Tag Archives: hallux varus

Hallux Malleus develops after Flexible Hallux Varus correction with Tensioned Suture Device: A Case Report

by Francis Chan, DPM, Brent Wendel, DPM FACFAS

The Foot and Ankle Online Journal 5 (1): 2

Tensioned suture device has been described successfully for hallux varus corrections. A case report is presented of a flexible hallux varus correction with tensioned suture device. Transverse plane component of flexible hallux varus was successfully corrected; however, a previously mild extensor hallucis longus contracture worsened postoperatively and led to recurrence of hallux varus.

Key Words: Tension suture device, hallux varus, surgical complication.

Accepted: December, 2011
Published: January, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0501.0002

Hallux varus (HV) is most commonly seen as a complication of surgery, though it can present from a traumatic injury, scar contracture secondary to burn injury, systemic inflammatory arthritides and congenital malformation. [1,2] The incidence of iatrogenic HV has been reported to be 2% to 15.4%. [1-4] For iatrogenic HV, multiple surgical steps have been attributed to its development: excision of fibular sesamoid, aggressive lateral collateral ligament release about the first metatarsophalangeal joint (MTPJ), excessive resection of first metatarsal medial eminence, overcorrection of intermetatarsal angle, excessive medial capsulorrhaphy and aggressive bandaging. [1,2]

Different techniques have been described for correction for HV, such as abductor hallucis release, extensor hallucis longus (EHL) transfer, EHL release, phalangeal osteotomy, first metatarsal osteotomy and first MTPJ arthrodesis. [3-8] Recently, tensioned suture device (TSD) has become more utilized in foot and ankle surgery. Several articles have demonstrated adequate correction of HV using TSD. [6,7,9]

Complications have not been described with use of TSD about the first MTPJ but complications have been described when used in ankle fracture repairs. Knot and button irritation, foreign body reaction with poorly healing wounds, infection and loosening of TSD secondary to osteolysis have been described. [10-12]

This case report is presented to discuss use of TSD to correct the transverse plane deformity of HV, while a sagittal plane deformity worsened postoperatively.

Case report

A 46 year-old female presented with bilateral hallux pain and difficulty fitting into shoes. She previously received right bunionectomy 25 years ago by another physician, which included fibular sesmoidectomy. (Fig 1A and 1B) The time of HV development is unclear but fitting into her shoes became increasingly difficult in recent months prior to clinic visit. Her reducible HV was dominated by pain-free adduction, with flexible asymptomatic hallux malleus (HM) without EHL bowstringing on exam. Her HV was classified as Type 2A HV- adduction component with flexion at hallux IPJ – under the Clinical Practice Guideline of First Metatarsophalangeal Joint Disorder Panel Classification. [1] The patient had tried taping and shoe gear changes previously, which provided limited relief.


Figure 1A and 1B  Preoperative Radiograph of Right Foot . Dorsal Plantar (DP) view showing 20.5° Hallux Abduction Angle.  (A)  Lateral view, mild Hallus Malleus. (B)

Surgical Technique

Right HV correction was performed with Mini TightRope® (Arthrex Inc., Naples, FL) system, an implanted fixation device with suture and button (FiberWire®, Arthrex Inc.). A dorsal bunionectomy incision centered over 1st MTPJ was used. Standard bunion dissection was achieved with linear medial capsulotomy was used. Guide wires and Mini TightRope® were placed as described in technique described by Gerbert, et al.,6 with drill holes being placed parallel to weight-bearing surface. Buttons were applied such that the distal and proximal anchors lie within the same transverse plane. (Fig. 2A and 2B) Surgical site was closed in layers and skin was closed using non-absorbable suture.


Figure 2A and 2B  Two week postoperative radiograph of right foot. A Dorsal plantar view (DP) shows 6° hallux abduction angle. (A)  The lateral radiographs shows suture anchors placed in transverse plane parallel to weightbearing surface.  Hallux malleus (HM) is reduced after correction of HV with TSD. (B) There is radiographic artifact in calcaneus.

Postoperative Course

Intraoperative correction of HV was achieved and HM had appeared to improve after HV correction. (Fig. 2A and 2B) Patient was allowed to heel-touch weightbear after surgery with use of postoperative shoe. Correction was maintained at 2-week follow up. Sutures were removed at 2-week postoperatively and she was transitioned to running shoes with activities as tolerated.

At the 4 week postoperative visit, she began to develop mild recurrence of HV with mild HM. (Fig. 3A and 3B) Distal suture anchor seems to be shifted dorsally (Fig. 3B) as a result of rotation caused by recurrence of mild HV. EHL became bowstrung over first ray on exam. During subsequent follow up visits, new plantar first metatarsal pain and symptomatic tightness over the EHL were described, while mild recurrence of HV remained clinically reducible.


