Revision hallux valgus: causes and correction options

Hallux Valgus Deformities: Preferred Surgical Repair Techniques and All-Cause Revision Rates

INTRODUCTION

Hallux valgus is a commonly treated condition by foot and ankle surgeons with more than 200 different described correction techniques. Recurrence rates range from 5% to 50%, with increasing support of the theory that arthrodesis procedures may have a lower recurrence rate than osteotomies. Arthrodesis procedures to the first metatarsophalangeal (MTP) joint or tarsometatarsal (TMT) joint for correction of hallux valgus deformity are becoming more commonly utilized. The purpose of this study is to investigate the surgical incidence and revision rates of hallux valgus deformities corrected by arthrodesis compared to osteotomy in the state of South Carolina.

METHODS

The South Carolina Revenue and Fiscal Affairs Office was queried from 2000 to 2017 to identify all surgically treated hallux valgus deformities. Data extraction included patient demographics, ICD-9 diagnoses, CPT procedure codes, and dates of surgery. A logistic regression model was used for statistical inference.

RESULTS

A total of 22 199 feet had surgical treatment for hallux valgus during this time period, with 20 422 (92.0%), 592 (2.7%), and 1185(5.3%) receiving an osteotomy, arthrodesis, or other procedure at initial treatment, respectively. There was an all-cause revision rate of 5.6% in the osteotomy group and 6.4% in the arthrodesis group. Demographic factors such as female sex, white race, and surgery pre-2010 were associated with higher revision rates. Multiple comorbidities were correlated with higher revision rates such as tobacco use, hypothyroidism, osteoarthritis, recurrent dislocations, hallux rigidus, lesser toe deformities, metatarsus varus, and talipes cavus.

CONCLUSION

Despite the recent increase in arthrodesis procedures for the treatment of hallux valgus deformity, our results suggest that osteotomy procedures are more commonly performed and there is no difference in all-cause revision surgery. However, there are multiple patient demographics and comorbidities that are associated with higher rates of revision surgery and should be considered and discussed during the preoperative planning period.

LEVEL OF EVIDENCE

Level IV.

Surgical interventions for treating hallux valgus and bunions

BACKGROUND

Hallux valgus (lateral angulation of the great toe towards the lesser toes, commonly known as bunions) presents in 23% to 35% of the population. This condition leads to poor balance and increases the risk of falling, adding to the difficulty in fitting into shoes and pain. Conservative (non-surgical) interventions treating pain rather than curing deformity are usually first-line treatments. When surgery is indicated, the overall best surgical procedure is an ever-evolving topic of discussion.

OBJECTIVES

To assess the benefits and harms of different types of surgery compared with placebo or sham surgery, no treatment, non-surgical treatments and other surgical interventions for adults with hallux valgus.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and trial registries to 20 April 2023. We did not apply any language or publication restrictions.

SELECTION CRITERIA

We included randomised controlled trials evaluating surgical interventions for treating hallux valgus compared to placebo surgery or sham surgery, no treatment, non-surgical treatment or other surgical interventions. The major outcomes were pain, function, quality of life, participant global assessment of treatment success, reoperation (treatment failure), adverse events and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE.

