Comparison of Postoperative Height Changes of the Second Metatarsal Among 3 Osteotomy Methods for Hallux Valgus Deformity Correction

Comparison of triplanar chevron osteotomy with chevron osteotomy in hallux valgus treatment for the prevention of transfer metatarsalgia

Hallux valgus (HV) is often accompanied by metatarsalgia. This study compared the radiological and clinical outcomes of new triplanar chevron osteotomy (TCO) and chevron osteotomy (CO) in the treatment of HV, especially for patients with plantar callosities and metatarsalgia. In this retrospective analysis, 90 patients (45 patients per group) with mild to moderate HV and plantar callosities were treated with TCO and CO from July 2020 to January 2022. In both procedures, the apex was located in the center of the head of the first metatarsal bone, and the CO was oriented towards the fourth MTPJ at a 60° angle. Plantar-oblique chevron osteotomy was defined as chevron osteotomy and a 20° plantar tilt; TCO was defined as plantar-oblique chevron osteotomy-based metatarsal osteotomy with a 10° tilt towards the metatarsal head. Primary outcome measures included preoperative and postoperative hallux valgus angle, 1 to 2 intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal length (FML), and second metatarsal head height X-ray images; clinical measurements, including visual analogue scale and American Orthopaedic Foot & Ankle Society (AOFAS) scores; changes in callosity grade and area; and changes in the number of people with metatarsalgia. Secondary outcomes included complications, recurrence rates, and cosmetic appearance. The hallux valgus angle, IMA, and DMAA were significantly lower after surgery (P  < .001) in all patients. In the TCO group, the mean FML and second metatarsal head height increased significantly postoperatively (P < .001). The AOFAS and visual analogue scale scores improved postoperatively in both groups (P < .001). All patients experienced satisfactory pain relief and acceptable cosmesis. The plantar callosity areas were smaller postoperatively in both the TCO and CO groups, but the change in the area (Δarea) in the TCO group significantly differed from that in the CO group (P < .001). The number of postoperative patients with metatarsalgia and the plantar callosity grade were both significantly lower in the TCO group than in the CO group after osteotomy (P < .05). TCO prevents dorsal shift of the metatarsal head and preserves and even increases FML, thereby preventing future metatarsalgia in patients. Therefore, compared with CO, TCO has better orthopedic outcomes and is an effective method for treating mild to moderate HV and preventing transfer metatarsalgia.

Radiographic factors associated with painful callosities after forefoot surgery in patients with rheumatoid arthritis

OBJECTIVES

Operative procedures for rheumatoid forefoot deformities have gradually changed from arthrodesis or resection arthroplasty to joint-preserving surgery. Although joint-preserving arthroplasty has yielded good outcomes, painful plantar callosities may occur post-operatively. This study aimed to reveal the radiographic factors associated with painful callosities after joint-preserving surgery for forefoot deformities in patients with rheumatoid arthritis (RA).

METHODS

We retrospectively evaluated 166 feet in 133 patients with RA who underwent forefoot joint-preserving arthroplasty, including proximal rotational closing-wedge osteotomies of the first metatarsal, between January 2012 and December 2015. Logistic regression analysis was performed with the objective variable set as the presence/absence of painful plantar callosities at the final observation and the explanatory variables set as several radiographic factors, including post-operative relative first metatarsal length (RML), amount of dorsal dislocation of the fifth metatarsal (5DD), and arc failure of the lesser toes.

RESULTS

At the final follow-up, 42 of the 166 feet (25.3%) had painful callosities under the metatarsal heads post-operatively. Logistic regression analysis showed that the RML, 5DD, and lesser toes' arc failure were significantly associated with painful callosities.

CONCLUSIONS

We identified that RML, 5DD, and arc failure of the lesser toes were associated with painful plantar callosities after the surgery.

Plantar pressure distribution in hallux valgus feet after a first metatarsal proximal crescentic osteotomy with a lesser metatarsal proximal shortening osteotomy

BACKGROUND

Plantar pressure distribution after the first metatarsal proximal crescentic osteotomy (FMPCO) with lesser metatarsal proximal shortening osteotomy (LMPSO) for hallux valgus with metatarsalgia has not been previously described.

METHODS

The pre- (Pre) and postoperative (Post) groups comprised of 18 patients who underwent unilateral FMPCO with LMPSO; fifteen healthy volunteers constituted the control (C) group. For each of the 10 regions, peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force-time integral (FTI) were measured.

RESULTS

The mean Peak-P of the second metatarsal head was significantly lower in the Post group than the Pre group. The mean Peak-P, Max-F, Con-T, and FTI were not significantly different between the Post and C groups. The mean Con-A was significantly lower in the Post group than the C group.

CONCLUSION

FMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.

A prospective study to compare the operative outcomes of minimally invasive proximal and distal chevron metatarsal osteotomy for moderate-to-severe hallux valgus deformity

PURPOSE

The effectiveness of minimally invasive surgery (MIS)-distal chevron metatarsal osteotomy (DCMO) for the correction of moderate-to-severe hallux valgus deformity is unclear. This study aimed to compare the radiographic and clinical outcomes of our novel MIS-proximal chevron metatarsal osteotomy (PCMO) with those of MIS-DCMO performed during the same timeframe.

