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The cause of Hallux valgus lies in the insufficiency of the intermetatarsal band between the 1st and 2nd metatarsal heads. The author believes that the reconstruction of the band provides a causal therapy. To this end, the proposed operation procedure shows, that in 91% of cases, there are from good to very good long lasting results.
The purpose of this study was to investigate radiographic measurements in a cohort of patients with juvenile hallux valgus (with a hallux valgus angle > 15 degrees ) using standardized weightbearing x-rays compared with an age-matched control group. First metatarsal protrusion distance, metatarsus primus adductus angle, metatarsus adductus, first metatarsal cuneiform angle, calcaneal inclination angle, and talocalcaneal angles were assessed with discriminant functional analysis. A total of 37 sets of data were analyzed from patients with a mean age of 13.45 +/- 1.75 years. The study identified 2 significant components of juvenile hallux valgus: a positive first metatarsal protrusion distance (P <.001) and metatarsal primus adductus angle (P = .002). Discriminant functional analysis was then used to determine the best predictors of juvenile hallux valgus. This analysis allowed only 1 variable, metatarsal protrusion distance, as a predictor of whether juvenile hallux valgus was present (P < .001), with 94.3% accuracy. This study showed that a positive metatarsal protrusion distance is a significant component of juvenile hallux valgus.
Surgical for adolescent hallux valgus (HV) was performed on 32 feet. Five feet (16%) required revision surgery, and technical errors accounted for recurrence in all five. Satisfaction was obtained in 70% of patients. According to a new bunion rating score, 59% of patients had good to excellent results. In a subgroup of patients treated with metatarsal osteotomy for metatarsus primus varus, the Mitchell osteotomy provided an excellent rating in 95% of patients. Surgery for adolescent HV provides satisfying results in most patients. The one factor most highly correlated with both decreased risk of recurrence of angular deformity and patient satisfaction was a reduction of the intermetatarsal (IM) angle.
Abnormalities in the hallux valgus foot and changes after surgery were investigated by measuring the distribuiion of load on the foot in walking. Hallux valgus was associated with reduced load imposed on the toes, and on the medial side of the forefoot, compared with a large sample of healthy feet. Abnormalities correlated with the degree of the deformity. Both Keller's operation and a wedge displacement osteotomy of the first metatarsal not only failed to restore normal loading but increased the abnormalities of loading seen preoperatively. A large decrease in the angle between first and second metatarsals as a result of surgery minimized this increase. A silastic arthroplasty did not carry high loads when used to treat hallux valgus, but near normal loads were imposed on it when used for hallux rigidus. Considerable variability was found in the loading distribution on the healthy feet. The distribution between first and second metatarsal heads was partially dependent upon their protrusions, relative to the direction of walking. The changes in the relationships between the loadings on the forefoot and skeletal shape in response to surgical operations are important for our understanding of treatment of the hallux valgus foot.
BACKGROUND: Although surgery for the treatment of hallux valgus is frequently performed, the exact rate of deep vein thrombosis following this procedure is unknown. We performed a single-center, prospective, phlebographically controlled study to quantify the rate of venous thrombosis following operative correction of hallux valgus. METHODS: Consecutive patients undergoing chevron bunionectomy for correction of hallux valgus deformity were enrolled in the study. Patients with clinical or hematological risk factors for venous thrombosis were excluded. One hundred patients with a mean age of 48.9 years were operated on and did not receive medical prophylaxis against thrombosis. All patients were assessed with phlebography at a mean of twenty-nine days postoperatively. RESULTS: Venous thrombosis was found in four patients (4%). The mean age of these patients (and standard deviation) was 61.7 +/- 6.1 years compared with a mean age of 48.4 +/- 13.9 years for the patients in whom thrombosis did not develop (p = 0.034). CONCLUSIONS: Patients are at a low risk for venous thrombosis following surgical treatment of hallux valgus. The need for prophylaxis against thrombosis should be calculated individually for each patient according to his or her known level of risk. Routine medical prophylaxis against thrombosis might be justified for patients over the age of sixty years.
