Hallux valgus surgery affects kinematic parameters during gait

Lower limb kinematic changes during gait after hallux valgus surgery: A prospective observational study

BACKGROUND

Patients with hallux valgus are known to alter lower limb joint kinematics during gait. However, little information is available about gait changes following hallux valgus surgery. We aimed to longitudinally investigate lower limb kinematic changes at the mid and terminal stances of gait after hallux valgus surgery.

METHODS

This prospective observational study included 11 female patients (17 feet), who underwent first metatarsal osteotomy. Gait analyses were performed preoperatively and 1- and 2-year postoperatively using a three-dimensional motion capture system. Toe-out angle, ankle, knee, and hip joint angles during gait were calculated from the recorded data. The spatiotemporal parameters and these angles at the mid and terminal stances of gait were statistically compared between preoperative and postoperative periods.

FINDINGS

All spatiotemporal parameters remained unchanged postoperatively. The toe-out angle was significantly greater at 1- and 2-year postoperatively. The ankle pronation angle, the knee abduction angle, and the hip adduction angle at the mid and terminal stances of gait were smaller postoperatively compared to the preoperative. These angular changes showed a similar trend at 1 and 2 years postoperatively. However, the postoperative changes of the sagittal joint angles were relatively small.

INTERPRETATION

Hallux valgus surgery can affect the toe-out angle and the lower limb coronal kinematics at the mid and terminal stances of gait in patients with hallux valgus. However, surgical correction of hallux valgus deformity did not directly improve the gait characteristics in patients with hallux valgus.

The Effect of Therapeutic Approaches on Hallux Valgus Deformity

Hallux valgus (HV) is a relatively frequent disease caused by a complicated structural malformation of the primary ray. The bunion or middle projection generated by the hallux's lateral displacement and pronation is merely one element of the three-dimensional abnormality. HV may trigger severe discomfort and affect joint kinematics. The specific kinematic cause is still unknown. Female age, gender, restrictive footwear, and heritage are risk indicators. HV frequently coexists along metatarsal adducts, equines contracture, hammertoe imperfection, and pes planus. HV is a frequent foot ailment with multiple, complicated, unknown etiology and course. HV has a preference for females. It is an ongoing condition for which there is no known treatment to reduce or prevent improvement. Fibrodysplasia ossificans progressiva (FOP) is distinguished by hereditary symmetrical HV deformities or symptoms that begin heterotopic calcification that is either idiopathic or caused by trauma, such as subcutaneous immunizations. Localized heterotopic calcification may be preceded by aggravating, recurring soft-tissue enlargements (flare-ups). Heterotopic calcification may happen anywhere; however, it most commonly impacts locations near the axial bone structure during the early/mild phases until advancing to the appendicular skeleton. As an effect of calcification affecting the flexibility of the joints, it might cause limitations in motion. The initial line of therapy focuses on non-surgical methods including night splinting, orthotics, and larger shoes. The next suggested line of action is surgical intervention if conservative therapy fails. Patients have good postoperative tolerance, and bone union often happens six to seven weeks after surgery. Stretching exercises help to restore function by extending shortened soft tissue and restoring range of motion (ROM). The goal of joint mobilization, a form of manual treatment method, is to extend the ligament, the soft tissue surrounding the limited joint, and the restricting joint capsule by applying modest amplitude passive movement to the joint components.

Biomechanical comparison of two surgical methods for Hallux Valgus deformity: Exploring the use of artificial neural networks as a decision-making tool for orthopedists

