Comparison of Radiographic and Clinical Results After Extended Distal Chevron Osteotomy With Distal Soft Tissue Release With Moderate Versus Severe Hallux Valgus

Radiographic and Clinical Results of Minimally Invasive Chevron Akin Osteotomy for Moderate to Severe Hallux Valgus Deformities

BACKGROUND

Few studies have reported results of minimally invasive chevron Akin osteotomy (MICA) for moderate to severe hallux valgus correction. This study aims to evaluate MICA for moderate to severe hallux valgus radiographically and clinically.

METHODS

Forty feet were prospectively reviewed. Twenty-eight feet (70%) had a severe deformity (hallux valgus angle (HVA) ≥40° and/or first intermetatarsal angle (IMA) ≥18°). We measured HVA, IMA, lateral shape of the metatarsal head (round sign), tibial sesamoid position, first metatarsal shortening on anteroposterior weightbearing radiographs, and inclination angle of first metatarsal on lateral weightbearing radiographs. We evaluated the Japanese Society for Surgery of the Foot hallux scale and Self-Administered Foot Evaluation Questionnaire responses preoperatively and at the most recent follow-up.

RESULTS

All measurements except shortening and inclination angle improved significantly. Both clinical scale and all subscores significantly improved.

CONCLUSIONS

MICA improved moderate to severe hallux valgus both radiographically and clinically.Level of Evidence: Level IV: case series.

Immediate effect of hallux valgus surgery on the biomechanical behavior of the first ray

BACKGROUND

The surgical treatment of hallux valgus (HV) deformity has been the subject of countless publications but few focus on the altered windlass mechanism or analyze the biomechanical behavior immediately after surgery.

METHODS

Patients treated for HV between January and March 2023 were included. The surgery consisted of a L-reverse first metatarsal osteotomy. To analyze the windlass mechanism we record two different measurements; the isolated first metatarsophalangeal joint (MTPJ) dorsiflexion angle (IDA) and dynamic plantarization of the first metatarsal head when performing first MTPJ dorsiflexion imprinting a mark on a modeling foam.

RESULTS

A total of 30 patients diagnosed with symptomatic HV were included. In all patients, a change in the IDA angle was evident, being overall statistically significant. About modeling foam imprinted mark, all measurements, in all planes of space, had a clear tendency to increase, which turned out to be statistically significant (p < 0.001).

CONCLUSIONS

An altered windlass mechanism may be successfully recovered immediately after hallux valgus deformity surgery. This could be evinced by an indirect measurement analyzing the imprint of the head of the first metatarsal in a modeling foam and the IDA.

LEVELS OF EVIDENCE II

None.

Comparison of the outcomes of first metatarsophalangeal joint arthrodesis by locking plate and compression screw in patients with severe hallux valgus or hallux valgus revision

INTRODUCTION

Arthrodesis of the first metatarsophalangeal joint (MTP1) is indicated for hallux rigidus, septic arthritis, severe hallux valgus (HV) or HV revision. Few studies have compared the functional and radiographic outcomes between indications. The goal of this study was to compare the results of MTP1 arthrodesis in patients with severe HV or HV revision at 6 months postoperative. The hypothesis was that there are no differences in the fusion rate, functional scores and radiological correction between the two groups.

MATERIALS AND METHODS

This was a retrospective, observational, single-center study conducted between January 1, 2018 and July 31, 2021. The inclusion criteria were patients treated for severe HV or HV revision by MTP1 arthrodesis with a compression screw and locking plate who were at least 18 years of age. The exclusion criteria were a history of septic arthritis of MTP1 without prior HV surgery, primary hallux rigidus, rheumatoid arthritis, incomplete medical record. The functional outcomes consisted of the Foot Function Index (FFi-f) and the European Foot and Ankle Society (EFAS) score. Radiographs were made to evaluate preoperative and postoperative deformity, the correction and the fusion rate. These outcomes were compared between two groups: severe HV and HV revision.