Figure 3A and 3B  Four week postoperative radiograph of right foot. The dorsal plantar view showing 1.5° hallux abduction Angle.  Distal suture anchor rotated within frontal plane.  (A)  The lateral view shows the distal suture anchor more superior, secondary to rotation of proximal phalanx with recurrence of HV and dorsiflexion at first MTPJ from the hallux malleus. (B)  Again, radiographic artifact is seen in the calcaneus.

Strapping and tapping of HM were tried postoperatively. Physical Therapy was not pursued as gait was asymptomatic and range of motion through gait was normal. Seven months postoperatively, she continued to have sub first metatarsal head pain with progression of EHL bowstringing. Subsequently, EHL lengthening procedure was performed. HM and HV corrected with this procedure and the TSD did not show any laxity or displacement. Skin was closed using absorbable suture. There were no postoperative complications and transition to athletic shoe gear was achieved two weeks postoperatively. Seven months after EHL lengthening, her right foot continues to be asymptomatic and she has returned to her baseline level of activity – performing ADLs and playing tennis. (Fig. 4A and 4B)


Figure  4A and 4B   Seven  months after extensor hallucis longus (EHL) tendon lengthening.  The dorsal plantar (DP) view shows 7° hallux abduction angle. (A)  The lateral radiograph shows the rotation of proximal phalanx reduced after EHL lengthening.  Radiographic artifact is again seen in the calcaneus. (B)


There are currently no large case reports or long-term studies with use of TSD for HV correction. Case studies using various TSD systems have shown adequate HV correction without complications. [6,7,9]

Postoperative progression of EHL contracture caused worsening of HM and recurrence of HV. However, after EHL lengthening, TSD realigned HV deformity without other manipulations or procedures. In retrospect, EHL lengthening or transfer to correct for the Type 2A HV might have prevented development of HM, although these procedures are not indicated for a Type 2A HV. [1]

Use of TSD remains a viable option for HV correction, when 1). Patient’s bone stock is adequate, 2). Patient’s first MTPJ is absent of arthritis or has low-grade arthritis, 3). Patient’s tendons about the first MTPJ, is not the deforming force. A patient with the aforementioned criteria, presenting with a reducible, flexible HV with only transverse plane deviation is most appropriate for HV correction with the described TSD technique. In the senior author’s experience (B.W.), TSD provides more control over the amount HV correction and is technically easier than soft tissue transfers or osteotomies.

It is unclear if progression of the mild sagittal plane deviation could have been prevented with more aggressive bandaging or aggressive range of motion with physical therapy. The technique that was used corrected the adduction deviation of a flexible Type 2A HV, but the TSD could not prevent deviations in other planes. Application of TSD to correct for multi-planar correction has yet to be described. Possible biplanar HV correction using TSD may be considered. This would require placement of the first metatarsal button more plantarly than the proximal phalanx button, with placement of suture drill holes remaining parallel to the weight-bearing surface. Cadaveric studies of multiplanar correction with TSD will be required prior to clinical applications.


1. Vanore JV, Christensen JC, Kravitz SR, Schuberth JM, Thomas JL, Weil LS, Zlotoff HJ, Couture SD. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: Hallux Varus. J Foot Ankle Surg 2003 42: 137-142. [PubMed]
2. Bevernage BD, Leemrijse T. Hallux Varus: Classification and treatment. Foot Ankle Clin N Am. 2009. 14: 51-65. [PubMed]
3. Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM, Schuberth JM. Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus. J Foot Ankle Surg. 2008 47: 267-272. [PubMed]
4. Leemrijse T, Hoang B, Maldague P, Docquier PL, Bevernage BD. A new surgical procedure for iatrogenic hallux varus: Reverse transfer of the abductor hallucis tendon A report of 7 case. Acta Orthop Belg 2008 74: 227-234. [PubMed]
5. Lau JTC, Myerson MS. Technique Tip: Modified split extensor halluces longus tendon transfer for correction of hallux varus. Foot Ankle Int 2002 23: 1138-1140. [PubMed]
6. Gerbert J, Traynor C, Blue K, Kim K. Use of the Mini TightRope for correction of hallux varus deformity. J Foot Ankle Surg 2011 50: 245-251. [PubMed]
7. Pappas AJ, Anderson RB. Management of acquired hallux varus with an endobutton. Tech Foot Ankle Surg 2008 7: 134-138. [Website]
8.Skalley TC, Myerson MS. The operative treatment of acquired hallux varus. Clin Orthop Relat Res 1994 306: 183-191. [PubMed]
9. Labovitz JM, Kaczander BI. Traumatic hallux varus repair utilizing a soft-tissue anchor: A case report. J Foot Ankle Surg 2000 39: 120-123. [PubMed]
10.Naqvi GA, Shafqat A, Awan N. Tightrope fixation of ankle syndesmosis injuries: Clinical outcome, complications and technique modification. Injury 2011: doi:10.1016/j.injury.2011.10.002.  [PubMed]
11.Willmott HJS, Singh B, David LA. Outcome and complications of treatment of ankle diastasis with tightrope fixation. Injury 2009 40: 1204-1206. [PubMed]
12. Coetzee JC, Ebeling P. Treatment of syndesmoses disruptions: a prospective, randomized study comparing conventional screw fixation vs TightRope® fiber wire fixation-medium term results. South African Orthopaedic J 2009 8: 32-37. [PDF]