MAIN RESULTS

We included 25 studies involving 1597 participants with hallux valgus. All studies included adults and most were women. One study compared surgery (V-shaped osteotomy) with no treatment and with non-surgical treatment. Fifteen studies compared different surgical techniques, including a V-shaped osteotomy (Chevron osteotomy), to other types of osteotomy. Nine studies compared different simple osteotomy techniques to each other or to a mid-shaft Z-shaped osteotomy (Scarf osteotomy). Most trials were susceptible to bias: in particular, selection (80%), performance (88%), detection (96%) and selective reporting (64%) biases. Surgery versus no treatment Surgery may result in a clinically important reduction in pain. At 12 months, mean pain was 39 points (0 to 100 visual analogue scale, 100 = worst pain) in the no treatment group and 21 points in the surgery group (mean difference (MD) -18.00, 95% confidence interval (CI) -26.14 to -9.86; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in function. At 12 months, mean function was 66 points (0 to 100 American Orthopedics Foot and Ankle Scale (AOFAS), 100 = best function) in the no treatment group and 75 points in the surgery group (MD 9.00, 95% CI 5.16 to 12.84; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in little to no difference in quality of life. At 12 months, mean quality of life (0 to 100 on 15-dimension scale, 100 = higher quality of life) was 93 points in both groups (MD 0, 95% CI -2.12 to 2.12; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in participant global assessment of treatment success. At 12 months, mean participant global assessment of treatment success was 61 points (0 to 100 visual analogue scale, 100 = completely satisfied) in the no treatment group and 80 points in the surgery group (MD 19.00, 95% CI 8.11 to 29.89; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may have little effect on reoperation (relative effect was not estimable), adverse events (risk ratio (RR) 8.75, 95% CI 0.48 to 159.53; 1 study, 140 participants; very low-certainty evidence), and serious adverse events (relative effect was not estimable), but we are uncertain. Surgery versus non-surgical treatment Surgery may result in a clinically important reduction in pain; a slight increase in function and participant global assessment of treatment success; and little to no difference in quality of life (1 study, 140 participants; low-certainty evidence). We are uncertain about the effect on reoperation, adverse events and serious adverse events (1 study, 140 participants; very low-certainty evidence). Complex versus simple osteotomies Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies (7 studies, 414 participants; moderate-certainty evidence). Complex osteotomies may increase reoperation (7 studies, 461 participants; low-certainty evidence), and may result in little to no difference in participant global assessment of treatment success (8 studies, 462 participants; low-certainty evidence) and serious adverse events (12 studies; data not pooled; low-certainty evidence). We are uncertain about the effect of complex osteotomies on function and adverse events (very low-certainty evidence). No study reported quality of life.

AUTHORS' CONCLUSIONS

There were no trials comparing surgery to placebo or sham. Surgery may result in a clinically important reduction in pain when compared to no treatment or non-surgical treatment. Surgery may also result in a slight increase in function and participant global assessment of treatment success compared to no treatment or non-surgical treatment. There may be little to no difference in quality of life between surgery and no treatment or non-surgical treatment. We are uncertain about the effect of surgery on reoperation (treatment failure), adverse events or serious adverse events, when compared to no treatment or non-surgical treatment. Complex and simple osteotomies demonstrated similar results for pain. Complex osteotomies may increase reoperation (treatment failure) and may result in little to no difference in participant global assessment of treatment success and serious adverse events compared to simple osteotomies. We are uncertain about the effect of complex osteotomies on function, quality of life and adverse events.

Outcomes After Chevron Osteotomy with and Without Additional Akin Osteotomy: A Retrospective Comparative Study

Background

Chevron osteotomy is one of the most common approaches to hallux valgus corrective surgery. This procedure is often combined with Akin osteotomy of the proximal phalanx of the hallux. There are no definitive guidelines specifying the indications for a given osteotomy technique nor data on postoperative loss of correction or the effect of the type of first-ray surgery on the development of adjacent-joint arthritis. The aim of this study was to assess radiographic treatment outcomes via chevron osteotomy with and without Akin osteotomy.

Methods

The study evaluated 117 patients treated in the period 2016-2019. Ninety-nine of those patients underwent distal chevron osteotomy alone, and 18 patients underwent a combined chevron-Akin double osteotomy. The analyzed radiograms had been obtained preoperatively, at 6 weeks after surgery, and after a long-term follow-up. The following parameters were assessed: the intermetatarsal angle (IMA), hallux valgus angle (HVA), interphalangeal angle (IPA), postoperative recurrence of valgus deformity, adjacent-joint arthritis, and complications.

Results

Chevron-Akin osteotomy helped maintain lower HVA and IPA values in long-term follow-up in comparison with those in the patients who underwent chevron osteotomy alone. The chevron osteotomy group showed a significant increase in the mean HVA from 18.37° at the first follow-up visit to 20.81° at the last follow-up visit. There were no differences between the groups in terms of the remaining assessed radiographic parameters. Hallux valgus surgery does not increase adjacent-joint arthritis.

Conclusion

The use of combined chevron-Akin osteotomy does not affect HVA or IMA correction. The combination of chevron and Akin osteotomies reduces the risk of increased HVA and IPA in long-term follow-up. The additional Akin osteotomy does not increase the risk of adjacent-joint arthritis. Combining chevron osteotomy with Akin osteotomy is recommended in hallux valgus deformity correction.

Iatrogenic transfer metatarsalgia after hallux valgus surgery: a comprehensive treatment algorithm

Current literature has described many of the complications following hallux valgus surgery and their treatment options.

Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet.

Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique.

We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication.

With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

Managing Complications of Foot and Ankle Surgery: Hallux Valgus

Hallux valgus deformity is nowadays one of the most common and symptomatic disorders affecting the foot. Surgical corrections of hallux valgus deformity are among the most common orthopedic procedures. Despite the general high success rate complications can occur. The treatment of complications start before the first incision has been performed by thorough preoperative planning and choice of the right procedure. Once the complication is evident, thorough planning is necessary to address the patient's individual needs. In this paper the treatment of recurrent hallux valgus, hallux varus, malunion, and avascular necrosis are discussed.

Hallux Valgus Nonunion Correction in an Active Duty Military Member

Hallux valgus is one of the most common conditions treated by foot and ankle orthopedists; over 140 surgical procedures have been developed for management of the condition. A rare complication of hallux valgus repair is nonunion, and the literature regarding nonunion after hallux valgus repair is correspondingly sparse. We present a 39-year-old active duty male who underwent operative management after developing nonunion and transfer metatarsalgia following a proximal oblique metatarsal osteotomy. The patient underwent nonunion correction and metatarsal lengthening via bone allografting. No complications were observed during the intra- or perioperative periods. At 2.5-years postoperatively, the patient's symptoms had largely resolved. He expressed high satisfaction with his outcome and was able to continue activity duty. Our findings indicate that nonunion repair can have excellent clinical outcomes with high patient satisfaction, even in an active military population.

The Modified Subcapital Metatarsal Osteotomy in the Treatment of Hallux Valgus Recurrence

The purpose of the present study is to illustrate the use of a modified subcapital metatarsal osteotomy (MSMO) in the treatment of hallux valgus (HV) recurrence. The article reports the clinical and radiological outcomes of a cohort of 52 consecutive patients presenting with recurrent HV, treated with MSMO. A total of 52 patients (54 feet) underwent operations between May 2010 and November 2015. The mean time of follow-up was 2.5 years (range 5.5-1.0 years), and the mean age was 49 years (range 22-76 years). The patient cohort comprised 46 female and 6 male patients. The results of this research show that MSMO is a reliable technique for the correction of HV recurrence. The postoperative radiographic assessments show a statistically significant postoperative improvement of the HV angle (P < .05) and the intermetatarsal angle (P < .05). The postoperative position of the tibial sesamoid was significantly improved (P < .1). The distal metatarsal articular angle was improved (P < .001), though assessment may be affected by the previous operations performed on the first metatarsophalangeal joint. The statistical analysis shows that the postoperative American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale parameters were significantly improved (P < 0.001). Results of this study indicate that the minimally invasive MSMO is effective in restoring anatomical alignment and improving patient outcomes in recurrent cases of HV.Levels of Evidence: Level III: Case-control study.

Complications of Minimally Invasive Surgery for Hallux Valgus and How to Deal with Them

This article discusses the possible complications in minimally invasive surgery (MIS) for hallux valgus. The rate of complications and the outcomes are at least comparable with open techniques. A percutaneous technique provides the best conditions for undisturbed healing. Some possible complications exist in MIS that do not exist in open surgery, such as lesion of soft tissue structures that are not under direct visible control or skin burns. These complications usually result from technical mistakes in performing the operation. It is therefore crucial to get proper education from cadaver training and visiting experienced colleagues, as is done in open surgery.

Management of Complications After Hallux Valgus Reconstruction

Complications following hallux valgus (HV) reconstruction will have an expected incidence of between 10% and 55% of cases. The more commonly reported complications include undercorrection/recurrence, overcorrection (hallux varus), transfer metatarsalgia, nonunion, malunion, avascular necrosis, arthritis, hardware removal, nerve injury, and ultimately patient dissatisfaction. The presence of arthritis will be an indication for fusion, whereas osteotomies will be the procedure of choice if the first metatarsophalangeal joint is healthy. Wide experience in primary HV surgery is advised before dealing with complex cases of failed HV surgery.