Hallux Valgus foot deformity affects gait performance. Common treatment options include distal oblique metatarsal osteotomy and chevron osteotomy. Nonetheless, the current process of selecting the appropriate osteotomy method poses potential biases and risks, due to its reliance on subjective human judgment and interpretation. The inherent variability among clinicians, the potential influence of individual clinical experiences, or inherent measurement limitations may contribute to inconsistent evaluations. To address this, incorporating objective tools like neural networks, renowned for effective classification and decision-making support, holds promise in identifying optimal surgical approaches. The objective of this cross-sectional study was twofold. Firstly, it aimed to investigate the feasibility of classifying patients based on the type of surgery. Secondly, it sought to explore the development of a decision-making tool to assist orthopedists in selecting the optimal surgical approach. To achieve this, gait parameters of twenty-three women with moderate to severe Hallux Valgus were analyzed. These patients underwent either distal oblique metatarsal osteotomy or chevron osteotomy. The parameters exhibiting differences in preoperative and postoperative values were identified through various statistical tests such as normalization, Shapiro-Wilk, non-parametric Wilcoxon, Student t, and paired difference tests. Two artificial neural networks were constructed for patient classification based on the type of surgery and to simulate an optimal surgery type considering postoperative walking speed. The results of the analysis demonstrated a strong correlation between surgery type and postoperative gait parameters, with the first neural network achieving a remarkable 100% accuracy in classification. Additionally, cases were identified where there was a mismatch with the surgeon's decision. Our findings highlight the potential of artificial neural networks as a complementary tool for surgeons in making informed decisions. Addressing the study's limitations, future research may investigate a wider range of orthopedic procedures, examine additional gait parameters and use more diverse and extensive datasets to enhance statistical robustness.

Comparison of foot function and physical performance between women with and without bilateral painful hallux valgus

BACKGROUND

We aimed to investigate whether foot function and physical performance differ between women with and without bilateral painful hallux valgus (HV).

METHODS

Forty-four women with bilateral painful HV and forty-three controls were included. The Foot Function Index, American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joints Scale, and Manchester-Oxford Foot Questionnaire were used. The time while walking 10 m-walkway at maximum speed and ascending and descending ten stairs as fast as possible also single-limb stance time were measured.

RESULTS

All self-reported and performance-based measures showed that women with HV had poorer foot function and physical performance than controls (p < 0.05). Women with mild HV had better self-reported foot function than those with moderate HV or severe HV (p < 0.05), but physical performance did not differ (p > 0.05).

CONCLUSIONS

Women with bilateral painful HV exhibited poorer self-reported foot function and performance-based physical function than those without HV.

LEVELS OF EVIDENCE

Level III.

Impact of pain in other body regions on the foot-specific quality of life in patients with hallux valgus

OBJECTIVES

The purpose of this study was to clarify the prevalence of pain outside the foot, and to determine the associations of pain outside the foot with foot-specific quality of life (QOL) in patients with hallux valgus.

METHODS

Patients scheduled to undergo hallux valgus surgery were recruited. Patients answered whether they experienced disabling pain in 13 body regions other than the foot. Foot-specific QOLwas assessed using the Self-Administered Foot Evaluation questionnaire (SAFE-Q). Foot pain was quantified using the visual analogue scale (VAS). Patient characteristics, including age, sex, comorbidity, anxiety, and depression, were also surveyed. The association between pain elsewhere and the SAFE-Q and pain VAS scores were assessed using univariate and multivariate analyses.

RESULTS

Of 102 patients, 55 (54%) experienced pain other than the foot. All SAFE-Q subscale scores were lower, and pain VAS was higher in patients with pain elsewhere than in patients without. In the multivariate analysis, an increase in the number of pain regions was independently associated with a decrease in SAFE-Q scores and an increase in pain VAS.

CONCLUSION

More than half of the patients with hallux valgus experienced pain elsewhere. The presence of pain elsewhere was associated with poorer foot-specific QOL and severer foot pain.

Exploring the Relationship Between Clinical Presentation in Hallux Valgus and Response to AbobotulinumtoxinA Treatment

