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Unilateral Versus Bilateral Same-Day Surgery Outcomes for Hallux Valgus: An Eight Year Prospective Cohort Study

by Jill Dawson, DPhil1emailsm, Michele Peters, PhD2emailsm, Crispin Jenkinson, DPhil3emailsm, Helen Doll, DPhil4emailsm, Grahame Lavis, BSc (Hons)5emailsm, Robert Sharp, MA FRCS (Ortho)6emailsm, Mark Rogers, FRCS (Ortho)7emailsm, Paul Cooke, ChM FRCS8emailsm

The Foot and Ankle Online Journal 5 (11): 2

Objective: To evaluate patient-reported outcomes and satisfaction 8 years following hallux valgus (HV) surgery and compare unilateral and bilateral cases.
Methods: Prospective Cohort with postal follow-up patient survey. Consecutively-recruited patients self-completed the Manchester-Oxford Foot Questionnaire (MOxFQ) ≤ 4 weeks before surgery. Of 91 patients proceeding to one-stage HV surgery (on 124 feet, 23 (18.5%) receiving further surgery), 69 (78%) of 88 eligible patients (representing 95/124, 77% feet: 43/95, 45.3% unilateral, 52/95, 54.7% bilateral) returned a follow-up questionnaire including the MOxFQ and standard satisfaction rating for surgical outcome around 8 years (range 7.4 to 8.9) later.
Results: Of 69 respondents, mean pre-operative age 49.8 (SD 12.5) years, 66 (95.7%) were female. Reporting on 95 feet, 78 (82.1%) patients were either ‘Very pleased’ (All 53/95, 55.8%; unilateral: 22/43, 51.2; bilateral 31/52, 59.6%) or ‘Fairly pleased’ (All 25/95, 26.3%; unilateral 13/43, 30.2; bilateral 12/52 23.1) with the outcome; with 17/95 (17.9%) ‘Not very pleased/very disappointed’. Change in all 3 MOxFQ scales showed a significant linear relationship with satisfaction ratings (ANOVA p<0.001). The MOxFQ pain scale showed greatest change (decrease in score) associated with being ‘Very pleased’ (mean (95% CI) reduction in score: Pain -48.0 (-42.8 to -53.2); Walking/Standing -38.4 (-32.0 to -44.8); Social-Interaction -43.1 (-36.9 to -49.4)
Conclusions: At 8 years following HV surgery, the majority of patients were pleased with the outcome. Simultaneous bilateral HV correction produced results that were no worse than unilateral correction. Change in the MOXFQ pain scale is particularly important in interpreting patients’ satisfaction with surgery.

Key Words: Foot pain, hallux valgus, bunionectomy, first metatarsophalangeal joint

Accepted: October, 2012

Published: November, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0511.0002

Hallux valgus (HV) is a common condition, particularly in women.[1,2] HV can present unilaterally or bilaterally and is characterized by lateral deviation of the big toe and medial deviation of the first metatarsal with progressive subluxation of the first MTP joint.[1] The condition can be painful and disabling and has been shown to have a detrimental effect on quality of life.[3]

It is one of the most common indications for foot surgery, where between a quarter and a third of patients are dissatisfied with the outcome[4]; although many factors can affect outcomes and satisfaction.[5]

The evaluation of outcomes following HV correction tend to represent a relatively short period (i.e. 12 months or less) following surgery with few studies involving validated patient-reported outcome measures.[4] Standardized patient-reported methods of assessing outcomes, (particularly those devised with patients’ input), reflect the patients’ rather than the clinicians’ perspective[6,4,7] and are independent of the surgical team.

Where HV is bilateral, the question of whether patients do better to have both feet treated at the same time, or not, has received some attention, although again, outcomes evaluation has tended to be relatively short-term and not patient focused.[8]

This paper presents patient-reported outcomes data based on a service evaluation survey conducted of consecutive patients who had received surgery for HV at one center, between 7 and 9 years previously, and who had provided baseline data prior to their surgery. Results are also broken down to compare patients who had unilateral versus bilateral HV surgery.


Local ethics committee approval was obtained (Applied and Qualitative Research Ethics Committee reference A02.009) for the original study;[9] postal service evaluation survey approved by the institution’s Integrated Governance Committee (August 2011).

At baseline 100 out of 111 consecutive patients were approached and consented to take part, 38 of whom were booked for bilateral HV correction. Of these, 91 (/100) patients proceeded to surgery, of whom, 33 (/91, 36%) had bilateral surgery (total=124 operations/feet). All surgery was completed on the one day (i.e. no 2-stage operations).

Prior to conducting the postal survey, patients’ current address details were checked through the hospital information system. Questionnaires were mailed together with cover letters and a stamped addressed envelope. Where any questionnaires were returned as ‘unknown’ the patient’s last known GP practice was contacted by a member of the foot and ankle surgical team. In all other cases of non-response after 4 weeks, a reminder letter was sent out with a second copy of the survey questionnaire.

Overall, 2 patients were known to have died and one had emigrated. Of the remaining 88 eligible patients, 69 (/88, 78%) returned a completed follow-up survey questionnaire, with no response obtained from a further 19 (/88, 22%) patients. Of the 69 respondents, 26 (38%) were bilateral cases who contributed outcome data regarding two foot (HV) operations. Thus 69 patients completed questionnaires regarding ~8 year outcomes for 95 operations/feet. Their mean pre-operative age was 49.8 (SD 12.5) years; 66 (66/69, 95.7%) were female. The mean period of follow-up (original operation date until date of survey completion) was 8.03 (SD 0.37, range 7.41 to 8.87) years.


Patients completed the Manchester-Oxford Foot Questionnaire (MOxFQ) for each foot having surgery as well as the SF-36 general health survey (completed once per patient), at a pre-admission clinic, within 4 weeks prior to surgery. These measures were completed again as part of the 2011 postal survey.

