Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: Hallux varus

A Novel Manipulation Technique for Lapidus Fusion in Correction of Hallux Valgus Deformity With Underlying Metatarsus Adductus: A Case Series

Underlying metatarsus adductus (MA) is commonly seen in patients with hallux valgus (HV) deformity, with implications regarding procedure selection and hallux valgus recurrence. Lapidus, or first tarsometatarsal fusion, is commonly performed allowing reduction in intermetatarsal angle (IMA) but this procedure has not been established as an approach to provide partial correction of MA deformity. Retrospective assessment of preoperative and postoperative metatarsus adductus angle (MAA), IMA and hallux abductus angle (HAA) in patients treated with Lapidus fusion for HV. Significance was determined via paired t test with a p value of <.05. All cases involved manual transverse plane manipulation to reduce both IMA and MAA during screw insertion. Intermetatarsal angle and Engel's angle were measured on preoperative AP radiographs to determine the presence of underlying MA in patients undergoing Lapidus fusion for HV. Ten weeks and 1 year postoperative radiographs were measured to determine degree of correction of IMA, HAA, and MAA. Thirty-four patients met inclusion criteria, which is approximately 46% of our sample population. The average preoperative IMA was 19.4˚ (range 12-32) and the average postoperative IMA was 9.7˚ (range 6-14). The average preoperative Engel's angle was 27.4˚ (range 24-34) and the average postoperative Engel's angle was 22.6˚ (range 15-28) with mean improvement in MA of 6.6˚. Of the 34, 27 (79.4%) patients had a normal Engel's angle at 10 weeks postoperatively. All measures of change met level of significance (p < .05). Of the 34 patients, 21 had radiographs taken beyond the 1 year mark (average 53 weeks). These patients were found to have an average Engel's angle of 23.0˚, which is not statistically significantly different from their 10 week measurements. Of the 21 patients, 17 (81%) maintained normal Engel's angle past 1 year. Metatarsus adductus varies regarding degree of reducibility and complicates preoperative angular measurement and correction of HV. Based on these findings, we recommend Lapidus fusion using this specified manipulation technique to obtain comprehensive transverse plane correction.

Minimally Invasive Hallux Interphalangeal Joint Arthrodesis for Hallux Varus in Pfeiffer Syndrome: A Case Report

Pfeiffer syndrome is a rare hereditary condition with an autosomal dominant transmission caused by a mutation that affects fibroblast growth factor receptors. It is one of the acrocephalosyndactyly diseases causing cranial malformations owing to early suture fusion. In the foot, it is typically associated with hallux varus, first ray hyperplasia, and partial lesser digit syndactyly. We report a clinical case of a 10-year-old patient with Pfeiffer type I syndrome with bilateral severe hallux varus due to a hypoplastic trapezoidal shaped proximal phalanx, a distal, medial-facing articular surface, and interphalangeal instability. This deformity was addressed by minimally invasive hallux interphalangeal joint arthrodesis with internal and external fixation. We report the results at the 2-year follow-up point.

Hallux Varus: An Underreported Presentation of Rheumatoid Arthritis

The prevalence of hallux varus deformity in rheumatoid arthritis (RA) has been reported to be extremely rare. However, in South Asian Countries, where open-toed shoes are habitual footwear for the majority of people, we have found that hallux varus is a common deformity in patients with RA. This rate of occurrence is much more common than that in published hallux deformities in RA and reinforces the impact of footwear on the development of hallux deformities. In this report, we present 3 illustrative cases of hallux varus developed in patients with RA and review the etiology of hallux varus deformity.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Study.

Gradual Correction of Traumatic Hallux Varus With Metatarsal Hemicallotasis

Traumatic hallux varus associated with osseous deformity, especially in the case of a decreased distal metatarsal articular angle, is an extremely challenging, but rewarding, deformity to treat. To the best of our knowledge, no previous reports have referred to surgical correction of traumatic hallux varus using first metatarsal hemicallotasis. We report the case of a 54-year-old male with traumatic hallux varus associated with medial subluxation of the second metatarsophalangeal joint and second metatarsocuneiform joint arthrosis. The patient was successfully treated with metatarsal hemicallotasis with medial soft tissue release, a proximal second metatarsal shortening osteotomy, and second metatarsocuneiform joint arthrodesis. After 1 year and 6 months, the correction had been maintained in a suitable position, no discomfort or pain was present, and the patient was completely satisfied with the surgical results. Metatarsal hemicallotasis can safely determine the angle of correction and minimize the risk of avascular necrosis of the metatarsal head even in deformed halluces with previous traumatic injuries and/or surgical treatment. This technique should be indicated only for hallux varus with a decreased distal metatarsal articular angle, an angular-type metatarsal head, and good metatarsophalangeal joint congruence.

Iatrogenic hallux varus treatment algorithm

Iatrogenic hallux varus is a relatively rare complication of corrective hallux valgus surgery that has multiple pathologic facets. It requires a comprehensive assessment that focuses on joint flexibility, joint integrity, soft tissue balance, and bony deformity. A step-wise treatment approach is used to address all elements of the deformity. The literature on hallux varus treatments consists mainly of retrospective case series, with several proposed procedures addressing various degrees of deformity. Comparison of these procedures is a challenging endeavor and each case should be considered on an individual basis.

