Michael J. Coughlin

Hallux Valgus: Demographics, Etiology, and Radiographic Assessment:

Background The purpose of the study was to preoperatively evaluate the demographics, etiology, and radiographic findings associated with moderate and severe hallux valgus deformities in adult patients (over 20 years of age) treated operatively over a 33-month period in a single surgeons practice. Methods Patients treated for a hallux valgus deformity between September, 1999, and May, 2002, were identified. Patients who had mild deformities (hallux valgus angle < 20 degrees), concurrent degenerative arthritis of the first metatarsophalangeal joint, inflammatory arthritis, recurrent deformities, or congruent deformities were excluded. When enrolled, all patients filled out a standardized questionnaire and had a routine examination that included standard radiographs, range of motion testing, and first ray mobility measurement. A chart review and evaluation of preoperative radiographs were completed on all eligible patients. Results One-hundred and three of 108 (96%) patients (122 feet) with a diagnosis of moderate or severe hallux valgus (hallux valgus angle of 20 degrees or more) 70 qualified for the study. The onset of the hallux valgus deformity peaked during the third decade although the distribution of occurrence was almost equal from the second through fifth decades. Twenty-eight of 122 feet (23%) developed a deformity at an age of 20 years or younger. Eighty-six (83%) of patients had a positive family history for hallux valgus deformities and 87 (84%) patients had bilateral bunions. 15% of patients in the present series had moderate or severe pes planus based on a positive Harris mat study. Only 11% (14 feet) had evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that 86 of 122 feet (71%) had an oval or curved metatarsophalangeal joint. Thirty-nine feet (32%) had moderate or severe metatarsus adductus. A long first metatarsal was common in patients with hallux valgus (110 of 122 feet; 71%); the mean increased length of the first metatarsal when compared to the second was 2.4 mm. While uncommon, the incidence of an os intermetatarsum was 7% and a proximal first metatarsal facet was 7%. The mean preoperative first ray mobility as measured with Klaues device was 7.2 mm. 16 of 22 (13%) feet were observed to have increased first ray mobility before surgery. Conclusions The magnitude of the hallux valgus deformity was not associated with Achilles or gastrocnemius tendon tightness, increased first ray mobility, bilaterality or pes planus. Neither the magnitude of the preoperative angular deformity nor increasing age had any association with the magnitude of the first metatarsophalangeal joint range of motion. Constricting shoes and occupation were implicated by 35 (34%) patients as a cause of the bunions. A familial history of bunions, bilateral involvement, female gender, a long first metatarsal, and an oval or curved metatarsophalangeal joint articular surface were common findings. Increased first ray mobility and plantar gapping of the first metatarsocuneiform joint were more common in patients with hallux valgus than in the general population (when compared with historical controls).

Hallux valgus-etiology, anatomy, treatment and surgical considerations

The etiology of hallux valgus, method of patient selection, technique of carrying out a modified McBride procedure, and possible surgical pitfalls associated with the procedure are discussed. The results of the McBride procedure and the limitations that the authors feel should be placed upon the procedure were stressed. The authors believe that the modified McBride procedures is biomechanically sound and offers patients a most satisfactory correction of their deformity. The procedure has a very low incidence or postoperative complications, and if a complication arises, the surgeon has many good alternatives with which to correct the problem.

Hallux rigidus. Grading and long-term results of operative treatment.

