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

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion

Cheilectomy, a joint-conserving procedure, is often a first-line choice for treating early stages of hallux rigidus. Recent evidence has revealed its efficacy in treating more advanced stages. However, when degeneration is profound, first metatarsophalangeal (MTP) fusion remains the most appropriate strategy. Nevertheless, it is common for surgeons to proceed initially with cheilectomy, reserving joint fusion for subsequent considerations if cheilectomy fails. This article will explore the relationship between the 2 procedures and evaluate the research surrounding the effect of prior cheilectomy on first MTP joint arthrodesis.

Biomechanical comparison of reverse offset-L osteotomy and chevron osteotomy in cadaveric hallux valgus surgery

OBJECTIVE

Chevron osteotomy offers near-excellent clinical results and adequate stability at lower shift percentages, among the techniques used to correct hallux valgus deformity. This cadaveric study aimed to compare the Chevron osteotomy with the reverse offset-L osteotomy, which may provide a greater surface area and a more stable geometry to withstand higher cantilever forces at higher shift percentages.

METHODS

Metatarsal bones obtained from 20 human cadavers with similar bone quality were divided into two groups: Chevron osteotomy was applied to the 1st group and reverse offset-L osteotomy was applied to the 2nd group. The load-to-failure, displacement in the y-axis, and total displacement values of both groups were compared statistically. Furthermore, bone densities were compared between the groups with computed tomography imaging.

RESULTS

When outliers in both groups were excluded, a statistically significant difference was found in favor of reverse offset-L (143 ± 42 vs. 204 ± 51.2 N, p = 0.02) in terms of failure load. The groups were similar in terms of displacement on the y-axis and total displacement values. Bone densities were similar.

CONCLUSION

The reverse offset-L osteotomy has been shown to withstand greater loads before failure compared to the standard Chevron osteotomy. This significant difference in load-to-failure may enable reverse offset-L to provide reliable stability in osteotomies performed in advanced HV cases requiring higher shifts.

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.

Clinical and radiological outcome of surgical hallux valgus correction: open versus minimally invasive

INTRODUCTION

Hallux valgus (HV) is the most common forefoot deformity. Surgical correction of HV aims to reduce pain, preserve joints, and re-establish foot function while restoring the hallux valgus angle (HVA) and intermetatarsal angle (IMA). Many surgical procedures have been proposed, including open and minimally invasive (MI) techniques. This study aimed to compare the midterm outcomes of open vs. MI procedures and their impact on the duration of surgery, hospital stay, HVA, and IMA post-operatively.

MATERIALS AND METHODS

One hundred and twenty HV patients operated by open or MI surgery between October 2019 and October 2022 were included. One hundred three patients met the inclusion criteria and consented to the study. Patients were prospectively surveyed for foot functionality, post-operative pain, and complications using the AOFAS score. Radiographic measurements of HV angles, length of hospital stay, and surgery duration were analysed.

RESULTS

MI surgery patients had significantly better AOFAS scores (p < 0.001) 12 months post-operatively compared to open surgery. Complication rates were lower in the MI group (3.8% vs. 33.3%, p < 0.001). MI surgery patients also had shorter hospital stays (0.9 ± 0.3 days vs. 2.0 ± 0.0 days) and surgery duration (19.7 ± 2.3 min vs. 80.7 ± 6.8 min). MI surgery was more effective in correcting the IMA but equally effective as open surgery for HVA correction.

CONCLUSION

MI surgery resulted in better patient satisfaction, fewer complications, and more precise correction of IMA values. Moreover, the duration of surgery and hospital stay were significantly lower in patients undergoing MI surgery. Further research is needed to validate these findings in controlled, prospective randomised trials.

First-Ray Distal Metatarsal and Proximal Phalangeal Osteotomies Without Soft Tissue Procedure for Severe Hallux Valgus: A Case Series

Background

This case series reported the outcomes of severe hallux valgus treated with first-ray distal metatarsal and proximal phalangeal osteotomies without soft tissue procedure.