The MOxFQ has previously been validated with patients undergoing HV surgery.[9,10] It was subsequently revalidated in a separate study involving all patients undergoing foot or ankle surgery in a 12 month period, at one regional center.[11,12] It contains 16 items, each with 5 response options, comprising 3 separate underlying dimensions: foot pain (5 items), walking/standing problems (7 items) and issues related to social interaction (4 items), including feelings of self-consciousness about foot/footwear appearance (‘cosmesis’).

Item responses are each scored from 0 to 4, with 4 representing the most severe state. The scale score representing each dimension is produced by summing the responses to each item within that dimension. Raw scale scores are then converted to a 0 to 100 point scale (100=most severe).

The SF-3613 contains 36 items and is a widely used generic health status instrument. It provides scores on 8 dimensions of health: physical functioning, social functioning, role limitations due to physical problems, role limitations due to emotional problems, mental health, energy/vitality, bodily pain and general health perceptions over the last 4 weeks. Scores for each dimension are produced by summing the responses to each item within that dimension and then converting the raw scores to a 0 to 100 point scale, (100= good health) general population norm set at 50, SD 10.

The postal survey also included a transition item, (‘How are the problems related to your foot now, compared to before your surgery?’, response options: no problems now, much better, slightly better, no change, slightly worse, much worse), and 3 questions regarding patients’ satisfaction with the outcome (‘Overall, how pleased have you been with the result of the surgery on your foot?’; ‘How pleased are you with the appearance of your foot?’; ‘How pleased are you with the range of shoes that you can wear?’); each with response options: ‘Very pleased’, ‘Fairly pleased’, ‘Not very pleased, ‘Very disappointed’.

The transition and satisfaction items were asked in relation to each foot that had received surgery approximately 8 years previously. Additional questions asked whether the patient had received further surgery on the same foot since the original operation, and whether or not the patient currently had a problem with their other (contralateral) foot. A surgeon also checked for details of any subsequent foot surgery via the hospital patient information system.

Statistical analysis

Power calculations had determined that a sample size of 100 would give 80% power to detect, at p<0.05, a difference in proportions of 25%-30% and a medium effect size of around 0.55 between two groups of equal size. Data analysis was undertaken within SPSS release 17.0.14 Data are presented as mean (SD) at each assessment and mean change (SD) from pre-surgery to 8 years post surgery (post-surgical score minus pre-surgical score), with paired t-tests used to assess the statistical significance of any observed change. Statistical significance was taken at the 5% level throughout.

Some analyses (e.g. patient characteristics and SF-36 outcomes) have been conducted at the level of the patient (n=91 who had surgery, n=69 questionnaire respondents), while analyses of foot-specific outcomes and satisfaction with surgery have been conducted at the level of the foot (n=124 foot operations, involving n=95 completed questionnaires). Since 26 patients had bilateral operations, (which threatened the independence of patients’ observations on their two individual feet), baseline analyses were repeated three times: on the data for left feet only (n=61/124, 49.2%), right feet only (n=63/124, 50.8%), and for both feet (n=124; with 52 patients contributing data for both left and right feet). The results were, in fact, very similar for all analyses, and thus only the analyses that combined data for left and right feet are presented here.

The effect size (ES) statistic has been used to demonstrate the magnitude of change detected by the different outcome measures. This is calculated by dividing the mean change in scores (post-surgical score minus pre-surgical score) by the pre-surgical SD, this standardization by the SD allowing direct comparison to be made between instruments with different scales.[15]

An ES of 1.0 (or -1.0 for scales in which improvement is associated with a decrease in score) is equivalent to a change of one SD in the sample. Values of 0.2, 0.5 and 0.8 are typically regarded as indicating small, medium and large degrees of change, respectively.[15,16]

The relationship between MOxFQ change scores and four levels of response on the satisfaction with surgery rating have been explored using analysis of variance (ANOVA) test for linearity and Tukey post-hoc tests.

Survey respondents versus non-respondents

Survey non-respondents were somewhat more likely to be male, younger, and employed, than respondents (no differences were statistically significant), but were no more likely to have received bilateral surgery on the original operation date. Respondents and non-respondents did not differ significantly with regard to the type of surgery that they received (Foot level analysis/ Respondents: Scarf procedure, with or without Akin 57/68, 83.8%; chevron 8/68, 11.8%; ’another form of surgery’ 3/68, 4.4% versus Non-respondents: Scarf procedure, with or without Akin 17/21, 81.0%; chevron 4/21, 19.0%; ’another form of surgery’ 0/21, 0%); or with regard to the need to have subsequent surgery (including revision) to the same foot (Foot level analysis/ Respondents 17/95, 17.9% versus non-respondents 6/29, 20.7%). Respondents’ pre-operative MOxFQ scores were all somewhat higher (worse) than those of non-respondents, particularly for the Walking/standing scale, although they did not differ significantly [MOxFQ Walking/standing (W/S), Pain and Social-Interaction (SI) scores: Respondents’ mean (SD) scores: W/S 47.3 (25.5); Pain 55.3 (17.8); SI 47.7 (22.5) versus Non-respondents’ mean (SD) scores: W/S 38.5 (21.2); Pain 49.8 (22.6); SI 43.8 (22.2).]

Unilateral versus Bilateral patient characteristics

There were no significant differences in the characteristics of patients who received unilateral versus bilateral surgery in relation to age, sex, qualifications or work status. Unsurprisingly, while 15 of the 43 patients having unilateral surgery reported having a problem affecting the contralateral foot (at baseline), all patients having bilateral surgery reported this (15/43, 34.9% versus 26/26, 100.0%; p<0.001).

Person-level analyses

Table 1 shows pre-, post-operative and change scores, plus effect sizes (ESs), for the generic SF-36, for all patients, and separately for patients having unilateral and bilateral surgery.

Overall, with the exception of the Pain domain (ES 0.7), most of the SF-36 domains showed small to moderate (in terms of ES) increases in score (i.e., improvement) compared with patients’ pre-operative baseline measures ~8 years previously. The largest improvements in health status (i.e. ES ≥ 0.4) were all highly significant (P ≥ 0.001).

