Correctional osteotomy for metatarsus primus varus and hallux valgus.
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Adolescent↗
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The geriatric bunion: correction of metatarsus primus varus and hallux valgus with the Swanson total joint implant.
The authors have evaluated the long-term results of the Keller/Mayo bunionectomy with replacement of the first metatarsophalangeal joint with a Silastic double-stemmed implant (Swanson design). Examination of 50 preoperative and postoperative radiographs revealed a decrease in the hallux abductus angle of 21.46 +/- 2.66 degrees, and the intermetatarsal angle of 6.40 +/- 0.67 degrees; both of these figures have a statistically significant probability value of 0.05 attached. The mean patient age at time of surgery was 61.31 years; the mean follow-up time was 5.01 months. A literature review of implant arthroplasty for correction of hallux abducto valgus deformity is also presented.
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[Operative treatment of hallux valgus with varus of the first metatarsal (author's transl)].
In cases of hallux valgus tendon transfer combined with wedge osteotomy of metatarsus I yields good results. Considering the experience of 36 operated feet in 25 patients the operation can be recommended especially for young patients. An exact technique helps to avoid complications such as hallux varus and delayed ossification of the osteotomy.
Adolescent↗
Arthrodesis procedures for salvage of the hallux metatarsophalangeal joint.
First metatarsophalangeal (MTP) fusion has been recommended as a means to salvage various great toe deformities. These deformities include failed hallux valgus procedures, failed silicon implants, previous infection, rheumatoid arthritis, post-traumatic conditions, hallux rigidus, severe hallux valgus deformities, and neuromuscular disorders. A variety of complications, such as hallux varus, first MTP joint instability, infection, recurrent hallux valgus, and avascular necrosis of the first metatarsal head can develop from hallux valgus deformity treatment procedures.
Adult↗
The modified Lapidus arthrodesis: a retrospective analysis.
The authors present a review of 47 modified Lapidus arthrodesis procedures performed between 1985 and 1995. There were 29 females and 10 males. Eight patients underwent bilateral procedures. The average follow-up was 6.3 years (range, 1.5-10.6 years). The patients were evaluated preoperatively and postoperatively using standard weightbearing radiographs, clinical examination, and chart review. The average preoperative intermetatarsal angle was 13.8 degrees degrees, and the average postoperative intermetatarsal angle measured 2.1 degrees degrees, with a mean improvement of 10.8 degrees. The average effective shortening of the first metatarsal was 4.7 mm in those patients without bone graft. In patients whom bone graft was utilized, an average effective increase in first metatarsal length of 2.6 mm was identified. Complications included delayed union (n = 2), nonunion (n = 3), postoperative development of hyperkeratosis beneath the second metatarsal head (n = 4), elevation of the first ray (n = 3), and hallux varus (n = 2). There were no recurrences of hallux abducto valgus at follow-up. The average return to preoperative activity level was 13 weeks. Forty-two of the 47 procedures healed uneventfully. Of the remaining five feet, two required the use of a bone growth stimulator, and three required revisional surgery with autogenous bone graft to promote arthrodesis and restore alignment. In conclusion, the modified Lapidus arthrodesis is both a predictable and durable procedure for the correction of hallux abducto valgus.
Adolescent↗
Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release.
Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15 degrees, or hallux valgus (HV) angle > 30 degrees]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1 degrees preoperatively and 14.6 degrees postoperatively. The respective values for the IM angle were 17.8 degrees and 7.8 degrees. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15 degrees or HV angle > 30 degrees).
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The nonfixated Austin bunionectomy: a retrospective study of one-hundred procedures.
A retrospective evaluation of 64 randomly selected patients with 100 nonfixated Austin bunionectomy procedures was performed. A radiographic and a clinical evaluation were performed, including an analysis of preoperative and postoperative angles as well as postoperative complications. This study demonstrates a similar complication rate for nonfixated Austin bunionectomies as compared with previous studies with internal fixation. Removal of the fibular sesamoid was performed in 90% of the cases and did not increase the incidence of hallux varus. The nonfixated Austin bunionectomy is an acceptable alternative to the correction of hallux valgus. If internal fixation is utilized, the most cost-effective device should be used.
