Hallux valgus: demographics, etiology, and radiographic assessment

A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

PURPOSE

Several bony and soft tissue procedures have been described for the treatment of hallux valgus, and currently mini-invasive surgical techniques are preferred in order to reduce surgical trauma, complications, time of surgery and to allow an earlier recovery. The aim of this study is to analyse a series of 1,000 consecutive cases of hallux valgus, surgically treated by the minimally invasive SERI technique, reporting results at mid-term follow-up.

METHODS

We prospectively studied 641 patients (1,000 feet) with symptomatic hallux valgus surgically treated by SERI osteotomy. Inclusion criteria were: age between 20 and 65 years, reducible mild or moderate hallux valgus, HVA ≤ 40°, IMA ≤ 20°, and arthritis of the first metatarsophalangeal joint up to grade 2 according to the Regnauld classification.

RESULTS

The American Orthopaedic Foot and Ankle Society (AOFAS) score rose from 46.8 ±  6.7 preoperatively to 89 ± 10.3 at last follow-up. Radiographic control at follow-up showed a complete healing of the osteotomy and remodelling of the metatarsal bone. Low rate of complication has been reported.

CONCLUSIONS

This study demonstrated that the SERI technique is effective in treating mild to moderate hallux valgus in terms of relief from symptoms and functional improvement. This technique allowed correction of the main parameters of the deformity, with durable clinical and radiographic results at a mid-term follow-up.

The SERI distal metatarsal osteotomy and Scarf osteotomy provide similar correction of hallux valgus

BACKGROUND

Ideal surgical treatment for hallux valgus is still controversial. A traditional distal metatarsal osteotomy with rigid fixation (Scarf procedure) and a more minimally invasive approach to a distal metatarsal osteotomy, termed SERI (Simple, Effective, Rapid, Inexpensive), have proven successful with short-term followup. However, no data are available directly comparing the two procedures.

QUESTIONS/PURPOSES

We performed a prospective randomized trial to determine which technique (SERI or Scarf) was associated with (1) better functional outcomes, (2) better radiographic correction, and (3) fewer complications at 2 and 7 years followup.

METHODS

Twenty patients, 53 ± 11 years of age, with bilateral hallux valgus, clinically and radiographically similar, underwent bilateral surgery with Scarf on one side and SERI on the other, at random. Clinical (AOFAS score) and radiographic assessments were considered before surgery, and at 7 years followup.

RESULTS

SERI and Scarf techniques provided correction of the hallux valgus angle, intermetatarsal angle, and distal metatarsal angle in the range of normal. Both led to similar clinically important improvements in the AOFAS. No differences were observed between the groups. All osteotomies healed, and two patients who underwent the Scarf procedure required hardware removal. Reduction of ROM with respect to preoperative was observed in three patients for SERI and three patients for Scarf procedures.

CONCLUSIONS

Scarf and SERI techniques resulted in effective correction of hallux valgus with similar outcomes, however the SERI technique required a shorter skin incision, less surgical time, less expensive fixation device, and was without residual pain attributable to hardware.

LEVEL OF EVIDENCE

Level II, prospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Hallux valgus in males--part 2: radiographic assessment of surgical treatment

BACKGROUND

In an early report on this patient cohort, we concluded that a hallux valgus deformity in males is frequently hereditary in nature. An increase in the distal metatarsal articular angle (DMAA) was observed to be the major defining characteristic of hallux valgus in males. In this follow-up study, our goal was to evaluate the effectiveness of surgical treatment for this cohort of male patients.

METHODS

Data from 50 feet of male patients with hallux valgus who were surgically treated by the same surgeon between 1985 and 2005 were retrospectively analyzed. The technique was algorithmically chosen according to the severity and complexity of the deformity. Thus, 10 chevron osteotomies, 9 biplanar chevron osteotomies, 12 Mitchell osteotomies, 9 scarf osteotomies, and 10 basilar first metatarsal osteotomies were performed. The average follow-up was 10 years (range, 2-20).

RESULTS

After analyzing the angular radiological parameters, sesamoid subluxation, and the articular congruency, most procedures proved to have achieved adequate correction of the angular deformities. When examining each of the procedures separately, 4 of the 5 procedures had similar corrective capacities; the scarf osteotomy however had decidedly inferior results. The improvement in the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score demonstrated the clinical and functional improvement.

CONCLUSIONS

The algorithm was based mainly upon the presence of increased DMAA and increased severity of angular deformities. We conclude that hallux valgus deformities in males were adequately corrected with the selected techniques. Greater difficulty or resistance to surgical treatment could not be detected when we contrasted our results to females. The scarf osteotomy proved to have an inferior corrective capacity compared to the other techniques used in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Hallux valgus in males--part 1: demographics, etiology, and comparative radiology

BACKGROUND

The high frequency of hallux valgus deformities in females is well known and has been widely reported in the literature. This finding tends to obscure the importance and the characteristic details of hallux valgus deformities in males. The severity of the deformity, its onset at an earlier age, and its inheritability seem to be more frequent in males, but there are no reports in the literature to substantiate these concepts. The purpose of this study was to analyze these questions in regard to males with hallux valgus.

METHODS

The records and plain radiographs of 31 males (53 feet) with a diagnosis of hallux valgus that were treated over a 20-year period (1985-2005) were analyzed. During that same period, the senior author (CN) performed 812 procedures for the correction of hallux valgus deformities in women. In order to compare gender-related differences associated with this deformity, 31 women's charts-paired by age and affected side-were randomly selected and both clinical and radiological data were statistically compared.

RESULTS

The onset of the complaints of first ray pain in males was equally distributed by decades, indicating that the deformity begins earlier in this group. Among males, we found 68% of the subjects had a familial history of bunion deformities-58% were maternal and 10% were fraternal. In the control group of females, only 35% of the women reported inheritance of the deformity. No correlation with footwear was found among males. The radiographic measurements were significantly higher in the male group, which included the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the tarsal metatarsal angle (TMA). The main gender difference was found to be the DMAA with first metatarsophalangeal (MTP) joint congruence being much more common in males (males = 57%, females = 30%). No correlations were found for metatarsus primus varus or pes planus.

CONCLUSION

Based on our observations, we conclude that hallux valgus in males is commonly hereditary in nature and is mainly transmitted by the mother, with early onset and higher severity when compared to women. We report a female/male ratio of 15:1. The main intrinsic factor associated with a hallux valgus deformity in males is a high DMAA.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

[Lack of correlation between plantar arthrosis of the first metatarsal joint and sesamoids and pain in patients after hallux valgus surgery]

OBJECTIVES

To determine the relationship between osteoarthritis in the plantar region of the first metatarsophalangeal joint of the foot and patient pain after hallux valgus surgery.

MATERIAL AND METHODS

A total of 28 patients undergoing hallux valgus surgery were examined. The patients were examined for pain in the plantar region of the metatarsophalangeal joint (sesamoid bones area), by looking into their medical records and by means of palpation during the physical exam. X-rays were taken to look for metatarsophalangeal arthritis, and PASA and sesamoid displacement were measured. During the surgical procedure, the metatarsal head was macroscopically assessed for arthritis according to the ICRS Score.

