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Authors describe a method of therapy of hallux valgus not yet published in this country. Its advantage is that as a consequence of the shortening of the proximal phalanx the tension of the soft tissues is decreased and as a final result the movement occurs between the original cartilaginous surfaces.
A retrospective clinical and radiological review of 51 patients (mean age 66 years) was performed to assess the outcome of excision arthroplasty for hallux valgus in an elderly population and to compare the results of the Keller, which is still used frequently in many centers in the United Kingdom, and modified Mayo operations. Although significant correction of the deformity was obtained with both procedures, this was incomplete and the mean residual hallux valgus angle was greater than 20 degrees. Lateral metatarsalgia was present in over 40% of patients. Both procedures provided good pain relief, and considerable narrowing of the forefoot was obtained with the modified Mayo operation. Excision arthroplasty in the elderly should be reserved for the low demand patient with symptomatic degenerative changes in the first MP joint in the absence of lateral metatarsalgia.
The authors present a prospective intraoperative evaluation of the articular wear pattern of the first metatarsal, tibial and fibular sesamoids, and base of the proximal phalanx of 166 feet undergoing hallux valgus surgery. The collected data were compared with various clinical parameters and radiographic measurements to determine if any of these variables can predict the incidence and location of articular erosion. The incidence and predictability of the location of the articular erosion increased significantly as the patient's age ( P = .000), intermetatarsal angle 1-2 ( P = .004), hallux abductus angle ( P = .000), tibial sesamoid position ( P = .016), and proximal articular set angle ( P = .02) increased. The association of foot type (ie, digital length pattern), metatarsal protrusion distance, metatarsal head shape, and hallux abductus interphalangeus was not significant. Therefore, preoperative clinical parameters (ie, age) and radiographic measurements (ie, intermetatarsal angle 1-2, hallux abductus angle, tibial sesamoid position, and proximal articular set angle) can directly define the incidence and location of articular erosion and are helpful in the preoperative assessment of the hallux valgus deformity. In addition, nearly every first metatarsophalangeal joint evaluated had some degree of articular erosion and, in certain circumstances (ie, advanced age and increased proximal articular set angle), it was universal and extensive.
Of 54 patients, we reviewed 26 with 28 operations for hallux valgus according to the Viladot-Regnauld technique. Follow-up was 18.7 (12-26) years. In 26 operations, the score according to Kitaoka and modified by Calder was excellent or good, and in two, fair. There were no complications. Average valgus angle correction was 15 degrees (8 degrees-29 degrees) and average intermetatarsal angle correction was 7 degrees (4 degrees-12 degrees). Sesamoids were medialised, on average, by at least 25% compared to the pre-operative situation. The results confirm the validity of this surgical procedure.
The purpose of the study was to compare the range of motion, perceived pain and plantar loading characteristics of the Chevron (Austin) corrective procedures in treating hallux valgus (HV) 12 months postsurgically. Twenty-five female participants with the diagnosis of mild to moderate HV deformity were studied. All participants had a distal metatarsal osteotomy (Chevron (Austin)) to correct their deformity. First metatarsophalangeal and talocrural joint range of motion (ROM) and a 10-point analog pain scale were measured presurgically and 12 months post-surgically on each participant. Radiographic measures of hallux valgus and intermetatarsal (IM) angles were taken preoperatively and six weeks postoperatively for comparison. Five pressure distribution measurements were recorded of barefoot walking using the EMED-SF presurgically and 12 months postsurgically. Statistical analyses revealed that plantar loading is still altered 12 months postsurgically despite a decrease in perceived pain and adequate first metatarsophalangeal joint ROM. Greater loading occurred in the central forefoot (CFF) region with decreases in some of the loading parameters in the medial toe (MT) region postsurgically. Loading parameters in the lateral forefoot (LFF), heel (HL), midfoot (MF), and lateral toe (LT) were unchanged 12 months postsurgery compared to presurgery.
An osteotomy of the first row for the treatment of hallux valgus is indicated for younger patients with minor to moderate valgus deformation and only minor arthritic changes in the first metatarsophalangeal joint. The osteotomy has two prominent goals: Correction of the deformity and restoration of muscle function and muscular balance. Especially the later seems to be essential for preventing failures in the long term. Osteotomies can be carried out on os cuneiforme mediale, metatarsal bone (proximal, shaft, subcapital) and phalanx. The cuneiforme osteotomy isn't recommended because of alterations in the joint between the medial and intermedium cuneiforme. Osteotomies of the proximal metatarsal bone are rarely performed and mostly combined with an arthroplastic procedure of the metatarsophalangeal joint. The disadvantage of a shaft osteotomy (Ludloff's osteotomy) is the long time for healing of the osteotomy of diaphysis of the metatarsal bone. Subcapital osteotomies are most frequently performed. With a subcapital osteotomy you can correct more deformities than with the other osteotomies. The phalangeal osteotomy is indicated just in special cases. The combination of a subcapital and a phalangeal osteotomy is recommended by Magerl in order to reduce the failure rates.
Although most patients who seek relief are adults, the problem of hallux valgus frequently begins at an earlier age. In the juvenile patient, except for congenital anomalies or inflammatory juvenile rheumatic disease, hallux abducto valgus appears to be related to the biochemical malfunction. It requires not only surgical management, but also the use of orthotics or surgical stabilization.
