Background

The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity.

Background

Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiological outcomes. It remains unknown whether these clinical and radiological outcomes are maintained in the medium to long-term. The aim of this study was to investigate the five-year clinical and radiological outcomes following third-generation MIS hallux valgus surgery.

Introduction

Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weightbearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores.

Background

There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique.

Purpose

To explore the relationship in terms of time scale between pre-operative expectations and postoperative outcomes and satisfaction after Hallux valgus surgery.

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach.

Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption.

During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively.

For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control.

First Metatarsophalangeal joint fusion has been successfully used to treat Hallux rigidus. We have attempted to evaluate commonly used methods of fixation and joint preparation. To the best of our knowledge, this is the single largest comparative study on first MTPJ fusion. We aimed to evaluate the radiological union and revision rates. We included 409 consecutive MTPJ fusions performed in 385 patients. We collected demographic, comorbidities and complication data. We evaluated the radiographs for the status of the union. Logistic regression was used to calculate the Odds ratio (OR) of non-union for the collected variables. Our union rate was 91.4% (34/409). 29.4% of our non-unions were symptomatic (10/34). Hallux valgus showed a statistically significant relation to non-union (Odds ratio 9.33, p-value 0.017). Other potential contributing factors like sex (OR1.9, p-value 0.44), diabetes (OR 0, p-value 0.99), steroid use (OR 2.07, p-value 0.44), inflammatory arthritis (OR 0, p-value 0.99) and smoking (OR 2.69, p-value 0.34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR 0, p-value 0.99), plate (OR 3.6, p-value 0.187) or cannulated screws (OR 0.09, p-value 0.06) showed no correlation with non-union. We compared two techniques of joint preparation and found no significant difference in union rates (Chi-Square 1.0426, p-value 0.30). Our crude cost comparison showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plate. Only Hallux Valgus had a statistically significant relation to non-union. Solid screw could be economically the most viable option and a valid alternative

Short scarf osteotomy (SSO) retains the versatility of standard scarf in treating moderate and severe hallux valgus deformity with the added benefit of less invasiveness translated into less soft-tissue stripping, reduced exposure, less metalwork, less operative time and reduced cost. We present our medium-term clinical, radiographic and patient satisfaction results. All patients who underwent SSO between January 2015 and December 2017 were eligible (98). Exclusion criteria were: follow up less than a year, additional 1st ray procedures, inflammatory arthropathy, infection, peripheral vascular disease and hallux rigidus. Eighty-four patients (94 feet) were included: 80 females / 4 males with average age of 51-year-old (24–81). Minimum follow up was 12 months (12–28). Weight-bearing x-rays and AOFAS score were compared pre- and postoperatively. Non-parametric Mann-Whitney U test assessed statistical significance of our results. Hallux valgus angle (HVA) improved from preoperative mean of 30.8° (17.4°–46.8°) to 12° (4°–30°) postoperatively (p=0.0001). Intermetatarsal angle (IMA) improved from preoperative mean of 15.1° (10.3°–21.1°) to 7.1° (4°–15.1°) postoperatively (p=0.0001). Average sesamoid coverage according to Reynold's tibial sesamoid position improved from average grade 2.18 (1–3) to 0.57 (0–2) (p=0.0001). Average AOFAS score improved from 51.26 (32–88) to 91.1 (72–100) (p=0.0001). Ninety percent of patients were satisfied and 83% wound recommend the surgery. No troughing phenomenon or fractures. Four overcorrections were found 3 of which did not require surgery. One recurrence at 18 months was treated with standard scarf. We believe that this technique offers a safer, quicker and equally versatile way of dealing with Hallux Valgus