RESULTS

Of the 28 patients, 18 had no pain, 7 had mild pain (VAS 1-3) and 3 had moderate pain (VAS 4-6). Macroscopically, all the patients had some degree of plantar osteoarthritis. Only 5 patients had radiological signs of metatarsophalangeal arthritis. There was no correlation (P=.44) between pain and plantar osteoarthritis. There was a mild but non-significant correlation between PASA and osteoarthritis (P=.06). There was a weak but significant correlation between patient age and arthritis (P=.04).

CONCLUSION

Osteoarthritis in the plantar aspect of the first metatarsal head does not correlate with patient symptoms or with pain intensity in patients undergoing hallux valgus surgery.

Correction of intermetatarsal angle in hallux valgus using small suture button device

BACKGROUND

Hallux valgus is a common foot ailment causing pain and disability, and correction of the intermetatarsal angle (IMA) deformity is often accomplished using a first metatarsal distal or proximal osteotomy. These osteotomies can be technically challenging and may lead to complications such as loss of fixation, shortening of the first metatarsal, avascular necrosis, malunion, and nonunion. Endobuttons (Mini TightRope device) provide an alternative to first metatarsal osteotomies for correction of the IMA. The purpose of this preliminary study was to determine the short-term clinical and radiographic outcomes of hallux valgus correction using the Mini TightRope.

METHODS

A total of 14 cases of hallux valgus correction using the Mini TightRope technique with a 1.1-mm drill and mini-buttress plate were reviewed. Clinical examinations and radiographs were performed preoperatively and postoperatively at 1-week (non-weight-bearing), 3-month (weight-bearing), and 6-month (weight-bearing) follow-up.

RESULTS

The overall 1-week postoperative decreases in IMA and hallux valgus angle (HVA) of all cases compared with preoperative status were 9 degrees and 28 degrees, respectively. Decreases in IMA and HVA continued at 3 months postoperatively but to a lesser extent, with decreases of 7 degrees and 20 degrees, respectively. Reductions in IMA and HVA were maintained through 6 months of follow-up compared with preoperatively, with IMA and HVA decreases of 6 degrees and 19 degrees, respectively. Two minor soft-tissue complications and 1 intraoperative second metatarsal fracture were treated with a buttress plate, with uneventful healing.

CONCLUSIONS

Overall short-term results demonstrated notable improvements in IMA and HVA with use of the Mini TightRope, and few early complications were associated with the procedure.

Unilateral hallux valgus: is it true unilaterality, or does it progress to bilateral deformity?

BACKGROUND

This study was undertaken to determine whether unilateral hallux valgus progresses unilaterally and to evaluate the demographics, etiologies, and radiographic findings associated with symptomatic unilateral hallux valgus deformities.

METHODS

Patients treated for hallux valgus between January 2004 and December 2008 were identified, and of these, 33 patients with unilateral deformities were enrolled. Progression of deformities in normal feet were evaluated at last follow-up visit, and the clinical information and radiographic measurements of those with a deformed normal foot or an unchanged normal foot were compared.

RESULTS

Thirty-three patients (3.4%) had a unilateral hallux valgus deformity on preoperative radiographs. The mean length of follow up was 4.7 years (range, 2.4-11). Twenty-four cases had no deformity of the normal foot at last follow-up (the unchanged group), but 15 cases had developed hallux valgus deformity (the deformed group). No significant intergroup differences were found in terms of metatarsus adductus angle (P = .412), Meary angle (P = .771), talocalcaneal angle (P = 1.000), or calcaneal pitch angle (P = .267). However, members of the deformed group were significantly younger at disease onset (P = .045), exhibited a curved first metatarsal head (P = .046), and had a larger initial hallux valgus angle (P < .001).

CONCLUSIONS

The frequency of bilateral symptomatic hallux valgus was found to be over 97.3%, and significant differences were found between the deformed and unchanged groups in terms of age of onset, metatarsal head shape, and hallux valgus angle.

Distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus decided using intraoperative varus stress radiographs

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.

Minimally invasive distal linear metatarsal osteotomy for correction of hallux valgus: a preliminary study of clinical outcome and analytical radiographic results via a mapping system

PURPOSES

To date, actual results of a minimally invasive distal linear metatarsal osteotomy (DLMO) via more explicit radiographic delineation are poorly understood and radiographic findings and clinical results have not been systematically correlated. Purposes of this study were (1) to evaluate the effectiveness of DLMO using a precise radiographic mapping system; and (2) to determine the relationship between radiographic outcomes and clinical results.

MATERIALS AND METHODS

In 2008-2011, DLMO was performed in 30 patients (36 feet) who had reducible symptomatic hallux valgus. Clinical data were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed at preoperative and final follow-up for delineations of first ray construct, hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle, and other radiographic profiles. Correlation between postoperative AOFAS score and degree of malalignment was also analyzed.

RESULTS

A total of 36 feet had predominantly moderate hallux valgus (26 feet with HVA: 21-39°; 23 feet with IMA: 12-17°). Mean preoperative and postoperative AOFAS scores were 70.2 ± 11.3 and 95 ± 6.4, respectively (p < 0.001). Mapping system revealed improvements of first ray construct deformity (p < 0.05). Significant reductions in all angular measurements were observed at final follow-up period (p < 0.001) and correlated significantly with changes in AOFAS score (p < 0.001). Nine feet (25 %) were observed with recurrence of deformity which showed HVA >15°. Significant sesamoid lateralization was observed (p < 0.05). Twenty-four feet (66.7 %) showing overall sagittal malunions were found with significant plantar angulation (p = 0.026) and non-significant plantar displacement compared with preoperative reference (p = 0.43). These radiographic abnormalities were not related to clinical outcomes including postoperative AOFAS scores (p > 0.05).

CONCLUSION

DLMO is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity. Sagittal malunion, recurrence, and sesamoid lateralization are possibly radiographic abnormalities but are not associated with clinical impairments.

Mitchell's osteotomy with mini-plate and screw fixation for hallux valgus

BACKGROUND

The aim of this study was to evaluate the use of mini-plate and screw fixation to stabilize the first metatarsal osteotomy in patients undergoing Mitchell bunionectomy, with the outcomes of interest being radiological alignment and the time to bony union.

METHODS

We used mini-plates and screws in 43 feet of 25 patients to avoid cast immobilization and prevent osteotomy displacement. The mean age at operation was 45.4 ± 13.4 years (range, 17.0-65.0 years). The mean follow-up was 16.9 ± 3.6 months (range, 12.0-30.0 months). The hallux valgus angles, intermetatarsal angles, and American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were evaluated preoperatively and at postoperative month 12.

RESULTS

The mean preoperative value for the hallux valgus angle was 35.9 ± 4.4 degrees (range, 26.0-45.0 degrees) and for the intermetatarsal angle was 12.1 ± 1.4 degrees (range, 10.0-15.0 degrees). The mean postoperative value for the hallux valgus angle was 16.0 ± 2.12 degrees (range, 12.0-20.0 degrees) and for the intermetatarsal angle was 7.7 ± 1.2 degrees (range, 5.0-10.0 degrees). The mean AOFAS score was 50.5 ± 12.8 points (range, 30.1-76.0 points) preoperatively and 75.9 ± 11.3 points (range, 43.3-92.3 points) at postoperative month 12. Improvement of range of motion of the metatarsophalangeal joint, pain relief, and satisfactory alignment of the first ray were achieved in 41 feet (95.3%).