SF-36 pre-operative scores were mostly slightly higher (better) in patients having unilateral, compared with those having bilateral surgery, although none of these differences were statistically significant (p value range 0.21 to 0.79). SF-36 scores were even more similar for unilateral and bilateral surgical groups when analyses were repeated after excluding patients who only had a unilateral foot problem at baseline (results not shown). Conversely, SF-36 post-operative scores were mostly lower (worse) in patients having unilateral, rather than bilateral surgery, although again, none of these differences were statistically significant (p value range 0.10 to 0.70).


Table 1 Mean pre-operative, 8 year post-operative and change values, plus effect sizes for SF-36 patient-reported sub-scales in all patients, and comparing those who received unilateral versus bilateral surgery to correct hallux valgus [Patient-level analysis].


Table 2 Mean pre-operative, 8 year post-operative and change values, plus effect sizes for MOxFQ patient-reported domains/sub-scales, representing all feet that received bunion surgery and comparing outcomes of operations that represented a unilateral versus bilateral procedures [Foot-level analysis].


Table 3 Aspects of patient-rated satisfaction 8 years following surgery to correct hallux valgus deformity [Foot-level analysis N=95].

The magnitude of the differences between the pre- and post-operative SF-36 scores, within the unilateral and bilateral groups, are shown most clearly by the ESs. (Table 1) Amongst those who had unilateral surgery, ESs for the SF-36 domains were all small (≤ 0.3) with the exception of the Pain domain, which was moderate (ES 0.6); while amongst those who had bilateral surgery, most of the SF-36 domains achieved moderate ESs (ES 0.5 to <0.8); although the ES for the Pain domain was large (ES 0.8).

A comparison of the SF-36 change score differences between the unilateral and bilateral surgical groups revealed differences to be statistically significant in 3 domains: Role Physical (Uni/Bi mean change, SD: 1.4, 30.5/; p=0.02), Social Functioning (Uni/Bi mean change, SD: 3.6, 28.6/15.6, 21.6; p=0.03) and Mental Health (Uni/Bi mean change, SD: 3.6, 15.3/ 10.0, 12.4 p=0.004), with bilateral cases registering greater change on these scales than unilateral cases.

Foot level analyses

Within the period (~8 years) following the original operation, further surgery had been conducted on the same foot in 23 cases (23/124, 18.5%). Overall, each MOxFQ scale/domain registered a very large ES (WS -1.1, Pain -1.8, SI -1.3), representing decreases (i.e., improvement) from the pre-surgery baseline scores 8 years previously, with all related change scores highly significant (p<0.001). (Table 2) The magnitude of the differences/ changes between the pre- and 8 year post-operative MOxFQ scores within the unilateral and bilateral subgroups, are shown by the ESs. Amongst those who had unilateral surgery, ESs for all 3 MOxFQ scale domains were large (≥ -0.8); while ESs amongst those who had bilateral surgery, were slightly larger (ES ≥ -1.1). These changes over time were all highly significant.

A comparison of the change score differences between the unilateral and bilateral groups revealed very similar (and statistically insignificant) mean change scores for the differences in W/S and Pain scales, but the change scores did differ significantly for the SI domain, (which assesses aspects of work and social participation, footwear and ‘cosmesis’), with bilateral cases registering greater change on this scale than unilateral cases (Uni/Bilateral mean change, SD: -19.8, 29.4 versus -36.9, 25.5; p<0.01). The difference between these change scores (of 17.1 score points) was greater than the Standard Error of Measurement (SEM) (11.92 score points) that has previously been estimated for this scale.[10]

Patient satisfaction [per foot]

Table 3 reports patients’ responses to the transition and satisfaction items asked in relation to each foot that received surgery. Comparisons are made between responses that relate to a unilateral operation versus those relating to each foot comprising a bilateral (same day) procedure. Overall, more than half of the foot operations (53, 55.8%) were associated with patients being ‘Very pleased’ with the outcome of their surgery and a high proportion (78, 82.1%) were rated as either ‘Very pleased’ or ‘Fairly pleased’.

Three-quarters (72, 75.8%) of pre-operative foot problems were now reported as non-existent (‘No problems now’) or ‘Much better’. Poorer satisfaction ratings were given specifically in relation to the range of shoes patients could now wear (35, 36.8% ‘Very pleased’) and with the appearance of the foot (45, 47.4% ‘Very pleased’). Bilateral operations attracted the highest proportion of extremely positive satisfaction ratings across all 4 items, compared with unilateral operations, although none of these differences were statistically significant.

Relationship between patient satisfaction and foot outcome measures (MOxFQ)
[foot-level analysis]

Figures 1A and 1B show the mean 8 year post-operative MOxFQ W/S, Pain and SI scale scores and change scores respectively, together with 95% confidence intervals (CIs), broken down according to patients’ responses [‘Very pleased’, ‘Fairly pleased’, ‘Not very pleased’, Very disappointed’] to the satisfaction item: ‘How pleased are you now with the result of your foot surgery?’

Regarding post-operative MOxFQ scale scores (figure 1a), mean scores for all 3 MOxFQ scales that were associated with the most positive (‘Very pleased’) satisfaction rating (Mean, 95% CIs: W/S 8.8, 4.4 to -13.1; Pain 8.9, 5.1 to -12.8; SI 4.6, 1.9 to -7.3) were distinctly lower/better than scores associated with other responses to the satisfaction item with all patients who were ‘Very pleased’ with the outcome scoring <14 on each MOxFQ scale. Thus, there was also no overlap between 95% CIs for mean scores related to this response and those related to any other response. However, most of the 95% CIs associated with all other (less positive) ratings on the transition item overlapped.

Further analyses (ANOVA with testing for linear trend and Tukey post-hoc comparisons) confirmed significant linear trends in MOxFQ domain score across categories of response (p<0.001).

8yrHAVFig1a 8yrHAVFig1b

Figure 1A and 1B MOxFQ 8 year post-operative scores related to different levels of response concerning patient satisfaction.