RESULTS

An analysis was done of 58 cases of MTP1 arthrodesis: 45 severe HV and 13 HV revisions. The mean patient age was 66 years, and the mean follow-up was 15.7 months. There were no significant differences between the two groups in the postoperative functional scores: EFAS (p = 0.85) and FFI-f (p = 0.14). At the final review, there were no significant differences between the two groups in the foot angle measurements (hallux valgus angle, p = 0.08 and intermetatarsal angle, p = 0.15) and fusion rate (p = 0.89) with a 93% fusion rate in patients with severe HV and 92% in patients with HV revision.

CONCLUSION

Given the good radiographic and functional outcomes, MTP1 arthrodesis by locking plate and compression screw is indicated as a first line surgical treatment for patients with severe HV or for patients undergoing HV revision. There is no evidence of a significant difference in the functional scores, fusion rate and radiographic correction between these two indications.

LEVEL OF PROOF

IV; retrospective case series.

Proximal Supination Osteotomy for Hallux Valgus: Comparison of Clinical and Radiologic Outcomes for the Most Severe Deformities

BACKGROUND

There is little available information regarding the difference in outcomes between severe hallux valgus (S-HV), defined as 40 degrees ≤ hallux valgus angle (HVA) < 50 degrees, and what we consider to be "super-severe HV" (SS-HV), defined as >50 degrees, following a proximal metatarsal osteotomy. We aimed to retrospectively compare the outcomes of a proximal metatarsal osteotomy in S- and SS-HV.

METHODS

The series consisted of 57 female patients (57 feet) treated with a proximal supination osteotomy for symptomatic S- and SS-HV (33 and 24 feet, respectively). The outcome measures included radiographic parameters and for 45 patients included the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) score, and a visual analog scale pain score (VAS-PS) preoperatively and at a minimum follow-up of 12 months with a median of 26 months. No significant differences were found in age, body mass index, and the duration of follow-up between patients with S-HV and SS-HV (P > .10 for all comparisons) with the numbers available.

RESULTS

Preoperative HVA in patients with S- and SS-HV was significantly improved at the final follow-up (P < .0001 for both comparisons). No significant differences in postoperative HVA and IMA were observed between patients with S- and SS-HV (P = .51 and .50, respectively). All 5 preoperative subscale scores of SAFE-Q in patients with S- and SS-HV significantly improved postoperatively (P < .01 for all comparisons). Preoperative VAS-PS in patients with S- and SS-HV significantly improved postoperatively (P < .0001 and <.009, respectively). There were no significant differences in preoperative and postoperative scores of all the SAFE-Q subscales and VAS-PS between patients with S-HV and SS-HV (P > .10 for all) with the numbers available.

CONCLUSION

We found for this patient group that a proximal supination osteotomy can achieve a large correction for SS-HV as well as S-HV and significantly improve radiologic and clinical outcomes in SS-HV. The outcomes between patients with S- and SS-HV were not different in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Minimally Invasive Transverse Distal Metatarsal Osteotomy (MITO) for Hallux Valgus Correction: Early Outcomes of Mild to Moderate vs Severe Deformities

BACKGROUND

We compared the radiological and clinical outcomes of mild to moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon.

METHODS

Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) >40 degrees or preoperative first-to-second intermetatarsal angle (1-2 IMA) >16 degrees; the mild to moderate group was defined as having an HVA <40 degrees and a 1-2 IMA <16 degrees. Pre- and postoperative measurements of the HVA, 1-2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The visual analog scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 physical component summary were used to assess clinical outcomes.

RESULTS

A total of 116 feet were included in this study and median follow-up period of 29.0 months (range, 24-52 months). Both groups showed significant improvements in all radiologic parameters postoperatively, with the degrees of correction greater in the severe group than in the mild to moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups.

CONCLUSION

This study showed that short-term radiographic results for patients with either mild to moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. In this series, we found MITO with screw fixation to be a satisfactory surgical option for patients with mild to severe HV deformities.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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.

Short- and long-term results for severe hallux valgus correction using a first metatarsal distal osteotomy

PURPOSE

The purpose of this study is to analyze the short- and long-term results of severe hallux valgus (HV) treated with a L-Reverse osteotomy.

