The Surgical Learning Curve for Modified Lapidus Procedure for Hallux Valgus Deformity

Background Hallux valgus is one of the most common orthopaedic deformities of the foot, affecting as much as 23% of the population age 18 to 65. In addition to its high prevalence, it has a complex multifactorial pathogenesis. Surgical correction options have variable rates of success and new techniques are being developed. The modified Lapidus procedure attempts to correct in 3 planes of deformity, which may create a steeper learning curve for those newly adopting the technique. Methods A retrospective review was performed on patients who underwent hallux valgus reconstruction with a modified Lapidus procedure between March 2018 and July 2020. Exclusion criteria included revision surgery, 6 or more concurrent procedures, or a flexor digitorum longus tendon transfer for adult acquired flatfoot correction. Results There were a total of 81 modified Lapidus procedures for hallux valgus within the study time frame and 68 were included in the study. Over a period of 2 years there was a significant decrease in overall surgery duration from 78.93 minutes at month 0 to 61.80 minutes at 24 months ( P = .036). The average preoperative/postoperative intermetatarsal angles were 15.08° and 4.91°, respectively. There was an average decrease of 10.17°. The rate of nonunion was 4.41% (3/68), and the rate of recurrence at 6 months was 5.88% (4/68). There was not a significant difference in the rate of recurrence ( P = .394) or the rate of nonunion ( P = .817) as the surgeon increased in experience. Conclusion Although there is a significant learning curve for the modified Lapidus procedure, it is largely overcome by the 23rd case. Additionally, experience with the technique does not appear to affect the patient outcomes of nonunion or recurrence. Levels of Evidence Level IV: Retrospective

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Surgical Treatment of Patients with Painful Instability of the Second Metatarsophalangeal Joint

Foot & Ankle International ◽

10.1177/107110079801900304 ◽

1998 ◽

Vol 19 (3) ◽

pp. 137-143 ◽

Cited By ~ 63

Author(s):

Andre Gazdag ◽

Andrea Cracchiolo

Keyword(s):

Hallux Valgus ◽

Stress Test ◽

Excellent Result ◽

Proximal Phalanx ◽

Metatarsophalangeal Joint ◽

Valgus Deformity ◽

Joint Stability ◽

Hallux Valgus Deformity ◽

Flexor Digitorum ◽

Second Toe

An unstable second metatarsophalangeal joint may produce pain in the forefoot. Eighteen patients (20 feet) had a transfer of the flexor digitorum longus to the extensor side of the base of the proximal phalanx performed as the primary procedure to stabilize this painful joint. Most patients had a hallux valgus deformity that also required correction, because it either was also symptomatic or was preventing adequate reduction of the second toe. A ruptured plantar plate of the second metatarsophalangeal joint was demonstrated in 13 feet and in these joints appeared to be the cause of the vertical instability. However, all feet showed an unstable joint upon clinical examination. A vertical-stress test almost always reproduced the patient's pain while demonstrating instability in the joint; this was the most prominent physical finding in these patients. Eleven patients (13 feet) had an excellent result. Seven patients (seven feet) had a fair result, but they complained only of mild and occasional pain at the joint on exertion. Although difficult to quantify, it appears that postoperative stiffness in the joint provided some of the joint stability seen in our patients. The flexor tendon transfer appears to be a satisfactory method to treating the unstable metatarsophalangeal joint and of relieving patients' pain, but may not, however, restore a normal alignment of the second toe. Correction of other forefoot deformities as hallux valgus and hammertoes may also be important in restoring metatarsophalangeal stability.

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Percutaneous Chevron Akin (PECA) Correction of Hallux Valgus Deformity: Analysis of the Learning Curve

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00407 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0040

Author(s):

Peter W. Robinson ◽

Robbie Ray ◽

Paul M. Dearden ◽

Thomas A. Goff ◽

Michael R. Whitehouse ◽

...

Keyword(s):

