First metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy for treatment of hallux valgus: an intermediate-term retrospective outcomes study

Cohort Comparison of Radiographic Correction and Complications Between Minimal Invasive and Open Lapidus Procedures for Hallux Valgus

BACKGROUND

The Lapidus procedure corrects hallux valgus first ray deformity. First tarsometatarsal (TMT) fusion in patients with hallux valgus deformity using minimally invasive surgery (MIS) is a new technique, but comparative outcomes between MIS and open techniques have not been reported. This study compares the early radiographic results and complications of the MIS with the open procedure in a single-surgeon practice.

METHODS

47 MIS patients were compared with 44 open patients. Radiographic measures compared preoperatively and postoperatively were the intermetatarsal angle (IMA), hallux valgus angle (HVA), foot width (FW), distal metatarsal articular angle (DMAA), sesamoid station (SS), metatarsus adductus angle (MAA), first metatarsal to second metatarsal length, and elevation of the first metatarsal. Early complications were recorded, as well as repeat surgeries.

RESULTS

The mean follow-up was 82 (range, 31-182) months for the open group and 29 (range, 14-47) months for the MIS group. In both techniques, postoperative measures (IMA, HVA, DMAA, FW, and sesamoid station) were significantly improved from preoperative measures. When comparing postoperative measures between both groups, the IMA was significantly lower in the open group (4.8 ± 3.6 degrees vs 6.4 ± 3.2 degrees, P < .05). Differential between pre- and postoperative measures for both techniques were compared, and the open group was associated with more correction than the MIS group for IMA (12.4 ± 5.3 degrees vs 9.4 ± 4.4 degrees, P = .004) and HVA (25.5 ± 8.3 degrees vs 20 ± 9.9 degrees, P = .005). Wound complication and nonunion rates trended higher in the open group (4 vs 0) (P = .051).

CONCLUSION

Both techniques resulted in good to excellent correction. However, the open technique was associated with lower postoperative IMA values and more correction power for IMA and HVA, than the MIS.

A Clinicoradiological and Functional Evaluation of Lapidus Surgery for Moderate to Severe Bunion Deformity Shows Excellent Stable Correction and High Long-Term Patient Satisfaction

Background. Lapidus surgery involving arthrodesis of the first metatarsocuneiform (MTC) joint is an effective procedure for the correction of moderate to severe hallux valgus. The aim of this study was to collect and analyze radiographic data from our institution and determine the extent of first metatarsal shortening associated with the Lapidus procedure. Materials and Methods. A total of 53 patients (54 feet) who underwent arthrodesis of the first MTC joint combined with modified McBride bunionectomy for correction of moderate to severe hallux valgus deformity, between 2010 and 2015 were included in this study. Complete radiographic evaluation and AOFAS (American Orthopaedic Foot and Ankle Surgery) scoring was available for 54 feet. The average preoperative hallux valgus angulation (HVA) was 32° and the average intermetatarsal angle (IMA) was 16°. Results. Excluding 2 patients with postoperative hallux varus the average postoperative HVA correction at last follow-up was 14°. Average postoperative IMA was 9°. Although there was minimal bone resection during preparation of the MTC joint, no significant shortening of the first metatarsal was observed with this procedure. The relative length of the first metatarsal to the second metatarsal changed only 1.3%. Nonunion of the first MTC joint occurred in 10.3%, but only 1 foot was symptomatic requiring revision. The average postoperative hallux AOFAS score was 80.8. In sum, 63% of patients were very satisfied, 27% satisfied with reservations, and 10% were dissatisfied. Conclusion. The Lapidus bunion procedure offers excellent stable correction of moderate to severe hallux valgus deformity with minimal shortening of the first metatarsal and thereby higher patient satisfaction.Levels of Evidence: Level IV: Retrospective case series.

Relationship of Dome Height of the First Metatarsal Head with Hallux Valgus Angle and Metatarsophalangeal Alignment

OBJECTIVES

Hallux valgus (HV) is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected. The relationship between the dome height of the first metatarsal head and the HV deformity has not been studied previously. This study aimed to investigate a possible relation of the dome height of the first metatarsal head with articular alignment and the hallux valgus angle (HVA), which is frequently used to evaluate HV.

METHODS

A total of 129 feet of 68 patients were included in the study. Anteroposterior digital radiographic images of the foot taken in a weightbearing, standing position were used to assess the HVA, dome height, and shape of the first metatarsal head and the alignment of the MTP joint. The dome height of the first metatarsal head is the vertical distance from the base to the highest point of the articular surface doming. The alignment was categorized into three groups: aligned, deviated, and subluxated. Patients were assigned into three groups based on the HVA: Normal, Mild HV and Moderate HV.