BACKGROUND: One factor believed to contribute to the development of hallux valgus is an abnormality in collagen structure and makeup of the medial collateral ligament (MCL) of the first metatarsophalangeal joint (MTPJ). We hypothesized that the mechanical properties of the MCL in feet with hallux valgus are significantly different from those in normal feet and that these differences may be related to alterations in the type or distribution of collagen fibers at the interface between the MCL and the bone. MATERIALS AND METHODS: Seven normal fresh-frozen cadaver feet were compared to four cadaver feet that had hallux valgus deformities. The MCL mechanical properties, structure of collagen fibers, and content proportion of type I and type III collagen were determined. RESULTS: The load-deformation and stress-strain curves were curvilinear with three regions: laxity, toe, and linear regions. Laxity of the MCL in feet with hallux valgus was significantly larger than that of normal feet (p = 0.022). Stiffness and tensile modulus in the toe region in feet with hallux valgus were significantly smaller than those in normal feet (p = 0.004); however, stiffness and tensile modulus in the linear region were not significantly different. The MCL collagen fibrils in the feet with hallux valgus had a more wavy distribution than the fibrils in the normal feet. CONCLUSIONS: In general, strong staining for collagen III and to a lesser extent, collagen I was observed at the interface between the MCL and bone in the feet with hallux valgus but not in the normal feet. These results indicate that the abnormal mechanical properties of the MCL in feet with hallux valgus may be related to differences in the organization of collagen I and collagen III fibrils.
BACKGROUND: Surgical correction of hallux valgus deformities often results in decreased first metatarsophalangeal joint (MTPJ) range of motion. Loss of motion has been shown to affect patient satisfaction. The purpose of this study was to evaluate the immediate change in MTPJ range of motion that occurs after a distal soft-tissue reconstruction (DSTR) and proximal metatarsal osteotomy (PMO). METHODS: DSTR and PMO were done on 16 below-knee cadaver specimens with clinically apparent hallux valgus deformities. Two examiners assessed preoperative and postoperative dorsiflexion (DF), plantarflexion (PF), and the total range of motion of the first MTPJ. The hallux valgus angle (HVA) and 1-2 intermetatarsal angle (1-2 IMA) were measured on simulated weightbearing radiographs before and after operative correction. Changes in motion were analyzed and correlated with the angular measurements. RESULTS: The mean total range of motion preoperatively was 85.4 degrees (DF 70.5 degrees, PF 14.9 degrees) and significantly decreased (p < 0.005) 23.2 degrees to a postoperative value of 62.2 degrees (DF 47.9 degrees, PF 14.3 degrees). There was a significant (p < 0.005) decrease in DF (22.6 degrees) with the operative correction, but the loss of PF (0.6 degrees) was not significant (p = 0.7). There was no correlation between the magnitude of correction (HVA, 1-2 IMA) and the change in PF, DF, or total motion. CONCLUSIONS: Correction of a hallux valgus deformity with a DSTR and PMO is associated with an immediate loss of range of motion that primarily affects the DF arc of the first MTPJ. The selective loss of DF may be related to a nonisometric capsular repair or tight intrinsic musculature, although there was no correlation with the magnitude of angular correction. The immediate decrease in motion observed in this cadaver study underscores the importance of early postoperative joint mobilization to prevent long-term stiffness after bunion surgery.
The Mc Bride procedure for surgical treatment of the hallux valgus varies according to the different morphological features of the M. adductor hallucis. One hundred specimens of human adult feet-some with a hallux valgus deformity- were preserved in formaldehyde and examined under this aspect. The tendon of the M. adductor hallucis shows two heads-a caput transversum and a caput obliquum- and inserts at the basis as well as at the lateral sesamoid bone of the great toe. Morphological differences in type and place of confluence of both tendon heads give us a classification into 8 different types. In most cases the caput transversum inserted into the caput obliquum from the side and in the middle at the level of the lateral sesamoid bone of the great toe. In most cases, specimens with this muscle type showed a hallux valgus. In surgery of the hallux valgus deformity the tendon of the M. adductor hallucis should be detached from it insertion points in order to reduce the tension on the sesamoid bone and to prevent luxation. The insertion of the caput laterale of the M. flexor hallucis brevis at the lateral sesamoid bone should be left as it is.
BACKGROUND: The results of first metatarsophalangeal (MTP) joint arthrodesis as a specific treatment for failed hallux valgus correction has not been previously reported. We evaluated the results of first metatarsophalangeal (MTP) joint arthrodesis as a treatment for failed hallux valgus surgery. METHODS: The records of the senior author (MJC) were reviewed to identify patients treated for symptomatic failed hallux valgus procedures with arthrodesis of the first metatarsophalangeal joint over a 20-year period. Twenty-nine patients (33 feet) were available for followup examination. The patients completed a visual analog pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale, and a patient satisfaction scale at the final followup. Radiographs were obtained of both feet. RESULTS: The average followup was 8 (1 to 22) years. The average pain score improved from 7 to 3 points. The mean AOFAS score was 73 points at followup. Patient satisfaction was excellent for 13 feet (39%), good in 11 (33%), fair in eight (24%), and poor in one (3%). The mean hallux valgus angle was 16 degrees, with an intermetatarsal angle of 8 degrees. There were three asymptomatic and one symptomatic nonunions. Twenty-two feet (67%) had corrective procedures performed on the lesser toes at the time of the first MTP joint arthrodesis. CONCLUSIONS: First MTP joint arthrodesis is a reliable option for revision after failure of surgical treatment of hallux valgus. This procedure can be used to treat a number of failure modes following initial hallux valgus surgery including recurrence, hallux varus, cock-up deformity, degenerative arthritis of the MTP joint, and associated transfer lesions beneath the lesser metatarsals. First MTP joint arthrodesis can be used after failed proximal and distal osteotomies, arthrodesis of the metatarsocuneiform joint, McBride procedure, exostectomy, and resection arthroplasty. Revision procedures have poorer clinical outcomes than successful primary hallux valgus procedures.
