Introduction: The term dorsal bunion describes a condition characterised by a swelling in the region of the 1st MTPJ with an elevated first metatarsal and a flexed toe. The literature available concentrates on the forefoot aetiology- no author has yet documented the role of the hindfoot in its pathogenesis. Methods: We have conducted a review of 28 consecutive patients, excluding those with hallux rigidus collected prospectively in the course of a full-time foot and ankle practice between 1996 and 2005. All of the patients have been examined with respect to their primary pathology leading to the dorsal bunion and had the mobility and position of the hindfoot assessed. Results: In the series of 28 patients, the average age was 31.6 and there were 18 male and 10 females. Every patient examined had either a rigid hindfoot or stiffness contributing to a failure to correct for abnormal forefoot position. Conclusion: The causes of dorsal bunion may be considered to be Primary (Hallux Rigidus) or Secondary (CTEV, neurogenic, iatrogenic, global forefoot supination). It is the authors’ view that hindfoot stiffness in secondary cases of dorsal bunion causes an inability of the footto compensate for an abnormal position of the forefoot- the 1st ray must compensate by flexion of the hallux to allow the foot to adopt a plantigrade position

Aims: The results of arthrodesis of the þrst metatarso-phalangeal joint as salvage procedures after failure in bunion surgery are well documented in the medical literature. Usually, the results may be equivalent to those of primary arthrodeses. On the other hand, joint conserving methods in case of recurrence have not the same reputation in respect to arthrodesis which appears as the gold standard. Methods: We reviewed 27 patients (28 feet) with a mean follow-up of 6.5 years (range: 1–18 years) after treatment for recurrence after bunion surgery. The patients were submitted to a joint conserving procedure on grounds of absence of degenerative condition on the metatarsophalangeal joint. The procedure corrected point by point all the characteristics of the deformity: lateral release, mobilisation of the joint, tightening of the medial capsule and osteotomies on the þrst ray. Results: Preoperatively valgus of the great toe was on average of 38.9û. At time of follow-up (6.5 years on average) after revisional procedure, valgus of the great toe was on average 21.3û. Postoperatively 23 out of 27 patients were satisþed. The result was considered as good in 20 cases, fair in one, and poor in 7 cases. Conclusions: In spite of technical difþculties, these results can equal those of primary bunion procedure, if all the morphological disorders are corrected. Conservative methods may be rational when the joint remains ßexible with no pain and when the morphological particularities on the forefoot are sufþciently indisputable so that their correction could cure the patient

Hallux valgus continues to frustrate foot and ankle surgeons the world over. The condition is mostly clear in its aetiology but unclear in its pathogenesis. The key, as in all surgery, is decision making, patient selection and to have many surgical options available. The key things to consider are: joint congruency, the presence of arthritis, the presence of metatarsus adductus, the intermetatarsal angle, the hallux valgus angle and the presence of interphalangeal deformity. I consider true hypermobility of the first ray and Achilles tendon tightness to be less important factors. Patient expectations are particularly important as most patients with hallux valgus are women who want to wear high-heeled shoes!. The most successful operations consist of a combination of soft tissue and bony procedures. The most common error in bunion surgery, in my opinion, is the use of a procedure with inadequate power to correct the deformity. When the joint is markedly arthritic and deformed an arthrodesis is the procedure of choice. I will discuss the above points in the lecture

The incidence of first metatarsophalangeal joint (MTPJ) stiffness following bunion surgery varies in the literature from 2% to 60%. The causes include pre-existing degenerative joint disease, infection, chronic regional pain syndrome (Type 1), joint incongruence and avascular necrosis. The aim of this study was to establish whether closure of the capsule influences the range of motion in the first MTPJ. We performed a cadaveric study using a ‘Y’ shaped medial capsulotomy as our model. A mid-medial approach was performed on ten cadaveric feet, exposing the medial capsule of the 1st MTPJ. The range of motion of the 1st MTPJ was recorded, and a ‘Y’ shaped capsulotomy performed. The capsule was then closed in neutral, full plantar flexion, and full dorsi flexion and the range of motion recorded. When the capsule was closed with the first MTPJ at the limit of plantar flexion there was a mean loss of 13.7° of dorsi-flexion (range 12°–15°, p< 0.01) compared with the pre-capsulotomy range of motion. When the capsule was closed in dorsi-flexion there was a mean loss of 9.3° of plantar flexion (range 0°–20°, p< 0.05). There was no change in range of motion when the capsule was closed in neutral. Capsular closure can influence first MPTJ motion. Care should therefore be taken during capsular repair. Closure in extremes of extension or flexion, as advocated in some techniques such as the Mitchell osteotomy, should be avoided