CONCLUSIONS

We recommend this fixation for Mitchell's bunionectomy because it provided stable fixation without the need for casting.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Modified minimal incision subcapital osteotomy for hallux valgus correction

The potential advantages of minimal incision surgery for hallux valgus (HV) correction are the following: reduced surgical exposure, diminished soft-tissue stripping, and less blood supply impairment. These advantages imply fewer complications. We retrospectively reviewed patients who were consecutively treated with a modified minimally invasive osteotomy from January 2006 until December 2009 for HV deformity. We radiographically assessed the HV angle, 1-2 intermetatarsal (IM) angle, and tibial sesamoid position. Clinical outcomes were determined using the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal (AOFAS HMI) Clinical Rating Scale. A paired Student's t test was used to determine significance, with P < .01. There were 126 patients (146 feet) with an average age of 52.6 years and an average postoperative follow-up of 29.1 months. Preoperatively, the average HV angle was 32.3°, and postoperatively, it was 4.5° (P < .01). The preoperative average IM angle was 14.4°, whereas postoperatively, it was 4.8° (P < .01). The average tibial sesamoid position was 6.3 preoperatively and 2.5 postoperatively (P < .01). The average AOFAS HMI score was 54.6 preoperatively and 85.3 postoperatively (P < .01). There were 15 postoperative complications (10.3%) that included hallux varus, painful hardware, and delayed union. The results are comparable with those of traditional open techniques, with the additional advantages of a minimally invasive procedure.

Use of the iPhone for radiographic evaluation of hallux valgus

OBJECTIVE

The purpose of this study was to compare the measurements made using a smartphone accelerometer and computerized measurements as a reference in a series of 32 hallux valgus patients.

MATERIALS AND METHODS

Two observers used an iPhone to measure the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (of anteroposterior foot radiographs in 32 patients with symptomatic hallux valgus on a computer screen. Digital angular measurements on the computer were set as the reference standard for analysis and comparison. The difference between computerized measurements and all iPhone measurements, and the difference between the first and second iPhone measurements for each observer were calculated. Inter- and intraobserver reliability of the smartphone measurement method was also tested.

RESULTS

The variability of all measurements was similar for the iPhone and the computer-assisted techniques. The concordance between iPhone and computer-assisted angular measurements was excellent for the HVA, IMA, and DMAA. The maximum mean difference between the two techniques was 1.25 ± 1.02° for HVA, 0.92 ± 0.92° for IMA, and 1.10 ± 0.82° for DMAA. The interobserver reliability was excellent for HVA, IMA, and DMAA. The maximum mean difference between observers was 1.31 ± 0.89° for HVA, 0.90 ± 0.92° for IMA, and 0.78 ± 0.87° for DMAA. The intraobserver reliability was excellent for HVA, IMA, and DMAA.

CONCLUSIONS

We conclude that the Hallux Angles software for the iPhone can be used for measurement of hallux valgus angles in clinical practice and even for research purposes. It is an accurate and reproducible method.

Interobserver and intraobserver reproducibility of hallux valgus angular measurements and the study of a linear measurement

BACKGROUND

The intermetatarsal angle (IMA), the hallux valgus angle (HVA), and the lateral sesamoid malalignment in relation to the first metatarsal are among the most commonly employed parameters to estimate the severity of the deformity. The aim of this study was to compare HV angular measurements and a linear measurement among 4 observers to determine its intraobserver and interobserver reliability, to find out whether this linear measurement technique is more reproducible than those already-described angular measurements.

METHODS

The IMA, the HVA, and the distance between the lateral cortex of the first metatarsal and the lateral cortex of the lateral sesamoid bone were measured from 50 standing, nonoperated hallux valgus feet. Radiographs were shuffled and reforwarded to the observers at a minimum interval of 30 days for a new measurement.

RESULTS

When considering 2° of difference as significant, IMA and HVA measurements were not precise, showing low reproducibility for both intraobserver and interobserver assessment. Regarding the distance between the first metatarsal lateral cortex and the lateral sesamoid lateral cortex, when considering differences greater than 2 mm as significant, we observed higher precision and higher reproducibility.

CONCLUSIONS

Angular measurements of hallux valgus deformity in anteroposterior standing radiographs that are manually performed with a goniometer are not precise and have low reproducibility. The linear measurement of the distance between the lateral cortices of the first metatarsal head and the lateral sesamoid demonstrated higher precision and higher reproducibility, and may be a cheap form to assess the correct indication of a distal osteotomy.

LEVELS OF EVIDENCE

Diagnostic, Level II.

Characteristics of foot structure and footwear associated with hallux valgus: a systematic review

OBJECTIVE

Factors associated with the development of hallux valgus (HV) are multifactorial and remain unclear. The objective of this systematic review and meta-analysis was to investigate characteristics of foot structure and footwear associated with HV.

DESIGN

Electronic databases (Medline, Embase, and CINAHL) were searched to December 2010. Cross-sectional studies with a valid definition of HV and a non-HV comparison group were included. Two independent investigators quality rated all included papers. Effect sizes and 95% confidence intervals (CIs) were calculated (standardized mean differences (SMDs) for continuous data and risk ratios (RRs) for dichotomous data). Where studies were homogeneous, pooling of SMDs was conducted using random effects models.

RESULTS

A total of 37 papers (34 unique studies) were quality rated. After exclusion of studies without reported measurement reliability for associated factors, data were extracted and analysed from 16 studies reporting results for 45 different factors. Significant factors included: greater first intermetatarsal angle (pooled SMD = 1.5, CI: 0.88-2.1), longer first metatarsal (pooled SMD = 1.0, CI: 0.48-1.6), round first metatarsal head (RR: 3.1-5.4), and lateral sesamoid displacement (RR: 5.1-5.5). Results for clinical factors (e.g., first ray mobility, pes planus, footwear) were less conclusive regarding their association with HV.

CONCLUSIONS

Although conclusions regarding causality cannot be made from cross-sectional studies, this systematic review highlights important factors to monitor in HV assessment and management. Further studies with rigorous methodology are warranted to investigate clinical factors associated with HV.

Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus

PURPOSE

This study compared results of distal and proximal metatarsal osteotomy for moderate to severe hallux valgus in terms of radiographic correction and functional outcome.

METHODS

We analyzed 125 moderate to severe hallux valgus surgeries. Patients were divided into two groups. Group 1 underwent distal metatarsal osteotomy, and group 2 underwent proximal metatarsal osteotomy. Patients were interviewed for functional scores before and one year after surgery. The anteroposterior (AP) weight-bearing radiography of the foot was taken before and one year after surgery.

RESULTS

There were no significant differences in pain and function after one year in either group. Both groups experienced significant pain reduction and increase in all functional scores. There was significant improvement of hallux valgus and intermetatarsal angle corrections in group 2. There was less improvement in radiographic correction in group 1.

CONCLUSION

Either distal or proximal metatarsal osteotomy is an appropriate pain-relieving procedure and can increase functional outcome in moderate to severe hallux valgus. However, distal metatarsal osteotomy provides lower correction power.