METHODS

Patients treated with L-Reverse osteotomy for severe HV between the years 2006-2015 were included. Patients were evaluated preoperatively, at 3 months and 4 or more years postoperatively. Changes in the HV angle (HVA) and intermetatarsal angle (IMA) were measured. Clinical outcomes were assessed using the AOFAS score.

RESULTS

28 patients were included. Pre-operative IMA changed from 18.1° (18-18.9°) to 7° (6.3-8.5°), and HVA from 38.5° (34.5-41.3°) to 10.0° (8.4-11.8°) at 3 month follow up (p < 0.005). Long term follow up was of 5.6 (4.9-6.4) years. IMA value was 7.5° (6.1°-8.1°) and HVA was 10.1° (6.7°-16.3°), with no statistical difference with initial correction (p = 0.14). Median AOFAS score was 92.7 (89-4-96.1).

CONCLUSION

L-Reverse osteotomy can achieve correction of HV severe deformities with good outcomes in long term follow up.

LEVEL OF EVIDENCE

III.

Extended Distal Chevron Osteotomy and Akin Osteotomy Using Bioabsorbable Materials for Treatment of Moderate to Severe Hallux Valgus

The purpose of this study was to investigate the suitability of bioabsorbable materials for fixation of extended distal chevron osteotomy and Akin osteotomy for the treatment of moderate to severe hallux valgus. We performed a retrospective analysis of extended distal chevron osteotomy and Akin osteotomy for the treatment of moderate to severe hallux valgus (33 patients, 42 feet). Fixation of extended distal chevron osteotomy and Akin osteotomy was performed using poly-l-lactic acid pins and polylactic acid/polyglycolic acid copolymer sutures, respectively. The radiological outcomes were evaluated based on the preoperative and 3-year follow-up intermetatarsal angle, hallux valgus angle, and hallux interphalangeal angle. The clinical results were assessed according to 3-year follow-up Manchester-Oxford Foot Questionnaire scores, patient satisfaction, and postoperative complications. All radiological and clinical results were compared with those of a control group treated with metallic implants. The mean 3-year follow-up intermetatarsal angle, hallux valgus angle, and hallux interphalangeal angle were significantly corrected from the preoperative values (all p < .001). The mean 3-year follow-up Manchester-Oxford Foot Questionnaire scores score was significantly improved from the preoperative values (p < .001). Regarding patient satisfaction, 88.1% of the patients reported good to excellent results. A total of seven complications were reported. All radiological and clinical results were comparable with those of control group treated with metallic implant. Based on these results, we recommend using bioabsorbable materials as another reliable device for fixation of extended distal chevron osteotomy and Akin osteotomy even for the treatment of moderate to severe hallux valgus.

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.

Outcomes of Simultaneous Bilateral vs Unilateral Distal Chevron Metatarsal Osteotomy in Hallux Valgus Patients Aged ≥60 Years

BACKGROUND

The purpose of this study was to compare radiographic outcomes of simultaneous bilateral and unilateral distal chevron metatarsal osteotomy (DCMO) in hallux valgus patients aged ≥60 years.

METHODS

This retrospective study analyzed consecutive outcomes of simultaneous bilateral DCMO and unilateral DCMO performed between June 2010 and August 2018 in 90 feet of 60 patients. Thirty patients underwent simultaneous bilateral DCMO, and 30 underwent unilateral DCMO. Comparative analysis of radiographic and clinical parameters between a simultaneous bilateral DCMO group (SB) and a unilateral DCMO group (U) was performed.

RESULTS

Mean age at surgery (65.7±4.8 vs 65.2±5.2 years), mean length of follow-up period (20.0 vs 18.6 months), and preoperative radiographic parameters were similar between the 2 groups (SB vs U). Mean hallux valgus angle (HVA) improved from 34.2 to 5.4 degrees (correction angle SB 28.8 vs U 28.8 degrees). Mean first-to-second intermetatarsal angle improved from 15.8 to 6.8 degrees (correction angle SB 8.9 vs U 8.9 degrees). Hallux varus deformity was observed in 4 feet (SB 3 vs U 1), and mechanical instability with callus formation in 1 foot in the unilateral group.