Methods

The medical records of patients who underwent this surgery from February 2018 to December 2021 were reviewed, including patients with a hallux valgus angle (HVA) ≥40 degrees who were followed up for >2 years. The analyzed data included age, sex, height, weight, and body mass index at the surgery, HVA and intermetatarsal angle (IMA) on the weighted anteroposterior radiograph of the affected foot, the Japanese Society for the Surgery of the Foot score, visual analog scale (VAS) score, and passive plantarflexion and dorsiflexion angles of the first metatarsophalangeal joint 1 month before surgery and at final follow-up.

Results

The study group included 35 feet in 29 patients (26 females) with a mean age of 67 ± 10.6 years and mean follow-up of 3.5 ± 0.8 years. Average preoperative and final follow-up measures were HVA, 46.8 to 7.7 degrees; IMA, 18.8 to 9.5 degrees; and VAS score, 61.5 ± 29.6 to 2.7 ± 4.6. Range of motion decreased on average: dorsiflexion, 83.6 ± 14.7 to 71.3 ± 12.0 degrees; and plantarflexion, 63.0 ± 14.7 to 53.0 ± 11.8. All changes were statistically significant (P < .001).

Conclusion

This surgery achieved good correction and clinical outcomes for severe hallux valgus, but the postoperative range of motion decreased.Level of Evidence: Level IV, case series.

First tarsometatarsal arthrodesis for severe hallux valgus using the tension band principle - Technical tip and case series

BACKGROUND

Hallux valgus (HV) is a common foot pathology. Severe HV in the presence of Tarsometatarsal joint (TMTJ) instability is often managed with arthrodesis of the 1st TMTJ. There are concerns regarding non-union and malunion (particularly the early loss of inter-metatarsal angle correction before complete arthrodesis). We report our medium-term results of a small series of patients that underwent an evolved surgical technique utilising orthogonal staples and a transverse suture button fixation to address biomechanical concerns with traditional Lapidus arthrodesis.

METHODS

A retrospective study of a consecutive series of patients who underwent this surgical technique between February 2017 and May 2022. Clinical outcomes were validated through Patient-reported outcomes measures (PROMS); EuroQol-5 Dimension (EQ-5D) and Manchester-Oxford Foot Questionnaires (MOXFQ). Radiographic parameters (hallux valgus (HVA), intermetatarsal (IMA), distal metatarsal articular angle (DMAA)) were assessed. Union of the arthrodesis and complications were recorded.

RESULTS

During the study period, 9 feet underwent the procedure. Radiographic data was available for all nine and PROMS data for seven (77.8%). Significant improvement occurred in all radiographic deformity parameters at mean 6-month follow-up. Mean ± standard deviation correction calculated preoperatively as HVA 40.2°, IMA 19.3° and DMAA 15.8°, corrected to HVA 15.4°, IMA 5.8° and DMAA 5.9° postoperatively. (HVA; P < 0.001, IMA; P < 0.001, DMAA; P < 0.001) Clinical PROMs at mean follow-up of 2 years were MOXFQ 34.4 ± 25.2, EQ-5D-5 L 0.819 ± 0.150 and VAS pain 13.6 ± 13.6. There were no cases of non-union, Tibialis anterior tendon irritation or hallux varus. Complications included first MTPJ stiffness in one case and CRPS and dorsiflexion malunion of the first ray in another patient.

CONCLUSION

This preliminary study of the procedure used in this series confirm this is a safe surgical technique to address severe HV with a low rate of non-union and significant radiographic improvements. A larger patient dataset is needed to evaluate this procedure robustly.

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.

The chevron bunionectomy for moderate to severe hallux valgus deformity: Effects of procedural factors on hallux valgus correction

BACKGROUND

Effects of procedural factors on chevron bunionectomy outcomes were studied.