METHODS

We prospectively compared the outcomes of patients who underwent MIS-PCMO (n = 20 patients; 22 cases) with those of patients who underwent MIS-DCMO (n = 23 patients; 26 cases) for moderate-to-severe hallux valgus deformity (hallux valgus angle [HVA] ≥ 30° and first-to-second intermetatarsal angle [IMA] ≥ 13°) between June 2017 and January 2019. The minimum follow-up duration for study inclusion was two years. The HVA, IMA, distal metatarsal articular angle (DMAA), relative length of the second metatarsal, medial sesamoid position, and Meary's angle to evaluate the degree of deformity correction and its maintenance were measured pre-operatively and at the final follow-up.

RESULTS

Compared with MIS-DCMO, MIS-PCMO resulted in significantly greater correction of the HVA (P < 0.001) and IMA (P = 0.01), along with Meary's angle improvement (P < 0.001); however, the DMAA worsened (P = 0 .01). Furthermore, a significantly greater change was found in the relative second metatarsal length in the MIS-DCMO group (P = 0.01). No significant between-group differences were noted in the correction of the medial sesamoid position (P = 0.445).

CONCLUSION

Compared with MIS-DCMO, MIS-PCMO can be a better option for correcting moderate-to-severe hallux valgus deformities. However, this technique should be applied carefully when the pre-operative DMAA is already large because the DMAA can become worse post-operatively.

The plantarward oblique Chevron osteotomy: an optional method to treat hallux valgus with painful plantar callosities

Hallux valgus (HV) is a foot deformity that can be treated with Chevron osteotomy, and a modified plantarward oblique osteotomy has been proposed in recent years. However, no research has focused on the correctional power of the osteotomy. The aim of this study was to examine the character of this plantarward oblique Chevron osteotomy (POCO) and to determine the rationale of this method.Radiographs and clinical data from 65 HV patients (77 feet) with painful callosities were evaluated. The intermetatarsal angle, hallux valgus angle, and relative height of the second metatarsal were measured, and a valid width of the first metatarsal was proposed. A visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society hallux-metatarsophalangeal interphalangeal scale (AOFAS) were used to evaluate the patients’ clinical results.There were significant differences in the HVA and IMA. The decline in the height of the second metatarsal was positively related to the decline in the height of the first metatarsal, but the changes were smaller for the first metatarsal. Painful callosities disappeared in 77 feet, 4 (5.1%) patients had no pain but a remaining plantar callosity, and 2 (2.6%) patient had relieved pain with a plantar callosity after follow-up. The VAS scores improved from 8.58 ± 0.50 to 1.96 ± 0.75 points after the operation (p < 0.001). Significant differences were demonstrated in the AOFAS scores (65.81 ± 4.05 vs 87.88 ± 3.41, p < 0.001). The modified POCO prevents the dorsal migration of the metatarsal head, preserves other lesser metatarsals and provides an opportunity for patients who may possibly need additional future deformity correction. Therefore, POCO is a safe and effective method to treat hallux valgus and offers the superior potential benefits of correction and transfer metatarsalgia.

Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity: Magnetic resonance imaging evaluation

BACKGROUND

The importance of preoperative evaluation of the position and degree of arthritic changes of the medial sesamoid bone before hallux valgus correction is emerging. This is an observational study to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in medial sesamoid-metatarsal (mSM) joints.

METHODS

We reviewed weight-bearing anteroposterior radiographs, forefoot axial radiographs and MR images of 514 feet of 405 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first metatarsophalangeal (MTP) and mSM joints were categorized into 5 classes. Binary logistic regression analysis was performed to identify the factors affecting the arthritic changes.

RESULTS

The binary logistic regression analysis showed that advanced age, more lateralized position of medial sesamoid bone on forefoot axial radiograph, and higher MRI grade of arthritic change of the 1st MTP joint were significant factors contributing to medial sesamoid arthritis (P<0.001, 0.001. 0.006, respectively).

CONCLUSIONS

Medial sesamoid arthritis can be assessed using MRI. The position of medial sesamoid bone on forefoot axial radiographs can strongly help predict the possibility of mSM joint arthritis.

LEVEL OF EVIDENCE

III, observational study.

Lateral hemiepiphysiodesis of the first metatarsal for juvenile hallux valgus

BACKGROUND

Juvenile hallux valgus (JHV) frequently results in an impaired quality of life because of pain and deformity. We used a validated clinical score to investigate the efficacy of lateral hemiepiphysiodesis of the first metatarsal base as a treatment for JHV.

METHODS

We conducted a prospective, nonrandomized, single center cohort study of children who underwent lateral hemiepiphysiodesis for 31-IV, with a clinical and radiologic follow-up of at least 2 years. The efficiency of the procedure was assessed with the Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), the metatarsophalangeal angle (MPA), and intermetatarsal angle (IMA).

RESULTS

Twelve patients (22 feet) with JHV were treated by lateral hemiepiphysiodesis between 2012 and 2015. Average age at surgery was 10 years, and average follow-up was 3.5 years. The average HMIS score increased from an average of 56 at baseline, to 92 at last follow-up ( p < 0.01). The average IMA decreased by 2°, from 13° preoperatively to 11° postoperatively. Average MPA decreased from 26° at baseline to 22° after surgery. No complications occurred in the immediate postoperative period, and no patient needed an additional procedure.

CONCLUSION

The HMIS score was significantly improved after lateral hemiepiphyslodesis, with a clear improvement in pain and functional impairment at last follow-up. We noted a stabilization of the IMA and MPA, but the radiologic benefit did not reach statistical significance. Our data support the use of lateral hemiepiphysiodesis as an effective and safe treatment of JHV.

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients' mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p = .179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p = .215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.