In particular, however, post-operative MOxFQ scores associated with the ‘Very pleased’ response were significantly different (p<0.001) from scores associated with other ‘less pleased’ responses, while scores associated with these less pleased responses were generally not significantly different from each other.
Regarding MOxFQ scale change scores (figure 1b), mean change in the MOxFQ scales associated with the most positive rating (‘Very pleased’) to the satisfaction item was greatest in the Pain domain (Mean, 95% CIs: Pain -48.0, -42.8 to -53.2; W/S -38.4, -32.0 to -44.8; SI -43.1; -36.9 to-49.4). This change in the Pain domain was considerably greater than pain change scores associated with all other responses to the satisfaction item, with the 95% CIs not overlapping with those of any other category of response. This was not the case in relation to MOxFQ W/S and SI scales, where overlap of mean change score 95% CIs occurred across most levels of response to the satisfaction item. The response options ‘not very pleased’ or ‘Very disappointed’ represented small numbers of operations/feet and therefore associated mean MOxFQ change scores generally had wide 95% CIs which tended to overlap with 95% CIs for most of the MOxFQ change scores associated with other patient responses.

Further analyses (ANOVA, with Tukey post-hoc comparisons) confirmed that the change in the MOxFQ pain scale that was associated with the ‘Very pleased’ response was significantly different from pain changes associated with other ‘less pleased’ responses; while change scores associated with the less pleased responses were generally not significantly different from each other. Associations between changes in the MOxFQ W/S and SI scales and responses to the satisfaction item were found to be not so clear-cut, with change scores associated with the ‘very pleased’ response not significantly different from other responses, although change on the MOxFQ SI scale that was associated with the ‘very disappointed’ response was significantly different from changes associated with any other responses (p<0.001)


This paper has presented standard patient-reported outcomes at around eight years following one-stage surgery for HV, based on a response rate of 78% to a postal survey and compared with patients’ pre-operative data. This is the first time that a validated foot-specific measure (the MOxFQ) has been used to evaluate and benchmark long-term outcomes following surgery for HV.

Just over a third of patients who received unilateral foot surgery reported having a problem (unspecified) with the contralateral foot at baseline, but otherwise the characteristics of these patients, which included their pre-operative general health status (SF-36) scores, did not differ significantly from those of patients having bilateral surgery. This suggested that ill health was not a likely explanation for patients with bilateral foot problems having unilateral, rather than bilateral, surgery.

An examination of pre-operative versus 8 year post-operative changes in patients’ health status showed that the 3 foot-specific domains of the MOxFQ detected changes that were much greater and more consistent than was the case for those detected by the generic SF-36 domains. This was unsurprising, as generic measures detect perturbations in health-related quality of life that can be due to any condition affecting any part of the body. Over time, the likelihood increases that symptoms related to a different condition (‘noise’) will arise that ‘drown out’ changes that are specific to the condition of interest. Nonetheless, in the current study, when comparisons were made between bilateral and unilateral cases, significant differences in changes between the two groups were detected by the SF-36, albeit by the Social Functioning, Role Physical and (in particular) Mental Health domains, and not by the more obviously relevant domains (i.e. Physical function or Pain).

Interestingly, when changes in MOxFQ scores were compared for bilateral and unilateral operations, it was the Social-Interaction scale, rather than the Pain or Walking-Standing scales that detected a large and significant difference between the two groups. The Social-Interaction scale addresses work/everyday and social/recreational activities, patients’ attitude to their foot appearance (‘cosmesis’) and wearable range of shoes, which overall construct chimes with aspects of the more Social-Psychological oriented SF-36 scales. The magnitude of the difference (in the S-I scale) observed between the two groups was greater than the SEM previously estimated for this scale. Changes greater than the SEM of a PROM are considered to be a real (ie. beyond the measurement error of the scale) and likely clinically relevant magnitude of change/difference when comparing outcomes between patient groups.[17]

A high proportion of the foot operations (over 80%) were associated with respondents being at least ‘Fairly pleased’ with the outcome of surgery. Bilateral operations attracted the highest proportion of extremely positive satisfaction ratings. Limitations in the range of shoes respondents could now wear (which could, of course, be influenced by either or both feet) and with their attitude to the appearance of their foot, since surgery, appeared important influences on patients’ satisfaction with the outcome of their surgery.

Few studies have investigated the medium to long-term outcomes of surgery for HV and those that have mostly used a retrospective design. Findings are also commonly restricted to reporting radiographic changes and a clinical assessment (e.g. the AOFAS hallux metatarsophalangeal (MTP)-interphalangeal (IP) rating,[18,19] although some have included a patient satisfaction rating (e.g. a visual analogue scale; or a question with ordinal response options).[20] One larger study, included 200 patient interviews to gain insights into patient satisfaction with the surgical outcome and with their pre-operative expectations.[6]

Findings here highlighted the importance of footwear problems, the alleviation of pain and restoration of adequate walking function as being the most important influences in the outcome of surgery for HV.[6]

Other studies have compared the results of unilateral versus simultaneous bilateral correction for HV. One, based on AOFAS scores, patient satisfaction rating and radiographic outcomes (follow-up period ‘at least 12 months’) concluded that simultaneous bilateral HV correction produced results that were no worse than unilateral correction.[21] Our own analysis of longer-term patient-reported data certainly supports this position.


