Intraoperative and Postoperative Evaluation of Hallux Valgus Correction: What Is Important?

Comparative effects of modified rotary scarf osteotomy and traditional scarf osteotomy in treating moderate to severe hallux valgus: a retrospective cohort study

BACKGROUND

Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of TSO, Modified Rotary Scarf osteotomy (MRSO) was introduced in this study, which aimed to compare the clinical and radiological outcome in the patients treated with MRSO or TSO.

METHODS

Of 175 patients (247 feet) with MSHV, 100 patients (138 feet) treated with MRSO and 75 patients (109 feet) treated with TSO were evaluated according to relevant indicators in twenty-four months follow-up. Pre-surgical and post-surgical HVA, IMA, DMAA, MTP-1 ROM, sesamoid grade and AOFAS (American Orthopaedic Foot and Ankle Society) scores and postsurgical complications were evaluated.

RESULTS

Both groups manifested similar baseline characters. The mean follow-up was of 25.9 (range, 22-37) months. Significantly lower IMA, lower Sesamoid grade and higher DMAA at six months, twelve months and twenty-four months post-surgically had been showed in MRSO group compared to TSO group. There was no significant difference in HVA, MTP-1 ROM and AOFAS data at each follow-up time point post-surgically between the two groups. No major complications occurred in either group.

CONCLUSION

MRSO showed comparable results to TSO, and improved IMA and sesamoid grade to a greater extent, with a lower probability of throughing effect. Although DMAA could be increased by MRSO, MRSO could still be a reproducible, non-dangerous and efficacious alternative procedure for treating HV patients which do not have severe DMAA.

Minimally invasive Chevron Akin (MICA) osteotomy for severe hallux valgus

INTRODUCTION

The minimally invasive Chevron Akin (MICA) osteotomy has been widely used to treat hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure and to evaluate the clinical and radiographic outcomes.

MATERIALS AND METHODS

Retrospective study including 60 consecutive feet (52 patients) undergoing MICA for severe HV. The data were collected pre- and post-operatively at the last follow-up. Patients were clinically evaluated by the visual analog pain scale (VAS) and AOFAS hallux MTP-IP score. Radiographic assessments included measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length, distal metatarsal articular angle (DMAA), and plantar translation of MT head. The complications were recorded during the follow-up.

RESULTS

The mean age was 59.9 years, and the mean follow-up was 20.5 months. The average AOFAS increased from 41.2 to 90.9 points, and the VAS from 8.1 to 1.3 at the last follow-up. The average HVA decreased from 41.2º to 11.6º, the IMA from 17.1º to 6.9º, and the DMAA from 17.9º to 7.8º. The average shortening of the first metatarsal and the plantar translation of the MT head was 5.1 mm and 2.8 mm, respectively. The most observed complication was hardware discomfort, observed in 5 feet (8.3%). There were two cases of recurrence (3.3%).

CONCLUSION

MICA technique was demonstrated in this series of cases to be an effective procedure for severe HV, with a low rate of recurrence and an acceptable rate of complications.

LEVEL OF EVIDENCE

IV; case series.

A comparative analysis of clinical, functional and radiographic outcomes of patients with and without fusion between the first and second metatarsals after the lapidus procedure

BACKGROUND

The aim of this study was to compare the clinical, functional and radiographic outcomes in patients who underwent the original Lapidus procedure (OLP) with fusion and undesired non-fusion between the first (M1) and second (M2) metatarsals.

METHODS

A retrospective and comparative analysis of 29 patients (38 feet) who underwent the OLP was performed. They were divided in two groups: (1) 23 feet in which fusion occurred and (2) 15 with undesired non-fusion. Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF-12 comprises physical and mental health scales (PCS-12 and MCS-12). Radiographic parameters assessed were bony and soft tissue forefoot widths (BSFW), intermetatarsal-angle (IMA) and HV-angle (HVA).

RESULTS

Separately, the groups presented significant improvements in all questionnaires (p < 0.001), except on MCS-12 (fusion p = 0.08 and non-fusion p = 0.27). When comparing both groups, patients with fusion had higher AOFAS scores (p < 0.05). Both groups presented the same improvements on BSFW, IMA and HVA (p = 0.09, p = 0.16, p = 0.52 and p = 0.63).