The relationship between pain/disability and angular deviation of the hallux valgus (HV), and the impact of orthotic use, laterality, and pain variability on treatment outcomes remain unclear. This was explored in post hoc analyses of a placebo-controlled trial of abobotulinumtoxinA (aboBoNT-A; Dysport®) for HV-associated pain (NCT03569098). The primary endpoint was not met in this study (change from baseline Numeric Pain Rating Scale [NPRS] score vs placebo at week 8); however, there was a greater reduction from baseline in mean NPRS score at week 12 with aboBoNT-A 500U versus placebo (p = .06). Adults with painful HV without surgery were randomized (1:1:1) to aboBoNT-A 300U, aboBoNT-A 500U, or placebo. NPRS was completed for 7 days before baseline and weeks 4, 8, and 12. Over-the-counter orthoses were permitted. Participants (N = 186) had a mean [standard deviation, SD] age of 48.2 [13.1] years, 18% (33/186) used orthotics, and 67% (124/186) had bilateral HV. No associations between baseline pain severity and angular deviation were identified. Participants with high pain variability at baseline (SD > 2) had a poorer response to aboBoNT-A treatment than those with less variability. In conclusion, no relationship between HV-related pain/disability and angular deviation was observed. PLAIN LANGUAGE SUMMARY: A bunion (medical term: hallux valgus) is a common adult foot problem in which the big toe points inward toward the other toes, and this can be painful. How much the big toe points inward (how deformed the foot is) has been linked to the amount of pain the patient experiences. A better understanding of this foot deformity and bunion pain will help doctors and patients to make the right treatment decisions. A study was completed looking at how injections of a type of botulinum toxin (abobotulinumtoxinA) into specific muscles in the foot may help to reduce bunion pain in patients without surgery. This subsequent analysis of the study data looked at the amount of foot deformity in patients, the bunion pain they experienced, and which factors affected how well abobotulinumtoxinA worked to reduce bunion pain. The results of this study showed that the amount of foot deformity was not linked to the level of bunion pain. When deciding the best treatment option to relieve bunion pain, it is important that doctors not only consider how deformed the foot is, but also other important factors such as foot pain levels.

Association of Hallux Valgus with Degenerative Spinal Diseases: A Population-Based Cohort Study

Background: Although hallux valgus is known to cause lower-back pain, the association between hallux valgus and spinal degenerative disease remains unclear. Methods: A retrospective cohort study was conducted between 1 January 2000 and 31 December 2015 using data from the Longitudinal Health Insurance Database in Taiwan. After propensity score matching for age, sex, and some potential comorbidities, 1000 individuals newly diagnosed with hallux valgus were enrolled in the study group, while 1000 individuals never diagnosed with hallux valgus served as the control group. Both groups were followed up until 2015 to evaluate the incidence of hallux valgus. Kaplan-Meier analysis was used to determine the cumulative incidence of hallux valgus, while the Cox proportional hazard model was adopted to estimate the hazard ratio (HR) and adjusted hazard ratio (aHR) with 95% confidence intervals (CIs). Results: The incidence densities of spinal degeneration in the hallux valgus and non-hallux valgus groups were 73.10 and 42.63 per 1000 person-years, respectively. An increased risk of spinal degenerative changes was associated with hallux valgus (adjusted HR = 1.75, 95% CI = 1.50−2.05). Age- and sex-stratified analyses showed a significantly higher risk of spinal degeneration in the hallux valgus group. Moreover, sub-outcome evaluations revealed significantly higher risks of spondylosis (aHR = 2.01, 95% CI = 1.55−2.61), intervertebral disorder (aHR = 2.27, 95% CI = 1.62−3.17), and spinal stenosis (aHR = 1.24, 95% CI = 1.47−1.76). There was also an increased risk of spinal degenerative change in those with hallux valgus without surgical intervention (aHR = 1.95, 95% CI = 1.66−2.99, p < 0.001). Conclusions: Hallux valgus was associated with increased risk of degenerative spinal changes and other spinal disorders.

Can a Biomechanical Foot Orthosis Affect Gait in Patients With Hallux Valgus? A Pilot Study

OBJECTIVE

To investigate the effects of customized biomechanical foot orthosis (BFO) on kinematic data during gait in patients with hallux valgus (HV) deformities and compare the results with those of a normal control group.

METHODS

Ten patients with HV deformities and 10 healthy volunteers were enrolled in this study. HV deformity was diagnosed using biomechanical and radiological assessments by a rehabilitation physician. Patients received the customized BFO manufactured at a commercial orthosis laboratory (Biomechanics, Goyang, South Korea) according to the strictly defined procedure by a single experienced technician. The spatiotemporal and kinematic data acquired by the Vicon 3D motion capture system (Oxford Metrics, Oxford, UK) were compared between the intervention groups (control vs. HV without orthosis) and between the HV groups (with vs. without orthosis).

RESULTS

The temporal-spatial and kinematic parameters of the HV group were significantly different from those of the control group. After applying BFO to the HV group, significantly increased ranges of plantar flexion motion and hindfoot inversion were observed. Furthermore, the HV group with BFO showed improved gait cadence, walking speed, and stride length, although the results were not statistically significant.