Learning Curve ◽

Hallux Valgus ◽

Pearson Correlation ◽

Weight Bearing ◽

Learning Phase ◽

Plateau Phase ◽

Tourniquet Time ◽

Hallux Valgus Deformity ◽

Parametric Data ◽

Significant Difference

Category: Bunion Introduction/Purpose: Percutaneous hallux valgus correction is increasing in popularity, with good correction of deformity and improvement in outcomes. The learning curve is reported as steep, based on arbitrary analysis. Methods: We performed a prospective study of a single surgeon series on the 1st 58 feet in 53 patients undergoing PECA hallux valgus correction, following cadaveric training and surgical observation. Pre- & post-operative (6 month) hallux valgus angles (HVA) & 1-2 intermetatarsal angles (IMA) were measured on weight bearing radiographs. Tourniquet time & number of fluoroscopy images were recorded. Complications were analysed. Parametric data was described with mean+-SD & non- parametric data with median+-interquartile range. Unpaired 2-tailed t tests were used to compare continuous data. The learning curve was calculated by plotting the tourniquet time against case number using a smoothed cubic spline with straight lines fitted to the slope. This was used to define a learning phase & a plateau phase. Results: Median age was 62 (IQR 56-66). The mean HVA improved from 32°+-4.7 to 9°--+-5.9 (p<0.0001). Mean IMA improved from 16°+-3.1 to 8°+-2.3 (p<0.0001). There were 6 re-operations (ostectomy & screw removal). The learning curve inflection point was between case 38 & 39. 38 were analysed in the learning phase & the remaining 20 in the plateau phase. No significant difference between the learning and plateau phases were seen for age, pre- & post-operative HMA or IMA, difference from normal angles or return to theatre. Pearson correlation revealed that only tourniquet time (p=0.001) & number of fluoroscopy shots (p=0.019) were significantly correlated with the learning or plateau phase. Conclusion: The learning curve for the PECA hallux valgus technique is around 40 cases, reflected by tourniquet time and number of fluoroscopy shots. It does not affect radiological correction or complications, showing that if taught properly this technique is reproducible and reliable.

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The Significance of Pes Planus in Juvenile Hallux Valgus

Foot & Ankle ◽

10.1177/107110079201300201 ◽

1992 ◽

Vol 13 (2) ◽

pp. 53-56 ◽

Cited By ~ 47

Author(s):

Timothy E. Kilmartin ◽

W. Angus Wallace

Keyword(s):

Hallux Valgus ◽

Metatarsophalangeal Joint ◽

Valgus Deformity ◽

Pes Planus ◽

First Metatarsophalangeal Joint ◽

Joint Deformity ◽

Hallux Valgus Deformity ◽

Significant Difference ◽

Footprint Area ◽

Arch Index

Pes planus of the foot is believed to be an important etiological factor in hallux valgus. This study compares the degree of pes planus in normal and hallux valgus feet. The arch index, or ratio of the area of the middle third of the foot to the total footprint area, was calculated on 128 footprints. An unpaired t-test determined no significant difference between the arch index of 32 11-year-old children with hallux valgus and 11-year-olds with no first metatarsophalangeal joint deformity ( P >.05). The height of the arch is not relevant to the hallux valgus deformity. Arch supports designed to raise the height of the arch can play only a palliative role in the management of the condition.

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Mitchell and Golden metatarsal osteotomies for the treatment of moderate hallux valgus deformity: A comparative analysis

Vojnosanitetski pregled ◽

10.2298/vsp161230105m ◽

2019 ◽

Vol 76 (4) ◽

pp. 404-411

Author(s):

Nadan Mikic ◽

Dusanka Grujoska-Veta ◽

Goran Cobeljic ◽

Ismet Gavrankapetanovic ◽

Zoran Vukasinovic ◽

...

Keyword(s):

Comparative Analysis ◽

Hallux Valgus ◽

Valgus Deformity ◽

Metatarsal Osteotomy ◽

Postoperative Results ◽

Results Of Treatment ◽

Hallux Valgus Deformity ◽

Valgus Angle ◽

Significant Difference ◽

Distal Metatarsal Osteotomy

Background/Aim. Despite bunion surgery having been performed for more than 100 years, there has yet to be a technique considered as the ?Gold Standard?. The aim of the study was to compare postoperative results of Mitchell vs. Golden methods of treating moderate hallux valgus deformity. Methods.This observational case control study included 49 patients (81 feet) who had the Mitchell distal metatarsal osteotomy performed, and 49 patients (77 feet) that had the Golden proximal metatarsal osteotomy performed. The results of treatment were evaluated using Hellal?s modification of the Bonney and McNab classification and the Hallux Metatarsophalangeal Interphalangeal Score (HMIS). The statistical analysis of the results was done, thus the values p < 0.05 were considered statistically significant. Results. Both operative procedures showed successful and statistically significant postoperative results compared to the preoperative status (p < 0.001). Comparative analysis of the results from the Mitchell and Golden procedures, according to the Hellal?s modification of Bonney and McNab classification, proved that there was a high statistically significant difference in favor of the Mitchell method (p < 0.001), whereas the comparison based on the HMIS showed no statistically significant difference (p = 0.123) between the two methods. The estimated results analysis of both procedures, based on the values of hallux valgus angle, intermetatarsal angle, sesamoid position, length of immobilization, treatment duration and complications demonstrated that there was a highly significant difference in favor of the Mitchell method (p < 0.001), whereas the value of the shortening of the first metatarsal bone indicated that the shortening was greater in the Mitchell method (p < 0.001), which goes in favor of the Golden method. Regarding the flexion of the thumb of the feet operated on, there was no statistically significant difference (p = 0.723). Conclusion. The examinations performed indicated that both methods showed good postoperative results, but applying the Mitchell method they were better.

