Aims. The first metatarsal pronation deformity of hallux valgus feet is widely recognized. However, its assessment relies mostly on 3D standing CT scans. Two radiological signs, the first metatarsal round head (RH) and inferior tuberosity position (ITP), have been described, but are seldom used to aid in diagnosis. This study was undertaken to determine the reliability and validity of these two signs for a more convenient and affordable preoperative assessment and postoperative comparison. Methods. A total of 200 feet were randomly selected from the radiograph archives of a foot and ankle clinic. An anteroposterior view of both feet was taken while standing on the same x-ray platform. The intermetatarsal angle (IMA), metatarsophalangeal angle (MPA), medial sesamoid position, RH, and ITP signs were assessed for statistical analysis. Results. There were 127 feet with an IMA > 9°. Both RH and ITP severities correlated significantly with IMA severity. RH and ITP were also significantly associated with each other, and the pronation deformities of these feet are probably related to extrinsic factors. There were also feet with discrepancies between their RH and ITP severities, possibly due to intrinsic torsion of the first metatarsal. Conclusion. Both RH and ITP are reliable first metatarsal pronation signs correlating to the metatarsus primus varus deformity of hallux valgus feet. They should be used more for preoperative and postoperative assessment. Cite this article: Bone Jt Open 2024;5(11):1037–1040

Aims. The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures. Methods. We reviewed clinical records of a single surgical practice from its entire 2014 calendar year. In total, 71 patients (121 surgical feet) qualified for the study with a mean follow-up of 20.3 months (SD 6.2). We measured their metatarsus adductus angle with the Sgarlato’s method (SMAA), and the intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA) with Hardy’s mid axial method. We also assessed their American Orthopaedic Foot & Ankle Society (AOFAS) clinical scale score, and photographic and pedobarographic images for clinical function results. Results. SMAA increased from preoperative 15.9° (SD 4.9°) to 17.2° (5.0°) (p < 0.001). IMA and MPA corrected from 14.6° (SD 3.3°) and 31.9° (SD 8.0°) to 7.2° (SD 2.2°) and 18.8° (SD 6.4°) (p < 0.001), respectively. AOFAS score improved from 66.8 (SD 12.0) to 96.1 (SD 8.0) points (p < 0.001). Overall, 98% (119/121) of feet with preoperative plantar calluses had them disappeared or noticeably subsided, and 93% (113/121) of feet demonstrated pedobarographic medialization of forefoot force in walking. We reported all complications. Conclusion. This study, for the first time, reported the previously unknown metatarsus adductus side-effect of the syndesmosis procedure. However, it did not compromise function restoration of the forefoot by evidence of our patients' plantar callus and pedobarographic findings. Level of Clinical Evidence: III. Cite this article: Bone Jt Open 2021;2(3):174–180

The purpose of this prospective study was to evaluate the functional outcome of patients who underwent the Lapidus procedure as a treatment for moderate to severe metatarsus primus varus and hallux valgus deformities. Inclusion criteria were failure of non-surgical management for moderate or severe deformity, inter-metatarsal angles of more than 14° and hallux valgus angles of more than 30°. Exclusion criteria were any previous hallux valgus procedures, insulin-dependent diabetics, previous ankle or subtalar fusions, peripheral vascular disease or peripheral neuropathy. Bilateral procedures had to be at least six months apart to be included. The AOFAS Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), Visual Analogue Pain Scale (VAPS), Musculoskeletal Function Assessment Scale, clinical examination and weight-bearing radiographs were used for assessment. All patients were followed up for at least six months. Patients lost to follow-up in less than a year were excluded from the analysis. For a mean of 3.7 years (1 to 6.2), 126 feet in 110 patients were followed up, 105 of them (91 patients) for at least one year. At most recent follow-up, HMIS scores increased from 52 preoperatively to 87 (p < 0.0001). VAPS improved from 5.3 to 1.3 (p < 0.0001). The hallux valgus angle improved from 37° to 16° and the intermetatarsal angle improved from 18° to 8.2°. At 3.7 years, 88.5% of patients were very satisfied, 5% somewhat dissatisfied and 1.5% dissatisfied. With proper technique and attention to detail, the Lapidus procedure is an excellent alternative for moderate to severe metatarsus primus varus and hallux valgus deformities