Outcomes of proximal chevron osteotomy for moderate versus severe hallux valgus deformities

BACKGROUND

Proximal chevron osteotomy with a distal soft tissue procedure has been widely used to treat moderate to severe hallux valgus deformities. However, there have been no studies comparing the results of proximal chevron osteotomy between patients with moderate and severe hallux valgus. We compared the results of this procedure among these groups.

METHODS

A retrospective review of 95 patients (108 feet) that underwent proximal chevron osteotomy and distal soft tissue procedure for moderate and severe hallux valgus was conducted. The 108 feet were divided into two groups: moderate hallux valgus (Group A) and severe hallux valgus (Group B). Group A was composed of 57 feet (52 patients) and Group B of 51 feet (43 patients). Average followup was 45 months.

RESULTS

Mean American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal scores were 54.1 points in Group A and 53.0 points in Group B preoperatively, and these improved to 90.8 and 92.6, respectively, at the last followup. Mean hallux valgus angles in Groups A and B reduced from 32.3 and 40.8 degrees, preoperatively to 10.7 and 13.2 degrees, postoperatively. Similarly, mean first intermetatarsal angles in Groups A and B reduced from 15.0 and 19.2 degrees, preoperatively to 9.0 and 9.2 degrees, postoperatively.

CONCLUSION

The clinical and radiographic outcomes of proximal chevron osteotomy with a distal soft tissue procedure were found to be comparable for moderate and severe hallux valgus. Accordingly, our results suggest that this procedure provides an effective and reliable means of correcting hallux valgus regardless of severity of deformity.

Validity and reliability of hallux valgus angle measured on digital photographs

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To investigate the reliability and concurrent validity of photographic measurements of hallux valgus angle compared to radiographs as the criterion standard.

BACKGROUND

Clinical assessment of hallux valgus involves measuring alignment between the first toe and metatarsal on weight-bearing radiographs or visually grading the severity of deformity with categorical scales. Digital photographs offer a noninvasive method of measuring deformity on an exact scale; however, the validity of this technique has not previously been established.

METHODS

Thirty-eight subjects (30 female, 8 male) were examined (76 feet, 54 with hallux valgus). Computer software was used to measure hallux valgus angle from digital records of bilateral weight-bearing dorsoplantar foot radiographs and photographs. One examiner measured 76 feet on 2 occasions 2 weeks apart, and a second examiner measured 40 feet on a single occasion. Reliability was investigated by intraclass correlation coefficients and validity by 95% limits of agreement. The Pearson correlation coefficient was also calculated.

RESULTS

Intrarater and interrater reliability were very high (intraclass correlation coefficients greater than 0.96) and 95% limits of agreement between photographic and radiographic measurements were acceptable. Measurements from photographs and radiographs were also highly correlated (Pearson r = 0.96).

CONCLUSIONS

Digital photographic measurements of hallux valgus angle are reliable and have acceptable validity compared to weight-bearing radiographs. This method provides a convenient and precise tool in assessment of hallux valgus, while avoiding the cost and radiation exposure associated with radiographs.

Operative management of common forefoot deformities: a representative survey of Australian orthopaedic surgeons

BACKGROUND

Hallux valgus and hallux rigidus are common conditions for which numerous operative interventions have been described in the literature. Various clinical and radiological measurements have been used to help grade severity and to guide treatment.

MATERIALS AND METHODS

A survey was e-mailed to all members of the Australian Orthopaedic Association. Questions were asked regarding respondents' demographics as well as their preferred treatment for 3 separate cases of hallux valgus and hallux rigidus of varying severity. They were specifically asked about type of deformity correction and type of fixation. The responses were collected and statistically analyzed.

RESULTS

The authors collected the answers of 454 respondents with a response rate of 36%. There was a disproportionately large percentage of respondents who were members of the Australian Orthopaedic Foot and Ankle Society. Preferred treatments were different for the 3 different cases. Older surgeons were more likely to use Chevron osteotomies, and Australian Orthopaedic Foot and Ankle Society members were more likely to use a scarf. Scarf osteotomy was preferred by more than 50% for the cases of moderate and severe hallux valgus, whereas first metatarsophalangeal joint fusion was preferred for the case with significant arthritic changes.

CONCLUSIONS

There are significant associations between the surgeons' age and expertise and their training and their preferred operative intervention. Considerable differences were found in the practice of the general orthopaedic surgeons and the foot and ankle specialists. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons. Although anecdotally aware that lesser deformity is treated with distal osteotomies and more severe deformity with a proximal osteotomy, the authors are unaware of any current literature that verifies this.

Os intermetatarseum - A case report

Accessory ossicles and sesamoid bones are skeletal variations, more commonly seen in the region of foot and ankle. Most such accessory and sesamoid bones remain asymptomatic. However overuse and trauma can make such feet symptomatic. Knowledge of such bony ossicles is essential in the management of patients presenting with foot pain. Dorsal foot pain can be caused by a symptomatic Os intermetatarseum - an accessory ossicle found between the bases of first and second metatarsals and the medial cuneiform. Its incidence has not been well established because of insufficient appropriate multi-centric anatomical, radiological and orthopaedic studies. A case of dorsal foot pain in a soccer player, caused by an Os intermetatarseum is reported here. A brief review of the literature is also presented.

The first tarsometatarsal joint and its association with hallux valgus

Introduction

The aetiology of hallux valgus is almost certainly multifactoral. The biomechanics of the first ray is a common factor to most. There is very little literature examining the anatomy of the proximal metatarsal articular surface and its relationship to hallux valgus deformity.

Methods

We examined 42 feet from 23 specimens in this anatomical dissection study.

Results

This analysis revealed three distinct articular subtypes. Type 1 had one single facet, type 2 had two distinct articular facets, and type 3 had three articular facets one of which was a lateral inferior facet elevated from the first. Type 1 joints occurred exclusively in the hallux valgus specimens, while type 3 joints occurred exclusively in normal specimens. Type 2 joints occurred in both hallux valgus and normal specimens. Another consistent finding in regards to the proximal articular surface of the first metatarsal was the lateral plantar prominence. This prominence possessed its own articular surface in type 3 joints and was significantly flatter in specimens with hallux valgus (p < 0.001) and the angle with the joint was significantly more obtuse (p < 0.001).

Conclusions

We believe the size and acute angle of this prominence gives structural mechanical impedance to movement at the tarsometatarsal joint and thus improves the stability.

