Aims. The purpose of this study was to analyse the biomechanics of walking, through the ground reaction forces (GRF) measured, after first metatarsal osteotomy or metatarsophalangeal joint (MTP) arthrodesis. Patients and Methods. A total of 19 patients underwent a Scarf osteotomy (50.3 years, standard deviation (. sd. ) 12.3) and 18 underwent an arthrodesis (56.2 years,. sd. 6.5). Clinical and radiographical data as well as the American Orthopaedic Foot and Ankle Society (AOFAS) scores were determined. GRF were measured using an instrumented treadmill. A two-way model of analysis of variance (ANOVA) was used to determine the effects of surgery on biomechanical parameters of walking, particularly propulsion. Results. Epidemiological, radiographical and clinical data were comparable in the two groups and better restoration of propulsive function was found after osteotomy as shown by ANOVA (two way: surgery × foot) with a surgery effect on vertical forces (p < 0.01) and a foot effect on anteroposterior impulse (p = 0.01). Conclusion. Patients who underwent Scarf osteotomy had a gait pattern similar to that of their non-operated foot, whereas those who underwent arthrodesis of the first (metatarsophalangeal) MTP joint did not totally recover the propulsive forces of the forefoot. Take home message: The main findings of this study were that after surgical correction for hallux valgus, patients who underwent scarf osteotomy had a gait pattern similar to that of their non-operated foot in terms of forefoot propulsive forces (Fz3, Iy2), whereas those who underwent arthrodesis of the first MTP joint had not. Cite this article: Bone Joint J 2016;98-B:641–6

The Chevron osteotomy was described in 1976. There have, however, been only short- to mid-term follow-up reviews, often with small numbers of patients. We looked at 112 feet (73 patients) with a minimum follow-up of ten years following Chevron osteotomy with a distal soft-tissue procedure. Clinical evaluation was calculated using the hallux score of the American Orthopedic Foot and Ankle Society (AOFAS). For 47 feet (30 patients), the results were compared with those from an interim follow-up of 5.6 years. The AOFAS-score improved from a pre-operative mean of 46.5 points to a mean of 88.8 points after a mean of 12.7 years. The first metatarsophalangeal (MTP) angle showed a mean pre-operative value of 27.6° and was improved to 14.0°. The first intermetatarsal (IM) angle improved from a pre-operative mean value of 13.8° to 8.7°. The mean pre-operative grade of sesamoid subluxation was 1.7 on a scale from 0 to 3 and improved to 1.2. Measured on a scale from 0 to 3, arthritis of the first MTP joint progressed from a mean of 0.8 to 1.7. Comparing the results in patients younger and older than 50 years, the Chevron osteotomy performed equally in both age groups. Analysing the subgroup of 47 feet with a post-operative follow-up of both 5.6 and 12.7 years, the AOFAS pain and the overall score showed a further improvement between both follow-up evaluations. The MTP angle, first IM angle and sesamoid position remained unchanged. The progression of arthritis of the first MTP joint between 5.6 and 12.7 years post-operatively was statistically significant. Only one patient required a revision procedure due to painful recurrence of the deformity. Excellent clinical results following Chevron osteotomy not only proved to be consistent, but showed further improvement over a longer follow-up period. The mean radiographic angles were constant without recurrence of the deformity. So far, the statistically significant progression of first MTP joint arthritis has not affected the clinical result, but this needs further observation

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

We reviewed 91 patients (103 feet) who underwent a Ludloff osteotomy combined with additional procedures. According to the combined procedures performed, patients were divided into Group I (31 feet; first web space release), Group II (35 feet; Akin osteotomy and trans-articular release), or Group III (37 feet; Akin osteotomy, supplementary axial Kirschner (K-) wire fixation, and trans-articular release). Each group was then further subdivided into severe and moderate deformities.

The mean hallux valgus angle correction of Group II was significantly greater than that of Group I (p = 0.001). The mean intermetatarsal angle correction of Group III was significantly greater than that of Group II (p < 0.001). In severe deformities, post-operative incongruity of the first metatarsophalangeal joint was least common in Group I (p = 0.026). Akin osteotomy significantly increased correction of the hallux valgus angle, while a supplementary K-wire significantly reduced the later loss of intermetatarsal angle correction. First web space release can be recommended for severe deformity. Additionally, K-wire fixation (odds ratio (OR) 5.05 (95% confidence interval (CI) 1.21 to 24.39); p = 0.032) and the pre-operative hallux valgus angle (OR 2.20 (95% CI 1.11 to 4.73); p = 0.001) were shown to be factors affecting recurrence of hallux valgus after Ludloff osteotomy.

Cite this article: Bone Joint J 2013;95-B:803–8.

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group.

These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals.

We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others.

The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained.

One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal.

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.

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy.

The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one.

With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.