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Postoperative Rehabilitation after Hallux Valgus Surgery: A literature review

Posted on June 1, 2011 | Comments Off on Postoperative Rehabilitation after Hallux Valgus Surgery: A literature review

by Massimiliano Polastri, PT1 

The Foot and Ankle Online Journal 4 (6): 4

Background: Hallux valgus deformity is a common condition and several surgical treatments are discussed in the literature. The main purpose of this study is to review the literature concerning rehabilitation treatment following hallux valgus surgery.
Methods: The present literature review is performed by searching the following databases: PubMed and Embase using the Medical Subject Headings terms ‘hallux valgus’, ‘postoperative rehabilitation’, ‘surgical procedures’ matched by the Boolean operator AND; The Cochrane Library using ‘hallux valgus’, ‘postoperative rehabilitation’ matched by the Boolean operator AND; and PEDro using ‘hallux valgus’.
Results: The initial search identified ninety-four citations, and of those, eighty-five were excluded because they were related to surgical techniques, including percutaneous access and/or different osteotomy modalities, to radiological evaluations before and after the correction to describe the deformity, to surgical complications or to anesthesia management. Study design, patients, outcome measures, and the main results were extracted. After the selection, nine documents related to rehabilitation were included.
Discussion: The findings of this review indicated that areas peripheral to the surgery, such as the ankles and toes (second to fifth) should be included in the rehabilitation program. Treatment may include physical instruments as magnetic fields in order to manage pain and edema postoperatively. In the included studies, American Orthopedic Foot and Ankle Society (AOFAS) score, range of motion, and visual analogic scale were mainly used as tools for evaluating outcomes.
Conclusion: Postoperative rehabilitation timeframe may vary depending on the surgical technique and can be performed in an outpatient setting. The use of appropriate footwear that allows safe walking and does not compromise the surgical result is important immediately after surgery. Postoperative rehabilitation is mainly oriented to encourage both plantar pressure on the first ray and joint mobility. It also represents an important component of recovery following the correction of hallux valgus deviation, where it helps to restore physiological gait and foot function.

Key words: Hallux Valgus, Motion Therapy, Postoperative Rehabilitation, Prevalence, Surgical Procedures.

Accepted: May, 2011
Published: June, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0406.0004

Hallux valgus deformity (HVD) is a common condition [1-12] and several surgical treatments are discussed in literature. [13-19] A study of the prevalence of forefoot and hallux valgus surgery in Sweden found that hallux valgus was by far the most common forefoot surgery and that it was performed more in urban than rural regions, and in private clinics than in community hospitals. [20]

In 2007, Saro and colleagues reported that quality of life following surgical correction of HVD was not influenced by the severity of the deformity.21 The aim of the present study was to review the literature concerning rehabilitation treatment following hallux valgus surgery. The main purpose of this review was to determine the need to perform the postoperative rehabilitation (PR) after the corrective surgery of the hallux valgus.

Methods

The present review sourced literature from database searches of PubMed and Embase using the Medical Subject Headings (MeSH) terms ‘hallux valgus’, ‘postoperative rehabilitation’, ‘surgical procedures’ using the Boolean operator AND; The Cochrane Library using the MeSH terms ‘hallux valgus’, ‘postoperative rehabilitation’ with the Boolean operator AND; and PEDro using the MeSH term ‘hallux valgus’. The MeSH terms were different for each database to allow the author to obtain the greatest number of citations. (Table 1) The search was performed between October of 2010 and November of 2010 with no limits on the date setting. Studies were included if they a) were written in English, Italian, German, or French; b) were related to therapeutic exercises; and c) investigated patients with hallux valgus-related surgery.

Table 1 Search’s criteria and number of studies in the review.

In one case, the English abstract of a paper in German was read. Potentially relevant studies were identified by searching titles and abstracts, and then the full text of the selected articles was reviewed.

Results

The initial search identified ninety-four citations, and of those, eighty-five were excluded because they were related to surgical techniques. This included percutaneous access and/or different osteotomy modalities, to radiological evaluations before and after the correction to describe the deformity, to surgical complications or to anesthesia management. Study design, patients, outcome measures, and the main results were extracted. After the selection, nine documents focusing on rehabilitation were included in the present review. The included studies were conducted in Europe and North America. Only two experimental studies related to rehabilitation were found (Table 2). Most of the papers were descriptive in nature and small-sample studies were mainly present among the selected reports. Four were non experimental (Table 3) and three had low level evidence to rehabilitation (Table 4).

Table 2 Experimental studies.

PR postoperative rehabilitation, CPM continuous passive motion, ROM range of motion, G gauss (the unit of the magnetic flux density), VAS visual analogic scale.

Table 3 Non experimental studies.

PR postoperative rehabilitation, AOFAS American Orthopaedic Foot and Ankle Score, ROM range of motion, MTP metatarsophalangeal, kPa kilopascal (Pa: unit of pressure = 1Newton/m2; 1kPa = 1 000 Pa), CPM continuous passive motion, N Newton.

Table 4 Low level evidence studies.

N/A not applicable.

Discussion

In order to understand if the PR is necessary after the surgical correction of the hallux valgus, a literature review was performed. Among those included, was a recent study by Schuh, et al., which adds a significant meaning to the matter. Their findings, observed in a medium-long term, showed significant improvements in weight bearing in the forefoot region as well as in the American Orthopedic Foot and Ankle Society (AOFAS) score at the follow-up one year after the surgery. [22] According to these authors, PR should improve outcome after surgical correction of hallux valgus deviation.

It is possible to assume that change of the angular values in the first metatarsophalangeal (MTP) joint should develop alterations in forefoot biomechanics.

In fact, the reduction on maximum force in this region should shift the weight bearing, over the time, toward the others metatarsal heads (second to fifth) developing a potential secondary metatarsal pain. On the other hand, one may consider PR as a necessary pathway to prevent and eventually treat this condition.

This includes restoring weight bearing in the first ray which is a necessary condition in order to maintain equilibrium of the biomechanical forces in the forefoot. The authors also describe the rehabilitation approach’s including different modalities.

In 2009, Schuh, et al., performed a pedobarographic analysis to investigate the function of the big toe and first ray concluding that PR helps to restore the physiological gait pattern after the Austin or Scarf osteotomy. [23] Connor and Berk used continuous passive motion (CPM) to recover range of motion (ROM) of flexion and extension in patients who had surgical complications. [24] Their results demonstrated that joint mobility is reduced as a consequence of surgery. The association between hallux valgus surgery and iatrogenic hallux limitus highlights the importance of conserving and restoring mobility of the first MTP joint. The authors did not describe the type of surgery that caused the hallux limitus. CPM reduced the pain, and joint mobility was sufficiently restored to prevent a second surgery, even when the therapy was started 6 months after surgery. These findings lead one to speculate that if CPM, although passive, could improve ROM in subjects with surgical complications; the motion would aid functional recovery in people who had no complications following common corrective procedures of hallux valgus. As discussed by Connor, et al., the primary benefits of starting rehabilitative treatment with CPM immediately after surgery are related to the prevention of the adhesions and a quick return to the conventional shoes. [25] In a prospective study, Schuh, et al., found that rehabilitation treatment increased big toe function and restored the physiological gait pattern in patients who underwent Austin or Scarf osteotomy to correct mild to moderate deviations. [26] The pedobarographic analysis showed improvement in the AOFAS score and an increase in plantar pressure following a rehabilitation regimen starting 4 weeks after the surgery. Subjects included in this study wore Rathgeber shoes during the first 4 weeks. Unver, et al., developed an orthosis with a 3-mm polyethylene thermoplastic sheet and a velcro strap to maintain the surgical correction and reduce the risk of complications in subjects who underwent McBride osteotomy. [27]

The Authors emphasized the importance of postoperative rehabilitation after a 6-week period. Among the selected, this study recommended the earliest mobilization of the ankle and second to fifth toes, starting from the first day after surgery.