BACKGROUND There have been few long-term studies documenting the outcome of surgical treatment of hallux rigidus. The purposes of this report were to evaluate the long-term results of the operative treatment of hallux rigidus over a nineteen-year period in one surgeons practice and to assess a clinical grading system for use in the treatment of hallux rigidus. METHODS All patients in whom degenerative hallux rigidus had been treated with cheilectomy or metatarsophalangeal joint arthrodesis between 1981 and 1999 and who were alive at the time of this review were identified and invited to return for a follow-up evaluation. At this follow-up evaluation, the hallux rigidus was graded with a new five-grade clinical and radiographic system. Outcomes were assessed by comparison of preoperative and postoperative pain and AOFAS (American Orthopaedic Foot and Ankle Society) scores and ranges of motion. These outcomes were then correlated with the preoperative grade and the radiographic appearance at the time of follow-up. RESULTS One hundred and ten of 114 patients with a diagnosis of hallux rigidus returned for the final evaluation. Eighty patients (ninety-three feet) had undergone a cheilectomy, and thirty patients (thirty-four feet) had had an arthrodesis. The mean duration of follow-up was 9.6 years after the cheilectomies and 6.7 years after the arthrodeses. There was significant improvement in dorsiflexion and total motion following the cheilectomies (p = 0.0001) and significant improvement in postoperative pain and AOFAS scores in both treatment groups (p = 0.0001). A good or excellent outcome based on patient self-assessment, the pain score, and the AOFAS score did not correlate with the radiographic appearance of the joint at the time of final follow-up. Dorsiflexion stress radiographs demonstrated correction of the elevation of the first ray to nearly zero. There was no association between hallux rigidus and hypermobility of the first ray, functional hallux limitus, or metatarsus primus elevatus. CONCLUSIONS Ninety-seven percent (107) of the 110 patients had a good or excellent subjective result, and 92% (eighty-six) of the ninety-three cheilectomy procedures were successful in terms of pain relief and function. Cheilectomy was used with predictable success to treat Grade-1 and 2 and selected Grade-3 cases. Patients with Grade-4 hallux rigidus or Grade-3 hallux rigidus with <50% of the metatarsal head cartilage remaining at the time of surgery should be treated with arthrodesis.

Prospective Controlled Trial of STAR Total Ankle Replacement versus Ankle Fusion: Initial Results

Background: Mobile-bearing ankle replacements have become popular outside of the United States over the past two decades. The goal of the present study was to perform a prospective evaluation of the safety and efficacy of a mobile-bearing prosthesis to treat end stage ankle arthritis. We report the results of three separate cohorts of patients: a group of Scandanavian Total Ankle Replacement (STAR) patients and a control group of ankle fusion patients (the Pivotal Study Groups) and another group of STAR total ankle patients (Continued Access Group) whose surgery was performed following the completion of enrollment in the Pivotal Study. Materials and Methods: The Pivotal Study design was a non-inferiority study using ankle fusion as the control. A non-randomized multi-centered design with concurrent fusion controls was used. We report the initial perioperative findings up to 24 months following surgery. For an individual patient to be considered an overall success, all of the following criteria needed to be met: a) a 40-point improvement in total Buechel-Pappas ankle score, b) no device failures, revisions, or removals, c) radiographic success, and d) no major complications. In the Pivotal Study (9/00 to 12/01), 158 ankle replacement and 66 arthrodesis procedures were performed; in the Continued Access Study (4/02 to 10/06), 448 ankle replacements were performed, of which 416 were at minimum 24 months post-surgery at time of the database closure. Results: Major complications and need for secondary surgical intervention were more common in the Pivotal Study arthroplasty group than the Pivotal Study ankle fusion group. In the Continued Access Group, secondary procedures performed on these arthroplasty patients decreased by half when compared with the Pivotal Arthroplasty Group. When the Pivotal Groups were compared, treatment efficacy was higher for the ankle replacement group due to improvement in functional scores. Pain relief was equivalent between fusion and replacement patients. The hypothesis of non-inferiority of ankle replacement was met for overall patient success. Conclusion: By 24 months, ankles treated with STAR ankle replacement (in both the Pivotal and Continued Access Groups) had better function and equivalent pain relief as ankles treated with fusion. Level of Evidence: II, Prospective Controlled Comparative Surgical Trial