METHODS

Included were 109 feet with distal chevron osteotomy and preoperative intermetatarsal angle (IMA) greater than 15 degrees. IMA and hallux valgus angles (HVA), release type, fixation, second-digit procedures, and risk factors were evaluated.

RESULTS

Eighty-three percent (91/109 feet) had satisfactory outcomes; nine had moderate pain. From preoperative, IMA improved 7.2 and HVA 20.5 degrees. Risk factors or second-digit procedures had no effect. Lateral release improved IMA (p < 0.01), with no difference between open lateral and transarticular release; 86% percent (64/74) were satisfied with open lateral release compared with 83% (19/23) and 66% (8/12) with no release and transarticular release, respectively. Fixation did not affect outcomes.

CONCLUSION

Chevron bunionectomy corrected IMA and HVA to normal with few complications. Lateral release increased IMA correction. Transarticular release had lower satisfaction than open lateral release or no release.

LEVEL OF EVIDENCE

Level III, retrospective.

First Metatarsophalangeal Arthrodesis for the Failed Hallux

Hallux metatarsophalangeal joint (MTPJ) arthrodesis was first described in 1894 by Clutton, who recommended ankylosing the MTPJ to treat painful hallux valgus (HV). He used ivory pegs to stabilize the MTP joint. Surgeons over the last century have modified the procedure and added indications, including hallux rigidus, rheumatoid arthritis, and revision of failed surgeries. This article addresses many common yet challenging clinical scenarios, and a few hot topics, related to hallux MTPJ arthrodesis, including matarsus primus elevatus, severe hallux valgus, avascular necrosis, and infections. The article provides a condensed evidence-based discussion on how to manage these challenges using MTPJ arthrodesis.

Minimally invasive surgery for severe hallux valgus in 106 feet

BACKGROUND

There is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1-2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA).

METHODS

This was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale).

RESULTS

Between September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%.

CONCLUSION

This study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.

Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up

BACKGROUND

Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known.

METHODS

A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction.

RESULTS

Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%.

CONCLUSION

Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Third-Generation Minimally Invasive Chevron and Akin Osteotomies (MICA) in Hallux Valgus Surgery: Two-Year Follow-up of 292 Cases

BACKGROUND

There is interest in hallux valgus deformity correction using internal fixation with the minimally invasive chevron and Akin osteotomies (MICA) technique. The objective of this study was to assess the correction measured on postoperative radiographs and clinical outcomes, using validated outcome measures, at 2 years following third-generation MICA.

METHODS

This is a prospective single-surgeon case series of 333 consecutive feet that underwent MICA surgery between July 2014 and April 2018. The primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index, EuroQol-visual analogue scale (EQ-VAS), and a VAS for pain (VAS-pain). Secondary outcome measures included radiographic parameters and complication rates.

RESULTS

Preoperative and 2-year postoperative patient-reported outcome measures (PROMs) were collected for 292 feet (87.7%). At a minimum 2-year follow-up, the MOXFQ scores (mean ± standard deviation [SD]) had improved in each domain-i.e., reduced from 44.5 ± 21.0 preoperatively to 9.4 ± 15.8 postoperatively for pain (p < 0.001), from 38.7 ± 23.4 to 6.5 ± 14.6 for walking and standing (p < 0.001), and from 48.0 ± 22.3 to 6.6 ± 13.5 for social interaction (p < 0.001). The VAS-pain score improved from 31.4 ± 22.7 preoperatively to 8.4 ± 16.4 at the 2-year follow-up (p < 0.001), the 1-2 intermetatarsal angle was reduced from 15.3° ± 3.6° preoperatively to 5.7° ± 3.2° at the 2-year follow-up (p < 0.001), and the hallux valgus angle was reduced from 32.9° ± 10.2° to 8.7° ± 5.2° (p < 0.001).

CONCLUSIONS

The third-generation MICA provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.