Donnery and DiBacco suggested a group of simple exercises that could be integrated into the postoperative treatment of patients who underwent McBride hallux abducto valgus reduction. [28] The Authors recommended that patients perform active ROM exercises beginning 3–4 weeks after surgery. In contrast, Weil and Benton-Weil described a technique in which patients performed a series of exercises that encouraged plantar flexion starting 1 week after surgery. [29] Simoncini, et al., used magnetic fields to reduce pain and edema in the short term after hallux valgus surgery. [30] Physiotherapists are aware in the daily clinical practice of postoperative edema and pain. In the study of these authors, controls did not receive the treatment in allowing them to assume its effectiveness. Furthermore, Simoncini, et al., are the first to introduce this issue confirming the importance of a treatment to include physical instruments. [30]

Before drawing the final conclusions one should reflect on the possibility to prevent surgery in people with HVD. Torkki and coll. (2001), first in literature, have conducted a randomized controlled trial on a sample of 209 people with mild to moderate HVD in order to compare two different treatment modalities: surgery (chevron procedure) or orthosis. [31] They concluded that the surgical treatment was more effective and it resulted in a better cosmetic result if compared with the orthosis. However, the orthotic treatment may be considered an option while waiting for the surgery.

Recently, John and Willis published a paper on a series of ten patients (six with hallux valgus and four with hallux varus) treated with a dynamic splint. [32] Both the study design and the sample size, did not allow to draw firm conclusions about their findings. The authors describe deformity corrections of ten degree at one month in patients with HVD.

The findings of this literature review indicate that other areas of the foot unrelated to the surgery, such as the ankle and toes (second to fifth) should be included in the rehabilitation program. In the studies reviewed, AOFAS score, ROM measurement, and VAS were mainly used as tools for evaluating outcomes.

PR is not necessarily related to the onset of surgical complications but contributes to restoring function even in presence of good surgical results. A potential limitation of this study is the restricted number of citations. A second limit is represented by the age of some sources that were published more than ten years ago. Again, some have a low evidence level and only one, among experimentals, has a control without treatment.

Conclusion

In the present literature review, nine studies on rehabilitation therapy in subjects who had undergone hallux valgus surgery were discussed. The results suggest that the PR timeframe may vary depending on the surgical technique and can be performed in an outpatient setting.

Furthermore, PR should be an important component of recovery following the correction of HVD, where it helps to restore physiological gait and foot function; from the review emerged that PR is mainly oriented to encourage both plantar pressure on the first ray and joint mobility. The use of appropriate footwear that allows safe walking and does not compromise the surgical result is important immediately after the surgery. Management of edema and pain must be also achieved. Consultation between orthopedic surgeon and physiotherapist, about the surgical technique used, is advisable before starting rehabilitation. PR after the hallux valgus surgical correction is rarely described in the literature, however, highlighting what was discussed, one should consider that it is necessary to recover foot function. More comparative experimental studies are needed.

Acknowledgements

The author thanks Professor Mauro Di Bari, at the University of Florence, for critical reading of this manuscript. Furthermore, Dr. Stefano Cantagalli, orthopedic surgeon at the Bologna University Hospital St. Orsola-Malpighi Polyclinic, for his support on hallux valgus surgery topic.

References

1. Cho NH, Kim S, Kwon DJ, Kim HA. The prevalence of hallux valgus and its association with foot pain and function in a rural Korean community. JBJS 2009 91B: 494 – 498.
2. Roddy E, Zhang W, Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum 2008 59: 857 – 862.
3. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2007 28: 759 – 777.
4. Yu GV, Sellers CS, Shook JE, Karlock LG: Iatrogenic deformities of the first ray. Clin Podiatr Med Surg 1996 13: 367 – 422.
5. Kusumoto A, Suzuki T, Kumakura C, Ashizawa K. A comparative study of foot morphology between Filipino and Japanese women, with reference to the significance of a deformity like hallux valgus as a normal variation. Ann Hum Biol 1996 23: 373 – 385.
6. Michelson J, Easley M, Wigley FM, Hellmann D: Foot and ankle problems in rheumatoid arthritis. Foot Ankle Int 1994 15: 608 – 613.
7. Hung LK, Ho YF, Leung PC: Survey of foot deformities among 166 geriatric inpatients. Foot Ankle 1985; 5(4): 156 – 164.
8. Gottschalk FA, Solomon L, Beighton PH: The prevalence of hallux valgus in South African males. S Afr Med J 1984 65: 725 – 726.
9. Gottschalk FA, Beighton PH, Solomon L: The prevalence of hallux valgus in three South African populations. S Afr Med J 1981 60: 655 – 656.
10. Gottschalk FA, Sallis JG, Beighton PH, Solomon L. A comparison of the prevalence of hallux valgus in three South African populations. S Afr Med J 1980 57: 355 – 357.
11. Halebian JD, Gaines SS. Juvenile hallux valgus. J Foot Surg 1983 22: 290 – 293.
12. Shine IB. Incidence of hallux valgus in a partially shoe-wearing community. Br Med J 1965 1(5451): 1648 – 1650.
13. Giannini S, Vannini F, Faldini C, Bevoni R, Nanni M, Leonetti D: The minimally invasive hallux valgus correction (S.E.R.I.). Interact Surg 2007 2: 17 – 23.
14. O’Donnell T, Hogan N, Solan M, Stephens MM. Correction of severe hallux valgus using a basal chevron osteotomy and distal soft tissue release. Foot Ankle Surg 2010 16: 126 – 131.
15. Robinson AHN, Limbers JP: Modern concepts in the treatment of hallux valgus. JBJS 2005 87B: 1038 – 1045.
16. Pinney S, Song K, Chou L. Surgical treatment of mild hallux valgus deformity: the state of practice among academic foot and ankle surgeons. Foot Ankle Int 2006 27: 970 – 973.
17. Pinney S, Song K, Chou L. Surgical treatment of severe hallux valgus deformity: the state of practice among academic foot and ankle surgeons. Foot Ankle Int 2006 27: 1024 – 1029.
18. Bauer T, Biau D, Lortat-Jacob A, Hardy P. Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Orthop Traumatol Surg Res. 2010 96: 407 – 416.
19. Waizy H, Stukenborg-Colsman C, Abbara-Czardybon M, Emmerich J, Windhagen H, Frank D. A special soft tissue procedure for treatment of hallux valgus. Oper Orthop Traumatol 2011; 23: 46 – 51.
20. Saro C, Bengtsson AS, Lindgren U, Adami J, Blomqvist P. Surgical treatment of hallux valgus and forefoot deformities in Sweden: a population-based study. Foot Ankle Int 2008 29: 298 – 304.
21. Saro C, Jensen I, Lindgren U, Fellander-Tsai L. Quality of life outcome after hallux valgus surgery. Qual Life Res 2007 16: 731 – 738.
22. Schuh R, Adams S, Hofstaetter SG, Krismer M, Trnka HJ. Plantar loading after chevron osteotomy combined with postoperative physical therapy. Foot Ankle Int. 2010 31: 980 – 986.
23. Schuh R, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ. Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Phys Ther 2009 89: 934 – 945.
24. Connor C, Berk DM. Continuous passive motion as an alternative treatment for iatrogenic hallux limitus. J Foot Ankle Surg. 1994 33: 177 – 179.
25. Connor JC, Berk DM, Hotz MW. Effects of continuous passive motion following Austin bunionectomy. A prospective review. JAPMA 1995 85: 744 – 748.
26. Schuh R, Hofstaetter SG, Kristen KH, Trnka HJ. Effect of physiotherapy on the functional improvement after hallux valgus surgery-a prospective pedobarographic study. Z Orthop Unfall 2008 146: 630 – 635.
27. Unver B, Sampiyon O, Karatosun V, Gunal I, Angin S. Postoperative immobilisation orthosis for surgically corrected hallux valgus. Prosthet Orthot Int 2004 28: 278 – 280.
28. Donnery J, DiBacco RD. Postsurgical rehabilitation exercises for hallux abducto valgus repair. JAPMA 1990 80: 410 – 413.
29. Weil LS, Benton-Weil W. Postoperative hallux valgus exercises. J Foot Ankle Surg 1998 37: 355.
30. Simoncini L, Giuriati L, Giannini S: Clinical evaluation of the effective use of magnetic fields in podology. Chir Organi Mov 2001 86: 243 – 247.
31.Torkki M, Malmivaara A, Seitsalo S, Hoikka V, Laippala P, Paavolainen P. Surgery vs orthosis vs watchful waiting for hallux valgus. A randomized controlled trial. JAMA 2001 285: 2474 – 2480.
32.John MM, Willis FB. Dynamic splinting for hallux valgus and hallux varus: a pilot study. FAOJ 2010 3(1): 1.