Adolescent hallux valgus is a progressive deformity of childhood. Patients with this disorder complain of pain, deformity, redness at the site of deformity, shoewear limitation and altered cosmesis. Surgery to correct the bunion is considered as pain gets worst, deformity increases or significant shoe wear limitation is present. However, there is still not an uniformly satisfying surgical treatment for the adolescent hallux valgus. This kind of surgery has been often associated with a high rate of recurrence and poor results. The adolescent condition often includes significant metatarsus primus varus as a primary element. This is the reason why isolated soft tissue procedures frequently fail. Surgical treatment often combines first metatarsal osteotomy with a soft tissue realignement of the first metatarsal phalangeal joint. Simmonds and Menelaus in 1960 reported their results with an osteotomy of the base of the first metatarsal in addition to McBride’s soft tissue recostruction. The procedure addresses the three main components of the adolescent hallux valgus deformity: the medial eminence, the hallux valgus and the metatarsus primus varus. Although Simmonds and Menelaus did not use any internal fixation to fix the osteotomy site, they performed a complete transverse osteotomy at the base of the first metatarsus. Besides they used an immobilization for six weeks in the post operative period. We describe a modified procedure where the osteotomy is performed incompletely at the base of the first metatarsal bone and we shortened the post operative immobilization period with a cast for three weeks. Simmonds’ procedure does not interfere with the sesamoid bones while in our method a repositioning of the sesamoids below the metatarsal head has been performed. Materials and methods: From 1997 to 2000, 22 feet in 12 female and 1 male patients were treated surgically with the modified Simmonds-Menelaus bunion procedure. A primary operation was performed on all feet treated. The average age at surgery was 12.4 years (range 10.5 – 14.6 years). Preoperative, postoperative and final follow up evaluation included history, physical examination, record of range of motion of the first metatarsophalangeal joint, anteroposterior and lateral radiograph of the feet in the weight bearing position. Results: Lenght of follow up averaged 3.9 years. The average pre operative Hallux Valgus Angle (HVA) was 31.2°. The average pre operative Inter Metatarsal Angle ( IMA) was 13.5°. The average HVA was reduced to 17.8°; the IMA was reduced to 11.3°. Of the 22 feet with preoperative subluxation of the sesamoids, all feet were improved after operation and none were worse. In order to assess our outcomes we used the duPont bunion rating score, which incorporates objective and subjective criteria. We had 5 excellent and 17 good results. There were no fair or poor results. Conclusion: Our proposed modified procedure is easy to perform and does not need any internal fixation device. The complications linked to the use of the hardware are removed. Our proposed procedure does not interfere with the shape or the length of the first metatarsal and does not preclude the possibility of further surgical correction

Purpose:. To describe a plating technique for the Lapidus procedure as an alternative to the traditional screw fixation technique. To look at the complications experienced during the Lapidus procedure and to find possible solutions to prevent these complications. Methods:. A retrospective study of 34 Lapidus procedures in 26 patients (8 bilateral) between 2006 and 2009 was performed. All were done with a plating technique and a primary bone graft. The indications were:. metatarsus primus varus. hypermobility. degenerative TMT joint. Results:. The average intermetatarsal angle pre-operatively was 17.1° and this was reduced to 6,4° post – operatively. The complications experienced were:. post –operative metal removal = 6. transfer metatarsalgia = 1. hallux varus = 1. screw breakage = 1. delayed union = 1. non-union = 1. Conclusion:. The plating technique for the Lapidus procedure gives stable fixation and the outcome compares well with other methods of fixation

Crossover second toe deformity is a multiplanar deformity derived from multiple etiologies with the common endpoint of metatarsophalangeal joint instability. The stability of the joint is compromised through laxity of the volar plate, secondary rupture of the lateral collateral ligament, and ultimately dorsal subluxation or dislocation of the metatarsophalangeal joint. The digital malalignment often includes a hammertoe deformity, but should not be confused with a routine clawtoe. Elimination of alternative diagnoses relies on precise palpation to negate Morton's neuroma, 2nd metatarsalgia, Freiberg's infraction, and 2nd metatarsal stress fracture. Radiographs assist in the diagnosis in not only eliminating the above mentioned differential diagnoses, but also in evaluating confounding anatomic variables such as hallux valgus, metatarsus primus varus, and metatarsal length. These variables may necessitate additional osteotomies in conjunction with ligament reconstruction to minimise recurrence. Operative intervention has revealed long term failure of secondary ligament reconstruction, mandating tendon transfers such as the flexor-to-extensor and the extensor digitorum brevis to support the repair. We will explore these techniques and subsequent modifications to achieve patient satisfaction