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4. Ferrari J, Higgins JPT, Prior TD. Interventions for treating hallux valgus (abductovalgus) and bunions. DOI: 10.1002/14651858.CD000964.pub3. Cochrane Database Syst Rev 2009;(2):CD000964.5.
5. Dawson J, Coffey J, Doll H, Lavis G, Sharp RJ, Cooke P, Jenkinson C.  Factors associated with satisfaction with bunion surgery in women: a prospective study. The Foot 2007; 17:119-125. [Website]
6. Schneider W, Knahr K. Surgery for hallux valgus. The expectations of patients and surgeons. Int Orthop 2001; 25:382-385. [PubMed]
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10. Dawson J, Doll H, Coffey J, Jenkinson C; Oxford and Birmingham Foot and Ankle Clinical Research Group. Responsiveness and minimally important change for the Manchester-Oxford foot questionnaire (MOxFQ) compared with AOFAS and SF-36 assessments following surgery for hallux valgus. Osteoarthritis Cartilage 2007 15: 918-931.[PubMed]
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Address Correspondence to: Jill Dawson DPhil, Senior Research Scientist & University Research Lecturer, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX37LF & Visiting Professor, Oxford Brookes University, Oxford. Email: jill.dawson@dph.ox.ac.uk

1,2Senior Research Scientist & University Research Lecturer1, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX37LF & Visiting Professor1, Oxford Brookes University, Oxford
3Professor of Health Services Research, Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford OX37LF.
4Senior Medical Statistician, Department of Public Health, University of Oxford, Old Road, Oxford OX37LF.
5,6,7,8Consultant of Podiatric5 and Orthopaedic6,7,8 Surgery, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX37LD.

Repair of Iatrogenic Rupture of the Flexor Hallucis Longus Tendon Following an Akin Osteotomy: A Case Report and Review of Literature

by E. Gillott1, P.S. Ray2

The Foot and Ankle Online Journal 5 (5): 1

Rupture of the flexor hallucis longus (FHL) tendon is rare in the absence of trauma and associated systemic disease. Rupture of FHL is also rare in hallux valgus corrective surgery. We present a case of FHL rupture after Akin osteotomy for hallux interphalangeus, a brief literature review and treatment options. We assert the benefit of exploration and primary repair of the FHL, especially if the rupture is distal to the knot of Henry. The aim of repair is to regain proprioceptive input from the joint and facilitate Metatarsophalangeal (MTP) joint plantarflexion.

Key Words: Hallux valgus, bunion, flexor hallucis longus (FHL), hallux interphalangeus, FHL tear, FHL rupture, Akin osteotomy

Accepted: April, 2012
Published: May, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0505.0001

Flexor hallucis longus (FHL) rupture is commonly associated with trauma and occasionally systemic disease. Those patients with systemic disease, such as diabetes, lupus, gout, psoriatic arthritis, Systemic lupus erythematosus (SLE), kidney disease and Reiter’s disease are susceptible due to weakness within the tendon structure. Trauma can be direct open injury causing laceration to the plantar aspect of the foot resulting in injury to the FHL tendon, or closed injury commonly associated with overuse in athletes and ballet dancers. Due to its contribution to maintenance of the longitudinal arch, damage may lead to pes planus.

Rupture can occur at one or 3 sites or zones [1].
• Zone 1; just proximal to the FHL insertion, distal to the sesamoids
• Zone 2: the area between the sesamoids and the knot of Henry.
• Zone 3; proximal to the knot of Henry.

Treatment options for disruption of the FHL include non-operative, primary open end-end repair, tenodesis to the FDL, tenodesis of the distal FHL to the remnant of FHB tendon, tendon transfer using a slip of the FDL tendon IPJ fusion.

Case Report

An otherwise fit and well 45 year-old female patient was seen six weeks post bilateral Akin osteotomies (Fig. 1). There were no reported complications at surgery but at review, she was unable to plantar-flex the right big toe, noticeable as she was able on the contralateral side. She had no neurological deficit. Her surgeon had recommended interphalangeal joint (IPJ) fusion. She was unconvinced by this and sought second opinion.

Figure 1 Post-operative radiograph of bilateral Akin osteotomies.

She was seen at eight weeks post-operation in a dedicated foot and ankle clinic where an ultrasound of her right foot was carried out. It suggested an intact flexor hallucis brevis (FHB) tendon and revealed a torn FHL tendon. The tendon distally appeared to extend to the base of the proximal phalanx which suggested the site of the rupture to be the base of the proximal phalanx, i.e., in close proximity to the akin osteotomy. She was counselled regarding the treatment options, namely non-operative, IPJ fusion or exploration with a view to repair of the torn tendon.

One of her main concerns was her inability to grip the floor with her toe and therefore non-operative management or fusion of the IPJ were unacceptable to her. She opted for exploration and repair and gave informed consent.

She underwent exploration and repair of the FHL tendon with re-alignment of the sesamoid mechanism of the big toe ten weeks post Akin osteotomy. A longitudinal lazy “S” incision was made in the plantar aspect of the right big toe, centred over the metatarsophalangeal (MTP) joint. The ruptured distal and proximal ends of FHL tendon were identified (Fig. 2). The flexor hallucis brevis tendon was found to be intact. The proximal tendon had retracted to the level of mid metatarsal. Following soft tissue release, the two ends of the FHL tendon were approximated and primarily repaired. Tendon transfer was not required.

Figure 2 Intra-operative identification of FHL Tendon.

The big toe was placed in a plaster of Paris with the toe flexed at the MTP Joint to reduce tension and kept initially for 2 weeks when her plaster was removed for wound check. The plaster was then reapplied for a further 2 weeks.


The FHL originates at the distal 2/3 of the posterior fibula, interosseous membrane and adjacent intermuscular septum within the deep compartment. It is supplied by the tibial nerve from branches of the S1/S2/L5 roots. The tendon passes through the posterior aspect of the fibro-osseous tunnel and plantar midfoot, known as the knot of Henry. It inserts on the plantar surface of the base of the distal phalanx of the greater hallux, passing between the medial and lateral sesamoid bones at the metatarsophalangeal joint. It passes beneath the sustentaculum in an oblique manner prior to inserting on the base of the distal phalanx.

The FHL flexes the great toe. It has a synergistic action with flexor hallucis brevis in assisting with plantar flexion of the foot at the ankle. In addition, it contributes to the distribution of forces at the plantar side of the forefoot and maintains the longitudinal arch of the foot along with the plantar fascia [2].

Literature Review

A search of the literature was carried out on Embase and PUBMED using the search strings 1) “FHL rupture” “Flexor hallucis longus rupture”, “FHL tear” “flexor hallucis longus tear” and 2) “akin osteotomy” “hallux valgus” “bunion”. The two search strings were also combined to ascertain whether there was literature pertaining to the two conditions concurrently.