Address correspondence to: Massimiliano Polastri, Unità Operativa Medicina Fisica e Riabilitazione, Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant’Orsola-Malpighi, Via G. Massarenti, 9. 40138 – Bologna, Italy.

1  Unit of Physical Medicine and Rehabilitation, Bologna University Hospital, St. Orsola-Malpighi Polyclinic, 40138 – Bologna, Italy.

© The Foot and Ankle Online Journal, 2011

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Does Wearing High-heeled Shoe Cause Hallux Valgus? A Survey of 1,056 Chinese Females

Posted on May 1, 2010 | Comments Off on Does Wearing High-heeled Shoe Cause Hallux Valgus? A Survey of 1,056 Chinese Females

by Daniel Wu, MD1  , Lobo Louie, DPE2  

The Foot and Ankle Online Journal 3 (5): 3

Objective: To determine the prevalence of hallux valgus and its relationship to wearing high-heel shoes in Chinese females.
Methods: A total of 1,056 healthy females between the ages of 18 and 65 responded to the self-reported questionnaires. Photographs of each classified hallux valgus condition were given as references and each respondent was asked to rate her foot condition as well as completing a questionnaire. The study took place between June and August 2008 in Hong Kong.
Data analysis: Cross-tabulation and frequencies commands were used to compute the incidences of hallux valgus with regard to age, severity of illness, complaints and actions taken by the respondents. A chi-square statistic was used to compare the frequencies of occurrences between younger and older respondents. The relative risk (RR) was calculated in order to understand the probability of having hallux valgus in relation to wearing high-heels and family history.
Results: Of the 1,056 respondents, 36.5% indicated having various degree of hallux valgus. 29.5% (n=312) had ‘mild’ condition, 4.8% (n=50) had ‘moderate’ and only 2.2% (n=24) reported ‘severe’ hallux valgus. No ‘extreme’ case was reported. Subjects over aged 40 had higher injury prevalence (chi-square=34.4; p<.01) than the young counterparts. 88.8% of those having hallux valgus reported that their family members had history of hallux valgus. 73.2% of them who did not wear high-heels regularly but with family history also had hallux valgus. For those with no family history but often wore high-heels, only 2.8% had hallux valgus. Subjects with family history of hallux valgus would be 26 times (RR=26) as likely as those without family history and often wore high-heeled shoes to develop hallux valgus.
Conclusion: Hallux valgus is prevalent in the Chinese females. Wearing high-heels seemed to not be a predisposing factor of hallux valgus in Chinese females; however a family history was a major concern.

Key words: Hallux valgus, bunion, hallux abductovalgus, High-heeled shoe, Chinese females.

ISSN 1941-6806
doi: 10.3827/faoj.2010.0305.0003

Hallux valgus is a chronic condition with deformity of the first metatarsophalangeal joint. It is characterized by lateral drift of the great toe in association with joint subluxation. The occurrence rates for hallux valgus varied depending on the age of the subjects involved. [1]

It was reported that the frequency rates of hallux valgus in the adult wearing population were about 33%. [2] Another study indicated that the standardized prevalence of hallux valgus was 28.4% based upon a large sample of 4,249 respondents in a primary care population. [3] It was found that this deformity was associated with age, female sex, and components of generalized osteoarthritis, such as knee pain and big toe pain. However, hallux valgus was found as high as 64.7% in rural Korean women with age between 40 and 69, but it did not significantly correlate with age. [4]

In a study done by Coughlin and Jones, [5] they collected data from patients treated for a hallux valgus deformity and found that 83% of patients had a positive family history for hallux valgus deformities. Constricting shoes and occupation were implicated by 34% patients as a cause.

A recent study found that the prevalence of hallux valgus was associated with body mass index and high-heel use during ages between 20 and 64. [6] They also reported that women, who wore regularly high-heeled shoes increased likelihood of hallux valgus. It is widely believed that dancers may put a great deal of stress through the first metatarsophalangeal joint which caused hallux valgus, but research did not support this assumption. [7,8]

Although the literature pertaining to the etiology of hallux valgus tends to be varied, there would appear predominantly on female population. The purpose of this study was to focus on evaluating the prevalence of hallux valgus and its relationship to wearing high- heeled shoes in Chinese females.

Methods

A user-friendly self-report instrument containing photos of different degrees of hallux valgus were utilized (Fig. 1). Such classifications obtained high reliability and validity and this non-invasive method of assessing the severity of hallux valgus deformity was suggested for clinical and research purposes. [9,10] In addition, data collected also included demographic information, wearing high-heeled shoes habit, family history, pain and symptoms, influence on daily life, diagnosis and treatment. Convenience sample method was used but the age of the respondents must be between 18 and 65 years. Questionnaires were delivered to the potential respondents in the community centers located in various districts in Hong Kong. In order to minimize the sample selection bias, the researcher distributed the questionnaires to the potential respondents in a random order. The researcher did not know whether the respondents had hallux valgus or not prior to distributing the questionnaires. Each respondent was asked to rate her own foot condition according to the given photos as well as filling out a questionnaire. The study took place between June and August 2008 in Hong Kong. Ethical approval was obtained.

Figure 1 Self-rated hallux valgus conditions by the respondents. Characterized as normal foot (A), mild bunion (B), moderate bunion (C), severe bunion (D) and extreme bunion (E).