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Hallux Valgus*†

Hallux valgus occurs with lateral deviation of the great toe and medial deviation of the first metatarsal. Commonly, the deformity is characterized by progressive subluxation of the first metatarsophalangeal joint (Figs. 1-A, 1-B, and 1-C). Occasionally, there is a static deformity due to valgus angulation of the distal articular surface of the first metatarsal or the proximal phalangeal articular surface (Fig. 2). Figs. 1-A, 1-B, and 1-C: Radiographs demonstrating the different degrees of a hallux valgus deformity. The arrow indicate the direction of the subluxation, and the arrowheads indicate the extent of the joint surface. Fig. 1-A: A mild hallux valgus deformity with subluxation of the first metatarsophalangeal joint. The hallux valgus angle is 19 degrees, the first-second intermetatarsal angle is 10 degrees, and there is less than 50 per cent (mild) subluxation of the sesamoids. Fig. 1-B: Moderate hallux valgus deformity with subluxation of the first metatarsophalangeal joint. The hallux valgus angle is 30 degrees, the first-second intermetatarsal angle is 14 degrees, and there is 50 to 75 per cent (moderate) subluxation of the sesamoids. Fig. 1-C: A severe, recurrent hallux valgus deformity with severe subluxation of the first metatarsophalangeal joint. The hallux valgus angle is 50 degrees, the intermetatarsal angle is 17 degrees, and there is more than 75 per cent (severe) subluxation of the sesamoids. The second metatarsophalangeal joint is dislocated. Radiograph of a foot with moderate hallux valgus deformity without subluxation of the first metatarsophalangeal joint. The hallux valgus is due mainly to 25 degrees of valgus angulation of the distal articular surface of the metatarsal. A sagittal groove (or sulcus) has developed medial to the articular surface. There is a prominent medial eminence. The dotted line indicates the medial and lateral extent of the distal articular surface of the metatarsal. Hallux valgus …

Rheumatoid Forefoot Reconstruction. A Long-Term Follow-up Study*

Background: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present. Methods: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author. Results: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints. Conclusions: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschner-wire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.

Juvenile Hallux Valgus: Etiology and Treatment

In an 11-year retrospective study of 45 patients (60 feet) with juvenile hallux valgus, a multiprocedural approach was used to surgically correct the deformity. A Chevron osteotomy or McBride procedure was used for mild deformities, a distal soft tissue procedure with proximal first metatarsal osteotomy was used for moderate and severe deformities with MTP subluxation, and a double osteotomy (extra-articular correction) was used for moderate and severe deformities with an increased distal metatarsal articular angle (DMAA). The average hallux valgus correction was 17.2° and the average correction of the 1–2 intermetatarsal angle was 5.3°. Good and excellent results were obtained in 92% of cases using a multiprocedural approach. Eighty-eight percent of patients were female and 40% of deformities occurred at age 10 or younger. Early onset was characterized by increased deformity and an increased DMAA. Maternal transmission was noted in 72% of patients. An increased distal metatarsal articular angle was noted in 48% of cases. With subluxation of the first MTP joint, the average DMAA was 7.9°. With a congruent joint, the average DMAA was 15.3°. In patients where hallux valgus occurred at age 10 or younger, the DMAA was increased. First metatarsal length was compared with second metatarsal length. While the incidence of a long first metatarsal was similar to that in the normal population (30%), the DMAA was 15.8° for a long first metatarsal and 6.0° for a short first metatarsal. An increased DMAA may be the defining characteristic of juvenile hallux valgus. The success of surgical correction of a juvenile hallux valgus deformity is intimately associated with the magnitude of the DMAA. Moderate and severe pes planus occurred in 17% of cases, which was no different than the incidence in the normal population. No recurrences occurred in the presence of pes planus. Pes planus was not thought to have an affect on occurrence or recurrence of deformity. Moderate and severe metatarsus adductus was noted in 22% of cases, a rate much higher than that in the normal population. The presence of metatarsus adductus did not affect the preoperative hallux valgus angle or the average surgical correction of the hallux valgus angle. Constricting footwear was noted by only 24% of patients as playing a role in the development of juvenile hallux valgus. There were six recurrences of the deformities and eight complications (six cases of postoperative hallux varus, one case of wire breakage, and one case of undercorrection).