CONCLUSION

Our results suggest that it is imperative to understand the pathophysiology of HV, and the application of customized BFO can be useful for improving kinematics in HV deformities.

Comparison of the effects of foot-toe orthoses on three-dimensional pelvic kinematics in individuals with hallux valgus during gait

BACKGROUND

Most previous studies focused on the possible relationship between hallux valgus deformity and biomechanical characteristics in the foot and lower leg. Very few investigated the association of pelvic kinematics and hallux valgus during gait according to various foot-toe orthoses for hallux valgus.

OBJECTIVE

To investigate the effect of soft or hard foot-toe orthoses on pelvic kinematics in individuals with hallux valgus deformity during gait.

STUDY DESIGN

This study has a repeated measures design.

METHODS

Three-dimensional range of motion in the pelvic segment was collected from 22 individuals (18 women and 4 men) aged 21 to 52 years (mean 31.7 years, SD 8.7) with hallux valgus. All participants exhibited a hallux valgus angle of more than 20 degree in both feet. A motion analysis system with eight infrared cameras was used to obtain pelvic kinematic data in the hard plastic orthosis, soft silicone orthosis, and without foot-toe orthosis conditions during gait. The two types of hallux valgus orthoses used in this experiment were commercially available products. The participants performed 8-10 walking trials. The walkway length was 6 m. Repeated-measures analysis of variance was used to determine the effects of each orthosis condition on the pelvic kinematic values.

RESULTS

The hard plastic orthosis condition was associated with decreased pelvic motion compared with the soft-type orthosis and no orthosis conditions for depression (F (2,42) = 7.329, P = 0.004), external rotation (F (2,42) = 4.367, P = 0.027), and overall transverse motion (F (2,42) = 4.897, P = 0.019) of the pelvic segment during gait. There were no significant differences in other pelvic motion variables between the without foot-toe orthosis and soft silicone orthosis conditions ( P > 0.05).

CONCLUSIONS

The results of this study suggest that the hard-type foot-toe orthosis for hallux valgus reduced pelvic motion and contributed to preventing excessive pelvic movement during gait.

Gait biomechanics evaluation of the treatment effects for hallux valgus patients: A systematic review and meta-analysis

BACKGROUND

Hallux valgus (HV) is a foot deformity characterized by lateral deviation of the big toe and medial deviation of the first metatarsal.

RESEARCH QUESTION

This study aimed to shed light on the treatment effects of different interventions and surgical procedures for HV deformity to determine the effectiveness of gait biomechanics correction.

METHODS

English-language searches of the electronic databases were conducted in the Cochrane Library, Web of Science, PubMed, Scopus, and Embase. Gait biomechanics evaluation before and after conservative or operative treatments was essential for inclusion in this review. Methodological quality was assessed by the Institute of Health Economics (IHE) quality appraisal tool. All pooled analysis was based on the random-effects model.

RESULTS

Twenty-five articles (1003 participants) were identified in this review. Three studies chose conservative therapies for HV deformity, incorporating foot orthotics and minimalist running intervention, and surgeries were performed in twenty-two studies. For the pressure parameter alteration under the hallux, the effect size (ES) in the conservative treatment subgroup was - 0.95 with 95%CI [- 1.69, - 0.21]. It demonstrated a moderate ES of - 0.44% and 95%CI [- 0.81, - 0.07] in the surgery subgroup. The five operations' peak pressure alteration under the hallux demonstrated a moderate ES of - 0.45% and 95%CI [- 0.54, - 0.36].

SIGNIFICANCE

Both non-operative and operative treatments could achieve the forefoot pressure redistribution, decreasing loading beneath the hallux and first metatarsal regions，However, the treatment effects of surgeries were not very robust. The percutaneous DSTR-Akin technique is recommended as an adequate operative treatment, with a large ES and moderate heterogeneity. The negative gait return effect should be noticed while using Scarf osteotomy, despite positive clinical and radiographic outcomes.

Transverse laxity of the forefoot

BACKGROUND

Splay of the forefoot reflects the loss of tension in the soft tissues and indicates failure of the biomechanics of the tie-bar system. By identifying and quantifying the soft tissue structures involved in the destruction of forefoot stability we could increase the understanding of forefoot pathologies.