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Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up.
We retrospectively reviewed the results for seventy-five patients (109 feet) in whom a hallux valgus deformity had been corrected with the release of the distal soft tissues, excision of the medial eminence, plication of the medial part of the capsule, and proximal crescentic osteotomy of the first metatarsal. The patients were followed for an average of thirty-four months (range, twenty-four to fifty-six months). The preoperative hallux valgus angle averaged 31 degrees, and the postoperative angle averaged 9 degrees. The preoperative intermetatarsal angle averaged 14 degrees and the postoperative angle, 6 degrees. Ninety-three per cent of the patients were satisfied with the result of the procedure. They stated that, given the same circumstances, they would have the operation again. The most common complication was hallux varus, which occurred in thirteen feet (nine patients). The other complications included recurrence of the hallux valgus in two feet, pain under a fibular sesamoid in one foot, and a tailor's bunion that was unrelated to the operation in one foot. Only five of forty-eight feet that had had a symptomatic plantar keratosis beneath the second metatarsal head preoperatively remained symptomatic postoperatively.
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Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies.
During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.
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Tricorrectional bunionectomy for hallux abducto valgus. A comprehensive outcome study.
A longitudinal outcome study of the tricorrectional bunionectomy with AO screw fixation for the correction of hallux abducto valgus was undertaken involving 84 consecutive patients (121 feet) with a mean age of 48.4 years who underwent the procedure over a 6-month period. Preoperative and postoperative measurements of forefoot angles were calculated, with the following mean results obtained: intermetatarsal angle of 14.46 degrees corrected to 5.72 degrees, hallux abductus angle of 26.38 degrees corrected to 11.65 degrees, proximal articular set angle of 19.85 degrees corrected to 6.06 degrees, and tibial sesamoid position of 4.75 corrected to 1.87. The average time to return to athletic shoes was 12.63 days. Postoperative complications were minor, with no delayed unions, malunions, hematomas, bone infections, or hallux varus. Long-term follow-up (mean, 21.33 months) using the American Orthopaedic Foot and Ankle Society's objective Hallux Metatarsophalangeal-Interphalangeal Scale revealed an overall mean score of 88.94 points out of a possible 100. An excellent mean result of 95 points out of a possible 100 on the subjective patient rating scale was also reported.
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[Resection arthroplasty in the treatment of hallux valgus].
Sixty-six feet operated on for hallux valgus in 1984 were reviewed. Keller-Brandes' operation was performed in all cases, together with Lelièvre's "fibrous cerclage" and flexor hallucis longus tendon anchoring to the sesamoid pad, as described by A. Viladot. In most cases, satisfactory clinical correction was achieved and the patients could wear standard shoes. More than half of the cases presented partial limitation of movement at the first metatarsophalangeal joint; however, flexion power of the big toe was preserved, and the range of motion was wide enough to allow a painless and limp-free gait. Radiologically, good correction of the angle between the first and second metatarsals and the metatarsophalangeal angle was obtained, but all cases presented proximal displacement of sesamoid bones. A baropodometric study showed that the toe-off phase of the gait does not change after this operation. In our series, central metatarsalgia was present in 17 feet; however, it did not compromise the functional result and was easily relieved with orthopaedic devices. Four feet showed radiographic images, suggesting necrosis of the first metatarsal head; all four were asymptomatic. The only case that required reoperation was the one that developed hallux varus deformity. The Keller-Brandes-Lelièvre-Viladot procedure is still a simple and effective method for the surgical treatment of hallux valgus in elderly people with osteoarthritis at the first metatarsophalangeal joint.
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Advanced hallux valgus deformity: long-term results utilizing the distal soft tissue procedure and proximal metatarsal osteotomy.