Introduction:. All reported RA forefoot deformities in the literature so far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod to a non-shod population. Methods:. A case-control study was undertaken in two specialist foot and ankle units, one in India and one in the UK. All patients suffering from RA and attending for consideration of forefoot surgery from January 2007 to October 2013 were included in this study. Standardized anteroposterior weight bearing radiographs were obtained to measure the hallux valgus, inter-metatarsal and metatarsus primus varus angles. Results:. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity and 90 feet with varying degrees of hallux valgus deformity. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the 5. th. toe in a varus position. This was seen in 95% (n=96) of the shod population. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. This was present in 80% (n=20) of the unshod population. Conclusion:. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. External forces of shoe wear dictate the deformity, with hallux valgus being the most likely scenario in a shoe-wearing patient. In the non-shoe wearing population, intrinsic forces and weight bearing forces determine the deformity, with hallux varus being the most common presenting problem

Background: This study compares two diaphyseal osteotomies (scarf and Ludloff) which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow up at twelve months. Materials and Methods: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardised weight bearing radiographs were analysed. Results: There was no stastically significant difference between the two groups at 6 and 12 months in subjective satisfaction, AOFAS score, improvement in functional activities and range of movements. The improvement in pain (at best) and transfer lesions at 12 months was significantly better in the scarf group (p< 0.05). The radiological results at 6 and 12 months including intermetatrsal angle (p< 0.001), hallux valgus angle (p< 0.01), distal metatarsal articular angle and seasmoid position (p< 0.05) were significantly better in the scarf osteotomy group. There were three cases (5%) of delayed union in the Ludloff group. Two of these healed with dorsiflexion malunion. One patient in the Ludloff osteotomy group developed a complex regional pain syndrome. There were two wound complications in the scarf group. Conclusion: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months

Introduction: This study compares two diaphyseal osteotomies (scarf and Ludloff), which correct moderate to severe metatarsus primus varus. This is a single surgeon, prospective cohort study with clinical and radiological follow up at six and twelve months. Material and methods: Clinical assessment included visual analogue scale questionnaires for subjective assessment and functional activities and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Standardised weight bearing radiographs were analysed. Results: There were 57 patients in each group. Both groups were similar in terms of age, gender and preoperative deformity. There was no statistically significant difference in the two groups at 6 and 12 months in subjective satisfaction, AOFAS forefoot score, improvement in functional activities and range of movements. The improvement in pain (at best) and plantar callosities at 12 months was significantly better in the scarf group (p< 0.001). The radiological results at 6 and 12 months including intermetatarsal angle (p< 0.001), hallux valgus angle and shortening of the first ray (p< 0.01), distal metatarsal articular angle and sesamoid position (p< 0.05) were significantly better in the scarf osteotomy group. There were six complications in the Ludloff group with three delayed unions, two dorsiflexion malunions and one complex regional pain syndrome. There were two wound complications in the scarf group. Conclusion: Overall the patients who had a scarf osteotomy had a superior outcome at 6 and 12 months

Aims: Metatarsus osteotomies usually require an internal metal þxation in order to achieve the required stability. Taking the metal out means an operation. This is unpleasant for the patients by all means. Absorbing screws are rather expensive. The authors used an absorbing polydioxanone thread in case of osteotomies. Methods: þxation by absorbing thread has been used in three types of operations: A: chevron osteotomia Hallux valgus/metatarsus primus varus/, B: Weil osteotomia II-III-IV metatarsalgias, C: Assimetricus ÔVñ osteotomia II III-IV metatarsalgias. In all the cases mentioned above a polydioxanone thread has been used. Altogether 62 operations have been carried out, 27 in case of A, 19 in case of B, and 16 in case of C. The patients received full burden 2 weeks after the operation, just like in case of þxation with a metal screw. Follow-up examination was done 1, 3 and 6 months after the operation. Rtg examination was done immediately in postoperative time and following a 3-month interval. Results: during follow-up examination no symptoms revealing the tear of thread have been observed. In the measures of the consolidation of bones no difference between the two methods has been revealed. Conclusions: þxation by absorbing thread is a perfect alternative of that by metal screws. The patients have a positive opinion about not having to undergo another operation. This method does not make the operation more expensive