Complications after Metatarsal Osteotomies for Hallux Valgus: Malunion, Nonunion, Avascular Necrosis, and Metatarsophalangeal Osteoarthritis

Avascular necrosis (AVN), nonunion, malunion, and metatarsophalangeal (MTP) osteoarthritis following hallux valgus osteotomies, as well as pathophysiology, diagnosis, prevention strategies, and treatment are discussed in this article. AVN and nonunion are very infrequent, and they can be effectively prevented taking into consideration local anatomy preservation, biomechanics, and patient comorbidities. Shortening, elevation, plantarflexion, varus/valgus, and rotational of the first metatarsal are the most common types of malunion. They can lead to pain, stiffness, deformity recurrence, and transfer metatarsalgia. MTP osteoarthritis can develop after metatarsal malunion or AVN. Treatment options include cheilectomy, osteotomies to correct malunions, and MTP arthrodesis.

[Effectiveness comparison between Scarf osteotomy combined with Akin osteotomy fixed by absorbable screws and fixed by metal screws for the treatment of moderate to severe hallux valgus]

Objective

To evaluate the effectiveness of Scarf osteotomy combined with Akin osteotomy in the treatment of moderate to severe hallux valgus with absorbable screws or metal screws fixation by clinical and radiological data.

Methods

Between March 2014 and May 2016, the Scarf osteotomy combined with Akin osteotomy was used to treat 62 patients (83 feet) with moderate to severe hallux valgus. Twenty-five patients (35 feet) were fixed by absorbable screws (group A) and 37 patients (48 feet) were fixed by metal screws (group B). The difference in gender, age, affected side, etiology, severity, disease duration, preoperative hallux valgus angle (HVA) and first-second intermetatarsal angle (1-2IMA) measured in weight-bearing anteroposterior X-ray film, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analogue scale (VAS) scores between 2 groups ( P>0.05). The complications and healing time of 2 groups were recorded and compared. At last follow-up, the AOFAS and VAS scores, and HVA, 1-2IMA measured by weight-bearing anteroposterior X-ray film were used to evaluate the effectiveness.

Results

All incisions healed by first intention and no incision-related complication occurred in the two groups after operation. Both groups were followed up, the follow-up time in group A was 12-36 months (mean, 24.4 months) and in group B was 14-38 months (mean, 25.7 months). In group A, 1 foot was complicated with hallux varus, 2 feet had mild stiffness, 1 foot appeared metastatic metatarsal pain, and in group B was 2, 3, 2 feet, respectively. There was no recurrence of hallux valgus in both groups. The difference in the incidence of complications between the two groups after the first operation was not significant ( χ ²=0.275, P=0.843). The removal rate of internal fixator in group B was 89.2% (33 cases) during the second operation, among which 3 cases had screw slip and 1 case had screw fracture. And 10.8% (4 cases) refused the second removal operation due to their age. Postoperative X-ray films showed that both groups had good healing at the osteotomy site, and there was no significant difference in healing time between the two groups ( t=1.633, P=0.285). At last follow-up, the AOFAS score, VAS score, HVA, and 1-2IMA were significantly improved in the two groups when compared with preoperative ones ( P<0.05); but no significant difference was found between the two groups ( P>0.05).

Conclusion

The effectiveness of Scarf osteotomy combined with Akin osteotomy in the treatment of moderate to severe hallux valgus is significant, with few complications. Compared with being fixed by metal screws, being fixed by absorbable screws has the same effectiveness, but can avoid the risk of second operation to remove the internal fixator.

The progression of hallux valgus in the oriental Chinese population in Hong Kong

BACKGROUND

Hallux valgus is the lateral deviation of the great toe at the MTPJ that has many attributing aetiologies. This study will aim to identify whether hallux valgus progresses over time in the oriental Chinese population in Hong Kong.

METHODS

Patients with acquired symptomatic hallux valgus who presented to clinic between 2008 and 2013 were included. The deformities were analysed radiologically at presentation and pre-operative and angles were measured. These angles were analysed in relation to the waiting time from presentation to surgery.

RESULTS

A sample of 43 cases from 38 patients (Mean age 63 years, range 48-80 years) were included. Forty-one cases had a hallux valgus angle (HVA) >24° at presentation (Mean 40.4°) and all had an intermetatarsal angle (IMA) >9°. A significant difference is seen with HVA (p=0.040, t=-2.128) at presentation and pre-op but not IMA (p=0.281, t=-1.095). The average wait for surgery was 705.7days which had shown significant correlation with progression in HVA (p=0.031). No significant difference was seen between IMA and waiting time to surgery (p=0.195).

DISCUSSION

The findings suggests severe hallux valgus deformity does progress over time in Hong Kong. Shorter waiting times for surgery could be beneficial to this population. Level III, retrospective comparative series.