In an 11-year retrospective study of 45 patients (60 feet) with juvenile hallux valgus, a multiprocedural approach was used to surgically correct the deformity. A Chevron osteotomy or McBride procedure was used for mild deformities, a distal soft tissue procedure with proximal first metatarsal osteotomy was used for moderate and severe deformities with MTP subluxation, and a double osteotomy (extra-articular correction) was used for moderate and severe deformities with an increased distal metatarsal articular angle (DMAA). The average hallux valgus correction was 17.2 degrees and the average correction of the 1-2 intermetatarsal angle was 5.3 degrees. Good and excellent results were obtained in 92% of cases using a multiprocedural approach. Eighty-eight percent of patients were female and 40% of deformities occurred at age 10 or younger. Early onset was characterized by increased deformity and an increased DMAA. Maternal transmission was noted in 72% of patients. An increased distal metatarsal articular angle was noted in 48% of cases. With subluxation of the first MTP joint, the average DMAA was 7.9 degrees. With a congruent joint, the average DMAA was 15.3 degrees. In patients where hallux valgus occurred at age 10 or younger, the DMAA was increased. First metatarsal length was compared with second metatarsal length. While the incidence of a long first metatarsal was similar to that in the normal population (30%), the DMAA was 15.8 degrees for a long first metatarsal and 6.0 degrees for a short first metatarsal. An increased DMAA may be the defining characteristic of juvenile hallux valgus. The success of surgical correction of a juvenile hallux valgus deformity is intimately associated with the magnitude of the DMAA. Moderate and severe pes planus occurred in 17% of cases, which was no different than the incidence in the normal population. No recurrences occurred in the presence of pes planus. Pes planus was not thought to have an affect on occurrence or recurrence of deformity. Moderate and severe metatarsus adductus was noted in 22% of cases, a rate much higher than that in the normal population. The presence of metatarsus adductus did not affect the preoperative hallux valgus angle or the average surgical correction of the hallux valgus angle. Constricting footwear was noted by only 24% of patients as playing a role in the development of juvenile hallux valgus. There were six recurrences of the deformities and eight complications (six cases of postoperative hallux varus, one case of wire breakage, and one case of undercorrection).
An uncommon etiologic factor of hallux valgus was encountered in two patients. Crush injury and gunshot wound of the foot were associated with metatarsal bone fractures. malunion of the second metatarsal and malunion of an avulsed fracture at the base of the proximal phalanx of the big toe, resulted in a symptomatic hallux valgus deformity.
The development of painful degenerative hallux valgus in adult patients is commonly related to unrecognized or incompletely corrected foot conditions in the growing child or adolescent. A review of the anatomy, incidence, and etiology of the deformity is presented. Early treatment of juvenile hallux valgus and predisposing factors is advocated. Basic surgical criteria is outlined.
The purpose of this study was to determine the intraobserver and inter-observer reliability of physicians on a repetitive basis in making angular measurements of hallux valgus deformities. The hallux valgus angle, the 1-2 intermetatarsal angle, and the distal metatarsal articular angle and the assessment of congruency/subluxation of the first MTP joint were evaluated on a repetitive basis. Physicians were provided with a series of black and white photographs of radiographs with a hallux valgus deformity. Three different sets of photographs randomly ordered were sent at a minimum interval of six weeks to the participants. Participating physicians were extremely reliable in the measurement of the 1-2 metatarsal angle. 96.7% of the photographs were repeatedly measured within a range of 5 degrees or less. The angular measurements to determine the hallux valgus angle were slightly less reliable, but 86.2% of photos were repeatedly measured within a range of 5 degrees or less. In the measurement of the distal metatarsal articular angle, 58.9% of photographs were repeatedly measured within a range of 5 degrees or less. There was a wide range within physician evaluators who recognized very few congruent joints (2 of 21) and those who recognized several congruent joints (11 of 21). Most physicians appeared to be internally consistent in the assessment of MTP congruency; however, some photographs were much more difficult to assess than others. This study validates the reliability of the measurement of the hallux valgus and the 1-2 metatarsal angle. The interobserver reliability in the measurement of the distal metatarsal articular angle is questioned.