A series of 28 cases with a moderate to severe hallux valgus deformity and intermetatarsal angle of 14 degrees or greater was followed an average of 5 1/2 years to determine whether any significant loss of correction occurred. All feet were treated with a distal soft tissue procedure and proximal metatarsal osteotomy. The average correction of the intermetatarsal angle was 13.2 degrees (7-20 degrees), and the average loss of correction was 1.4 degrees; the average correction of the hallux valgus angle was 26.7 degrees (-2 degrees to 48 degrees), and the average loss of correction was 3.8 degrees. In three cases, a recurrent deformity developed; in three other cases, a hallux varus deformity developed, two of which were symptomatic. Patient satisfaction was 85%. This study indicates that in most patients with a hallux valgus deformity and an intermetatarsal angle of 14 degrees or greater, there is sufficient inherent stability of the first metatarsocuneiform joint that it does not require stabilization to obtain a satisfactory long-term result.
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Return to activity after sesamoidectomy in athletically active individuals.
Sesamoidectomy of the first metatarsophalangeal joint in athletically active patients may be indicated in cases of chronic sesamoiditis resistant to nonsurgical care or symptomatic displaced fractures or nonunion. Painful scar, hallux deviation, and delayed return to activity are all potential complications. These need to be considered especially when performing surgery in the athletically active individual. Twenty-six sesamoidectomies in 24 patients (21 females and 3 males) were reviewed for type of sesamoidectomy, incision location, time to return to activity, and complications. Mean age was 35.4 years (range, 16-68 years) with mean follow-up 86.4 months. Eleven athletes (defined as professional or varsity level sports) operated on had a mean return to activity of 7.5 weeks (range, 4-10 weeks), while 13 "active" patients had a mean return to activity of 12.0 weeks. This difference was statistically significant using the t-test, (p < .02). There were 10 fibular and 16 tibial sesamoids excised. Complications included one hallux varus and two cases of postoperative scarring with neuroma-like symptoms, all associated with fibular sesamoidectomy; there was one case of hallux valgus deformity with tibial sesamoidectomy. Despite the functional importance of tibial and fibular sesamoids, athletically active individuals can return to sports after a sesamoidectomy as early as 7.5 weeks.
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The spike osteotomy for hallux valgus: a clinical and radiological evaluation.
A distal metatarsal osteotomy with soft tissue correction is a frequently performed operation to correct mild to moderate hallux valgus deformity. This is a prospective study of 28 feet in 25 patients who underwent spike osteotomy of the first metatarsal with medial capsulorraphy for symptomatic hallux valgus. The osteotomy is a distal metatarsal osteotomy with a spike fashioned in the plantar and lateral quarter of the proximal fragment and impacted into the trough created in the center of the distal fragment, providing lateral and plantar shift of the distal fragment. The American Orthopaedic Foot and Ankle Society's rating scale was used for functional assessment, and a visual analog scale gauged pain. The average follow-up was 27 months. The rating scale score improved from a mean preoperative value of 39/100 to 84/100. Twenty-six feet had complete pain relief, whereas 2 feet had a lesser degree of persistent metatarsalgia. A review of preoperative and postoperative radiographs showed that the hallux valgus angle improved from a mean 36 degrees preoperatively to 18 degrees postoperatively. Likewise, the mean 1 to 2 intermetatarsal angle improved from 13 degrees to 7.3 degrees. There was no incidence of avascular necrosis. Fourteen patients (16 feet) rated the outcome as excellent, 10 (11 feet) as good, and 1 patient with asymptomatic mild hallux varus deformity rated the result as fair. These results demonstrate that the spike osteotomy is a suitable operation for treatment of mild to moderate hallux valgus.
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Chevron osteotomy: analysis of factors in patients' dissatisfaction.