Address correspondence to: Francis Chan, DP. Swedish Medical Center Podiatric Residency Program, Seattle, WA.

1  Podiatric Resident Physician (PGY-2), Swedish Medical Center Podiatric Residency Program, Seattle, WA.
2 Attending Physician, Swedish Medical Center Podiatric Residency Program, Seattle, WA.

© The Foot and Ankle Online Journal, 2012

Congenital Bilateral First Brachymetatarsia: A Case Report and Review of Available Conservative and Surgical Treatment Options

by Mark J. Mendeszoon, DPM, FACFAS, FACFAOM1  , Yelena L. Kaplan, DPM2 ,
Robert S Crockett, DPM3 , Natalie Cunningham, DPM4

The Foot and Ankle Online Journal 2 (9): 1

Synonyms of first metatarsal brachymetatarsia include metatarsus primus atavicus, metatarsus primus brevis, metatarsus primus brevis varus syndrome, pied ancestral (French), pied de Neanderthal (French), short first metatarsal syndrome and Morton’s syndrome (Dudley Joy Morton). Brachymetatarsia is a condition in which the metatarsal physis closes prematurely yielding a pathologically shortened metatarsal length. The podiatric and orthopedic literature mostly agree that the most common metatarsals to be affected are the fourth and third, although any of the five metatarsals can be affected. The etiology of this condition can be genetic or idiopathic, with strong female to male predilection. Presentation of first brachymetatarsia is far less common than that of third or fourth metatarsals. Management of this condition can present as a challenge to the foot and ankle surgeon. This case report will review the present conservative and surgical treatment options.

Key Words: Brachymetatarsia, Morton’s syndrome, Hallux varus, metatarsus primus atavicus, metatarsus primus brevis, metatarsus primus brevis varus syndrome, short first metatarsal syndrome.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: July, 2009
Published: September, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0209.0001

Brachymetatarsia of the first metatarsal is also known as “Morton’s syndrome”. [1] Tachdjian reported that first metatarsal is the most commonly affected metatarsal, although the incidence was found to be 1 in 10,000, whereas a majority of other podiatric and orthopaedic authors claim the fourth brachymetatarsia to be the most common. [2] The largest series of studies, which are from Japan, report the incidence of Morton’s syndrome to be somewhere between 1 in 1820-4586 (0.022%-0.05%), and bilateral congenital brachymetatarsia is noted to be 72 %. [3,4]

The etiology of brachymetatarsia can be associated with idiopathic congenital conditions and acquired disorders. Idiopathic congenital conditions can include such conditions as hereditary early epiphyseal plate closure, associated congenital disorders such as Down’s, Turner’s, Larsen’s, Albright’s syndromes, pseudohypoparathyroidism, poliomyelitis, dystrophic dysplasia, pseudohyperparathyroidism,, multiple epiphyseal dysplasia and myositis ossificans. Acquired disorders can include trauma, neurotrophic disorder, radiation exposure, surgical resection of metatarsal head, infection, or osteochondrosis. [5] There is a strong female to male predisposition in the majority of the podiatric and orthopedic literature. The average ratio is 25:1 [3,6], and the majority of the population studied is between the ages of 5 and 14 years of age. [7]


The first metatarsal secondary ossification center is located at the lateral aspect of the metatarsal base. In 1971, Lelievre [8] stated that the order from longest to the shortest metatarsal should be 1 = 2>3>4>5. Harris and Beath [9] studied 7167 military recruits and found that metatarsals 1>2 in 40 %, 1=2 in 22 %, 1 <2 in 38 %. According to Schmizzi and Brage [3] “the exact diagnosis of brachymetatarsia can be made when one metatarsal is 5mm or more proximal to the parabolic arc of the metatarsal heads.” [6,10]


Because of its location in the medial longitudinal arch the first ray plays an integral role in providing stability and maintaining structural integrity during weight bearing activities. [18] In fact, the base of the first metatarsal is the site for insertion of extrinsic muscles that are vital for medial column stability.