Scarf versus chevron osteotomy for the correction of 1-2 intermetatarsal angle in hallux valgus: a systematic review and meta-analysis

The chevron and scarf osteotomies are commonly used for the surgical management of hallux valgus (HV). However, there is debate as to whether one osteotomy provides more 1-2 intermetatarsal (1-2 IMA) correction than the other. The objective of this systematic review and meta-analysis was to compare the effectiveness of 3 types of first metatarsal osteotomy for reducing the 1-2 IMA in HV correction: the chevron osteotomy, the long plantar arm (modified) chevron osteotomy, and the scarf osteotomy. A systematic search for eligible studies was performed of the following databases: Medline, Embase (Ovid), CINAHL (EBSCO Host), and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials. Only English-language studies previous to May 2010 were included in the review. Additional hand and electronic content searches of relevant foot and orthopaedic journals were performed. Criteria for inclusion in this analysis included systematic reviews of randomized controlled trials, prospective and retrospective cohort studies, and case-control studies, as well as case-series studies involving the chevron, scarf, or long plantar arm chevron osteotomy of >20 participants with a minimum of 80% follow-up. Quality of evidence of the included studies was assessed with the Grading of Recommendations Assessment, Development and Evaluation system. All pooled analyses were based on a fixed effects model. There was a total of 1351 participants who underwent either a chevron (n = 1028), scarf (n = 300), or long plantar arm chevron osteotomy (n = 23). Only one study for the long plantar arm chevron group fitted the eligibility criteria for this review; however, it was not amenable to meta-analysis. The chevron osteotomy was associated with a mean reduction of 1-2 IMA from preoperative to postoperative of 5.33° (95% confidence interval, 5.12 to 5.54, p < .001), and the scarf osteotomy was associated with a mean reduction of 6.21° (95% confidence interval, 5.70 to 6.72, p < .001). There was a statistically significant 0.88° increase in the correction of the 1-2 IMA in favor of the scarf osteotomy compared with the chevron osteotomy. The studies included in this review were of very low- to low-quality evidence. Our findings indicate that the scarf osteotomy provides greater correction of the 1-2 IMA when used for HV correction. However, only a weak recommendation in favor of the scarf osteotomy can be made based on the low quality of evidence of the studies included in this analysis.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study

BACKGROUND

Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition.

METHODS

Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained.

RESULTS

Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities.

CONCLUSION

In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

The pathogenesis of hallux valgus

The first ray is an inherently unstable axial array that relies on a fine balance between its static (capsule, ligaments, and plantar fascia) and dynamic stabilizers (peroneus longus and small muscles of the foot) to maintain its alignment. In some feet, there is a genetic predisposition for a nonlinear osseous alignment or a laxity of the static stabilizers that disrupts this muscle balance. Poor footwear plays an important role in accelerating the process, but occupation and excessive walking and weight-bearing are unlikely to be notable factors. Many inherent or acquired biomechanical abnormalities are identified in feet with hallux valgus. However, these associations are incomplete and nonlinear. In any patient, a number of factors have come together to cause the hallux valgus. Once this complex pathogenesis is unraveled, a more scientific approach to hallux valgus management will be possible, thereby enabling treatment (conservative or surgical) to be tailored to the individual.

Correction of metatarsus primus varus associated with hallux valgus deformity using the arthrex mini tightrope: a report of 44 cases

Metatarsus primus varus must be addressed during correction of moderate to severe hallux valgus deformity. As an alternative to proximal osteotomy or first tarsometatarsal fusion for hallux valgus correction, this study presents a series of patients treated using the Arthrex Mini TightRope. A total of 36 patients (44 operations) with hallux valgus and metatarsus primus varus underwent correction using the Arthrex Mini TightRope. Assessment included measurement of radiographic parameters, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot outcomes score, and the SF-12. The average hallux valgus angle improved from 32.2° to 15.2° (P < .0001). The average first intermetatarsal angle improved from 14.6° to 8.2° (P < .0001). The average distal metatarsal articular angle improved from 17.0° to 9.6° (P < .0001). The average AOFAS midfoot outcomes scores improved from 45.44 to 84.72 (P < .0001). Postoperative SF-12 physical and mental scores averaged 52.99 and 56.63. Only one patient had recurrence of deformity. Correcting metatarsus primus varus in association with hallux valgus deformity using the Arthrex Mini TightRope should be considered a treatment option. This technique is less invasive and seems capable of maintaining correction while allowing for early weight bearing and avoiding the need for a proximal first metatarsal osteotomy or Lapidus procedure.

Mass-induced unilateral hallux valgus

Various causes of hallux valgus exist. However, mass-induced hallux valgus is a rare phenomenon. To the best of our knowledge, there has been 1 previous report on mass-induced hallux valgus in the English literature; however, that report described giant cell tumor of the extensor digitorum longus tendon sheath. We believe ours to be the first published case of osteochondroma of the second metatarsus-induced hallux valgus. A 19-year-old woman presented with pain and tenderness in the left hallux of 3 months' duration. After a diagnosis of bony mass with hallux valgus, an operative excision was performed through a dorsal approach on the first web space of the left foot. The histopathologic diagnosis was osteochondroma. One-year follow-up radiographs showed a decreased hallux valgus angle and intermetatarsal angle. Unilateral hallux valgus occurs in a mass area. After excision of the mass, hallux valgus angle and intermetatarsal angle decrease. The rotational deformity is not severe. There is little probability of discovering its etiology, but mass-like osteochondroma should be considered.

Development and reliability of an intraoperative first metatarsophalangeal joint cartilage evaluation tool for use in hallux valgus surgery

The objective of this study was to examine the reliability of an intraoperative evaluation tool for assessing cartilage degeneration of the first metatarsophalangeal joint in hallux valgus surgery. During hallux valgus reconstruction, 2 examiners documented the location, depth, and surface area of cartilage lesions affecting the first MTPJ in 20 females aged 17 to 69 (mean 50.9 ± 13.5) years. Depth of cartilage lesions was assessed using the 5-level International Cartilage Repair Society (ICRS) scale and a 3-level scale (normal, partial thickness, full thickness). Interexaminer reliability of lesion location and depth was assessed using absolute percentage agreement and kappa (κ) statistics, and interexaminer reliability of lesion surface area was assessed using intraclass correlation coefficients (ICCs) and 95% limits of agreement (LOAs). For lesion location, percentage agreement ranged from 90% to 100% and κ values ranged from 0.78 to 1.00, reflecting substantial to excellent levels of agreement. For lesion depth using the ICRS and 3-level scale, percentage agreement ranged from 33% to 100% and weighted κ values ranged from 0 to 1.00, reflecting poor to excellent levels of agreement. For lesion surface area, the ICC was 0.98 (95% confidence interval = 0.97 to 0.99) and 95% LOA was 0.74 to 1.41, indicating excellent reliability. The results of this study demonstrate a generally high degree of reliability between examiners for the intraoperative use of the first metatarsophalangeal joint cartilage evaluation tool, and the tool may have some value in predicting surgical outcomes associated with hallux valgus.

Deformity of the great toe in fibrodysplasia ossificans progressiva

BACKGROUND

As invasive medical procedures can induce permanent heterotopic ossification in fibrodysplasia ossificans progressiva (FOP), caution should be exercised in clinical practice. The present study was conducted to examine the characteristics of the great toe deformity in patients with FOP, which may lead to an early diagnosis of this condition.

METHODS

The subjects consisted of 31 feet from 16 FOP patients (8 males, 8 females) with an average age of 17.3 years (range 1-47 years) at the time of this study. Gross and radiographic findings, including the hallux valgus angles (HVA), intermetatarsal angles (IMA), and the deformity of the proximal phalanx and metatarsal bone, were examined.