We evaluated the results of 33 feet in 23 patients who underwent a basilar crescentic osteotomy with a modified McBride procedure with a minimum 24-month follow-up. The average hallux valgus improved from 37.5 degrees to 13.8 degrees and the intermetatarsal 1-2 angle from 14.9 degrees to 4.7 degrees. The angle of declination of the first metatarsal was found to have dorsiflexed an average of 6.2 degrees. Unfortunately, osteotomies secured with staples dorsiflexed to a greater degree. Bilateral foot surgery produced results similar to those with unilateral procedures. Four of our patients developed a hallux varus (range 2-8 degrees); however, none were dissatisfied at the time of evaluation. Although this bunion procedure resulted in more prolonged swelling and pain than a distal osteotomy, it should be considered for more complex deformities to avoid the failure that a distal metatarsal osteotomy might produce given a high 1-2 intermetatarsal angle or a high hallux valgus angle.
In this article, the authors describe the indications, contraindications, surgical technique and its fixation considerations, postoperative care, results, and potential complications of the offset V and the traditional Z osteotomies. Because of its versatility, inherent stability, minimal first metatarsal shortening, good intermetatarsal reduction, and ease of rigid internal fixation, shaft osteotomies are gaining popularity as procedures for the correction of hallux valgus. Strong and stable internal fixation allows for earlier functional recovery and primary bone healing. Shaft osteotomies can provide predictable and rewarding results for the patient and surgeon for the correction of hallux valgus.
Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.
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This paper presents results of wedge subcapital osteotomy of the first metatarsal bone with lateral and plantar translation of the distal fragment in 47 feet (44 women age 37-72) operated for hallux valgus deformity. Bone fragments were stabilized with Kirschner wire introduced obliquely from lateral side of the head to the shaft. Protruding out of the skin part of the wire between I and II toe was shaped parallel to the lateral side of hallux preventing from valgisation. The mean AOFAS score improved from the preoperative value of 49 points to 86 points postoperatively. Hallux valgus angle improved from the mean preoperative value of 38 degrees to 17 degrees after operation. The mean postoperative AOFAS score in the group with major deformity (over 40 degrees valgity and 14 degrees intermetatarsal angle) was 76 points. Proposed method of stabilization allows limited activity without fear of correction loss during bone healing. Clinical and radiological results are similar to other authors' results, indicating that subcapital osteotomy gives satisfactory results in correction of medium grade deformity and disappointing results in severe deformities.
For most patients with hallux valgus, the problem is caused by wearing shoes that are too tight, and conservative measures can help. We review how primary care physicians can evaluate and treat this problem, and when to refer to an orthopaedic surgeon.
The Cedell procedure consists of: a proximal valgus osteotomy of the first metatarsal bone to correct the metatarsus primus varus, a soft tissue plasty at the first metatarsophalangeal joint with lateral release, and tightening of the medial capsule to correct the hallux valgus. A total of 45 operations in 31 patients (2 men and 29 women) were performed. Forty-one of these operations were followed. The average age at surgery was 24 years (range 16 to 43 years), and the average follow-up time was 23 months (range 8 to 56 months). The postoperative decrease in the intermetatarsal angle averaged 10 degrees, and the average decrease in the metatarsophalangeal angle was 26 degrees. Only a few postoperative complications were observed. At the time of follow up, 75% of the patients had no pain, 23% had only slight pain, and 2% had severe pain. Ninety-five percent were cosmetically satisfied with the operation. The Cedell operative technique has proved to be an effective procedure to correct the combined hallux valgus and metatarsus primus varus in younger patients.
The distal soft tissue procedure is the basis of surgical hallux valgus correction. It involves release of the transverse metatarsal ligament, adductor hallucis, and lateral joint capsule, which permits the proximal phalanx to be realigned on the metatarsal head. The attenuated medial capsule is plicated after the medial bony prominence has been excised. We describe a new endoscopic approach for the distal soft tissue procedure with better cosmetic results.
One hundred seventy-two patients who underwent surgical correction of hallux valgus deformity were evaluated. The procedures chosen were: first metatarsal osteotomy in 96, Keller procedure in 42, metatarsophalangeal arthrodesis in 25, and simple bunionectomy in 9. This study allowed the establishment of the following guidelines for surgery. 1) Osteotomy alone yields a satisfactory result in patients under the age of 50 years who have minimal osteoarthritis of the metatarsophalangeal joint. 2) The Keller procedure is suggested in patients over the age of 50 who have significant osteoarthritis. 3) Metatarsophalangeal fusion is suggested in patients under the age of 50 with significant osteoarthritis. 4) Simple bunionectomy revealed poor results in the majority of patients. It should be reserved for the elderly patient with an infected bunion.
The Mitchell's osteotomy is an established and successful operation for hallux valgus. We report a previously undescribed procedure comprising a step or 'Z' osteotomy that is a simplified version of the Mitchell's osteotomy which involves less extensive soft tissue dissection and avoids opening the first metatarsophalangeal (MTP) joint. In total, 51 operations in 40 patients were reviewed with a mean follow-up of 4.7 years. The results were compared with those reported by Mitchell in his paper of 1958, using the same criteria. The mean age was 24 years and 82% of patients were women. In 88% of patients the results were rated excellent or good and there were no serious complications. These results suggest that this procedure is as successful as the Mitchell osteotomy in young patients, and it may have long-term benefits.
The osteocartilaginous bone graft, conceived by Regnauld for surgical treatment of hallux valgus, is to-day widely known and practised. We have preferably employed the so called "inverted graft", while Regnauld, in his recent monography, defines it less satisfactory than the "cork" or "hat" shaped grafts. Therefore, we have observed the radiological evolution of our inverted grafts, to evaluate the possible differences of their "rootage" in comparison to the cork grafts, studied by Valenti in 1976. Some possible causes of the infrequent failures of this grafting are also examined and discussed. We conclude that the osteocartilaginous graft evolution do not show radiological differences referable to the graft morphology and that unfavourable evolution, when is present, concern at first the articular (cartilaginous) side of the graft, being independent of failed rootage or aseptic necrosis of the bony side.