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Radiographic Correction after Hallux Valgus Surgery: A Meta-analysis

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00235 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0023

Author(s):

Christopher E. Gross ◽

Alexej Barg

Keyword(s):

Hallux Valgus ◽

Meta Analysis ◽

Corrective Osteotomy ◽

Valgus Deformity ◽

Pool Data ◽

Inclusion Criteria ◽

Hallux Varus ◽

Radiographic Outcomes ◽

Hallux Valgus Deformity ◽

Significant Difference

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: There are over 100 different means by which to surgically correct hallux valgus. None have been proven to be more effective in radiographic correction over another. Frequently, recurrence is noted. There has been no large-scale meta-analysis of studies reporting radiographic outcomes of surgical treatment for hallux valgus deformity. The purpose of the meta-analysis was to pool data to see if certain osteotomies have higher complication or recurrence rates. Methods: We performed a meta-analysis of studies reporting the radiographic outcomes of surgical correction for hallux valgus deformity. We pooled the data of 287 studies since 1980 that met our inclusion criteria. We divided the surgical procedures into proximal-based osteotomies (PB, n=2047), shaft-based (SB, n=1569), and distal-based (DB, n=7835). We calculated the hallux valgus angle (HVA) and intermetatarsal angle (IMA) correction as well as metatarsal shortening, recurrence, and hallux varus after surgery. ANOVA analysis was used to compare the means among the groups. Results: A total of 287 treatment studies met the inclusion criteria. The pooled rates of HVA correction between the PB, SB, and DB were: 20.7, 20, and 16.8 degrees respectively (p=.0004). The pooled rates of IMA correction between the PB, SB, and DB were: 8.5, 7.3, and 6.0 degrees respectively (p<.0001).There was a significant difference among the groups with the development of hallux varus (p=.003) and with metatarsal shortening (p=.025). There was no difference in the rate of recurrence. Conclusion: Despite the large pooling of data, no consistent superiority of any corrective osteotomy stood out. Fortunately, there is no difference in the recurrence rate among the osteotomies. Further randomized studies could help elucidate the best surgery for each patient.

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Efficacy of Bilateral Simultaneous Hallux Valgus Correction in the Elderly Aged 70 to 79 Compared to Middle Age

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00270 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0027

Author(s):

Chul-Young Jang ◽

Ho-Jin Lee ◽

Eui Hyun Park ◽

In Tak Chu

Keyword(s):

Elderly Patients ◽

Hallux Valgus ◽

Middle Age ◽

The Elderly ◽

Valgus Deformity ◽

Elderly Group ◽

Age Group ◽

Hallux Valgus Deformity ◽

Significant Difference ◽

Severe Hallux Valgus

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Due to the increase in life expectancy, the frequency of elderly patients with moderate to severe hallux valgus deformity is expected to increase. The aim of this study was to evaluate the clinical and radiological efficacy of bilateral simultaneous correction of hallux valgus in elderly patients aged 70s and to compare the results with those of middle age. Methods: From August 2014 to July 2017, 92 women (184 feet) patients, who underwent bilateral simultaneous correction surgery (proximal chevron metatarsal osteotomy, Akin osteotomy, and distal soft tissue procedure) due to moderate to severe hallux valgus deformity, were retrospectively analyzed. Based on the age at the time of surgery, elderly patients in their 70’s (70˜79 years) were defined as the ‘elderly’ group and middle aged patients in the 45˜50 years as the ‘middle age’ group. The VAS score, AOFAS-Hallux Metatarsophalangeal-Interphalangeal score, hallux valgus angle, 1-2 intermetatarsal angle, and post-operative complications were compared and analyzed between the two groups. The mean follow-up period was 30.6(24˜57) months. There was no significant difference in improvement of VAS scores after surgery between the middle age and elderly group (p=0.710). Results: Although the final AOFAS scores were significantly different between two groups, there was no significant difference in AOFAS score improvement after surgery between two groups (p=0.129) (Table 1). At the last follow up after surgery, the HV angles and 1-2 IM angles were all significantly improved compared to the preoperation (Table2). Complications occurred in 16 cases, 5 in middle age (11.1%) and 9 in the elderly (19.1%). In the middle age group, 1 case (2.2%) of HV recurrence (> 15 degrees), 1 case of medial incision site paresthesia, 2 plantar pain, and 1 MTP joint stiffness occurred. In the elderly group, 3 case (6.4%) HV recurrence, 2 cased of displacement after metatarsal bone fixation, 2 cases of medial incision site paresthesia, and 2 plantar pain. Conclusion: In patients aged 70s, bilateral simultaneous correction of moderate to severe hallux valgus showed good improvement of clinical and radiologic outcome without any significant difference compared to the middle age group. However, the attention should be paid to the fixation failure after correction in the simultaneous treatment of hallux valgus in elderly patients aged 70s. [Table: see text][Table: see text]