Introduction: The scarf osteotomy is a reliable technique in bunion surgery. A so-called « self stable technique» was developed in our department since 1992. We report the results of retrospective study including two groups of patients which had a scarf osteotomy. In the first group they had an internal fixation and in the second one an ‘selfstable technique’ with no device. Material and methods: One hundred and seventy one patients operated for hallux valgus were reviewed for this study. There were 105 feet operated with the so called ‘self stable techniqu’, using modified saw cuts and 103 had the conventional technique with an internal fixation. All patients had a clinical and radiological pre- and postoperative examination. The result was assessed according to the AOFAS Score. Results: The follow-up was on average 6.3 years (ranging from 2 to 13 years). The result was considered satisfactory globally in 74% of the cases, 76% in the « selfstable group and 72% in the conventional group. All items were significantly improved in both groups and the good results remained with time: improvement in shoe wear, pain, angular corrections. The hallux valgus angle decreased from 34° to 16°, there was no difference between both groups. The first intermetatarsal angle changed from 15° to 10. No significant difference was found in term on bone healing and complications between both groups. Discussion: These results are comparable with those of the literature. The « selfstable technique » is significantly identical to the conventional one. The patients have the same rate of complications. The corrections that this osteotomy is able to offer are not altered by the change of fixation of the osteotomy. Conclusion: This modified scarf osteotomy of the first metatarsal provides equivalent long-term results in our experience

Background:. Various angles have been used to grade the severity of hallux valgus deformity. They are useful in surgical planning but do not correlate with symptom severity or improvement. We feel that there is a fundamental mismatch between the width of the forefoot and the width of the hindfoot and that this is more clinically relevant, we describe two techniques for measuring this. We aim to measure the degree of foot narrowing after surgery and moreover how this correlates to the severity of pre- and post operative outcomes. Methods:. 200 consecutive bunion operations were assessed with weight bearing radiographs. The HVA and IMA were measured according to standard practice. We also assessed forefoot width using two methods we have described. The first is the ‘Forefoot Width’ measured as a perpendicular to the midfoot (a technique we have previously validated). The ‘Foot Ratio’ is calculated as a function of the calcaneal width. Clinical outcomes were assessed using the MOXFQ and AOFAS. Results:. Bunion surgery narrows the osseous width of the forefoot. This narrowing can be by as much as 23 mm in cases with severe deformity. We found that the Forefoot: Hindfoot ratio correlated with symptom severity and that normalisation of the ratio to below 2.5 was associated with better outcomes. This is important as small absolute corrections were associated with good outcomes. Conclusion:. Our measure of Forefoot Width is reproducible and allows for variations such as forefoot adductus. We feel that the Forefoot: Hindfoot ratio is more important as this determines the ability to fit into off-the-shelf footwear rather than requiring bespoke or modified footwear. This is the first study to look at the ability to narrow the forefoot and has important implications in determining patient selection and post-operative outcomes

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.

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.