The results of all Chevron osteotomies for hallux valgus performed at the Mayo Clinic between January 1976 and June 1982 were reviewed at least 1 year after surgery. Of the total 157 patients with 228 operations eligible for inclusion in this study, 154 patients with 225 operations were interviewed. Complete satisfaction was expressed for 79.1% of the procedures, satisfaction with minor reservations for 12.9%, and dissatisfaction for 8%. For the osteotomies producing incomplete satisfaction, further investigation identified failure to achieve correction and technical errors as the most prominent factors. There were no cases of avascular necrosis, osteotomy nonunion, or hallux varus.
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Clinical and radiographic features of operatively treated stiff clubfeet after skeletal maturity: etiology of the deformities and how to prevent them.
BACKGROUND: Residual deformities of operatively treated severe clubfeet evaluated radiographically have been rarely studied in detail in adults. METHODS: Twenty-five operatively treated stiff clubfeet were analyzed at a mean age of 21 years and 6 months. The clinical evaluation used the Laaveg and Ponseti scale for clubfeet. Radiographic assessment was done with weightbearing and dynamic views. RESULTS: Clinical evaluation was globally good except for motion (poor). Radiographic assessment showed residual abnormalities in all feet. The distal tibial epiphysis showed slanting of its posterior part in seven feet (28%) and notching of its anterior lip in 13 (52%). Talar length, calcaneal length, and talar trochlear height were significantly smaller in clubfeet compared to normal feet. Undercorrection of hindfoot varus, was found in 19 feet (76%) but was well tolerated. Navicular wedging was present in seven (28%), and cavus deformity was found in seven (28%). Dorsal bunion, hallux varus, and skewfoot were found in four (16%), two (8%), and three (12%), respectively. The dynamic views demonstrated a significant decrease in the foot and ankle mobility with compensation mechanisms such as anterior talar incongruence or midfoot hypermobility. CONCLUSION: Severe clubfeet never become normal at adult age either clinically or radiographically. Multiple radiographic deformities exist. Their etiology and possible prevention are discussed. Despite the numerous abnormalities, clinical results were good at skeletal maturity.
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The chevron osteotomy: a clinical and radiographic analysis.
This is a retrospective study of the chevron osteotomy for hallux valgus. Subjective and objective postoperative results were evaluated. Differences in the postoperative correction of the intermetatarsal 1-2 angle and the first metatarsophalangeal angle were noted using two accepted measurement methods. Seventeen patients (23 feet) with an average age of 39 years (range, 15-51 years) and an average follow-up of 3 years (range, 1-5 years) were studied. The average preoperative intermetatarsal 1-2 angle was 11 degrees (range, 8 degrees to 14 degrees), and the average hallux valgus angle was 23 degrees (range, 7 degrees to 39 degrees). The apparent postoperative correction differed depending on the method of measurement used. One method consistently indicated a greater amount of correction in both the intermetatarsal and metatarsophalangeal angles. The chevron procedure resulted in an overall satisfactory improvement of symptoms, function, and cosmesis. Four feet exhibited postoperative radiographic changes that could be construed as avascular changes, but there was no collapse noted, nor were there clinical symptoms of avascular necrosis. No nonunions, malunions, or infections developed, and no cases of hallux varus occurred.
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Salvage treatment of failed hallux valgus operations with proximal first metatarsal osteotomy and distal soft-tissue reconstruction.
We reviewed the results of 15 patients (16 feet) in whom a hallux valgus procedure had failed. Salvage was by proximal crescentic first metatarsal osteotomy with distal soft-tissue reconstruction. Results based on a clinical scale considering the level of pain, activity limitations, support requirement, footwear limitations, and alignment were good in 11, fair in two, and poor in three. Patients were satisfied with the results in 10 feet, satisfied with reservations in four feet, and dissatisfied in two feet. Complications were: transfer metatarsalgia in three, hallux varus in one, and osteotomy nonunion in one. One of the patients required reoperation to bone graft a proximal osteotomy. Metatarsal osteotomy was helpful in the salvage treatment of recurrent, symptomatic hallux valgus when the first metatarsophalangeal joint was functional and painless.
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