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Augmented Reality Guided Osteotomy in Hallux Valgus Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00518 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0051

Author(s):

Stephan Wirth ◽

Arnd Viehöfer ◽

Jaberg Laurenz ◽

Stefan Zimmermann ◽

Cyrill Dennler ◽

...

Keyword(s):

Augmented Reality ◽

Hallux Valgus ◽

Ex Vivo ◽

Valgus Deformity ◽

Transverse Plane ◽

Hallux Valgus Deformity ◽

Second Metatarsal ◽

Significant Difference ◽

Improve Accuracy ◽

Inexperienced Surgeon

Category: Bunion Introduction/Purpose: An optimal osteotomy angle can avoid shortening of the first metatarsal bone after hallux valgus surgery and therefore reduce the risk of transfer-metatarsalgia. Up to date the osteotomy is performed free-hand without guidance and is therefore prone to unwanted variability in accuracy. The purpose of the present ex-vivo study was to investigate whether overlaying a hologram (augmented reality, AR) would improve accuracy of the distal osteotomy during hallux valgus surgery. Methods: A polyamide foot skeleton was constructed based a CT scan of a cadaveric foot and covered with medical silicon soft tissue. Three different polyamide first metatarsals were inserted to simulate a light, moderate and severe hallux valgus deformity. Distal Osteotomies of the first metatarsals were performed by two surgeons with different levels of surgical experience each with (AR, n=15x2) or without (controls, n=15x2) overlay of a hologram depicting an angle of osteotomy perpendicular to the second metatarsal in the transverse plane. Subsequently, the deviation to the plumb line of the second metatarsal in the transverse plane of all 60 osteotomies angles were optically measured and statistically analyzed. Results: Overall, the AR-guided osteotomies were more accurate (4.9 ± 4.2°) compared to the freehand cuts (6.7± 6.1°) by tendency (p=0.2). However, while the inexperienced surgeon performed more accurate osteotomies with AR with a mean angle of 6.4± 3.5° compared to freehand 10.5 ± 5.5° (p=0.02), no significant difference was noticed for the experienced surgeon with an osteotomy angle of around 3° in both cases. Conclusion: This pilot-study suggests that augmented reality guided osteotomies can potentially improve accuracy during hallux valgus surgery, particularly for less experienced surgeons. However, clinical studies are needed to investigate the clinical benefit of augmented reality in hallux valgus surgery.

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Effects of insole with toe-separator and night splint on patients with painful hallux valgus: A comparative study

Prosthetics and Orthotics International ◽

10.1080/03093640701669074 ◽

2008 ◽

Vol 32 (1) ◽

pp. 79-83 ◽

Cited By ~ 19

Author(s):

Ali Tehraninasr ◽

Hassan Saeedi ◽

Bijan Forogh ◽

Mahmood Bahramizadeh ◽

Mohammad Reza Keyhani

Keyword(s):

Pain Intensity ◽

Hallux Valgus ◽

Valgus Deformity ◽

Hallux Valgus Angle ◽

Intermetatarsal Angle ◽

Hallux Valgus Deformity ◽

Valgus Angle ◽

Significant Difference ◽

Before And After ◽

Night Splint

The objective of this study was to compare the effects of wearing an insole with toe separator and night splint on hallux valgus and intermetatarsal angles and also on the intensity of pain in patients suffering from painful hallux valgus deformity. Subjects in this study consisted of 30 female patients aged 19 – 45 years (mean 27.83 ± 8.91) who were divided into two groups. The first group received the insole and toe separator and the second group received night splint. Hallux valgus angle and intermetatarsal angle were radiographically measured before and after a 3-month study period. Foot pain intensity was assessed by 10 cm Visual Analogue Scale before and after intervention. After statistical analysis the reduction of pain was significant in the first group ( p < 0.05) whereas in the second group no significant difference was obtained. The hallux valgus angle and intermetatarsal angle decreased in both groups; however, the reduction was not significant. According to the results of this study, using night splint seems to have no effect on painful hallux valgus deformity. On the other hand, although the insole with toe separator significantly decreased the pain intensity in these patients and was a good option for pain reduction, it was not effective in improvement of the great toe angles.

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