RESULTS

Of the 31 feet, 29 (93.5%) showed several degrees of great toe deformity. A shortened great toe was the typical gross finding and was observed in 20 feet (64.5%). The mean HVA and IMA were 19.7° and 8.5°, respectively; and 22 (71.0%) feet satisfied the radiographic definition of hallux valgus (HVA ≥ 20° or IMA ≥ 10°). The proximal phalanx was consistently shortened but morphologically dissimilar from case to case. The metatarsal bone was also shortened and sharpened to the medial side, deviating the proximal phalanx laterally from the metatarsal axis. Fusion between the distal and proximal phalanx occurred with advancing age. Only two feet in one patient showed no obvious deformity of the great toe.

CONCLUSIONS

A shortened great toe and hallux valgus were frequently found in patients with FOP. Shortening and sharpening of the proximal phalanx and metatarsal bone consistently existed and contributed to the great toe deformity. These findings were thought to exist from birth and may be a key to an early diagnosis.

Distal chevron osteotomy with distal soft tissue procedure for moderate to severe hallux valgus deformity

BACKGROUND

Distal chevron osteotomy has been widely employed to treat mild to moderate hallux valgus deformity. The purpose of the present study was to evaluate the outcomes of distal chevron osteotomy with a distal soft tissue procedure for the correction of moderate to severe hallux valgus.

MATERIALS AND METHODS

We reviewed 76 patients (86 feet) that underwent distal chevron osteotomy with a distal soft tissue procedure for symptomatic moderate to severe hallux valgus deformity. At a mean followup of 31 months, all patients were evaluated using subjective, objective and radiographic measurements.

RESULTS

Ninety-four percent of the patients were very satisfied or satisfied. Average AOFAS score improved from 54.7 points preoperatively to 92.9 at final followup. Average hallux valgus angle changed from 36.2 degrees preoperatively to 12.4 degrees at final followup, and average first-second intermetatarsal angle changed from 17.1 to 7.3 degrees. Average tibial sesamoid position changed from 2.4 preoperatively to 1.2 at final followup. Dorsal angulation of the head was observed in two feet, and plantaflexion of the head in four feet. There were no cases of avascular necrosis of the metatarsal head.

CONCLUSION

Our results indicate that distal chevron osteotomy with a distal soft tissue procedure provides an effective and reliable means of correcting moderate to severe hallux valgus deformity, and that it does so with high levels of patient satisfaction and low incidence of complications.

Bilateral second metatarsal stress fractures after hallux valgus correction with the use of a tension wire and button fixation system

The pathomechanics and treatments of hallux valgus vary widely by deformity and surgeon, and are extensively described in the orthopedic and podiatric literature. With each newly described treatment, new complications can be encountered. In this report, we describe the case of a 22-year-old woman who underwent bilateral hallux valgus repair with a tension wire and button fixation system, and developed bilateral second metatarsal stress fracture at the point of fixation application during the postoperative period. Although this fixation system has been useful in our practice, like other surgical implants, it conveys a certain amount of risk that should be considered by surgeons using the device.

Efficacy of outpatient bilateral simultaneous hallux valgus surgery

Bilateral simultaneous hallux valgus correction is traditionally performed as an inpatient procedure due to concerns regarding adequate postoperative analgesia and difficulty mobilizing. We prospectively evaluated 40 consecutive patients (80 feet) who underwent outpatient surgical correction of bilateral symptomatic hallux valgus. Patients underwent preoperative radiological and clinical assessment using pain and American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scores. Patients underwent preoperative counseling and were assessed for medical suitability for outpatient surgery. They were instructed to have responsible adult caregivers available for 24 hours postoperatively, easy access to after-hours emergency medical care, and access to a telephone. Procedures were performed under general anesthesia with local anesthetic ankle block. Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff with an oral analgesia regimen. Cast immobilization was not used. Patients were reviewed at 6 weeks and 3 months postoperatively with repeated clinical and radiological assessment. All patients were discharged home and none required inpatient ward admission. Post-discharge, no patient presented to the emergency department or their general practitioner as a consequence of poor pain control. At final follow-up assessment, mean AOFAS hallux scores had improved from 58.1 (range, 29-80) to 89.0 (range, 47-100) (P<.001). The mean hallux valgus angle improved from 33.2 degrees (range, 15 degrees -53 degrees) to 16.9 degrees (range, 3 degrees -39 degrees) and the intermetatarsal angle had improved from 13.2 degrees (range, 6 degrees -23 degrees) to 8.5 degrees (range, 4 degrees -15 degrees) (P<.001). Eighty-five percent of patients reported that they would recommend outpatient surgery. Bilateral hallux valgus surgery can be performed safely as an outpatient procedure in selected patients with acceptable levels of patient satisfaction.

Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study

OBJECTIVE

To examine potential risk factors for hallux valgus in community-dwelling elders.

METHOD

Data from 600 MOBILIZE Boston Study participants (386 women and 214 men) were analyzed. Hallux valgus was defined as >15 degrees angular deviation of the hallux with respect to the first metatarsal bone toward the lesser toes. Associations of hallux valgus with age, body mass index (BMI), race, education, pes planus, foot pain, and in women, history of high heel shoe use, were assessed using sex-specific Poisson regression with robust variance estimation for risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

Hallux valgus was present in 58% of women and 25% of men. Higher BMI was inversely associated with presence of hallux valgus in women (P trend=0.001), with the strongest inverse association observed in those with BMI of 30.0 or more compared to those with normal BMI (RR=0.7, 95% CI: 0.5, 0.9). Women, who usually wore high-heeled shoes during ages 20-64 years compared to those who did not, had increased likelihood of hallux valgus (RR=1.2, 95% CI: 1.0, 1.5). Among men, those with BMI between 25.0 and 29.9 had increased likelihood of hallux valgus compared to those with normal BMI (RR=1.9, 95% CI: 1.0, 3.5). Men with pes planus were more likely to have hallux valgus (RR=2.1, 95% CI: 1.3, 3.3) compared to men without pes planus.

CONCLUSION

In women, hallux valgus was associated with lower BMI and high heel use during ages 20-64, while in men, associations were observed with higher BMI and pes planus. Our results suggest that the etiologic mechanisms for hallux valgus may differ between men and women.

Increased hallux angle in children and its association with insufficient length of footwear: a community based cross-sectional study

BACKGROUND

Wearing shoes of insufficient length during childhood has often been cited as leading to deformities of the foot, particularly to the development of hallux valgus disorders. Until now, these assumptions have not been confirmed through scientific research. This study aims to investigate whether this association can be statistically proven, and if children who wear shoes of insufficient length actually do have a higher risk of a more pronounced lateral deviation of the hallux.

METHODS

858 pre-school children were included in the study. The study sample was stratified by sex, urban/rural areas and Austrian province. The hallux angle and the length of the feet were recorded. The inside length of the children's footwear (indoor shoes worn in pre-school and outdoor shoes) were assessed. Personal data and different anthropometric measurements were taken. The risk of hallux valgus deviation was statistically tested by a stepwise logistic regression analysis and the relative risk (odds ratio) for a hallux angle > or = 4 degrees was calculated.

RESULTS

Exact examinations of the hallux angle could be conducted on a total of 1,579 individual feet. Only 23.9% out of 1,579 feet presented a straight position of the great toe. The others were characterized by lateral deviations (valgus position) at different degrees, equalling 10 degrees or greater in 14.2% of the children's feet.88.8% of 808 children examined wore indoor footwear that was of insufficient length, and 69.4% of 812 children wore outdoor shoes that were too short. A significant relationship was observed between the lengthwise fit of the shoes and the hallux angle: the shorter the shoe, the higher the value of the hallux angle. The relative risk (odds ratio) of a lateral hallux deviation of > or = 4 degrees in children wearing shoes of insufficient length was significantly increased.