Although the search returned a number of case reports and series pertaining to FHL rupture [3-18], there was only one case of rupture associated with hallux valgus surgery [19] found in the literature. They reported this as likely partial iatrogenic laceration at the time of surgery. Their patient was treated with surgical debridement of the distal stump of the FHL from under the first MTP joint and tenodesis of the proximal stump to the flexor digitorum longus (FDL) tendon.


FHL and FDL have interconnections in the foot, so if it is cut proximal to knot of Henry (where the tendons cross), then the FDL has a mass action with FHL. This has implications for harvesting the FHL for tendon reconstruction; if harvested at this site it is safe to sacrifice. However, if the tendon is ruptured distal to Knot of Henry, then plantar flexion will be deficient and may be unacceptable to patients. This suggests repair of FHL should be attempted.

A high percentage of FHL ruptures are associated with nerve injuries (50% of patients had distal nerve lacerations), but our patient had an isolated FHL rupture. She also continued to have no plantar flexion at the IP joint which is in keeping with the experience of most authors who assert that primary repair of distal injuries are associated with minimal postoperative IP joint motion.

Following repair of FHL, patients may experience restricted IP joint motion, contracture of the IP joint due to a tight FHL tendon for which Coghlan & Clarke [20] suggest a Z-lengthening of the FHL to achieve acceptable results.

A literature search confirmed the rarity of rupture of the FHL in the absence of systemic disease. The paucity of case reports regarding iatrogenic rupture of the FHL tendon at the time of hallux valgus corrective surgery could be due to rarity of the event or reluctance to report.


The FHL is at risk during hallux valgus surgery and care should be taken to remember to protect it during Akin osteotomy. The authors postulate that iatrogenic rupture of the FHL is more common than the literature reflects, and paucity of papers is influenced by reluctance to report If the FHL is cut during Akin osteotomy, treatment options are either non-operative, fusion of IPJ or repair. The benefits of plantarflexion of the MTP joint and proprioception input from the joint must be weighed against the morbidity of exploratory surgery and the inherent risks it carries.

This case illustrates repair of a cut FHL to be a viable alternative to fusion for treating this complication. Repair can result in some success in regaining plantar flexion of the MTP joint validating its consideration. Patients should be counselled that flexion at the IPJ is unlikely to occur, even after the surgery.


  1. Couglan MJ, Mann RA, Saltzman CL (2007) Surgery of the Foot and Ankle.  Vol 1.  (8th Ed).  Mosby ElsevierPhiladelphia.
  2. Hamel AJ, Donahue SW, Sharkey NA. Contributions of active and passive toe flexion to forefoot loading. Clin Orthop Relat Res 2001 393:326-334.[PubMed]
  3. Boruta PM, Beauperthuy GD   Partial tear of the flexor hallucis longus at the knot of Henry: presentation of three cases. Foot Ankle Int 1997 18(4): 243-246. [PubMed]
  4. Frenette JP, Jackson DW.   Lacerations of the flexor hallucis longus in the young athlete.  JBJS 1977 59A: 673-676. [PubMed]
  5. Grispigni C, De Ponti A, Danasini P, Sarto L.  (2000  Closed subcutaneous rupture of the flexor hallucis longus tendon. Case report and review of the literature. J  Orthopaedics and Traumatology 2000 1:  107-110.
  6. Holt KW, Cross MJ.  Isolated rupture of the flexor hallucis longus tendon. A case report. Am J Sports Med 1990 18: 645-646. [PubMed]
  7. Inokuchi S, Usami N.  Closed complete rupture of the flexor hallucis longus tendon at the groove of the talus. Foot Ankle Int 1997 18: 47-49. [PubMed]
  8. Krackow KA.    Acute, traumatic rupture of a flexor hallucis longus tendon: a case report. Clin Orthop Relat Res 1980 150: 261-262. [PubMed]
  9. Rasmussen RB, Thyssen EP.  Rupture of the flexor hallucis longus tendon: case report. Foot Ankle 1990 10: 288-289. [PubMed]
  10. Romash MM.  Closed rupture of the flexor hallucis longus tendon in a long distance runner: report of a case and review of the literature. Foot Ankle Int 1994 15: 433-436. [PubMed]
  11. Sammarco GJ, Cooper PS.  Flexor hallucis longus tendon injury in dancers and nondancers.  Foot Ankle Int 1998 19: 356-362. [PubMed]
  12. Sammarco GJ, Miller EH.   Partial rupture of the flexor hallucis longus tendon in classical ballet dancers: two case reports. JBJS 1979 61A: 149-150. [PubMed]
  13. Scaduto AA, Cracchiolo A 3rd.   Lacerations and ruptures of the flexor or extensor hallucis longus tendons. Foot Ankle Clin 2000 5: 725-736. [PubMed]
  14. Thompson FM, Snow SW, Hershon SJ.  Spontaneous atraumatic rupture of the flexor hallucis longus tendon under the sustentaculum tali: case report, review of the literature, and treatment options. Foot Ankle 1993 14: 414-417. [PubMed]
  15. Trepman E, Mizel MS, Newberg AH.   Partial rupture of the flexor hallucis longus tendon in a tennis player: a case report. Foot Ankle Int 1995 16: 227-231. [PubMed]
  16. Trevino S, Baumhauer JF. Tendon injuries of the foot and ankle.  Clin Sports Med 1992 11: 727-739. [PubMed]
  17. Van Jonbergen J, Faber F, Treurniet F.  Non-traumatic isolated rupture of the flexor hallucis longus tendon related to an os trigonum: a case report. Foot and Ankle Surgery 2001 7: 109–111.
  18. Wei SY, Kneeland JB, Okereke E.  Complete atraumatic rupture of the flexor hallucis longus tendon: a case report and review of the literature. Foot Ankle Int 1998 19: 472-474. [PubMed]
  19. Brand JC Jr, Smith RW.  Rupture of the flexor hallucis longus after hallux valgus surgery: case report and comments on technique for adductor release. Foot Ankle 1991 11: 407-410.[PubMed]
  20. Coghlan BA, Clarke NM.   Traumatic rupture of the flexor hallucis longus tendon in a marathon runner. Am J Sports Med 1993 21: 617-618. [PubMed]