The Reliability of Angular Measurements in Hallux Valgus Deformities

The purpose of this study was to determine the intra-observer and inter-observer reliability of physicians on a repetitive basis in making angular measurements of hallux valgus deformities. The hallux valgus angle, the 1–2 intermetatarsal angle, and the distal metatarsal articular angle and the assessment of congruency/subluxation of the first MTP joint were evaluated on a repetitive basis. Physicians were provided with a series of black and white photographs of radiographs with a hallux valgus deformity. Three different sets of photographs randomly ordered were sent at a minimum interval of six weeks to the participants. Participating physicians were extremely reliable in the measurement of the 1–2 metatarsal angle. 96.7% of the photographs were repeatedly measured within a range of 5 degrees or less. The angular measurements to determine the hallux valgus angle were slightly less reliable, but 86.2% of photos were repeatedly measured within a range of 5 degrees or less. In the measurement of the distal metatarsal articular angle, 58.9% of photographs were repeatedly measured within a range of 5 degrees or less. There was a wide range within physician evaluators who recognized very few congruent joints (2 of 21) and those who recognized several congruent joints (11 of 21). Most physicians appeared to be internally consistent in the assessment of MTP congruency; however, some photographs were much more difficult to assess than others. This study validates the reliability of the measurement of the hallux valgus and the 1–2 metatarsal angle. The inter-observer reliability in the measurement of the distal metatarsal articular angle is questioned.

Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation : A prospective study

Background: Many techniques exist for arthrodesis of the first metatarsophalangeal (MTP) joint, as well as, indications for each method. The purpose of this study was to determine the results of one method using dome-shaped reamers to prepare the joint surfaces and a low-profile dorsal titanium plate for internal fixation. To date, no prospective studies have reported patient outcomes of arthrodesis of the first MTP joint using this technique. Methods: Fifty patients (54 feet) had first MTP joint arthrodesis from January, 2004, through January, 2005. All patients were evaluated preoperatively for underlying pathology, pain, function, and radiographic findings. First MTP joint arthrodesis was fixed with a dorsal titanium plate with preset valgus and dorsiflexion after the joint surfaces were prepared with matching male and female dome-shaped power reamers to achieve congruous cancellous bone surfaces. At a minimum of 1-year followup, patients returned for postoperative evaluation. In addition to evaluation of pain, function, and radiographic findings, patients were asked how long they remained off work, how long swelling persisted, and whether the hardware caused symptoms. Results: Forty-nine of 53 patients returned for followup at an average of 16 months after surgery. American Orthopaedic Foot and Ankle Society (AOFAS) scores improved significantly (z = −6.301, p > 0.01) from an average of 51 points preoperatively (range 24 to 97) to 82 points postoperatively (range 47 to 90). Pain scores at final followup demonstrated a significant improvement (z = −6.154, p > 0.01) from a mean of 6.3 to a mean of less than 1 point on the visual analog pain scale. Time off work averaged 3 weeks, while swelling persisted for an average of 11 weeks. Thirty-five feet in 32 patients (66%) were rated as excellent, 16 feet in 16 patients (30%) were rated as good, and two feet (4%) in one patient were rated as fair, with none reporting a poor result. There were four nonunions (8%), with one being a fibrous union having no progression of deformity. Three of four patients with a nonunion reported a good result subjectively with the fourth reporting a fair result. Conclusions: The 96% satisfaction rate in 49 patients indicates that first MTP joint arthrodesis with a low-profile contoured dorsal titanium plate and crossed lag screws after joint preparation with dome-shaped reamers is both reliable and reproducible. The union rate was high (92%), and the revision rate was low (4%).

Hallux rigidus: A review of the literature and a method of treatment.

Twenty patients with hallux rigidus were evaluated following cheilectomy. The surgical procedure involved resection of proliferative bone at the metatarsophalangeal joint to allow at least 45 degrees of passive dorsiflexion. The follow-up ranged from 7 months to 156 months. Postoperatively, there was minimal progression of the degenrative process. Subjectively, there was uniform patient satisfaction with the procedure.