Congenital hallux varus had been a well-described condition for many years before acquired hallux varus as a condition arising from bunion correction was not described until 1935. In that year, McBride discussed this potential problem when describing this as a potential problem from his described technique, identifying possible mechanisms to prevent the disorder from occurring. Authors such as Joplin and Kelikian echoed the concept in the early 1960's, spawning a series of corrective procedures. Miller brought this to common practice in 1975, describing the tendon imbalance seen across the precarious 1. st. MTP joint. The first metatarsophalangeal joint moves in the sagittal plane, dorsiflexion and plantarflexion only. Four intrinsic muscles stabilize the digit, with the abductor and adductor hallucis taking the lion share of this function. The abductor tendon actually functions primarily as a plantarflexor of the first metatarsophalangeal joint 83% of the time (Thompson) due to its primary plantar location. This fact, in combination with the pronation generally seen in severe bunion deformities, contributes to acquired hallux varus following bunion correction. Besides the obvious cause of over-correction of the metatarsal osteotomy creating hallux varus, imbalance of the tendon complex post-operatively can create an equally catastrophic circumstance. Hawkins demonstrated that severing the adductor tendon complex (the conjoined tendon) will not product hallux varus when the hallux is not rotated. However, in more severe hallux valgus, pronation of the hallux may be proportional to the deformity of the hallux itself. This rotational deformity places the insertions of the abductor (and medial insertion of the flexor brevis) more plantarward and lateral, increasing the valgus deformity. If the entire conjoined tendon is sectioned and the internal rotation deformity corrected the insertion of the contracted abductor moves medially, pulling the toe into varus. If the center of the base of the proximal phalanx is brought beyond the mid-point of the first metatarsal head, the extensor hallucis longus will bowstring, pulling the great toe into varus while creating a hallux flexus deformity. Finally, if the lesser toes are in varus and not corrected, this deforming force will create hallux varus following bunion correction with a lateral release. The message is clear: not all patients require a lateral release, and, if done, should be done with caution. Once present, correction can be difficult. Tendon transfers utilizing the extensor hallucis longus (Johnson) or extensor hallucis brevis (Myerson) only have beneficial effects in non-arthritic, mobile first metatarsophalangeal joints. In addition, if metatarsal deformity is not corrected, the deformity will recur. Thus, in many circumstances, arthrodesis of the first metatarsophalangeal joint becomes the treatment of choice, and is commensurate with a disappointed patient who underwent a primary bunion correction and was left with a fused great toe. This lecture will explore the above mechanism and salvage situations, in hopes of eliminating this unwelcomed outcome from your practice

The June 2015 Children’s orthopaedics Roundup. 360 . looks at: ACL reconstruction in paediatric knees; Hips, slips and cams; The adolescent clavicle; 3D fluoroscopy in DDH?; The psychiatric aspects of hip pain in adolescents; Adolescent bunions: dealer’s choice?; Medial epicondylar fractures revisited

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

About 20% of orthopaedic surgery is foot and ankle. This area of orthopaedics has undergone huge changes in last few decades. Not that long ago we were still performing Keller's procedure for bunions and using a Charnley clamp for ankle fusions. It is becoming increasingly more difficult for the general orthopaedic surgeon to stay abreast of current surgical treatment. Some of the newer foot and ankle surgical surgical techniques will be discussed. Ankle arthroplasty is undergoing a period of revival. This is a difficult procedure with results not as reliable as hip and knee arthroplasty and I would not recommend it to the occasional foot and ankle surgeon. Ankle arthroscopy is now a commonly performed procedure and with the right equipment is a procedure that is useful to the generalist. Foot and ankle fusion are now performed with rigid internal fixation. The actual procedures are not difficult but it does require a reasonable amount of experience to obtain the correct position of the fusion. Bunion surgery is commonly done and can result in disappointment for all. The newer surgical options for the correction of hallux valgus will be discussed

Purpose: Scarf osteotomies are commonly performed in adults with symptomatic bunions. We have reported the radiological and clinical outcome of this procedure in the treatment of moderate to severe hallux valgus among adolescent children. Methods: Data was collected retrospectively from a tertiary referral children hospital between April 2001 and June 2006. The pre and postoperative intermetatarsal angle (IMA), hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA) were determined. Patients were followed up for a mean of 8.6 months (3–18). Results: 23 scarf osteotomies were performed in 16 patients with a mean age of 14.3 years (12–18). The mean pre operative IMA of 14.4 degrees was improved to a postoperative value of 9.3 degrees, p< 0.0001. The mean HVA angle was improved from 34.7 to 16.5 degrees, p< 0.0001. The DMAA was improved from 13.1 to 8 degrees, p< 0.0001. There were 2 cases of superficial wound infections successfully treated with oral antibiotics. One patient developed a complex regional pain syndrome that resolved with physiotherapy and analgesia. Conclusion: We believe that scarf osteotomy is a safe and effective option for the management of the adolescent symptomatic bunions. Significance: There are no published reports in the English literature of scarf osteotomy in the management of adolescent children with symptomatic hallux valgus. The aim of this paper is to report the radiological and clinical outcome of scarf osteotomy in the treatment of moderate to severe hallux valgus among adolescent children