RESULTS

A statistically significant, positive correlation was found between the HVA and the dome height of the first metatarsal head (r = 0.293, P = 0.001 and P < 0.05). The dome height was significantly lower in the patients with a normal HVA than those with a high HVA (P1 = 0.042, P2 = 0.039 and P < 0.05, respectively). The dome height of the first metatarsal head was found significantly higher in feet with subluxation, compared to feet aligned and deviated (P1 = 0.001; P2 = 0.0089 and P < 0.05, respectively).

CONCLUSIONS

Our study results suggest that HV deformity may be related to an increased dome height and the measurement of the dome height of the first metatarsal head might be used to evaluate an anatomic tendency toward HV development.

Double First Metatarsal and Akin Osteotomy for Severe Hallux Valgus

BACKGROUND

The technique of double first metatarsal osteotomies was first developed in response to the high frequency of recurrence noted in the treatment of severe adolescent congruent hallux valgus deformities. The concept behind the use of this technique is that it allows the individual correction of each component of the deformity. We have modified the technique for use in adult hallux valgus where the majority of deformities are incongruent deformities and the distal chevron osteotomy is used primarily for its additional translational properties rather than purely to correct the distal metatarsal articular angle (DMAA). We report on a series of double first metatarsal osteotomies (basal opening wedge and distal chevron osteotomy) with Akin osteotomy in the treatment of moderate to severe adult hallux valgus deformity.

METHODS

All patients presenting to our institution with a hallux valgus deformity and treated with this procedure between 2008 and 2013 with a minimum of 1 year of follow-up were identified. Data were obtained through review of case notes, electronic charts, and digital imaging. A total of 50 feet in 48 patients underwent double first metatarsal osteotomy with Akin osteotomy. Three patients were excluded due to loss to follow-up, leaving 47 feet in 45 patients with a mean follow-up of 45 months (range, 14-60 months). Of these 43 (96%) were female and the mean age was 56 years (range, 35-70 years).

RESULTS

The mean preoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, sesamoid position, and lateral first metatarsotalar angle were 42 degrees (range, 32-52 degrees), 18 degrees (range, 6-26 degrees), 12 degrees (range, 4-26 degrees), stage 6 (range, 4-7), and 2 degrees of dorsiflexion (range, 20 degrees of dorsiflexion to 4 degrees of plantar flexion), respectively. The mean postoperative HVA, IMA, DMAA, sesamoid position, and lateral first metatarsotalar angle were 7 degrees (range, 2 to 24 degrees), 4 degrees (range, 4-14 degrees), 6 degrees (range, 10-22 degrees), stage 2 (range, 1-5) and 6 degrees of plantar flexion (range, 8 degrees of dorsiflexion to 18 degrees of plantar flexion), respectively. The osteotomies consolidated at a mean of 7 weeks (range, 5-9 weeks). There were no cases of delayed union or nonunion. Of the cohort, 45 (96%) stated that they were satisfied overall with the results of their surgery and would have it again. The mean postoperative summary index Manchester-Oxford Foot Questionnaire (MOXFQ) score was 12.9 (range, 0-60.9) out of 100 at a mean follow-up of 45 months (range, 14-60 months). For the minority of cases, 8 (17%), that had preoperative scoring, the summary index MOXFQ score was 73.7 (range, 29.7-100).

CONCLUSIONS

The double first metatarsal osteotomy (basal opening wedge and distal chevron osteotomy) with Akin osteotomy provides powerful correction and facilitates correction of the individual components of the hallux valgus deformity. The individual osteotomies that make up this procedure are familiar to the majority of foot and ankle surgeons, thus limiting the associated learning curve.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The modified Lapidus fusion

Due to its proximal correction site and long lever arm, the Lapidus fusion, modified or not, is a powerful technique to correct hallux valgus deformities. The disadvantages are a high complication rate and a long postoperative rehabilitation period. It is only performed in 5% to 10% of all hallux valgus deformity corrections but remains, however, an important procedure, especially in moderate to severe deformities with intermetatarsal angles more than 14°, hypermobility of the first ray, arthritis of the first tarsometatarsal joint, and recurrent deformities. This article provides an overview of the procedure with special focus on the surgical technique.

First metatarsal head osteotomies for the correction of hallux abducto valgus

An array of distal first metatarsal osteotomies has been described over the decades for the correction of hallux valgus. No one procedure is proficient in correcting all forms and severities of hallux valgus deformities. To optimize results, it is imperative for the surgeon to match a procedure and its modifications to the patient's deformity. The dorsal long arm chevron osteotomy stands at the forefront for correction of mild to moderate hallux abductovalgus. The results with this specific osteotomy are predictable; it allows for early ambulation, and it is easily modified to compensate for the deformity at hand.