Address Correspondence to: Mr. Pinak S. Ray, Foot and Ankle Surgical Unit, Barnet General Hospital, Barnet, London, UK, EN5 3DJ

1, 2 Foot and Ankle Surgical Unit, Barnet General Hospital, Barnet, London, UK, EN5 3DJ

© The Foot and Ankle Online Journal, 2012

Complications associated with Mitchell's Osteotomy for Hallux Valgus Correction: A retrospective hospital review

by Kenneth. S. David-West, FRCS (Ed), FICS, FWACS (Orth. & Tr.)1

The Foot and Ankle Online Journal 4 (3): 1

Background: A retrospective review of complications in Mitchell’s osteotomy for mild to moderate hallux valgus correction, in which all osteotomies were fixed with sutures.
Methods: The study evaluated Mitchell’s osteotomy from a district General hospital. There were 82 feet in 68 patients (14 patients had bilateral osteotomies). The study included 60 females and 8 males; the mean age being 54 years, and the average follow-up was 9 months (6-24 months).
Results: Thirty seven feet (45.0%) had complications, of which 22 feet had recurrence and of these, 9 feet had recurrence plus transfer metatarsalgia, One foot had avascular necrosis, 2 feet with non union, one foot with cock-up deformity and two with infection. In the feet with recurrence (22 feet) there was no correction of the tibial sesamoid position.
Conclusions: This study demonstrates that Mitchell’s osteotomy for hallux valgus correction fixed with sutures is associated with high recurrence and transfer metatarsalgia.

Key words: Mitchell’s bunionectomy, Mitchell’s osteotomy, bunion complications.

Accepted: February, 2011
Published: March, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0403.0001

Leslie Mitchell in 1958 described an osteotomy of the distal first metatarsal for the correction of hallux valgus. [1] Hallux valgus is a common forefoot deformity which affects females more than males. There are over 150 different procedures for hallux valgus corrections which include soft tissue and bone operations. [2]

Mild deformities are usually corrected with a distal osteotomy, while moderate and severe deformities are corrected with diaphyseal or proximal osteotomies. [3,4]

Despite several techniques for hallux valgus correction, there is much controversy regarding the best procedure to use in a severe deformity, [5] Mitchell and Scarf osteotomies do not restore the load bearing function of the foot to normal, [6] Mitchell’s osteotomy appears to be performed in a variety of different ways [7], some modifications, such as the planter displacement of the metatarsal head has been shown to be important. [8]

Mitchell’s osteotomy has been used widely in the correction of hallux valgus deformities and is known to be associated with complications.

Some of the reported complications include transfer metatarsalgia, mal union, recurrence, avascular necrosis and non-union. Good outcomes have been reported with Modified Mitchell’s osteotomy in which the intermetatarsal angle is less than 20 degrees, offering a stable construct with easy post-operative care. [5] Mitchell’ osteotomies are associated with 40% of transfer metatarsalgia. [9]

This is a retrospective review of the complications of Mitchell’s osteotomies that were stabilized with sutures with an attempt to identify the incidence of recurrence and transfer metatarsalgia.


A retrospective review of Mitchell’s osteotomy from a district General hospital performed between January 2007 and December 2009 was studied. The patients were identified from the hospital coding databank. 82 feet in 68 patients were studied. Fourteen patients had bilateral Mitchell’s osteotomies. Patients’ records and radiographs were reviewed retrospectively noting the indication for surgery, method of osteotomy fixation and recurrence, shortening, avascular necrosis, infections and the positions of the sesamoid pre and post operation and the experience of the surgeons. Their radiographs at pre-operation, 2 weeks, 6 weeks and latest follow up were reviewed from the patient archive communication system (PAC system). The average follow-up was 9 months (range 6- 24 months).

The criteria for recurrence is pain over the bunion with clinical recurrence of deformity and loss of correction of the hallux valgus angle (HVA) ≥ 18° and intermetatarsal angle (IMA) ≥13° in the last follow-up weight bearing x-ray. The criteria for transfer metatarsalgia is a patient complaining of pain over the lesser toe metatarsal head and tenderness on clinical examination. All the surgeries were performed by a consultant or registrar. There was no significant difference in the complication noted between the surgeons.

Surgical Technique

All the patients had classical Mitchell’s osteotomy. This is a distal “Step Cut” metatarsal osteotomy that displaces the metatarsal head laterally in order to correct hallux valgus deformity. A dorsomedial incision is carried down to the joint capsule; a dorsal and plantar skin flap is created, with care being taken to avoid the cutaneous nerves.

A distally based flap is then created from the medial joint capsule in order to expose the medial eminence and is removed in line with the medial aspect of the metatarsal shaft.

Transverse osteotomy is performed through the metatarsal neck, just proximal to the level of sesamoids between 2 cortical holes. However, a lateral 3mm of metatarsal cortex is left uncut.
The lateral cortex is then cut proximal to the first cut which creates a step off in the distal fragment. The distal fragment is then displaced laterally by the width of step off and is placed into a slight degree of plantar flexion to accommodate the degree of shortening that had been created by removing the section of bone. The greater the deformity the larger was the need for more lateral displacement. The osteotomy site is then secured with an Ethibond™ suture. The medial joint capsule is plicated in order to align MP joint. (Fig. 1)

Figure 1 Mitchell’s osteotomy fixed with suture.

Shortening of the first metatarsal and transfer metatarsalgia to the second metatarsal is compensated by plantar flexion of the distal fragment at the time of surgery. A post operative toe spike cast is applied and allowed to bearing weight on the heels with post operation shoes. Stitches are removed in two week and, an x-ray taken, and then a plaster slipper cast is applied for another 4 weeks after which another x-ray is taken at 6 weeks. The average hospital stay was 36 hours.