The peroneus longus, anterior tibialis and posterior tibialis muscles all provide significant mechanical stabilizing forces during the toe off (propulsion) phase of gait. When the structural component of the medial longitudinal arch is compromised, abnormal function of the soft tissue is to be expected.

Pain is the most common symptom and is caused by a variety of etiologies such as:

1. Pain caused by stretching of the deep transverse intermetatarsal ligament.
2. A short metatarsal and associated proximal phalanx position between adjoining metatarsal heads.
3. Cock-up toe deformity [3], claw toe [11], and painful digital callus due to dorsal displacement of short metatarsal, associated proximal phalanx and correlating shoe pressure/irritation.
4. Transfer metatarsalgia 12 and transfer lesions.
5. Contractures of extensor/flexor tendons, capsule and skin can be seen with chronic deformities.

Case Report

A nine year-old, Amish female presented to the outpatient clinic, accompanied by her mother. The mother related the child’s chief complaint as generalized soreness and pain in both feet and legs with the right foot being more painful than the left. The mother also explained that her daughter had difficulty ambulating and standing on her feet in the morning. While obtaining the history, both the patient and mother denied any history of injury or trauma to child’s feet or legs. The child was enrolled into an Amish school full time and during the warm months of the year did not wear shoes. The mother denied having any problems during pregnancy with this child or any complications during the delivery. She also related that her daughter went through normal developmental stages, did not have any medical problems or allergies and did not take any medication. The family history revealed that the mother has a heart murmur and father had a stroke. All other family members are free of medical problems. Upon the review of systems, no remarkable findings were noted.

On physical examination the patient’s neurovascular and the dermatological examinations of the lower extremities were completely within normal limits. We did not observe any transfer lesions or callosities. However, on musculoskeletal examination it was noted that both halluces were very short when compared to the adjacent digits. (Figs. 1 and 2) In addition, the child had pain at the insertion of Achilles tendon bilaterally and she was unable to dorsiflex her foot at the ankle joint beyond 90 degrees with the knee flexed and knee extended.

Figure 1  Dorsal view of bilateral feet with short halluces.

Figure 2  Plantar view of foot with short hallux.

On weight bearing examination, the child was unable to get the heel to the ground. The patient propelled on her forefeet during gait and the heels were in a varus alignment during the resting calcaneal stance position.

On evaluation of anteroposterior (AP) and lateral plain radiographs, a short first metatarsal with closed physis in both feet was observed. (Figs. 3 and 4) The left first metatarsal was noted to be shorter than the second metatarsal by 24 mm, and right first metatarsal was shorter than the second metatarsal by 20 mm. These findings were consistent with the definition of brachymetatarsia.

In addition, several other biomechanical factors were seen on radiograph. There is observed metatarsus adductus and decreased talo-calcaneal angles bilaterally, although the right is more pronounced than the left. This was combined with and possibly due to an uncompensated ankle equinus or talipes equinovarus.


Figures 3  Anteroposterior (AP) radiograph of left (A) and right (B) foot with first brachymetatarsia.


Figures 4 The Lateral radiograph of the right (A) and left (B) foot with first brachymetatarsia.

The findings were discussed with the mother and the patient in detail. The patient was advised to initially be placed in custom orthotic device to evenly distribute plantar load and support the medial longitudinal arch. If the condition remained symptomatic after initial orthotic therapy, surgical correction involving distraction callotasis would be indicated upon near closure of adjacent metatarsals physes.


For this young patient with symptomatic pathology, and the presence of biomechanical abnormalities contributing to the pain, conservative therapy is initially recommended. The orthotic therapy would allow the necessary correction for the uncompensated ankle equinus. Three months following our patient’s initial consultation and orthotic therapy, the patient was doing well and not complaining of pain.