CONCLUSION

Excellent results were observed, even when without fusion between M1 and M2. Patients who evolved with fusion between the M1 and M2 showed greater improvements in the AOFAS score.

LEVEL OF EVIDENCE

III, retrospective comparative study.

CAN THE PERCUTANEOUS CHEVRON AND AKIN (PECA) TECHNIQUE CORRECT THE PRONATION OF THE FIRST METATARSAL IN HALLUX VALGUS?

Objective

Pronation of the first metatarsal in hallux valgus has recently been discussed among foot and ankle surgeons. This study aimed to evaluate the potential radiographic correction of moderate and severe hallux valgus using the percutaneous Chevron and Akin (PECA) technique.

Methods

We evaluated 45 feet in 38 patients (mean age 65.3 years old [36 - 83]; 4 men; 34 women; 7 bilateral) who underwent surgical correction using the PECA technique. The radiographic images evaluated were anteroposterior radiographs obtained pre- and postoperatively at least 6 months after surgery, including the metatarsophalangeal angle, the intermetatarsal angle, pronation of the first metatarsal, displacement of the distal fragment, medial sesamoid position and bone union.

Results

All parameters evaluated showed significant postoperative improvement, including correction of pronation of the first metatarsal (p < .05) and position of the sesamoid (p < .05). There was a union of osteotomies in all feet. No complications were observed, such as screw loosening or necrosis of the first metatarsal head.

Conclusion

The PECA technique can correct pronation of the first metatarsal in moderate and severe hallux valgus, and other deformity-associated parameters. Level of Evidence IV; Case Series.

Morphologic analysis of the 1st and 2nd tarsometatarsal joint articular surfaces

Tarsometatarsal joint arthrodesis is used to treat a variety of injuries and deformities in the midfoot. However, the surgical technique has not been optimized, in part due to limited knowledge of morphologic features and variation in the related joints. Previous research has relied primarily on dissection-based anatomical analysis, but quantitative imaging may allow for a more sophisticated description of this complex. Here, we used quantitative micro-CT imaging to examine dimensions, distance maps, and curvature of the four articular surfaces in the first and second tarsometatarsal joints. Image segmentation, articular surface identification, and anatomic coordinate systems were all done with semi or fully automatic methods, and distance and size measurements were all taken utilizing these anatomic planes. Surface curvature was studied using Gaussian curvature and a newly defined measure of curvature similarity on the whole joint and on four subregions of each surface. These data show larger articular surfaces on the cuneiforms, rather than metatarsals, and define the generally tall and narrow articular surfaces seen in these joints. Curvature analysis shows minimally curved opposing convex surfaces. Our results are valuable for furthering knowledge of surgical anatomy in this poorly understood region of the foot.

Intraoperative Technical Tips to Improve Fusion Between the First and Second Metatarsals in the Original Lapidus Procedure

The modified Lapidus procedure (MLP), which consists of fusion between the first metatarsal (M1) and medial cuneiform, has been widely performed with satisfactory clinical outcomes, but it has a variable nonunion rate ranging between 4% and 10% and loss of correction in up to 5.8% of the cases. Excessive motion around the site of tarsometatarsal arthrodesis, specially at the intercuneiform joint, is probably the reason. The original Lapidus procedure (OLP), which includes fusion of the M1 to second metatarsal (M2), may be beneficial in preventing nonunion and recurrence. The objective of this study was to describe intraoperative technical tips in the OLP to improve M1 to M2 fusion, which may prevent complications. Since the Lapidus procedure continues to gain popularity, it is the authors opinion that the OLP requires special attention because it is a more technically demanding surgery compared to the MLP.Level of Evidence: Level V: Expert opinion.