Failed Hallux Valgus Surgery Aim. We aim to explore the reasons behind long term failure of hallux valgus surgery. Patients & Methods. A series of patients with problems following failed hallux valgus surgery presenting to a tertiary referral unit is presented. There were 47 patients with 55 problematic feet, 45 were female. The mean age was 59 years (Range 25–79). The failed bunions were compared to a prospectively collected series of 80 patients with successful 1st metatarsal osteotomies, 40 ludloff and 40 scarf osteotomies. Before the index surgery, all the patients in the failed group, the predominant symptom was pain. Only 53% admitted deformity was an issue. A wide spectrum of procedures were performed, 13 Wilson's, 11 Keller's, 8 Chevron, 3 Bunionectomy, 2 Scarf, 1 Basal and 1 Mitchell's. In 16 patients the original procedure was unknown. The mean time to developing problems was 9.4 years (Range 0–45) with mean time to presentation 13.6 years. (Range 0–47) Radiographs revealed 2/3 of patients had relative shortening of the first metatarsal. Over 80% of x-rays demonstrated evidence of degenerative change. The mean AOFAS score deteriorated with increased shortening. The failed bunions had statistically significantly different AOFAS pain scores (15.1 vs 31.9 p < 0.05), function scores (25.02 vs 31.9 p < 0.05). Additionally, the hallux valgus angle was significantly higher (24 vs 11.7 p < 0.05) although there was no change in DMMA between the two groups (13 vs 7.6 p > 0.05). There was a significantly higher incidence of first ray shortening (12% vs 0% p < 0.05). Discussion. This represents an unusual series, with nothing similar in the literature. Problems following hallux valgus surgery do not present for over 10 years. Functional Scores deteriorate with increasing shortening. MTPJ degeneration is common and from our data we are unable to explain why

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. Methodology:. This is a consecutive case series performed between 2009 and 2012. This includes the learning curve for minimally invasive surgery. All cases were performed by a single surgeon at two different sites, one centre where minimally invasive surgery is available and the other where it is not. The standard procedure in both centres is a modified Chevron osteotomy. Regardless of whether the osteotomy was performed open or minimally invasive two-screw fixation was performed. Retrospective analysis includes the IMA, HVA, M1 length, forefoot width and forefoot: hindfoot ratio. Clinical outcomes include the MOXFQ, AOFAS, and assessment of complications. Results:. There were 70 cases in each arm. Follow-up was 4 years to 6 months. The radiological outcomes were similar in both groups. There was an increased rate of screw removal in the MICA group. There were also cases of hallux varus, these occurred in the cases with severe pre-operative IMA angles that also had a lateral release and an Akin. There was high satisfaction in both groups. Conclusion:. This is the only comparison of minimally invasive and open techniques that has been performed, providing a direct comparison of the utility of a burr compared to a saw. These early results demonstrate the efficacy of a Minimally Invasive Chevron/Akin in terms of achieving radiological correction. The clinical outcomes are excellent but there is a learning curve and this needs to be managed