The arthroscopic Lapidus procedure

BACKGROUND

Hypermobility of the first metatarsocuneiform (MC) joint is one of the causes believed to contribute to symptomatic hallux valgus. An arthrodesis of the first MC joint offers definitive correction of the intermetatarsal angle. This procedure can be associated with pseudoarthrosis and shortening of the first ray. This study presents our experience and results with an arthroscopic technique for performing this arthrodesis.

MATERIALS AND METHODS

Five patients with severe hallux valgus associated with hypermobility of the first MC joint were treated with this operation.

RESULTS

The functional assessment scales revealed very good results. Radiographic evaluation confirmed fusion in all the patients. The hallux valgus angle improved by 25.6°, the intermetatarsal angle improved by 10.6°. The shortening of the first ray was limited to 2.7 mm.

CONCLUSION

This new technique is a valid option for performing an arthrodesis of the MC joint.

A geometric analysis of hallux valgus: correlation with clinical assessment of severity

Background

Application of plane geometry to the study of bunion deformity may represent an interesting and novel approach in the research field of hallux valgus. For the purpose of contributing to development of a different perspective in the assessment of hallux valgus, this study was conducted with three objectives: a) to determine the position on the intersection point of the perpendicular bisectors of the longitudinal axes of the first metatarsal and proximal phalanx (IP), b) to correlate the location of this point with hallux valgus deformity according to angular measurements and according to visual assessment of the severity carried out by three independent observers, and c) to assess whether this IP correlated with the radius of the first metatarsophalangeal arc circumference.

Methods

Measurements evaluated were intermetatarsal angle (IMA), hallux valgus angle (HVA), and proximal phalangeal articular angle (PPAA). The Autocad^® program computed the location of the IP inside or outside of the foot. Three independent observers rated the severity of hallux valgus in photographs using a 100-mm visual analogue scale (VAS).

Results

Measurements of all angles except PPAA showed significantly lower values when the IP was located out of the foot more distantly and vice versa, significantly higher values for severe deformities in which the IP was found inside the foot (p < 0.001). The IP correlated significantly with VAS scores and with the length of the radius of the circle that included the first metatarsophalangeal arc circumference (p < 0.001)

Conclusion

The IP is a useful indicator of hallux valgus deformity because correlated significantly with IMA and HVA measurements, VAS scores obtained by visual inspection of the degree of deformity, and location of the center of the first metatarsophalangeal arc circumference.

The first metatarsophalangeal arc circumference: correlation with angular measurements

BACKGROUND

The contribution of the different anatomical aspects represented by individual angles to the overall hallux valgus deformity has not been previously examined, and data on the interrelationship of angular measurements are lacking. The objectives of this study were to determine the center of the circle formed by the first metatarsophalangeal arc circumference and to correlate the location of the center with the hallux valgus angle (HVA), the intermetatarsal angle (IMA), the distal metatarsal articular angle (DMAA), and the proximal phalangeal articular angle (PPAA) measurements.

METHODS

A total of 1933 dorsoplantar weightbearing radiographs of the foot from 1182 patients were analyzed. Measurements evaluated were the IMA, HVA, DMAA, and PPAA. All measurements were performed using a computer program. The arc was defined by the midpoint of the curvature of the medial metaphyseal flare of the hallux proximal phalanx and the proximal and distal metadiaphyseal junctions of the medial border of the hallux. By means of the computer program, the circle's center location was calculated and then outlined according to its position inside or outside of the foot.

RESULTS

The smaller the HVA, the larger the circle and the distance between the foot and the center, and vice versa. Similar findings were observed for the DMAA and IMA. Severe hallux valgus deformities (HVA of more than 40 degrees) were associated with location of the center inside the foot. The long radius of the circle was significantly correlated with the HVA values (p < 0.001).

CONCLUSIONS

This new approach offers the possibility of summarizing in a single point the correlation of different angular measurements.

The distal metatarsal osteotomy for the treatment of hallux valgus

This article discusses various forms of distal metatarsal osteotomy for the treatment of hallux valgus. The techniques for the various osteotomies have evolved over the years to allow the surgeon to match a procedure and its modifications to the individual patient's deformity, thus optimizing outcomes. Fixation techniques continue to evolve, and meticulous surgical technique to prevent complications remains a must. Regardless of the osteotomy used, the authors believe that adherence to the techniques laid out in current literature will provide gratifying results for the surgeon and the patient.