Taking into consideration this child’s ethnic background, after cold winter months, the patient will return to barefoot activities, as stated by the patient and her mother. If our patient begins to experience pain and discomfort after discarding orthotic therapy, surgical correction will be indicated. Indication for treatment is usually related to pain, prevention of progressive deformity or cosmesis. There are a variety of treatments available for conservative treatment and surgical correction of first brachymetatarsia:

1. Orthotic devices, metatarsal pads, wide toe-box shoe gear.
2. Metatarsal heads 2-4 resection.
3. Proximal ostectomy of metatarsals 2-4, followed by (Teflon prosthesis) implant arthroplasty in first metatarsal. [13]
4. Chiappara [19] procedure: First proximal phalanx shortening, combined with shortening of proximal aspect of metatarsals 2, 3, 4 and lengthening medial cuneiform – allowing hallucal interphalangeal joint (IPJ) to compensate for first metatarsophalangeal (MTP) joint. [13]

Surgical Lengthening procedures

1. One stage: distraction and bone graft.
2. Two stage: osteotomy and gradual distraction, followed by bone grafting.
3. Skirving and Newman procedure [20] = “callotasis“: osteotomy and gradual lengthening of first metatarsal with external mini external fixator, without bone graft utilization. [13,14]
4. Metatarsal slide lengthening procedure.

The one stage surgical approach is best for lengthening metatarsals up to 15 mm. Bone grafting can be wth allograft (such as tricortical iliac crest) or autograft (such as calcaneal or tibial strut). [3,6] If a greater than 15 mm lengthening is desired or indicated, recommendation is to perform distraction callotasis with a mini external fixator. Begin distraction approximately 1 week after surgery, and distract 0.5 mm to 1 mm per day. Keep the patient completely non-weight bearing for 8 – 12 weeks. Once the desired length is achieved, stop the daily distraction. As weight bearing status is progressed, the mini external fixator is kept in place until radiograph evidence shows bone consolidation.

With any lengthening procedure, the patient can experience complications, especially when the total lengthening is greater than 40 % of original length. [3] With excessive lengthening, there is possible risk of neurovascular compromise, vasospasm and toe gangrene, unless pre-surgical soft tissue releases, stress-relaxation techniques, and keeping the total increased length to less than 15 mm are employed. [3] Other complications can include stiff metatarsophalangeal or MTP joint, subluxation of the MTP joint, nonunion of the distraction site, ray angulation deformity, prolonged time to achieve osseous union and pin track infection. [3,15]

Considering the child in our case report will need to have the first metatarsal lengthened by greater than 15 mm, a two-stage approach or distraction callotasis seems to be the most appropriate procedures. Choi, et al., performed callotasis on 9 patients with average length gained 17.6 mm (15-23 mm), and the average time for “solid bony union” being 2.6 months (1.7 – 3.4 months). [16] Steedman and Peterson performed gradual first metatarsal distraction with the use of mini-external fixators (5/6 mini-Hoffman, 1/6 Orthofix), followed by fibular bone graft placement after gaining the desired lengthening. The average amount of lengthening was 10.3 mm (6 mm – 20 mm), with an average healing time of 3.5 months (1.9 months – 6.1 months). According to Steedman and Peterson, either the two-stage approach or the callotasis are acceptable surgical choices for correction of first metatarsal brachymetatarsia versus “procedures that shorten other metatarsals and destroy joints.” [13] Other factors to consider: bone grafting versus callotasis? When performing callus distraction with bone grafting, the surgeon should consider allograft versus autograft, graft incorporation, soft tissue adaptation (neurovascular damage) and status of adjacent metatarsal physes prior to the procedure. Timing of the surgical procedure should be aimed at “near closure of adjacent metatarsal physes” [17], thus assuring static relative correction. In addition, soft tissue stretching is recommended prior to the procedure.


Brachymetatarsia is a condition that has been described since ancient times, but the options for surgical correction did not become available until 1969, when McGlamry and Cooper began using a cylindrical autogenous calcaneal bone graft to lengthen the fourth metatarsal. [6] Brachymetatarsia is a relatively rare condition which most often affects the fourth metatarsal. We have presented a case of a nine year old female with bilateral short first metatarsals. Considering the patient’s age, length of deformities, the presence of uncompensated ankle equinus and metatarsus adductus, we have allowed this patient the opportunity for conservative management first. However, it is more than likely; a surgical correction of sorts will need to be performed to address this pathology. Many surgical options are available for correction of brachymetatarsia, but as with any surgery, the surgeon needs to be in tune with patient’s expectations. This relates to cosmesis versus pain relief, choosing the best surgical procedure based on digital position, amount of lengthening necessary and bone graft (if necessary). It is ideal to consider a reasonable expectation for post-operative healing, possible complications and outcome.


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Address correspondence to: Robert Crockett, DPM, Neshoba Foot and Ankle Clinic, 1004 Holland Ave. Philadelphia, MS
Email: drrcrockett@gmail.com.

Precision Orthopaedic Specialties, 150 Seventh Avenue, Suite 200 Chardon, OH 44106
1,2,3  Louis Stokes Veterans Affairs Medical Center, Podiatric Primary Care & Surgery, 10701 East blvd Cleveland, OH 44106.

© The Foot and Ankle Online Journal, 2009