 of 15 with neuropathy). Complications included 6 of 73 (8.2%) wound issues resolved with topical or oral treatment, 9 of 73 (12.3%) painful or broken hardware requiring hardware removal. Two of 73 (2.7%) had persistent pain despite union. One of 73 (1.4%) was overcorrected and required first MTP arthrodesis. Of 3 nonunions (2.7%), 1 resolved with corrected hypothyroidism, 1 was asymptomatic and required no treatment, 1 had a hallux valgus recurrence and sought revision surgery elsewhere. Preoperative radiographic angles were HVA 35 degrees, IMA 14 degrees which improved at final postoperative follow up to HVA 10 degrees, IMA 6 degrees. Tibial sesamoid position improved from 6.05 ± 1.00 to 2.22 ± 1.38. Thirty-two patients had preoperative and 42 had 1-year postoperative outcomes. PROMIS-PF (51% collection rate) was 43 (IQR 37,52) preoperatively, 37 (31, 39) at 6 weeks, 46 (42, 51) at 3 months, and 49 (41, 53) at >360 days postoperatively. The drop in PROMIS-PF between preoperative and 6 weeks and the rise from 6 weeks to 3 months were statistically significant. Pre- and postoperative PROMIS-PF scores were not significantly different. Implant cost averaged US$146.
DISCUSSION/CONCLUSION
We report low complication rates and costs with high patient postoperative functional and radiographic outcomes. PROMIS-PF decreased acutely postoperatively but recovered and maintained high levels by 3 months postoperatively.
LEVEL OF EVIDENCE
Level IV, case series.
PubMed: 37786608
DOI: 10.1177/24730114231200482