METHODS

We investigated the transverse forefoot laxity on healthy feet, feet with forefoot pathology and cadaveric feet undergoing sequential dissection.

RESULTS

Statistical difference in transverse laxity was seen between healthy feet (n = 160) and feet with symptomatic forefoot pathology requiring surgery (n = 29). Presence of lesser ray pathology is associated with increased transverse laxity. For the dissected cadaveric feet (n = 9) sequential sectioning the plantar plate causes a progressive evolution of transverse laxity. The repair of plantar plates greatly improves transverse stability.

CONCLUSIONS

Forefoot pathology causes increased transverse laxity. In case of a major transverse laxity of the forefoot a plantar plate lesion should be suspected.

Examination of gait characteristics and related factors in elderly subjects with and without hallux valgus

Objective:

Elderly people with hallux valgus have decreased gait speed, which can result in reduced capacity to perform the activities of daily living. Therefore, this study examined the gait ability and related factors of patients with hallux valgus.

Methods:

The study participants were 10 patients with hallux valgus and 10 without. Ground reaction forces were measured as front–rear (X), lateral (Y), and vertical (Z) components from the early to late stance phases. Three-dimensional motion analysis was used to measure gait speed; touchdown distance; release distance; the angles of the limb joints and trunk at heel contact, toe-off, and peak ground reaction force; and the center of mass (COM) displacement in the sagittal plane. The height of the COM was calculated as a percentage of the body height. The hallux valgus and control groups were compared using the Mann–Whitney U-test.

Results:

In the hallux valgus group, the ground reaction force showed a significant increase in the Y component in each stance phase and in the Z component in the late stance phase. The lowest COM position in the hallux valgus group was significantly higher than that in the control group, resulting in a smaller difference in COM height over a gait cycle.

Conclusions:

The hallux valgus group was found to have reduced gait speed because of a shortened touchdown distance. Moreover, the continued high COM position in the hallux valgus group meant that potential energy could not efficiently be converted to kinetic energy.

Quantifying the Dynamic Stability of Gait Patterns in People with Hallux Valgus

Hallux valgus (HV), which is mainly caused by the wearing of narrow-width and high-heeled shoes, disrupts gait behavior because it deforms lower limb joints. There is limited information regarding the relationship between the foot disease HV and lower limb joints. Previous studies evaluating abnormal gait patterns caused by deformity used spatiotemporal parameters; however, they failed to characterize the overall gait dynamics. To address this issue, this study is aimed at characterizing the gait stability of patients with HV and examining the joints that are critically affected by HV. To assess complex gait dynamics, we quantified the potential changes in gait stability by using the maximum Lyapunov exponent (MLE). Angular displacements of the ankle, knee, and hip in the sagittal plane during walking were investigated to calculate the MLE for gait stability based on foot conditions (i.e., barefoot, flat shoes, and high heels). During walking, a large MLE (P < 0.05) was noted for the knee joints of subjects with HV, relative to the other lower limb joints. HV appears to have the most critical effect on the knee joints during walking. Ankle movement exhibited higher dynamic stability than the other joint movements of the lower limb (P < 0.05). The type of shoe used in the experiment showed no significant dependence with gait stability and joint movement (P > 0.05). Quantitative assessments of dynamic stability using the MLE may help clinicians assess the overall gait dynamics of HV patients and other people suffering from gait disturbances.

Women after Bilateral Surgical Correction of Hallux Valgus Do Not Show Improvement in Spatiotemporal Gait Parameters at 18 Weeks Postoperatively