Pre- and Post-Operative Relationship between Radiological Measures and Clinical Outcomes in Women with Hallux Valgus

The surgical correction of a hallux valgus (HV) deformity improves radiological parameters and clinical outcomes. However, it is not known how these improvements are related between themselves. In this retrospective study, 73 women were assessed preoperatively and 60 months after HV surgical correction. Several radiological parameters were measured: the hallux valgus angle (HVA), I−II intermetatarsal angle (IMA) and sesamoid position. The functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal (HMI) scale, and patient-reported outcomes (PROMs) were recorded with the Manchester−Oxford Foot Questionnaire (MOXFQ). A pre−post-surgery comparison of radiological and clinical values was performed, the correlation among them was studied and the differences pre−post-surgery in the radiological measurements compared with those for the clinical outcomes were studied. The results show that all the radiological parameters, functional outcomes and PROMs improved significantly from their pre-operative values to the follow-up values. Multivariate regression analysis showed a significant relationship (p < 0.001) between the differential pre−post-surgery AOFAS scoring only with two sesamoid position differential pre−post-surgery measures: position of medial sesamoid (PMS) and translation of the first metatarsal head (TMH). However, no significant association was observed between the pre−post-surgery radiological differences and the pre−post-surgery MOXFQ scoring.

Radiographic measurements have limited effect in dynamic plantar pressures in hallux valgus patients

PURPOSE

Radiographic measurements are the gold standard in the management for preoperative surgical planning of hallux valgus deformity. Plantar pressure technology is a tool that is not commonly used to evaluate and manage hallux valgus patients, and few studies have reported the correlation of plantar pressure measurements and radiography.

METHODS

A prospective cohort study was designed to analyze plantar pressure measurements and radiographic variables. The inclusion criteria were age over 18 years old, and diagnosis of hallux valgus requesting surgical correction because of discomfort, pain or difficulty with shoe wear. Plantar pressure measurements were performed using a platform. Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements.

RESULTS

A total of 114 patients met the inclusion criteria. Mean age of the patients was 50 years, and 94 patients (82.5%) were women. We found significant correlations between dynamic plantar pressure measurements and HVA, DMAA, and MDA. Mean pressure under third metatarsal head was the most associated plantar pressure measurement with hallux valgus angle and metatarsal declination angle. However, this association showed signs of weakness.

CONCLUSION

Hallux valgus angle and metatarsal declination angle had a minimal influence on plantar-loading parameters. Pressure values did not discriminate the magnitude of HV deformity. Others factors responsible for the observed plantar pressures pattern should be addressed.

Triplanar Chevron Osteotomy: A Newly Proposed Method to Treat Hallux Valgus Deformities

Objective

To present a novel method called triplanar chevron osteotomy to treat hallux valgus (HV).

Methods

This is a retrospective study. In this study, the CT data of HV patients with painful callosities were evaluated retrospectively between 1 June 2018 and 1 June 2020. CT data from 49 consecutive patients (59 feet) with HV were evaluated. The average age at the time of surgery was 49.6 years (range, 30–63 years). The apex of the chevron osteotomy procedure was located at the center of the first metatarsal and was defined as the line formed by the central point perpendicular to the fourth metatarsal bone. The cut planes of the plantarward oblique chevron osteotomy (POCO) were defined as follows: chevron osteotomy along with 20° of plantarward obliquity. The triplanar osteotomy incision was made using the POCO method, with the direction inclined by 10° distally. The intermetatarsal angle (IMA), the HV angle (HVA), the projection of the second metatarsal (PSM), the metatarsal protrusion index (MPI), and the metatarsal protrusion distance (MPD) were all calculated before and after the operations. The length of the first metatarsal was measured and calculated with an equation.

Results

The results showed that the HVA was significantly decreased after surgery (32.7° ± 4.6° vs 14.9° ± 2.1°, t = 25.583, P < 0.001) in the triplanar, traditional, and POCO groups. The IMA was also significantly decreased (14.7° ± 2.0°) compared with the results before surgery (8.0° ± 1.1°, t = 22.739, P < 0.001) in these groups. Compared with traditional osteotomy and POCO, there were no differences in correcting deformities on axial planes for the HVA (14.5° ± 1.7° vs 14.9° ± 2.1°, t = 1.835, P = 0.072) and IMA (8.1° ± 1.1° vs 8.0° ± 1.1°, t = −0.97, P = 0.336). There was a statistically significant decrease following surgery in terms of the PSM, MPI, and MPD after triplanar osteotomy. The length of the first metatarsal increased (10.9 ± 1.3 mm), as measured through three‐dimensional images in the triplanar osteotomy group. The length was calculated as follows: H = L2 * Tan θ ≈ L/COS β * Tan θ.

Conclusion

The new triplanar osteotomy technique is safe and effective for treating HV, and in simulation experiments reveals potential benefits of correction and preventing transfer metatarsalgia.