CONCLUSIONS

There is a significant relationship between the hallux angle in children and footwear that is too short in length. The fact that the majority of the children examined were wearing shoes of insufficient length makes the issue particularly significant. Our results emphasize the importance of ensuring that children's footwear fits properly.

Treatment of hallux valgus with increased distal metatarsal articular angle: use of double and triple osteotomies

The treatment of the congruent hallux valgus deformity requires special consideration for a successful outcome to be obtained. The distal metatarsal articular angle is of critical importance in this deformity. The goal of correction is to achieve a realigned first ray and preserve the congruent first metatarsophalangeal articulation. In patients with an increased distal metatarsal articular angle and congruent joint, the use of double and triple first ray osteotomies must be used to achieve satisfactory correction.

The laterality of the surgical correction of forefoot pathology

Lateral prevalence has not been traditionally attributed to the development and presentation of pathologic forefoot complaints. The objective of this study was to determine if a laterality prevalence exists for surgically corrected forefoot deformities. All cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period were reviewed and classified into the following categories: hallux abductovalgus deformity correction, hallux limitus deformity correction, specific digital deformity correction, neuroma surgery, and combinations of these categories (n = 1821). Our analyses indicated no laterality difference in the surgical correction of most common forefoot pathologies. A measure of all examined surgical corrections (hallux abductovalgus, hallux limitus, digital deformity, and/or neuroma) did not demonstrate a difference between the surgical correction of the right and left extremities (chi(2) = 0.003; P = .94). There was also no significant difference in the surgical correction of the right and left extremities when studying the individual categories of any hallux abductovalgus correction (chi(2) = 0.416; P = .52), any hallux limitus correction (chi(2) = 2.050; P = .15), any digital deformity correction (chi(2) = 1.251; P = .26), or any neuroma surgery (chi(2) = 0.784; P = .38). Only the surgical correction of hallux limitus deformity without surgical correction of digital deformity or neuroma demonstrated a significant laterality with surgical correction of the right lower extremity being more common (chi(2) = 4.600; P = .03).

LEVEL OF EVIDENCE

2.

Epidemiological aspects of the surgical correction of structural forefoot pathology

The aim of this study was to associate structural forefoot surgical correction with theories related to the etiology of structural forefoot pathology. All forefoot surgical cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period (January 2001 through April 2007) were reviewed and classified according to the following surgical categories: hallux abductovalgus, hallux limitus, lesser digital deformity, and combinations of these categories (N = 1684 procedures in 1592 patients). The results suggested that the etiology of lesser digital deformity was associated with the etiology of hallux abductovalgus more so than it was with hallux limitus. In fact, a patient undergoing surgical correction of a hallux abductovalgus deformity displayed 4.63 times greater odds of undergoing surgical correction of a digital deformity, or deformities, compared to a patient undergoing surgical correction of hallux limitus (OR = 4.63, 95% CI 2.81-7.71, P < .0001). Furthermore, medial (second or second and third) toe deformity correction was statistically significantly associated with hallux abductovalgus surgery (OR = 3.34, 95% CI 2.52-4.44, P < .0001), whereas lateral (fifth or fourth and fifth) toe deformity correction was statistically significantly associated with cases that did not involve hallux abductovalgus surgery (OR = 0.27, 95% CI 0.20-0.37, P < .0001). The concept of flexor hallucis longus stabilization is introduced as a possible mechanical explanation for these results.

LEVEL OF EVIDENCE

2.

Z-osteotomy in hallux valgus: clinical and radiological outcome after Scarf osteotomy

Correction osteotomies of the first metatarsal are common surgical approaches in treating hallux valgus deformities whereas the Scarf osteotomy has gained popularity. The purpose of this study was to analyze short- and mid-term results in hallux valgus patients who underwent a Scarf osteotomy. The subjective and radiological outcome of 131 Scarf osteotomies (106 hallux valgus patients, mean age: 57.5 years, range: 22-90 years) were retrospectively analyzed. Mean follow-up was 22.4 months (range: 6 months-5 years). Surgical indications were: intermetatarsal angle (IMA) of 12-23°; increased proximal articular angle (PAA>8°), and range of motion of the metatarsophalangeal joint in flexion and extension >40°. Exclusion criteria were severe osteoporosis and/or osteoarthritis. The mean subjective range of motion (ROM) of the great toe post-surgery was 0.8±1.73 points (0: full ROM, 10: total stiffness). The mean subjective cosmetic result was 2.7±2.7 points (0: excellent, 10: poor). The overall post-operative patient satisfaction with the result was high (2.1±2.5 points (0: excellent, 10: poor). The mean hallux valgus angle improvement was 16.6° (pre-operative mean value: 37.5°) which was statistically significant (p<0.01). The IMA improved by an average of 5.96° from a pre-operative mean value of 15.4° (p<0.01). Neither osteonecrosis of the distal fragment nor perioperative fractures were noted during the follow-up. In keeping with our follow-up results, the Scarf osteotomy approach shows potential in the therapy of hallux valgus.

Foot problems in children presented to the family physician: a comparison between 1987 and 2001

BACKGROUND

In recent decades, studies on the management of common foot problems in children have suggested that in many cases, there is no indication for treatment. It is not known whether these studies have changed daily practice.

OBJECTIVE

Our aim was to establish and compare incidence and referral rates for foot problems in children in 1987 and 2001.

METHODS

A comparison was made of two large consecutive surveys in Dutch general practice performed in 1987 (86 577 children aged 0-17 years) and 2001 (87 952 children aged 0-17 years), which were carried out by The Netherlands Institute for Health Services Research. Both surveys included a representative sample of the Dutch population. Incidence and referral rates were calculated and, data were stratified for age group and gender.

RESULTS

Compared to 1987, in 2001 the overall incidence rate of foot problems presented to the family physician (FP) decreased substantially from 80.0 [95% confidence interval (CI) 77.0-84.7] to 17.4 (95% CI 16.5-18.3) per 1000 person-years (P < 0.0001). The incidence rate of flat feet decreased from 4.9 (95% CI 4.0-5.9) per 1000 person-years in 1987 to 3.4 (95% CI 3.0-3.8) per 1000 person-years in 2001 (P = 0.001). The distribution of referrals to other primary health care professionals and medical specialists has almost reversed in favour of primary health care professionals.

CONCLUSION

Total incidence rate of musculoskeletal foot problems seen by the FP has decreased substantially, between 1987 and 2001.

Effect of turf toe on foot contact pressures in professional American football players

BACKGROUND

The relationship between turf toe and plantar foot pressures has not been extensively studied. Two hypotheses were tested in a cohort of professional American football players: first, that a history of turf toe is associated with increased peak hallucal and first metatarsophalangeal (MTP) plantar pressures; second, that decreased range of motion (ROM) of the first MTP correlates with increased peak hallucal and first MTP plantar pressures.