Though there are many techniques utilised in the correction of hallux valgus (HV), no single approach has been reported to be ideal for all patients to date. A great deal of controversy remains concerning the type of osteotomy, method of fixation, and inclusion of soft tissue procedures. Herein, we compared the outcomes of two different operative techniques, the minimally-invasive modified percutaneous technique and the distal chevron osteotomy, used to treat mild to moderate hallux valgus. This study was conducted in line with the CONSORT 2010 guidelines. 41 patients (58 feet) with mild to moderate hallux valgus were randomly assigned by computer to two different groups. The first group containing 24 patients (33 feet) was treated by the modified percutaneous technique, whereas the second group included 17 patients (25 feet) treated by distal chevron osteotomy. In the modified percutaneous group, after a mean follow up of 43 months, the mean correction of hallux valgus angle (HVA) was 26.69° (P=0.00001), the mean correction of intermetatarsal angle (IMA) was 9.45° (P=0.00001), and the mean improvement of AOFAS score was 47.94 points (P=0.00001). In the chevron osteotomy group, after a mean follow up of 44 months, the mean correction of hallux valgus angle was 26.72° (P=0.00001), the mean correction of intermetatarsal angle was 9° (P=0.00001), and the mean improvement of AOFAS score was 44.76 points (P=0.00001). In our study, the modified percutaneous technique proved to be equally effective as the distal chevron osteotomy, but with fewer complications and a higher rate of patient satisfaction.

This paper tests the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line.

At a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n=30) – patients who on pre-operative weight bearing radiographs had a disrupted Meary's line, and Group B (n=44) – those with a normal Meary's line on pre-operative weight bearing radiographs.

Our results demonstrate a statistically significant higher recurrence in group A compared to Group B with an odds ratio of 5.2 p = 0.006 [95% CI 1.6–6]. The association between a disrupted Meary's line and increased risk of recurrence for Scarf osteotomy remains valid and strengthened to an odds ratio of 7.1 p = 0.015 [95% CI 1.46 −34.4] when adjusted for confounding variables of age, sex and pre-operative IMA. On this basis we reject the Null hypothesis.

In group A two out of 30 patients required revision surgery whilst none of the 44 patients in group B needed revision. In Group A the degree of IMA correction achieved equalled 8.1 degrees with a pre and post IMA of 16.0 and 7.9 degrees respectively. For Group B the degree of correction was 8.0 degrees with a pre and post IMA of 14.3 and 6.3 degrees respectively. Eight complications were reported in Group A and 9 in Group B.

Our results demonstrate a statistically significant increased risk of recurrence when scarf osteotomy is performed for mild and moderate hallux valgus in the presence of a disrupted Meary's line.

Background. In the adolescent population, operative management of hallux-valgus is controversial. Operations may be less successful than in adults and post-operative recurrence is more common before full skeletal maturity. This study assesses the radiographic, functional and qualitative outcomes of surgical Hallux Valgus correction in adolescents. Methods. Three independent reviewers retrospectively analysed pre and post-operative radiological markers of hallux valgus severity for 44 operations on patients age 13–18. The patient cohort were also asked the Manchester-Oxford foot questionnaire (MOXFQ) to assess functional outcome via telephone interview and patient notes were reviewed for any evidence of complications. Results. There was no evidence of NICE recognised complications from any of the operations performed, however there was persistence or recurrence in 20.8%, requiring a second operation in 10.3%. Radiologically, all operations performed resulted in a reduction in hallux valgus severity. The hallux valgus angle showed a mean reduction of 18.0 degrees (16.3–19.7) and the inter-metatarsal angle by 7.3 degrees (6.55–8.14). 93% of operations resulted in a good MOXFQ outcome score of less than 20 out of a possible 80 negative functional outcome points. This score worsened with age in a statistically significant manner (p=0.03) but had no significant correlation with BMI. Conclusion. Surgical correction of adolescent hallux valgus reduces the radiographic severity, which correlates with good long term outcome. This surgery provides beneficial results to the patient, however there is a high recurrence rate, correlating with younger age and this must be taken into account

Introduction

The management of adolescent hallux valgus (AHV) remains controversial, with reservations about both conservative and surgical treatments. Non-operative management has a limited role in preventing progression. Surgical correction of AHV has, amongst other concerns, been associated with a high prevalence of recurrence of deformity after surgery. We conducted a systematic review to assess clinical and radiological outcomes following surgery for AHV.