From January 2007 to December 2009, 82 feet in 68 patients that had Mitchell’s osteotomy for hallux valgus were reviewed that included 60 females and 8 males. Four had bilateral procedures. The mean age of the patients was 54 years (range 20-68 years).

Of the 82 feet reviewed 37 had complications (45.0%). Of which 22 feet 26.8% had recurrence, 9 feet 10.9% had transfer metatarsalgia. 2 feet (2.4%) had an infection, one superficial and one deep infection managed with debridement and antibiotics. (Table 1) 2 feet had non union these were diagnosed by pain at the osteotomy site and radiological signs of non union at 9 month’s x-ray, and 1 foot had cock-up deformity treated with Z-plasty of extensor hallucis longus (EHL). One foot had avascular necrosis 1.2% (Table 1) In feet which had recurrence, the intermetatarsal angle (IMA) of the patients were high, the mean IMA pre-operatively was 18.8° and the hallux valgus (HA) angle was 34.5,° with a mean distal metatarsal articular angle (DMAA) of 11.8 degrees. (Table 2)

Table 1 Complications (in 37 feet 45% of 82 feet total reviewed)

Table 2 Radiographic Measurements of feet with recurrence (mean.±SD,N=22)

Review of the tibial sesamoid in feet with recurrence showed that14 feet are grade 2 and 8 feet are grade 3 pre-operatively and post-operatively 16 feet are grade 2 and 6 feet are grade 3. (Table. 2) These positions are considered ‘abnormal’.10 None of the feet with recurrence had tibial sesamoid position corrected; hence there is not significant change in the position of the tibial sesamoid. There was no immediate post radiographic to show if the tibial sesamoid were corrected at time of the operation.

Of the 9 feet with transfer metatarsalgia, 5 had additional surgery to the lesser toes, see (Table 3), including partial proximal phalangectomy to 4 feet and excision of proximal interphalangeal joint in 1 foot. The procedures were performed at same time as the Mitchell’s osteotomy.

Table 3 Lesser toe procedures in feet with transfer metatarsalgia


Mitchell’s osteotomy is one of the distal metatarsal osteotomies used in the correction of hallux valgus, but the complications associated with the procedure make it less attractive.

Some modifications such as the planter displacement of the metatarsal head have been shown to be important [8], but many modifications are not supported by scientific evidence. In addition a number of surgeons have not altered their practice in accordance with published evidence. In the Northern Region of England 23% of surgeons who perform Mitchell’s osteotomies used sutures to hold the osteotomies. [7] In my District Hospital 90% of the hallux valgus correction was with Mitchell’s osteotomy fixed with sutures, but this practice was changed after this retrospective study.

The most common late sequela of Mitchell’s osteotomy is transfer metatarsalgia of the lesser toes. [3] In this study 10.9% had transfer metatarsalgia, but Kuo,CH, et al., reported 20% of transfer metatarsalgia and recommend Mitchell’s osteotomy as long as the indication criteria and the surgical technique are respected in a mild to moderate deformity. [3] In this review even in mild and moderate cases when a suture is used for the fixation there is a high incidence of recurrence of 26.8%.

Pain over the bunion caused by a recurrence of the hallux valgus deformity was the main reason for the late deterioration of results, Fokter SK, et al [11], all patients in this review with recurrence had pain over the bunion.

Controlling the osteotomy site in the Mitchell’s procedure may be difficult and a dorsal displacement may occur, if the osteotomy is fixed with sutures. This could have lead to the high recurrence in the review.

In this study, there was not a significant change in the position of tibial sesamoid bone post-operatively in the feet with recurrence. Avascular necrosis is rare after Mitchell’s osteotomies. In this review only 1.2% had avascular necrosis but Meier PJ, et al., reported osteonecrosis in 8% after Mitchell’s osteotomies [12], Desjardin, AL, et al., reported no case of avascular necrosis, pseudoarthrosis or infection. [13]

Recurrence of hallux valgus is a well known complication, attributable to several reasons including insufficient or no primary lateral displacement of the metatarsal head, malunion or fracture of the metatarsal osteotomy, untreated pes planovalgus, insufficient soft tissue technique or a combination of any of the above. [14] In this review, none of the patients had lateral soft tissue release and all osteotomies were fixed with suture, these could be contributing factors to the recurrences, also the DMAA (distal metatarsal articular angle) was not corrected.

Of the feet with transfer metatarsalgia, five feet also had additional procedure to the lesser toes. It is a well known fact that lesser toe procedure could cause transfer metatarsalgia. (Table 3) Figures 2 and 3 are typical examples of x-rays showing loss of correction 6 and 8 months after surgery using the Mitchell’s osteotomy for bunion correction. In our department since after this review, we have stopped using sutures to hold Mitchell’s osteotomies due to the high recurrence.

Figure 2 Example x-ray of lost bunion correction six weeks after the operation.

Figure 3 Example of foot x-ray eight months after surgery with healed osteotomy.  There is now recurrence and transverse plane displacement of the first metatarsal.


Mitchell’s osteotomy can be used in the correction of mild to moderate hallux valgus but could be associated with high recurrence and transfer metatarsalgia when the osteotomy is fixed with a suture.


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Foot & Ankle Int. 1999 May; 20(5):296-300
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14. Coughlin MJ, Mann RA, Saltzman CL (eds). Surgery of the Foot and Ankle. Edition 8, Part 1 Chapter 6: Hallux valgus. Philadelphia, PA: Mosby Elsevier; 2007:283-362.

Address correspondence to: Mr. K .S. David-West, 14 Kirkaig Avenue, Dean Park, Renfrew, PA4 0YH. Scotland.
Tel: +441415612103 or +447887766283

1 Orthopaedic Department, Crosshouse Hospital, Kilmarnock, KA2 0BE, Scotland, UK.

© The Foot and Ankle Online Journal, 2011