Introduction: The modified Lapidus-arthrodesis with standard AO screw-fixation is well known for the treatment of severe metatarsus primus varus deformity respectively a hypermobile or an arthrotic first tarso-metatarsal joint. High rates of non-union and malunion (range 3 to 12%) due to improper or poor fixation despite the postoperative course of nonweightbearing were reported in literature. The immediate postoperative weightbearing protocol varies from 2 to 6 weeks of cast immobilization. To our knowledge, this prospective investigation comprises the largest cohort of patients undergoing the Lapidus-arthrodesis, fixed with the Lapidus-Orthner locking plate. Methods: 130 feet with an average patient’s age of 52 years (range 23 – 83 years), underwent the Lapidus fusion with the locking Orthner-plate. Indications were severe hallux valgus deformities respectively moderate hallux valgus deformities with a hypermobile first TMT 1- joint or an arthrotic first tarsometatarsal joint. The surgical technique was standardized, and the operations were performed by the inventor of the plate. All patients had a failed trial of nonoperative management (shoe-wear modification). The 130 feet were divided into 2 groups. Group I was without TMT 1 – compression screw (n= 60) and group II with an additional compression-screw (n=70). Average age of group I was 54-years. The average age of group II was 50-years. The American-Orthopaedic-Foot and Ankle Society (AOFAS) Forefoot-Score, Visual-analog-pain-scale and foot radiographs were assessed preoperatively and after a mean of 23 months for group I and 39 months for group II. All 130 feet were treated immediately postoperative with a postoperative Darco orthowedge ® shoe. Results: The average AOFAS score improved significantly from preoperative to follow up time-point in both groups. AOFAS pain-subscore significantly improved in both groups. The intermetatarsal-angle (IMA) of all 130 feet decreased significantly from 14° to 6° after surgery. At time of follow-up 9 % of non-unions were seen in group I whereas 0% were seen in group II with proximal compression screw, the difference is significant (p=0,024). The mean immobilisation with the Darco-Ortho® wedge shoe was 7,2 weeks (range 6 to 14 weeks) in group I and 6,3 weeks (range 5 to 12 weeks) in group II. Conclusion: The prospective mid-term results from this study show that the locking Lapidus-Orthner plate is a very good and promising technique for the Lapidus-arthrodesis. The modified technique with compression screw has shown none non-union, despite of immediate weight-bearing in a post-op shoe after surgery. The procedure significantly reduced pain, the hallux valgus and intermetatarsal angle and increased the patient’s ambulatory capacity and patient satisfaction

Proximal Metatarsal osteotomies are used for larger deformities, generally those with an intermetatarsal angle greater than 15°. These osteotomies usually are combined with a Distal Soft Tissue Release, which is necessary to correct metatarsophalangeal (MTP) sub-luxation with a Hallux Valgus Angle greater than 35°. Many types of osteotomies have been described. These include a medial opening wedge, a lateral closing wedge, proximal chevron, and a crescentic. Additional osteotomies include the Scarf, Ludloff, and Mao osteotomies. Presently, the proximal chevon and crescentic osteotomies are widely used. In our study we used the proximal chevon osteotomy combined with Distal Soft Tissue Release and approximation of the 1. st. and 2. nd. metatarsus using a string to further decrease the intermetatarsal angle. From January 2000 to June 2005 the basal chevon osteotomy was selected in 44 patients (37 female and seven male patients, ages 14 to 80, mean: 54.97 years) total of 49 feet with moderate metatarsus primus varus (IMA 13 to 20 degrees) and hallux valgus deformities (less than 50 degrees). The AOFAS Hallux Metatarsopha-langeal-Interphalangeal Scale and patient satisfaction were monitored prior to surgery, and postoperatively. Changes in the IMA and HV angle were measured in the conventional method and documented. All patients were treated in a Darco Post operative splint. Results: Multiple complications were encountered. The most common is transfer metatarsalgia. This occurred in 10 patients (20%). Other complications include delayed union (4%), increase in the height of the first metatarsus (10%), floating toe (6%), superficial infection (15%), local parenthesis and early recurrence of deformity in 3%. 38 patients were available for follow-up. The hallux valgus angle improved significantly more than 20 degrees on average postoperatively. The intermeta-tarsal angle also improved significantly (more than 10 degrees on average) postoperatively. The position of the sesamoids was realigned to beneath the first metatarsal head and the metatarsal length remained essentially unchanged. The AOFAS score preoperatively was a mean of 75.64 with respect to pain, deformity, motion, disability, and cosmetic. The AOFAS score postoperatively was a mean of 94.55. The mean improvement was 18.91. About 95.45 percent (42/44) were satisfied and would recommend the surgery to a friend. Conclusions: The basal chevron osteotomy combined with Distal Soft Tissue Release and realignment using a string is a technically demanding procedure and has multiple potential complications but provdes a reliable method with respect to stability, technical ease and satisfactory surgical outcome for correction of moderate and severe bunion deformity, both as a primary and revision procedure

The December 2013 Foot & Ankle Roundup³⁶⁰ looks at: Maisonneuve fractures in the long term; Not all gastrocnemius lengthening equal; Those pesky os fibulare; First tarsometatarsal arthrosis; Juvenile osteochondral lesions; Calcanei and infections; Clinical outcomes of Weber B ankle fractures; and rheumatologists have no impact on ankle rheumatoid arthritis.