Correction method for moderate and severe degrees of hallux valgus associated with transfer metatarsalgia

BACKGROUND Hallux valgus(HV)is a common foot deformity that manifests with increasing age,especially in women.The associated foot pain causes impaired gait and decreases quality of life.Moderate and severe HV is a deformity that is charac-terized by the involvement of lesser rays and requires complex surgical treatment.In this study,we attempted to develop a procedure for this condition.AIM To analyse the treatment results of patients who underwent simultaneous surgical correction of all parts of a static forefoot deformity.METHODS We conducted a prospective clinical trial between 2016 and 2021 in which 30 feet with moderate or severe HV associated with Tailor’s bunion and metatarsalgia were surgically treated via a new method involving surgical correction of all associated problems.This method included a modified Lapidus procedure,M2M3 tarsometatarsal arthrodesis,intermetatarsal fusion of the M4 and M5 bases,and the use of an original external fixation apparatus to enhance correction power.Preoperative,postoperative,and final follow-up radiographic data and American Orthopaedic Foot and Ankle Society(AOFAS)scores were compared,and P values<0.05 were considered to indicate statistical significance.RESULTS The study included 28 females(93.3%)and 2 males feet(6.7%),20(66.7%)of whom had a moderate degree of HV and 10(33.3%)of whom had severe deformity.M2 and M3 metatarsalgia was observed in 21 feet,and 9 feet experienced pain only at M2.The mean follow-up duration was 11 months.All patients had good correction of the HV angle[preoperative median,36.5 degrees,interquartile range(IQR):30-45;postoperative median,10 degrees,IQR:8.8-10;follow-up median,11.5 degrees,IQR:10-14;P<0.01].At follow-up,metatarsalgia was resolved in most patients(30 vs 5).There was a clinically negligible decrease in the corrected angles at the final follow-up,and the overall AOFAS score was significantly better(median,65 points,IQR:53.8-70;vs 80 points,IQR:75-85;P<0.01).CONCLUSION The developed method showed good sustainability of correction power in a small sample of patients at the one-year follow-up.Randomized clinical trials with larger samples,as well as long-term outcome assessments,are needed in the future.

Footwear modification following hallux valgus surgery: The all-or-none phenomenon

AIM:To define footwear outcomes following hallux valgus surgery,focusing on patient return to comfortable and heeled footwear and patterns of post-operative footwear selection.METHODS:Surgical intervention is indicated for symptomatic cases of hallux valgus unresponsive to conservative methods,with favourable reported outcomes.The return to various types of footwear postoperatively is reflective of the degree of correction achieved,and corresponds to patient satisfaction.Patients are expected to return to comfortable footwear post-operatively without significant residual symptoms.Many female patients will additionally attempt to return to high-heeled,narrow toe box shoes.However,minimal evidence exists to guide their expectations.Sixtyfive female hallux valgus patients that had undergone primary surgery bet ween 2011 and 2013 were retrospectively identified using our hospital surgical database.Patients were reviewed using a footwearspecific outcome questionnaire at a mean 18.5 mo follow-up.RESULTS:Eighty-six percent of patients were able to return to comfortable footwear post-operatively with minimal discomfort.Of those intending to resume wearing heeled footwear,62%were able to do so,with 77%of these patients wearing these as or more frequently than pre-operatively.No significant difference was observed between pre-and post-operative heel size.Mean time to return to heeled footwear was 21.4wk post-operation.Cosmetic outcomes were very high and did not adversely impact footwear selection.CONCLUSION:We report high rates of return to both comfortable and heeled shoes in female patients following primary hallux valgus surgery.We observed an"all-ornone phenomenon"where patients rejected a return to heeled footwear unless able to tolerate them at the same frequency and heel size as pre-operatively.A minority of patients were unable to return to comfortable footwear post-operatively,which had adverse ramifications on their quality-of-life.We recommend that the importance of managing patient expectations through appropriate pre-operative counselling be emphasized in forefoot surgery.

CLINICAL CONCEPTION OF KELLER'S OPERATION FOR HALLUX VALGUS DEFORMITY——A SURVEY OF 112 CASES

In a long-term follow-up study (average, 6.5 years) of 112 feet (90 pa-tients) subjected to Keller’s operation for hallux valgus deformity, the author observed arelationship between Keller’s operation and the metatarsalgia which was located beneaththe central metatarsal heads. The data showed that the metatarsalgia developed or was ag-gravated in 26 feet (23%), and was eliminated or alleviated in 23 feet (21%) afterKeller’s operation. When more than one-third of the proximal phalanx of the big toe wasresected, the incidence of the metatarsalgia obviously increased following surgery. Theautho rpreferred a "Z" lengthening of the extensor hallucis longus tendon instead ofresecting excessive proximal phalanx. The total incidence of the metatarsalgia was 36%(40 feet) preoperatively and 38% (43 feet) postoperatively. This result indicated thatthere was no obvious difference in the incidence of the preoperative and postoperativemetatarsalgia. No more than one-third of the proximal phalanx of the big toe should beremoved. This seems to reduce the incidence of the metatarsalgia after Keller’s operation.After operation, the three princepal symptoms of hallux valgus deformity, painful bunionand difficulty in shoe-wearing were improved for more than 95% in the 112 feet.Eighty one% of the patients were satisfied with the result of the operation. We considerthat this method is one of the effective operation for correcting the hallux valgusdeformity and it is also important to select suitable patients.

A New Intramedulary Locking Plate for the Osteotomy of the V. Metatarsal in the Correction of the Tailors Bunion. Midterm Results of 21 Patients

Background: Since we are very successful in the operation of hallux valgus using a transverse sub-capital osteotomy fixated with an intramedullary angle-stable locking plate, and a tailors bunion is understood as a reversed hallux valgus, we have applied the operation also for such indication. Method: The osteotomy was carried out at a straight V. metatarsal subcapitally, and in case of an outwardly curved V. metatarsal at the bending location. The intramedullary plates are available in different designs and the plate and screws disappear completely in the bone, so the soft tissues are not disturbed. The head of the plate is either straight or curved in order to shift the distal fragment sufficiently. Results: 26 patients were operated within a period of 5 years (2008-2012). 21 patients were followed up after an average of 34.4 months. The IM angle IV/V could be improved by an average of 11.76 to an average of 4.10. This is a highliy significant pre- to postoperative difference of 7.66 (t = 15.07, p < 0.001). The AOFAS score was improved by an average of 42.24 points from 55.76 points preoperatively to 98.00 points postoperative. There was no pseudo-arthrosis and no wound healing impairment. All patients were either satisfied or very satisfied with the surgery. Conclusion: This method does not have the disadvantages of the other common operations of the Tailors bunion and is applied now as a standard method in this deformity.