Data Analysis

Data were analyzed utilizing the Statistical Package for Social Sciences (SPSS version 16.0). Cross-tabulation technique was used to compute the incidences of hallux valgus between younger and older age groups, and across various severity of illness. In addition, frequencies command was employed to compute the descriptive statistics for the complaints and related actions taken by the respondents with hallux valgus. A chi-square statistic was utilized to compare the frequencies of occurrences between the younger (age 18-40 years) and older (age 41-65 years) groups. In an attempt to understand the probability of having hallux valgus in relation to family history and wearing high-heels, the relative risk (RR) was calculated by dividing the number of hallux valgus cases who did not wear high-heels but with family history by those wore high-heels with no family history. In order to facilitate data interpretation, percentage scores were utilized. Significance level was less than 0.05.

Results

In total, 1,080 Chinese females responded to the survey. Twenty-four data entries were dropped due to incomplete information and thus 1,056 usable data were input for analysis (a return rate of 98.0%). The demographic characteristics of the respondents indicated that they were from different socio-economic backgrounds, including clerical workers (29.7%), salespersons (4.4%), flight attendants (6.2%), service workers (4.5%), teachers (12%), discipline force (6.8%), health care (6.4%), and housewives (30.1%).

Of the 1056 respondents, 36.5% indicated having various degree of hallux valgus. It was reported that 29.5% (n=312) had a ‘mild’ condition, 4.8% (n=50) had ‘moderate’ and only 2.2% (n=24) noted ‘severe’ hallux valgus. The findings also noted that 34.3% and 41.4% of the subjects with aged 18 – 40 and 41 – 65 years had hallux valgus, respectively. (Table 1) Respondents over aged 40 had significantly (chi-square = 34.4; p < 0.01) higher injury prevalence than their young counterparts.

Table 1 Age difference in the prevalence of hallux valgus.

Of the total respondents, 226 (21.4%) indicated that they always wore high-heeled shoes and 453 (42.9%) sometimes wore them. The average year of wearing high-heels was 9.4 years (minimum =0.5 years; maximum =38 years). Similar average year (10.0 years) of wearing high-heels was also found in the hallux valgus group. Table 2 showed the frequent complaints reported by the respondents with hallux valgus. Some actions taken by the respondents with hallux valgus were presented in Table 3.

Table 2 Frequent Complaints by the respondents with hallux valgus.

Table 3 Actions taken by the respondents with hallux valgus.

Eighty eight percent of respondents who had hallux valgus reported that their family members also had some forms of hallux valgus. However, it was found that 73.2% of them did not wear high-heels regularly but all had family history of hallux valgus. On the other hand, for those respondents without family history but often wore high heels, hallux valgus was found only in 2.8% of the total cases. It was estimated that subjects with family history of hallux valgus would be 26 times (rr = 26) as likely as those without family history and often wore high-heeled shoes to develop hallux valgus. A summary showing the prevalence of hallux valgus between high- heels and family history was shown in Table 4.

Table 4  A summary showing the prevalence of hallux valgus between wearing high-heels and family history.

Discussion

Occurrence rates for hallux valgus reported in the literatures varied from 33% and 70%.2,11,12 The present finding (36.5%) on the prevalence of hallux valgus in Chinese females was in line with previous data from other populations. [4,6]

Some people blame the causes of hallux valgus may be due to high heels. Wearing high-heels can be fashionable. Some people believe that high-heels can empower women at work and help women look and feel confident. Although wearing high-heels can cause several deleterious effects, such as putting too much force on the feet, ankles, knees, and lumbar, [13,14,15] high-heels are welcome by women around the world. While wearing high-heels the feet are in plantarflexed position, which in turn significantly increases pressure on the plantar of the forefoot.

The pressure increases as the height of the shoe heel increases. Wearing a 3 1/4 inch heel increases the pressure on the bottom of the forefoot by 76%. The increased pressure may lead to pain or foot deformities.

Conversely, previous literature reviewed that constricting footwear was only found in about one-quarter of the hallux valgus patients. [16] In the present study, for those with no family history but often wore high-heels, only 2.8% of them developed hallux valgus. Apparently, the present finding did not agree with the cause of hallux valgus was due to wearing high-heels. Yet there is still insufficient evidence to conclude that wearing high-heeled shoe is an etiological factor in the development of hallux valgus. [17]

Almost 90% of respondents who had hallux valgus indicating that their family members also had some forms of hallux valgus. Such prevalence of hallux valgus was in line with the study conducted by Coughlin and Jones, [5] 83% of hallux valgus patients had a positive family history. Recent study also showed that 90% of hallux valgus patients had at least one family member affected by the presence of hallux valgus and it might affect some family members across three generations. [18] Interestingly, the present survey reported that a majority of the hallux valgus respondents (73.2%) had family history of hallux valgus but they did not wear high-heels. This is exactly in line with Coughlin and Jones [5] who reported that a positive family history is the underlying factor for hallux valgus deformities.

Conclusion

Hallux valgus is considered by many to be a prevalent condition in the females. This present study found that wearing high-heels is not a predisposing factor to hallux valgus. Instead, a family history appeared to be a major concern for developing hallux valgus in Chinese females.

Disclosure

No conflict of interest is reported by the authors.

References

1. Gilheany MF, Landorf KB, Robinson P. Hallux valgus and hallux rigidus: A comparison of impact on health-related quality of life in patients presenting to foot surgeons in Australia. J Foot Ankle Res 2008 1: 14.
2. Mann RR, Coughlin MJ. Adult hallux valgus. St Louis: Mosby 1993.
3. Roddy E, Zhang W, Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum 2008 59(6): 857-862.
4. Cho NH, Kim S, Kwon DJ, Kim HA. The prevalence of hallux valgus and its association with foot pain and function in a rural Korean community. JBJS 2009 91B (4): 494-498.
5. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2007 28(7): 759-777.
6. Nguyen US, Hillstrom HJ, Li W, Dufour AB, Kiel DP, Procter-Gray E, Gagnon MM, Hannan MT. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston study. Osteoarthritis Cartilage 2010 18(1): 41-46.
7. Kennedy JG, Collumbier JA. Bunions in dancers. Clin Sports Med. 2008 27(2): 321-328.
8. Einarsdóttir H, Troell S, Wykman A. Hallux valgus in ballet dancers: a myth? Foot Ankle Int. 1995 16(2): 92-94.
9. Roddy E, Zhang W, Doherty M. Validation of a self-report instrument for assessment of hallux valgus. Osteoarthritis and Cartilage 2007 15: 1008-1012.
10. Garrow AP, Papageorgiou A, Silman AJ, Thomas E, Jayson MI, Macfarlane GJ. The grading of hallux valgus: the Manchester scale. JAPMA 2001 91(2): 74-78.
11. Dawson J, Thorogood M, Marks SA, Juszczak E, Dodd C, Lavis G, Fitzpatrick R. The prevalence of foot problems in older women: a cause for concern. J Public Health Med 2002 24(2): 77-84.
12. Menz HB, Lord SR. Gait instability in older people with hallux valgus. Foot Ankle Int 2005 26(6): 483-489.
13. Lee CM, Jeong EH, Freivalds A. Biomechanical effects of wearing high-heeled shoes. Int J Ind Ergo 2001 28: 321-326.
14. Mandato MG, Nester E. The effects of increasing heel height on forefoot peak pressure. JAPMA 1999 89(2): 75-80.
15. Kerrigan DC, Todd MK, Riley PO. Knee osteoarthritis and high-heeled shoes. Lancet 1998 351(9113): 1399-401.
16. Coughlin MJ. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int 1995 16(11): 682-697.
17. Easley ME, Trnka HJ. Current concepts review: Hallux valgus part 1: pathomechanics, clinical assessment, and nonoperative management. Foot Ankle Int 2007 28(5): 654-659.
18. Piqué-Vidal C, Solé MT, Antich J. Hallux valgus inheritance: pedigree research in 350 patients with bunion deformity. J Foot Ankle Surg 2007 46(3): 149-154.