MATERIALS AND METHODS

Forty-four athletes from one National Football League (NFL) team were screened for a history of turf toe during preseason training. Dorsal passive MTP ROM and dynamic plantar pressures were measured in both feet of each player. Anatomical masking was used to assess peak pressure at the first MTP and hallux.

RESULTS

First MTP dorsiflexion was significantly lower in halluces with a history of turf toe (40.6 +/- 15.1 degrees versus 48.4 +/- 12.8 degrees, p = 0.04). Peak hallucal pressures were higher in athletes with turf toe (535 +/- 288 kPa versus 414 +/- 202 kPa, p = 0.05) even after normalizing for athlete body mass index (p = 0.0003). Peak MTP pressure was not significantly different between the two groups tested. First MTP dorsiflexion did not correlate with peak hallucal or first MTP pressures.

CONCLUSION

This study showed that turf toe is associated with decreased MTP motion. In addition, increased peak hallucal pressures were found. Further study is warranted to determine whether these pressures correlate with the severity of symptoms or progression of turf toe to first MTP arthritis.

The first metatarsocuneiform joint, hypermobility, and hallux valgus: what does it all mean?

The etiology and treatment of the hallux valgus deformity has long been a subject of controversy. Early reports focused on increased first metatarsocuneiform joint mobility as the primary cause of the deformity. While this theory was widely accepted, little evidence was offered in its support. Recent reports have provided objective evidence calling into question the notion of hypermobility. While flexibility in the first metatarsocuneiform joint is necessary for hallux valgus to develop, increased mobility is the result rather than the cause of the deformity.

A randomized, double-blind, phase III study comparing multiple doses of tapentadol IR, oxycodone IR, and placebo for postoperative (bunionectomy) pain

OBJECTIVE

This study evaluated tapentadol immediate release (IR) for pain relief following orthopedic bunionectomy surgery.

METHODS

This randomized, double-blind, placebo- and active-controlled, phase III study included patients with moderate-to-severe pain following bunionectomy. Randomized patients (N = 603) received tapentadol IR 50, 75, or 100 mg; oxycodone HCl IR 15 mg; or placebo orally every 4-6 hours over a 72-hour period following bunionectomy. The primary endpoint was the sum of pain intensity difference (SPID) over 48 hours. Secondary endpoints included SPID over 12, 24, and 72 hours; total pain relief, and sum of total pain relief and sum of pain intensity difference (SPRID) over 12, 24, 48, and 72 hours; use of rescue medication; patient global impression of change; and onset of action assessment. Possible limitations of this study were that the intense dose monitoring and thorough nursing care were unlikely to represent actual use situations and could introduce similar bias across all treatment groups.

CLINICAL TRIAL REGISTRATION

NCT00364247.

RESULTS

Mean SPID(48) values were significantly higher for tapentadol IR (50, 75, and 100 mg) and oxycodone HCl IR 15 mg compared with placebo (all p <or= 0.001). The overall incidence of adverse events was 70% for tapentadol IR 50 mg, 75% for tapentadol IR 75 mg, 85% for tapentadol IR 100 mg, 87% for oxycodone HCl IR 15 mg, and 41% for placebo. Post hoc analyses showed that tapentadol IR 100 mg and oxycodone HCl IR 15 mg provided equivalent analgesia, yet tapentadol IR 100 mg had a significantly lower incidence of nausea and/or vomiting (53% vs 70%, respectively, nominal p = 0.007).

CONCLUSIONS

Multiple doses of tapentadol IR (50, 75, and 100 mg) significantly relieve acute pain after orthopedic surgery compared with placebo. These data suggest that at doses providing comparable efficacy, tapentadol IR 100 mg has improved gastrointestinal tolerability compared with oxycodone HCl IR 15 mg.

Hallux valgus and hallux rigidus: a comparison of impact on health-related quality of life in patients presenting to foot surgeons in Australia

Background

Hallux valgus and hallux rigidus are common foot conditions that lead to a deterioration in health status. Patients with significant pain or deformity from these conditions frequently resort to surgery. In this project, the foot health status of patients with hallux valgus and hallux rigidus presenting to foot surgeons in Australia was compared.

Methods

Foot health status was measured in 120 participants using the Foot Health Status Questionnaire (FHSQ), a validated 0 – 100 point health status instrument. All participants had presented for surgical advice regarding hallux valgus/rigidus. The mean age of participants was 48.0 years (SD ± 14.3, range 19 – 79).

Results

In the sample, 68% of participants were diagnosed with hallux valgus and 32% with hallux rigidus. Participants with hallux rigidus had greater levels of pain and functional limitation compared with hallux valgus. The mean difference for pain was 13.8 points (95% CI 4.6 to 22.9) and the mean difference for function was 15.0 points (95% CI 5.3 to 24.7). Both conditions result in similarly negative levels of impact on shoe fit and overall foot health.

Conclusion

This study found measurable differences in foot health status between hallux valgus and hallux rigidus in participants presenting for surgical consultation. While both appear to have a negative impact on health status, hallux rigidus has a more significant impact.

The efficacy and tolerability of multiple-dose tapentadol immediate release for the relief of acute pain following orthopedic (bunionectomy) surgery

OBJECTIVE

Tapentadol is a new, centrally acting analgesic with two mechanisms of action, combining μ-opioid agonism and norepinephrine reuptake inhibition in a single molecule. This study assessed tapentadol immediate release (IR) in patients with postsurgical orthopedic pain.

METHODS

This randomized, double-blind, phase II study involved patients with moderate-to-severe pain after bunionectomy surgery (first metatarsal with osteotomy). Patients (N = 269) were randomly assigned to receive tapentadol IR 50 or 100 mg, oxycodone HCl IR 10 mg, or placebo; the study drug was taken every 4-6 h, over a 72-h period starting 1 day after surgery (Evaluation Day 2). The primary endpoint was the sum of pain intensity over 24 h (SPI-24) on the second day after randomization (Evaluation Day 3). Potential limitations of this study included the use of rescue medication and the fact that it was not powered to statistically compare between-group differences in tolerability measures.

RESULTS

Mean (standard deviation [SD]) SPI-24 values on Evaluation Day 3 were significantly lower for tapentadol IR (50 mg: 33.6 [19.7], p = 0.0133; 100 mg: 29.2 [15.2], p = 0.0001) and oxycodone HCl IR 10 mg (35.7 [17.2]; nominal p = 0.0365) compared with placebo (41.9 [17.7]). The most common treatment-emergent adverse events for all treatment groups were characteristic of drugs with μ-opioid agonist activity. While providing similar analgesic efficacy, tapentadol IR 50 mg was associated with lower rates of nausea (46.3% vs. 71.6% for oxycodone HCl IR 10 mg), dizziness (32.8% vs. 56.7%), vomiting (16.4% vs. 38.8%), and constipation (6.0% vs. 17.9%), and a similar rate of somnolence (28.4% vs. 26.9%) compared with oxycodone HCl IR 10 mg.

CONCLUSIONS

Tapentadol IR 50 and 100 mg and oxycodone HCl IR 10 mg were effective in this study for the relief of acute postoperative pain following bunionectomy. The study results suggest improved gastrointestinal tolerability of tapentadol IR 50 mg compared with oxycodone at a dose showing comparable efficacy.