Fixation of lapidus arthrodesis with a plantar interfragmentary screw and medial locking plate: a report of 88 cases

Lapidus arthrodesis is a powerful procedure that can be used to correct pathologic features within the forefoot or midfoot. Many different methods of fixation for this procedure have been reported. The use of plating constructs has been shown to provide increased stability compared with screw-only constructs. The technique we have described consists of a plantar to dorsal retrograde lag screw across the arthrodesis site, coupled with a low-profile medial locking plate. A total of 88 consecutive patients were treated with this modification of the Lapidus procedure by 2 surgeons and were retrospectively evaluated. All patients followed an early postoperative weightbearing protocol. Patient age, gender, follow-up duration, interval to weightbearing and radiographic fusion, preoperative and postoperative intermetatarsal angle, hardware removal, preoperative and postoperative American Orthopaedic Foot and Ankle Society midfoot scores, and adjunct procedures were analyzed. The mean follow-up period was 16.76 ± 5.9 (range 12 to 36) months, and all healed fusions demonstrated radiographic union at a mean of 51 ± 19.1 (range 40 to 89) days. The patients were treated with weightbearing starting a mean of 10.90 ± 4.1 (range 5 to 28) days postoperatively. Complications included 15 patients (17%) requiring hardware removal, 2 cases (2%) of hallux varus, 6 cases (7%) of radiographic recurrent hallux valgus, and 2 patients (2%) with first metatarsocuneiform nonunion. The results of the present study have demonstrated that plantar lag screw fixation with medial locking plate augmentation for Lapidus arthrodesis allows for early weightbearing with satisfactory outcomes, improved clinical and radiographic alignment, and improved American Orthopaedic Foot and Ankle Society scores.

Fixation of the Lapidus arthrodesis with a plantar interfragmentary screw and medial low profile locking plate

The Lapidus arthrodesis can be used to correct pathology within the forefoot or midfoot, and severe hallux valgus deformities as well as hypermobility of the medial column may be amenable to correction with this procedure. Many different skeletal fixation methods have been described for this procedure, and one form that appears to provide enough construct stability to allow patients to bear weight early in the postoperative period is described herein. This construct consists of an interfragmental compression screw oriented from the plantar aspect of the first metatarsal to the superior aspect of the medial cuneiform, with medial locking plate augmentation.

In-shoe Plantar Pressure Distribution in Nonneuropathic Type 2 Diabetic Patients in Singapore

BACKGROUND

We sought to establish the in-shoe plantar pressure distribution during normal level walking in type 2 diabetic patients of Chinese, Indian, and Malay descent without clinical evidence of peripheral neuropathy.

METHODS

Thirty-five patients with type 2 diabetes mellitus without loss of tactile sensation and foot deformities and 38 nondiabetic individuals in a control group had in-shoe plantar pressures collected. Maximum peak pressure and peak pressure-time integral of each foot were analyzed as separate variables and were masked into 13 areas. Differences in pressure variables were assessed by analysis of covariance, adjusting for relevant covariates at the 95% confidence interval.

RESULTS

No significant differences were noted in maximum peak pressures after adjusting for sex, race, age, height, and body mass. However, patients with diabetes mellitus had significantly higher mean ± SD pressure-time integrals at the right whole foot (309.50 ± 144.17 kPa versus 224.06 ± 141.70 kPa, P < .05) and first metatarsal (198.65 ± 138.27 kPa versus 121.54 ± 135.91 kPa, P < .05) masked areas than did those in the control group after adjustment.

CONCLUSIONS

Patients without clinical observable signs of foot deformity (implying absence of motor neuropathy) and sensory neuropathy had similar in-shoe maximum peak pressures as controls. This finding supported the notion that either component of neuropathy needs to be present before plantar pressures are elevated. Patients with diabetes mellitus demonstrated greater pressure-time integrals, implying that this variable might be the first clinical sign observable even before peripheral neuropathy could be tested.

Reverse distal chevron osteotomy to treat iatrogenic hallux varus after overcorrection of the intermetatarsal 1-2 angle: technique tip

Level of Evidence: V, Expert Opinion

Results of lapidus arthrodesis and locked plating with early weight bearing

In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.

Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus

Level of Evidence: V, Expert Opinion

Arthrodesis of the first metatarsocuneiform joint: a comparative study of fixation methods

BACKGROUND

The Lapidus bunionectomy is a popular procedure for severe bunion deformity where metatarsus primus varus is equal to or exceeds 15 degrees. We evaluated a new locking compression plate which may improve outcomes with the Lapidus procedure.

METHODS

Ten matched pairs of cadaver feet were used to compare the standard crossed 4.0-mm compression screw method of fixation to the LPS Lapidus plate. After performing the matched operations the cadaver constructs were stressed to failure using the INSTRON and Wavemaker software.

RESULTS

The LPS Lapidus plate load to failure was 108 Nm with a bending moment of 6.0 Nm. The crossed screw technique was inferior at 78 Nm with a bending moment of 4.4 Nm (p = 0.02)

CONCLUSION

Unlike other H-plates or locking plates, load to failure was higher with the Lapidus plate constructs.

CLINICAL RELEVANCE

The increased rigidity provided by these plates may help to minimize the risk of nonunion or malunion.

Hallux varus: classification and treatment

Appropriate treatment for hallux varus requires comprehensive radiographic and systematic clinical assessment to identify the involved factors. A classification scheme must incorporate many variables in order to determine the best approach to correcting the deformity. This article focuses on iatrogenic hallux varus following bunion surgery, but the same principles apply to other causes of acquired hallux varus.