Address correspondence to: Stephen Hui Research Centre for Physical Recreation & Wellness, Hong Kong Baptist University, Kowloon, Hong Kong. (852)3411-5631 Email: s62591@hkbu.edu.hk

1  Department of Orthopaedics and Sports Injury, Hong Kong Adventist Hospital, Hong Kong. (852)2525-5035.
2  Stephen Hui Research Centre for Physical Recreation & Wellness, Hong Kong Baptist University, Kowloon, Hong Kong. (852)3411-5631.

© The Foot and Ankle Online Journal, 2010

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Opening Base Wedge Osteotomy of the First Metatarsal Using the Arthrex Low Profile Plate and Screw System™

Posted on April 1, 2009 | Comments Off on Opening Base Wedge Osteotomy of the First Metatarsal Using the Arthrex Low Profile Plate and Screw System™

by Mark A. Hardy, DPM, FACFAS1 , Jason R. Grove, DPM2

The Foot and Ankle Online Journal 2 (4): 2

A number of procedures have been described for the high-end hallux valgus deformity. The authors describe a modification of the proximal opening wedge osteotomy utilizing the Arthrex Low Profile Plate and Screw System™. The system allows for stable fixation of the osteotomy without the need of a bone graft to maintain position. It is hoped that this article will generate a renewed interest in this highly effective procedure.

Key words: Hallux abductovalgus deformity, open wedge base osteotomy, first metatarsal

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: April, 2007
Published: April, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0204.0002

 
First metatatarsal base osteotomies have been performed for many years to correct moderate to severe intermetatarsal angles of the hallux abducto valgus deformity. A plethora of procedures have been described. Some of the most common include the crescentic, closing base wedge osteotomy and the chevron osteotomy. In contrast, the opening base wedge osteotomy has not been commonly used among surgeons. Most authors have stated that the opening base wedge is more technically demanding, requiring longer healing time due to the use of a graft, and can lead to joint jamming at the metatarsophalangeal joint.

Arthrex, Inc. has introduced a low profile titanium plate with a central spacer to allow accurate and more stable correction of the opening base wedge osteotomy. (Figs. 1,2) Furthermore, the use of the Arthrex Low Profile Plate and Screw System™ eliminates the need for a bone graft to hold the metatarsal in the corrected position. This makes the procedure less cumbersome than it may have been in the past.

Figure 1   The Arthrex Low Profile Plate and Screw System™.

Figure 2   The opening wedge plate.

Surgical technique

The incision should begin just proximal to the first metatarsocuneiform joint and end at the base of the proximal phalanx of the hallux. (Fig. 3) A modified McBride procedure is performed and the medial eminence is harvested for the future bone graft. The base of the first metatarsal is then exposed both medially and dorsally.

Figure 3   The standard incision allowing for interspace dissection and access to performing the opening base wedge osteotomy.

The first metatarsocuneiform joint is identified and a skin scribe is used to mark the dorsolateral cortex 1cm distal to the metatarsocuneiform joint. (Fig. 4) A 0.045 inch Kirschner wire is then driven from dorsal to plantar at the site already marked. The wire is driven perpendicular to the weight bearing surface to serve as an axis guide as is similarly done when performing a closing base wedge osteotomy. (Fig. 5 and 6)

Figure 4   Measuring 1-1.5cm distal to the metatarsal-cuneiform joint for placement of the osteotomy.

 

Figures 5 and 6   Placement of the axis guide wire perpendicular to the weight-bearing surface.

The technique guide recommends performing the osteotomy halfway between and perpendicular to the metatarsal and the weight bearing surface; we prefer to make this cut entirely perpendicular to the weight bearing surface, as we feel this effects less sagittal plane elevation.

Once the k-wire is in the proper position, a sagittal saw is utilized to make a single osteotomy. This is done by aligning the saw blade parallel to the k-wire. Care is taken to ensure that the lateral cortex is left intact. The medial wedge is created. This is done by inserting a series of three osteotomes. (Fig. 7) The 12mm osteotome is inserted first, followed by the 10mm osteotome, and lastly the 5mm osteotome. All three osteotomes are then removed.

Figure 7   Multiple placement of osteotomes to incrementally distract the osteotomy.  Care is taken to not break the lateral cortical hinge.

The osteotomy distractor is then placed medially and the wedge is opened to the desired width. (Fig. 8) Fluoroscopy is used to ensure that the intermetatarsal angle is adequately corrected.

The plate may then be placed directly on the medial surface of the metatarsal with the spacer flush against the proximal and distal edges of the wedge. The plate should be oriented such that the L-shaped portion is proximal to the osteotomy.

Figure 8   Demonstration of the Arthrex Osteotomy spreader. This is used to “dial in” the desired correction.

The screws can then be used to fixate the opening wedge plate to the bone. The screws closest to the osteotomy should be inserted first. A 1.7mm drill is passed through both cortices and the hole is measured with a depth gauge. The 2.3mm fully threaded cortical screw is then inserted. (Fig. 9)

Figure 9  Placement of the low profile open wedge plate and measurement of appropriate screw length with the depth gauge.

Once all screws are placed and the plate secured, the remaining void of the osteotomy should be filled with bone graft. This is usually done with a combination of the bone graft harvested from the medial eminence of the metatarsal head as well as allogenic cancellous bone chips. (Fig. 10 and 11) In hallux abduco valgus with larger intermetatarsal angles, there is a greater chance for compromise of the lateral cortical hinge. Should this occur, one can place an oblique screw across the osteotomy or even use a static plate from the Arthrex set. This can be applied dorsally along the first metatarsal to help prevent secondary elevatus. (Fig. 12, 13 and14)

Figures 10 and 11   Pre and post operative films demonstrating the use of the Arthrex Low Profile Plate and Screw™.

Figures 12 and 13   Use of an additional dorsal plate after compromise of the lateral cortex.  For larger hallux valgus deformities, this helps prevent secondary post-operative elevatus.

Figure 14   Lateral view showing the dorsal metatarsal plate in place.