Background: Hallux valgus (HV) is a gait-altering orthopedic deformity, somewhat more prevalent in women, which often affects both limbs. Although surgery is a commonly applied treatment, there is no consensus in the literature on how invasive HV correction affects spatiotemporal gait parameters, or how quickly improvement can be expected. We investigated gait parameters in female HV patients who underwent bilateral surgical correction of hallux valgus, both preoperatively and 18 weeks following surgery (a timeframe relevant from the perspective of physical therapy), and also in relation to a non-HV control group. Methods: A total of 23 women aged 40–70 years, with moderate to severe HV deformity in both feet, were assessed preoperatively and 18 weeks postoperatively, and an age-matched control group of 76 healthy women was also assessed. A total of 22 spatiotemporal parameters were collected during 30 s walks over an electronic walkway (Zebris Medical System). Results: Of the 22 parameters analyzed, significant differences between the preoperative experimental and control groups were found only in 4 parameters (Velocity, Right step time, Total double support and Stride time), but in 16 parameters between the postoperative experimental and control groups (the greatest impact being found for: Left and Right Step time, Stride time, Cadence, Right Foot rotation, Left Step length (% leg length) and Stride length (% leg length)). Conclusions: Women after bilateral HV correction did not exhibit improved (i.e., more normal) gait parameters at 18 weeks postoperatively; rather, they showed more gait abnormalities than preoperatively. These findings urge longer-term planning of postoperative rehabilitation, involving continual evaluation of gait improvement.

Heel Height as an Etiology of Hallux Abductus Valgus Development: An electromagnetic Static and Dynamic First Metatarsophalangeal Joint Study

Background: Hallux abductus valgus (HAV) is a forefoot condition produced by extrinsic and intrinsic factors. Shoes with a high heel height and a typical narrow tip toe box can induce deviations in both the proximal phalanx of the hallux (PPH) and the first metatarsal (IMTT) bones. Nevertheless, the isolated role of heel height remains unclear in the development of HAV pathology. Objectives: The goal was to determine if the heel height increase of shoes without a narrow box toe could augment the PPH and IMTT deviation in frontal, sagittal, and transverse planes toward the first metatarsophalangeal joint (MPJ) and the first metatarsocuneiform joint (MCJ), respectively, during static and dynamic conditions in relation to precursor movements of HAV. Methods: Women with an average age of 25.10 ± 4.67 years were recruited in this cross-sectional study to assess the three planes of motion of PPH and IMTT while wearing high heels with heights at 3, 6, 9 cm and unshod conditions via sandals. The measurements used an electromagnetic goniometer device with sensors placed on medial aspects of the PPH and IMTT bones under static and dynamic conditions. Results: Wearing shoes with a 6 cm heel in dynamic condition may increase the PPH valgus and abduction deviation from 3.15 ± 0.10° to 3.46 ± 0.05° (p < 0.05) and from 1.35 ± 0.28° to 1.69 ± 0.30° (p < 0.001), respectively. In addition, a PPH abduction increase from 1.01 ± 0.36° to 1.31 ± 0.46° (p < 0.05) after wearing shoes with a 6 cm heel height was observed under static conditions. Conclusions: Wearing shoes with a heel height of 6 cm without a narrow box toe interference may produce PPH abduction and valgus deviations related to HAV formation.

Evaluation of foot static disturbances in patients with rheumatic diseases

Objectives

Rheumatic diseases such as osteoarthritis and rheumatoid arthritis constitute the most frequent pathological states leading to the development of foot deformities, which reduce quality of life and cause disability. The aim of the present study was to compare the results of plantoconturographic examinations, obtained by means of a computer podoscope, in osteoarthritis and rheumatoid arthritis patients. Special attention was paid to the differences in the values of each parameter determining the level of foot function.

Material and methods

The study was performed in 94 female patients divided into two groups according to the type of disease. There were 54 patients with rheumatoid arthritis and 40 with osteoarthritis. The control group consisted of 34 healthy women. The plantographic assessment of static foot structure was carried out by means of a device for computer-aided foot examination.

Results

A fallen transverse arch of the right foot was statistically much more frequent in the rheumatoid arthritis patients than in osteoarthritis patients or the control group (p < 0.005 and p < 0.05, respectively). Significant differences in the values of the Wejsflog index were observed in the case of left foot between rheumatoid arthritis patients and the control group (p < 0.05). Similarly, there were statistically significant differences in the values of the hallux valgus angle (α) for the right foot between rheumatoid arthritis and osteoarthritis patients or control group (in both cases p < 0.05).

Conclusions

Rheumatic diseases predispose patients to disturbances of static foot function. The obtained results highlight the importance of diagnosing foot static disturbances in the prevention of destructive changes affecting the functioning of osteoarthritis and rheumatoid arthritis patients.