Osteotomies as a treatment for hallux valgus require careful preoperative planning and meticulous attention to surgical technique. The procedure selected should be tailored to fit the deformity. For a patient with mild hallux valgus, the chevron osteotomy is the most intrinsically stable of the distal osteotomies and has the least potential for complications. Interest in the Ludloff osteotomy has had a resurgence because of its improved stability compared with more traditional osteotomies for correction of metatarsus primus varus. This osteotomy, however, is less forgiving and more dependent on technique than other procedures. The proximal chevron osteotomy, with plantar-to-dorsal screw placement, is easier to perform than the Ludloff and provides excellent stability. Regardless of the osteotomy used, screw fixation has been shown to be mechanically superior to all other modes of fixation (K-wire, staples, or no fixation). Postoperatively, a hard-soled postoperative shoe that permits weight-bearing on the heel and lateral foot is recommended; however, for the more unstable osteotomies and for those performed in patients with poor bone quality, a period of non-weight-bearing should be considered. Future studies with cyclic loading may help modify these current postoperative restrictions.
OBJECTIVE: To assess the effects of a new foot-toe orthosis on painful hallux valgus. DESIGN: Uncontrolled intervention study. SETTING: An outpatient clinic in a tertiary medical center with an orthotic laboratory in Taiwan. PARTICIPANTS: Seventeen patients with painful hallux valgus. INTERVENTION: Application of a new total contact insole with fixed toe separator. MAIN OUTCOME MEASURES: The hallux valgus angle, an 11-point numeric rating scale (NRS-11) for pain assessment, and walking ability scale. RESULTS: The average hallux valgus angle reduction +/- standard deviation was 6.5 degrees +/-3.8 degrees after insole application (P<.001). An improvement on the NRS-11 pain scale from 4.06+/-2.8 to 0.88+/-1.17 (P<.001) was noted after immediate insole application and was.42+/-.67 (P=.002) 3 months later for the 12 patients who completed the study. The walking ability scale improved at least 1 grade or more after the insole was worn for 3 months (P=.002). All patients tolerated the insole well without any clinical evidence of skin ulcers or blisters. CONCLUSION: Our new total contact insole with fixed toe separator reduced pain, and improved walking ability and the hallux valgus angle. It is an effective alternative treatment for patients with painful hallux valgus.
The prevalence of hallux valgus and its relationship to the metatarsal angles have been assessed in South African males from two Black communities and one White community. After the age of 11 years there is a small increase in the metatarsal angle of White males, but this remains within the normal range. In comparison with White females, who seem to be predisposed to the disorder of hallux valgus, neither White nor Black males show a significant increase in hallux angles after adolescence. Males of all ages and race groups seldom develop clinical hallux valgus, and this apparent resistance to the deformity is associated with a minimal increase in the metatarsal angle, and therefore in the width of the foot.
Sixty-three feet in 44 patients with a hallux valgus, which had been operated on using a modified distal osteotomy were reviewed after a mean follow-up of 4.6 years. A modification of Mitchell's and Mommsen's osteotomies was used without any fixation material. The mean correction of the intermetatarsal angle was 2.6 degrees and of the hallux valgus angle 5.2 degrees. Good subjective result was achieved in 90% of the feet. In six (9.5%) cases the hallux valgus angle was worse after the operation. The method used seems to be too unreliable to be continued. Patient selection was found to be of great importance. Hallux valgus angle of more than 40 degrees was less suitable for this kind of operation.
Twenty-six patients with moderate-to-severe hallux valgus deformities were evaluated before and after treatment. All of the patients had incongruent great toe joints. The patients underwent modified proximal crescentic osteotomy, which was termed proximal oblique crescentic osteotomy. The results were evaluated at an average follow-up time of 55 weeks. Objective criteria were hallux valgus angle, intermetatarsal angle, shortening of the first metatarsal, and angulation at the osteotomy site. Clinical evaluation was made according to the rating system of the American Orthopaedic Foot and Ankle Society. The mean correction of the hallux valgus and intermetatarsal angles was 22.1 degrees and 9.9 degrees, respectively. Short-term results indicate that proximal oblique crescentic osteotomy is effective in the treatment of hallux valgus; its advantages over other procedures include its technical ease and low rate of complications.