Discussion

The opening base wedge technique was first described by Trethowin in 1923. [1] In 1983, Beronio described using the medial eminence of the first metatarsal as a graft for the opening wedge osteotomy. [2] Sollitto, et al., described an opening base wedge osteotomy with implant arthroplasty of the first metatarsophalangeal joint. They utilized the resected metatarsal head as a wedge graft. [3] In the retrospective study of 20 patients, the average intermetatarsal angle was reduced from 16.13 to 3 degrees six months postoperatively. Limbirdm, et al., in 1989, reported results after performing an opening base wedge osteotomy and modified McBride bunionectomy in 15 patients. The intermetatarsal angle averaged 15 degrees preoperatively and 8 degrees postoperatively. [4]

The indications for an opening base wedge osteotomy include a short first metatarsal, intermetatarsal angle of 15 degrees or greater, adequate bone stock, and a compliant patient who understands the need for non-weight bearing. [3]

Fixation for the opening base wedge osteotomy has varied. Trethowin felt that an intact lateral cortex and a properly fitting wedge graft were adequate and no further fixation was required. Other authors have agreed that no internal fixation was needed. [3,4] Varied forms of internal fixation include screws, staples, cerclage wire, plates, and crossing pins. Amarnek, et al., described the use of the Hoffman miniature external fixator for immobilization of the first metatarsal osteotomy after bunionectomy. [5]

The opening base wedge osteotomy has had its critics. Many surgeons have felt that the opening wedge is difficult to perform and prefer to use other base wedge procedures. In the past, a bone graft had to be harvested and accurately sized in order to maintain proper correction of the metatarsal. The bone graft must be incorporated resulting in prolonged healing times. Scranton and Zuckerman noted that there was a rapid recurrence of the hallux abducto valgus deformity in 3 of 5 patients. [6]

They argued that the lengthening created with the opening wedge results in tightening of the soft tissue about the metatarsophalangeal joint, “promoting early hallux valgus recurrence.” The lengthening of the metatarsal has also been thought to predispose the metatarsophalangeal joint to jamming and subsequent arthritis. [7] Other authors have also noted that the quality of the bone graft collected from the medial metatarsal head is suboptimal for incorporation. [7]

With the development of the low profile plate and screw system by Arthrex, Inc., many of the aforementioned pitfalls can be prevented. The spacer on the plate acts as a pillar holding the wedge at the desired width. The Arthrex system eliminates the need for the bone graft to act as scaffolding for new bone growth. Moreover, it is not imperative that the surgeon make a precise fitting wedge of bone, allowing for the use of cancellous bone chips that will be more likely to incorporate into the bone. The plate is a permanent fixation device and will eliminate the risk of bunion recurrence.

About the Low Profile Plate and Screw System

The plates are titanium and have a thickness of 0.5mm. The plate spacers range from 2mm to 7mm in 0.5mm increments. The titanium screws are 2.3mm in diameter with a length ranging from 10mm to 30mm in 1mm increments. The screws are fully threaded, self-tapping cortical design. The thread hole drill bit is 1.7mm.

Summary

It is hoped that the Arthrex Low Profile Screw and Plate System™ will stimulate renewed interest of the opening base wedge osteotomy as a viable option for surgical correction of the hallux abducto valgus deformity. Many of the difficulties and complications seen in the past may be alleviated with this new design. The procedure is simple, offers adequate fixation of the osteotomy site, and ensures permanent correction.

References

1. Trethowan J. “Hallux valgus.” In: Choyce CC (Ed), A System of Surgery. New York, P.B. Hoeber, 1046 – 1049, 1923.
2. Beronio JP. One approach to a viable method of obtaining cancellous bone for grafting. J Foot Surg, 22: 240 – 242, 1983.
3. Sollitto RJ, Hart TJ, Sergi AR. Opening base wedge osteotomy with first metatarsophalangeal joint implantation arthroplasty: A retrospective study. J Foot Surg: 30 (2) 165 – 169, 1991.
4. Limbird TJ, DaSilva RM, Green NE. Osteotomy of the first metatarsal base for metatarsus primus varus. Foot & Ankle. 9 (4): 158 – 162, 1989.
5. Amarnek DL, Juda EJ. Opening base wedge osteotomy of the first metatarsal utilizing rigid external fixation. J Foot Surg 25(4): 321 – 326, 1986.
6. Scranton PE, Zuckerman JD: Bunion surgery in adolescents: results of surgical treatment. J Pediatr Orthopaed 4 (1): 39 – 43, 1984.
7. Mothershed RA. Osteotomies of the first metatarsal base. In: Banks AS, Downey MS, Martin DE, Miller SJ (Eds) McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Lippincott Williams & Wilkins , 2001.

Address correspondence to: Mark A. Hardy, DPM, FACFAS
Kaiser Permanente Foundation Department of Podiatric Surgery
12301 Snow Road Parma, OH 44130
E-mail: Markhardy@sbcglobal.net.

1  Director, Foot & Ankle Trauma Service, Kaiser Permanente, Cleveland, Ohio. Cleveland Clinic Foundation Residency Program.

2  Second-year resident (PGY-2), Kaiser Permanente/Cleveland Clinic Foundation Residency Program, Cleveland, Ohio.

© The Foot and Ankle Online Journal, 2009

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Quantitative Geometry of the Distal First Metatarsal Axis Guide Concept

Posted on January 1, 2009 | Comments Off on Quantitative Geometry of the Distal First Metatarsal Axis Guide Concept

by Andrew J. Meyr, DPM1 , Stephen F. Stern, DPM2

The Foot & Ankle Journal 2 (1): 1

The axis guide concept was introduced as an intra-operative tool to assist the surgeon in estimating the transverse and sagittal plane motion of the capital fragment during lateral transposition of a distal first metatarsal osteotomy for the surgical correction of the hallux abductovalgus deformity. The intention of this investigation was an attempt to provide a quantitative estimate to the previously qualitative axis guide concept. The Law of Cosines was applied to the morphologic characteristics of a sawbone first metatarsal model. Measurements were calculated based on 1/4, 1/3, and 1/2 lateral transpositions of the capital fragment of the first metatarsal. An average of all measurements resulted in a change of the absolute first metatarsal position of 1mm for every 10˚ change in axis guide orientation in both the transverse and sagittal planes. It is the authors’ hope that this data can be used to further understanding of the perioperative evaluation and surgical correction of the hallux abductovalgus deformity.

Key words: Distal first metatarsal osteotomy, hallux abductovalgus, axis guide, geometry

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 & Ankle Journal (www.faoj.org)

Accepted: December, 2008
Published: January, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0201.0001

The axis guide concept was first introduced as an intra-operative tool to assist the surgeon in estimating the transverse and sagittal plane motion of the capital fragment during lateral transposition of a distal first metatarsal osteotomy for the surgical correction of the hallux abductovalgus deformity. [1,2]

A temporary Kirschner wire (K-wire) is inserted in a medial to lateral direction through the center of the first metatarsal head and aimed distally or proximally (to achieve lengthening or shortening of the capital fragment respectively), and dorsally or plantarly (to achieve dorsiflexion or plantarflexion of the capital fragment respectively). An osteotomy is then performed with the saw blade orientated parallel to the axis guide.

Previous works have established the importance of appreciating a long [3-12] , short [3,4,8,13,14] , or elevated [13,6,8,9,15] first metatarsal as a contributing deformity in the pre-operative evaluation of hallux abductovalgus.

Specific measurements, such as Hardy and Clapham’s tangential lines [16] and the Seiberg index [17], have been introduced to quantify how “long”, “short” or “elevated” the first metatarsal is relative to the remainder of the lesser metatarsal parabola. [18,19] However, the axis guide concept is a qualitative estimate, with the relative position of the temporary K-wire allowing the surgeon to generally correct for lengthening, shortening, dorsiflexion, or plantarflexion of the first metatarsal. It does not provide a quantitative measurement for correction.

Geometric principles have been applied to distal first metatarsal and general forefoot surgeries in the past [20-31], but the intended emphasis of this investigation is an attempt to provide a quantitative estimate to the previously qualitative axis guide concept.