CONCLUSION

DCMOs in patients aged ≥60 years were radiographically effective and safe, even performed in one stage bilaterally. Radiographic parameters were similar in patients who underwent simultaneous bilateral and unilateral DCMO.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Distal chevron metatarsal osteotomy is a viable treatment option for hallux valgus with metatarsus adductus-multicentre retrospective study

PURPOSE

The purpose of this study was to evaluate the radiographic and clinical outcomes of patients with hallux valgus (HV) with concomitant metatarsus adductus (MA) treated with distal chevron metatarsal osteotomy (DCMO), without any procedure for the second or third metatarsal.

METHODS

A multicentre retrospective study involving four hospitals was conducted. A total of 45 feet from 38 patients who had received DCMO for HV with MA with at least one year post-operative follow-up were analysed. HV angle (HVâ), inter-metatarsal angle (IMâ), MA angle (MAâ), and the lateral sesamoid grade were measured. Foot function index (FFI) and visual analogue scale (VAS) were recorded. Patients were divided into mild (18° ≤ MAâ < 20°) and moderate (20° ≤ MAâ) MA groups, and results were compared.

RESULTS

The mean HVâ and IMâ improved significantly from 35.1° and 14.4° pre-operatively to 10.6° and 7.1° one year post-operatively (p < 0.001). There were no differences in pre-operative HVâ, IMâ, or the sesamoid grade, and also no difference in post-operative HVâ or the sesamoid grade between mild and moderate MA groups. Only the mean post-operative IMâ showed a difference between the two groups (8.3° vs. 6.3°; p = 0.019). All clauses of FFI and VAS improved significantly (p < 0.001). When the extent of improvement was compared between the two groups, there were no significant differences in any category (p > 0.05). The total rate of recurrence (HVâ ≥ 20°) was 11.1% (5/45), and although the moderate group (4/29, 13.8%) had a higher proportion than the mild group (1/16, 6.3%), this was not statistically significant (p = 0.641).

CONCLUSION

DCMO for patients with HV with MA had satisfactory radiographic and clinical outcomes with minimal recurrence. Except in cases of severe combined deformity, we recommend performing DCMO alone without any additional procedure or manipulation of the other metatarsals as a viable treatment option.

Distal Chevron Osteotomy Increases Anatomic Intermetatarsal Angle in Hallux Valgus

Background:

Distal chevron metatarsal osteotomy (DCO) is a common technique to address hallux valgus (HV), which involves coronal translation of the capital fragment resulting in a nonanatomic first metatarsal. The purpose of this study was to evaluate the radiographic effect of the DCO on the anatomic vs the mechanical axis of the first metatarsal. Our hypothesis was that patients undergoing DCO would have improvement in the mechanical metatarsal axis but worsening of the anatomic axis.

Methods:

This was a retrospective case series of consecutive patients who underwent DCO for HV. The primary outcomes were the change in anatomic first–second intermetatarsal angle (a1-2IMA) vs mechanical first–second intermetatarsal angle (m1-2IMA). Secondary outcomes included the change in hallux valgus angle (HVA) and medial sesamoid position.

Results:

40 feet were analyzed with a mean follow-up of 21.2 weeks. The a1-2IMA increased significantly (mean, 4.1 degrees) whereas the m1-2IMA decreased significantly (mean, 4.6 degrees) following DCO. There was a significant improvement in HVA (mean, 12.5 degrees). Medial sesamoid position was improved in 21 feet (52.5%). Patients with no improvement in sesamoid position were found to have a larger increase in a1-2IMA (mean, 4.7 vs 3.5 degrees, P = .03) and less improvement in m1-2IMA (mean, 3.8 vs 5.2 degrees, P = .02) compared to patients with improvement in sesamoid position.

Conclusion:

Distal chevron osteotomy for HV was associated with worsening of the anatomic axis of the first metatarsal despite improvements in the mechanical metatarsal axis, HVA, and medial sesamoid position. Greater worsening of the anatomic axis was associated with less improvement of sesamoid position. Our findings may suggest the presence of intermetatarsal instability, which could limit the power of DCO in HV correction for more severe deformities and provide a mechanism for HV recurrence.

Level of Evidence:

Level IV, retrospective case series.