Background

Patient reported outcomes/experience measures have been a fundamental part of the NHS since 2009. Osteotomy procedures for hallux valgus produce varied outcomes due to their subjective nature. We used PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to assess what the patient reported outcome/experience measures for scarf+/− akin osteotomy for hallux valgus are at UHSM.

Aims

The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy.

Background

Patient reported outcome and experience measures have been a fundamental part of the NHS. We used PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to assess the patient reported outcome/experience measures for scarf+/− akin osteotomy for hallux valgus.

Introduction. The aim of this study was to identify the effects of first MTPJ arthritis, ankle arthritis and hallux valgus on patient reported outcomes, and to assess the efficacy of surgery. Methods. Patients who underwent first MTPJ fusion, ankle fusion or hallux valgus correction from July 2013 to October 2014 were included in the study. Exclusion criteria included revision or simultaneous bilateral surgery, inflammatory arthropathy, or arthritis of a proximal joint awaiting arthroplasty. Subjects completed the Manchester-Oxford Foot Questionnaire (MOX-FQ), EQ-5D index, and EQ-5D health scale on presentation and at least six months post-operatively. Between group statistical analysis was carried out using one-way ANOVA, pre- and post-operative scores were compared using a paired t-test. Results. Eighty-two patients completed pre-operative questionnaires. Seventy-four (22 male, 52 female) of these (90%) completed post-operative questionnaires at a median of 10 months (range 6–17 months). The median age was 64 years (range 36–85 years). Pre-operative MOX-FQ and EQ-5D scores differed significantly between the groups (both p< 0.001) with ankle fusion patients reporting the worst scores and hallux valgus patients the best. Post-operative MOX-FQ and EQ-5D did not differ between groups (p=0.52, p=0.06 respectively). MOX-FQ significantly improved in all groups from pre-operatively (MTPJ p=0.0001; Ankle p=0.0002; Hallux Valgus p< 0.0001). EQ-5D only statistically improved following surgery for arthritic conditions (MTPJ p< 0.001; ankle p< 0.001; Hallux valgus p=0.06). The EQ-5D health scale did not show any differences between the groups either pre- or post-operatively, nor between pre- and post-op scores for each type of surgery. Conclusions. MOX-FQ and EQ-5D scores differ between patients with different foot and ankle pathologies. Both scores significantly improve following surgery for arthritic conditions, but only the more specific MOX-FQ improves following hallux valgus correction. These results will be of benefit when consenting patients pre-operatively, and potentially for prioritisation of healthcare provision

This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years.

Cite this article: Bone Joint J 2015;97-B:208–14.

Background:

Previous attempts at small incision hallux valgus surgery have compromised the principles of bunion correction in order to minimise the incision. The Minimally Invasive Chevron/Akin (MICA) is a technique that enables an open modified Chevron/Akin to be done through a 3 mm incision, facilitated by a 2 mm Shannon burr.

Background:

The Chevron osteotomy is straightforward, requires less dissection and allows earlier rehabilitation than some other osteotomies. However it is generally perceived as unsuitable for severe deformities even though a 2012 meta-analysis and an earlier RCT failed to show any advantage of the scarf over the chevron. We aim to assess the correctability of severe HV comparing the correction, the clinical outcomes and complications of the Chevron osteotomy with other techniques employed in a consecutive series.

Introduction:

It has been shown that inadequate reduction of the sesamoids can lead to recurrent hallux valgus. It can be difficult however to assess the sesamoid position. We propose a simple method of grading sesamoid position; the sesamoid width ratio. We aim to assess for a difference in ratio between those with and without hallux valgus and subsequent correlation with increased deformity. The new grading system can then be tested for inter-observer reliability.