Methods

The Law of Cosines was applied to the morphologic characteristics of a sawbone first metatarsal model. (Figs. 1 and 2) Several variables and limitations affect the mathematics when utilizing this technique. The variables include only the relative transverse plane position of the axis guide, the relative sagittal plane position of the axis guide, and the extent of lateral translation of the capital fragment. In terms of limitations, it is important to appreciate that all measurements represent absolute changes to the first metatarsal, and are not measured directly relative to the remainder of the lesser metatarsal parabola.

geometry_of_the_axis_guide_figure_1

Figure 1  Law of Cosines.

geometry_of_the_axis_guide_figure_2

Figure 2  The law of cosines applied to a sawbones model.  In this model, c represents the initial first metatarsal length, b represents the post-transposition first metatarsal length, and a represents a parallel to the axis of translation (axis guide).

Absolute axis guide positions relative to the first metatarsal in the transverse and sagittal planes can be correctly measured and effectively generalized to all hallux abductovalgus deformities. (Fig. 3)

geometry_of_the_axis_guide_figure_3a geometry_of_the_axis_guide_figure_3b

Figure 3   Absolute axis guide orientations measured directly from the first metatarsal represent absolute changes to the first metatarsal length and declination.  The only variables in this situation are the transverse plane position of the axis guide, the sagittal plane position of the axis guide, and the extent of lateral translation of the capital fragment.  These measurements can be correctly determined and effectively generalized to all hallux abductovalgus deformities.

However, relative axis guide positions, such as an axis guide that is perpendicular to the second metatarsal shaft (Figure 4A) or aimed at the third metatarsal head (Figure 4B), are additionally dependant on the intermetatarsal angle and metatarsal length pattern. Therefore, while it can be correctly measured in this sawbones model, the results cannot be generalized to all hallux abductovalgus deformities.

geometry_of_the_axis_guide_figure_4a geometry_of_the_axis_guide_figure_4b

Figure 4AB   Relative axis guide orientations, here demonstrated as perpendicular to the 2nd metatarsal shaft (A) and aimed at the third metatarsal head (B), are dependant on the intermetatarsal angle and metatarsal length pattern in addition to the transverse plane position of the axis guide and the extent of lateral translation of the capital fragment.  Although these measurements can be correctly determined in this model (α=12˚; β=4˚), the results cannot be generalized to all hallux abductovalgus deformities.

Specific for this study, measurements were calculated based on 1/4, 1/3, and 1/2 lateral transpositions of the capital fragment of the first metatarsal.

Results

Tables 1 and 2 provide data based on a 1/4 capital fragment lateral transposition. The average change in transverse plane axis guide orientation is 15.5˚ for every 1mm change in absolute first metatarsal length based on the measured calculations (or 0.6mm for each 10˚ change). The average change in sagittal plane axis guide orientation is 11.4˚ for every 1mm change in absolute first metatarsal sagittal plane position based on the measured calculations (or 0.9mm for each 10˚ change).

axisguidtable1pic

Table 1  Transverse Plane Motion Based on a 1/4 Lateral Translation

The average change in transverse plane axis guide orientation is 15.5˚ for every 1mm change of absolute first metatarsal length based on these specific calculations of a 1/4 capital fragment lateral translation (or 0.6mm for each 10˚ change).

axisguidtable2pic

Table 2  Sagittal Plane Motion Based on a 1/4 Lateral Translation

The average change in sagittal plane axis guide orientation is 11.4˚ for every 1mm change of absolute first metatarsal sagittal plane position based on these specific calculations of a 1/4 capital fragment lateral translation (or 0.9mm for each 10˚ change).

Tables 3 and 4 provide data based on a 1/3 capital fragment lateral transposition. The average change in transverse plane axis guide orientation is 13.2˚ for every 1mm change in absolute first metatarsal length based on the measured calculations (or 0.8mm for each 10˚ change). The average change in sagittal plane axis guide orientation is 8.7˚ for every 1mm change in absolute first metatarsal sagittal plane position based on the measured calculations (or 1.2mm for each 10˚ change).

axisguidetable3

Table 3  Transverse Plane Motion Based on a 1/3 Lateral Translation

The average change in transverse plane axis guide orientation is 13.2˚ for every 1mm change of absolute first metatarsal length based on these specific calculations of a 1/3 capital fragment lateral translation (or 0.8mm for each 10˚ change).

axisguidetable4

Table 4  Sagittal Plane Motion Based on a 1/3 Lateral Translation

The average change in sagittal plane axis guide orientation is 8.7˚ for every 1mm change of absolute first metatarsal sagittal plane position based on these specific calculations of a 1/3  capital fragment lateral translation (or 1.2mm for each 10˚ change).

Tables 5 and 6 provide data based on a 1/2 capital fragment lateral transposition. The average change in transverse plane axis guide orientation is 10.7˚ for every 1mm change in absolute first metatarsal length based on the measured calculations (or 1.1mm for each 10˚ change). The average change in sagittal plane axis guide orientation is 6.0˚ for every 1mm change in absolute first metatarsal sagittal plane position based on the measured calculations (or 0.9mm for each 10˚ change).

axisguidetable5

Table 5  Transverse Plane Motion Based on a 1/2 Lateral Translation

The average change in transverse plane axis guide orientation is 10.7˚ for every 1mm change of absolute first metatarsal length based on these specific calculations of a 1/2 capital fragment lateral translation (or 1.1mm for each 10˚ change).

axisguidetable6

Table 6  Sagittal Plane Motion Based on a 1/2 Lateral Translation

The average change in sagittal plane axis guide orientation is 6.0˚ for every 1mm change of absolute first metatarsal sagittal plane position based on these specific calculations of a 1/2  capital fragment lateral translation (or 1.7mm for each 10˚ change).

 

An average of all transverse plane measurements (with a range from1/4-1/2 capital fragment lateral transposition and 0-63.8˚ of axis guide orientation) results in a change of the transverse plane axis guide orientation of 13.1˚ for every 1mm change in absolute first metatarsal length (or 0.8mm for each 10˚ change). An average of all sagittal plane measurements (with a range from 1/4-1/2 capital fragment lateral transposition and 0-45˚ of axis guide orientation) results in a change of the sagittal plane axis guide orientation of 8.7˚ for every 1mm change in first metatarsal sagittal plane position (or 1.3mm for each 10˚ change).

An average of all measurements (transverse and sagittal planes) results in a change in the axis guide orientation of 11.2˚ for every 1mm change in first metatarsal position (or 1.0mm for each 10˚ change).

Discussion

This is proposed to be a theoretical exercise, rather than a study of functional outcomes. Just as the original axis guide concept was introduced to assist the surgeon in estimating capital fragment movement, this study only intends to add a quantitative measurement to this estimation. Two clinically relevant points may be taken from these findings. The first is that an average of all measurements results in approximately 1mm of metatarsal positional change per 10˚ of axis guide orientation change.

If a surgeon pre-operatively quantifies how long, short, dorsiflexed or plantarflexed the first metatarsal is relative to the lesser metatarsal parabola, then they may choose to use this quantified estimate during their surgical deformity correction.

The second clinical point is that the analyses indicate that a relatively wide range of hand positions result in relatively small changes to the metatarsal length and sagittal plane position. Put simply, even if a surgeon is not completely satisfied with the axis guide orientation prior to the osteotomy, a small change of the axis guide position is unlikely to result in a significant clinical change to the metatarsal position. While certainly there may be a difference between an axis guide orientated 60° plantar versus one aimed 20° plantar, there probably isn’t a difference between one aimed 25° compared to 20°.