Recent Department of Health guidelines have recommended that bunion surgery should be performed as a day case in a bid to reduce hospital costs, yet concurrently improving patient outcomes. Following an audit in 2012/3, we implemented a number of measures in a bid to improve the rates of day case first ray surgery. In this paper, we look to see if these measures were effective in reducing the length of stay in first ray surgery. We performed a prospective case note review of all patients undergoing first ray surgery between 01/01/2012 and 01/02/2013, and found the rates of same day discharge in this group to be lower than expected at just 24.19%. We recognised that the most commonly cited reasons for delayed discharge were that patients not being assessed by physiotherapy, and were unable to have their take home medication (TTO's) dispensed as pharmacy had closed. To address this, we implemented a pre-operative therapy led foot school, and organised ward analgesia packs which may be dispensed by ward staff, thus bypassing the need for pharmacy altogether. Together, we coined the term “care package” for these measures. We then performed a post implementation audit between 01/01/2014 to 01/01/2015 to ascertain if these measures had been effective. We identified 62 first ray procedures in the preliminary audit, with an average age of 50.5 years (range 17–78 years) and a M:F ratio of 1:5. The most commonly performed procedures were Scarf osteotomy, 1st MTPJ fusion, and distal Chevron osteotomy. We compared this to 63 first ray procedures post implementation of the care package. The average age was 55.3 years (range 15–78 years) and the M:F ratio was 1:2.5, and there was a similar distribution in terms of specific procedures. We found the length of stay had reduced from 1.00 to 0.65 days (p= 0.0363), and the rate of same day discharge had increased from 24.6% to 44.6% (p= 0.0310). We also noted that St Helens Hospital (SHH), the dedicated day case surgery unit, had a significantly increased rate of same day discharge than Whiston Hospital (WH- the main hospital) at 87.5% and 28.89% respectively (p= 0.0002). Preoperative physiotherapy assessment is an important tool in reducing length of stay for first ray surgery. The use ward analgesia packs has a synergistic effecting in increasing day case first ray surgery. We therefore commend its use to other centers. Additionally, we have shown dedicated day case surgery units are more effective at achieving same day discharge than general hospitals

The August 2023 Foot & Ankle Roundup³⁶⁰ looks at: Achilles tendon rupture: surgery or conservative treatment for the high-demand patient?; First ray amputation in diabetic patients; Survival of ankle arthroplasty in the UK; First metatarsophalangeal joint fusion and flat foot correction; Intra-articular corticosteroid injections with or without hyaluronic acid in the management of subtalar osteoarthritis; Factors associated with nonunion of post-traumatic subtalar arthrodesis; The Mayo Prosthetic Joint Infection Risk Score for total ankle arthroplasty.

The June 2024 Foot & Ankle Roundup³⁶⁰ looks at: First MTPJ fusion in young versus old patients; Minimally invasive calcaneum Zadek osteotomy and the effect of sequential burr passes; Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy; Revision ankle arthroplasty – is it worthwhile?; Tibiotalocalcaneal arthrodesis or below-knee amputation – salvage or sacrifice?; Fusion or replacement for hallux rigidus?.

Purpose of study:. Congenital hallux varus is a rare condition presenting with medial deviation of the big toe. It consists of 2 variants: classical congenital hallux varus caused by an abnormal metatarsal-phalangeal articulation, and a more recently described variant due to a “bracket physis” of the first metatarsal. Our aim was to perform an audit of the spectrum of presentation of congenital hallux varus with its management and complications in our unit over a five year period. Description of methods:. A retrospective review of congenital hallux varus treated by a single surgeon was performed. Clinical notes, photographs and x-rays were reviewed. Two surgical methods of treatment were used as directed by clinical and radiological findings. Summary of results:. Four patients with congenital hallux varus were identified. Three had bilateral involvement, i.e. seven feet were treated. The ages of the patients ranged from 1 to 9 years, with 2 boys and 2 girls receiving treatment. In two patients (4 feet) the deformity was associated with pre-axial polydactyly. One patient had associated hand deformities. Only one of our four patients had a “bracket physis” and was treated with a metatarsal osteotomy. The other three patients (6 feet) were treated by soft tissue realignment using the Farmer procedure. One patient who had bilateral Farmer procedures subsequently developed a bunion over the 1st metatarso-phalangeal joint of one foot due to uncovering of the metatarsal head. No complications or recurrences were recorded in the other three patients on follow up visits. Conclusion:. Careful clinical and X-ray analysis is important to determine the type of congenital hallux varus and which method of surgical treatment is appropriate. Long term follow up is required to identify subsequent deformities