It is important to note that the authors make no claims of clinical outcomes based on millimeters of positional change. It is also important to note that the authors make no attempt to correct for shortening that will occur as a result of the osteotomy itself, although this is assumed to be equal and independent of the axis guide position.

It is the authors’ hope that this data will be utilized to further understand the perioperative evaluation and surgical correction of the hallux abductovalgus deformity.

References

1. Chang TJ. Distal metaphyseal osteotomies in hallux abducto valgus surgery. In: Banks AS, Downey MS, Martin DE, Miller SJ, editors. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Third Edition. Philadelphia: Lippincott, Williams and Wilkins; p. 505 – 527, 2001.
2. Cain TD, Boyd D. Defining the limits of the modified Austin bunionectomy. In: DiNapoli DR, ed. Reconstructive surgery of the foot and leg: update ’90. Tucker, GA: Podiatry Institute; p. 128 – 134, 1990.
3. Coughlin MJ, Mann RA. Hallux valgus. In: Surgery of the Foot and Ankle. Eighth edition. Coughlin MJ, Mann RA, Saltzman CL, editors. Philadelphia: Mosby Elsevier; p. 183 – 362, 2007.
4. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 28(7): 759 – 77, 2007.
5. Martin DE, Pontious J. Introduction and evaluation of hallux abducto valgus. In: Banks AS, Downey MS, Martin DE, Miller SJ, editors. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Third Edition. Philadelphia: Lippincott, Williams and Wilkins p. 481 – 491, 2001.
6. Myerson MS. Hallux valgus. In: Myerson MS, editor. Foot and Ankle Disorders. Philadelphia: W.B. Saunders Company p. 213 – 88, 2000.
7. Reynolds JC. Adolescent hallux valgus and bunion. In: Gould JS, editor. The Foot Book. Baltimore: Williams and Wilkins; p. 193 – 205, 1998.
8. Mooney J, Campbell R. General foot disorders. In: Lorimer D, French G, O’Donnell M, Burrow JG, Wall B, editors. Neale’s Disorders of the Foot. Seventh Edition. Edinburgh: Churchill Livingstone Elsevier; p. 89 – 163, 2006.
9. Palladino SJ. Preoperative evaluation of the bunion patient. In: Gerbert J, editor. Textbook of Bunion Surgery. Third Edition. Philadelphia: W.B. Saunders Company; p. 3 – 71, 2001.
10. Richardson EG, Donley BG. Disorders of the hallux. In: Canale ST, editor. Campbell’s Operative Orthopedics. Tenth Edition. St. Louis: Mosby; p. 3915 – 4015, 2003.
11. DuVries HL. Static deformities of the forefoot. In: DuVries HL, editor. Surgery of the Foot. Second Edition. St. Louis: The C.V. Mosby Company; 1965. p. 379 – 467, 1965.
12. Tanaka Y, Takakura Y, Kumai T, Samoto N, Tamai S. Radiographic analysis of hallux valgus. A two-dimensional coordinate system. J Bone Joint Surg Am. 77(2): 205 – 13, 1995.
13. Hansen ST. The dysfunctional forefoot. In: Hansen ST, editor. Functional Reconstruction of the Foot and Ankle. Philadelphia: Lippincott, Williams and Wilkins; p. 215 – 226, 2000.
14. DuVries HL. Static deformities of the forefoot. In: DuVries HL, editor. Surgery of the Foot. Second Edition. St. Louis: The C.V. Mosby Company; p. 379 – 467, 1965.
15. Tollafield DR, Kilmartin TE, Prior T. The adult foot. In: Turner WA, Merriman LM, editors. Clinical Skills in Treating the Foot. Second Edition. Edinburgh: Elsevier Churchill Livingstone; p. 323 – 365, 2005.
16. Hardy RH, Clapham JC. Observations on hallux valgus; based on a controlled series. J Bone Joint Surg. 33B (3): 376 – 91, 1951.
17. Seiberg M, Felson S, Colson JP, Barth AJ, Green RM, Green DR. Closing base wedge versus Austin bunionectomies for metatarsus primus adductus. J Am Podiatr Med Assoc. 84(11): 548 – 63, 1994.
18. Roukis TS. Metatarsus primus elevatus in hallux rigidus: fact or fiction? J Am Podiatr Med Assoc. 95 (3): 221 – 8, 2005.
19. Valley BA, Reese HW. Guidelines for reconstructing the metatarsal parabola with the shortening osteotomy. J Am Podiatr Med Assoc. 81(8): 406 – 13, 1991.
20. Lamur KS, Huson A, Snijders CJ, Stoeckart R. Geometric data of hallux valgus feet. Foot Ankle Int. 17(9): 548 – 54, 1996.
21. Bettazzoni F, Leardini A, Parenti-Castelli V, Giannini S. Mathematical model for pre-operative planning of linear and closing-wedge metatarsal osteotomies for the correction of hallux valgus. Med Biol Eng Comput. 42 (2): 209 – 15, 2004.
22. Gerbert J, Moadab A, Rupley KF. Youngswick-Austin procedure: the effect of plantar arm orientation on metatarsal head displacement. J Foot Ankle Surg. 40 (1): 8 – 14, 2004.
23. Vienne P, Favre P, Meyer D, Schoeniger R, Wirth S, Espinosa N. Comparative mechanical testing of different geometric designs of distal first metatarsal osteotomies. Foot Ankle Int. 28(2): 232 – 6, 2007
24. Kummer FJ. Mathematical analysis of first metatarsal osteotomies. Foot Ankle. 9 (6): 281 – 9, 1989.
25. Harper MC, Canale ST. Angulation osteotomy. A trigonometric analysis. Clin Orthop Relat Res. (166): 173-81, 1982.
26. Badwey TM, Dutkowsky JP, Graves SC, Richardson EG. An anatomical basis for the degree of displacement of the distal chevron osteotomy in the treatment of hallux valgus. Foot Ankle Int. 18 (4): 213 – 5, 1997.
27. Harper MC. Dorsal closing wedge metatarsal osteotomy: a trigonometric analysis. Foot Ankle. 10(6): 303 – 5, 1990.
28. Nyska M, Trnka HJ, Parks BG, Myerson MS. Proximal metatarsal osteotomies: a comparative geometric analysis conducted on sawbone models. Foot Ankle Int. 23 (10): 938 – 45, 2002.
29. Palladino SJ. Orientation of the first metatarsal base wedge osteotomy: perpendicular to the metatarsal versus weight-bearing surface. J Foot Surg. 27(4): 294 – 8, 1988.
30. Loya K, Guimet M, Rockett MS. Proximal shortening lesser first metatarsal osteotomy: a mathematical-geometric basis. J Foot Ankle Surg. 39 (2): 104 – 13, 2000.
31. Demp PH. Pathomechanical metatarsal arc: radiographic evaluation of its geometric configuration. Clin Podiatr Med Surg. 7(4): 765 – 76, 1990.

Address correspondence to: Andrew J. Meyr, DPM
Inova Fairfax Hospital. Podiatric Surgical Residency Office, T6W
3300 Gallows Rd.
Falls Church, VA. 20042
Email: ajmeyr@gmail.com

1 Resident, INOVA Fiarfax Hospital Podiatric Surgical Residency Program, Falls Church, Virginia, USA.
2 Private Practice, Vienna, Virginia, USA

© The Foot & Ankle Journal, 2009

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