Tibialis Anterior Tendon Partial Release and Plantar Implant Placement for Midfoot Arthrodesis: Technique Tip

Category: Midfoot/Forefoot; Other Introduction/Purpose: Midfoot arthrodesis is a reliable procedure for deformity correction and pain relief. First tarsometatarsal arthrodesis can be used for correction of hallux valgus deformity with large intermetatarsal angles or first-ray hypermobility. Midfoot arthrodesis is also integral in correction of pes planovalgus deformity with midfoot collapse. First tarsometatarsal arthrodesis has a nonunion rate of 2-15%. Arthrodesis is completed traditionally through a dorsal approach. Due to high nonunion rates, recent studies have investigated plater based plates. These have been shown to have superior strength by creating a tension band construct as the foot is loaded. Tibialis anterior footprint is at risk when accessing first tarsometatarsal joint for arthrodesis. We explore whether the tibialis insertional footprint can be released and repaired with no deleterious effects. Methods: Patients included were undergoing first tarsometatarsal joint or naviculocuneiform joint arthrodesis with a plantar based plate and screw construct for hallux valgus deformity with large intermetatarsal angle or first-ray hypermobility, and those with first TMT joint arthritis, pes planovalgus, Lisfranc injury, or Charcot neuroarthropathy. Medial based surgical approach is centered over the first tarsometatarsal joint. Saphenous neurovascular bundle is retracted dorsally. Release of the capsular structures allowed for complete visualization and distraction of the joint. The distal-most attachment of the tibialis anterior tendon onto the first metatarsal is release in line with the capsulotomy. Primary insertion on the medial cuneiform was preserved. A cuff of released insertional tissue is preserved and reflected distally for repair. Standard tarsometatarsal arthrodesis joint preparation was completed. Plantar plate then fixed and compressed. Deep fascial layers were then closed over the plated were previous tendon release was performed. Results: In 62 patients, none had tibialis anterior tendon rupture, weakness, or irritation, with average follow-up of 36.2 months. Nine wound complications were recognized during the study. Twelve percent of patients experiencing delayed incisional healing that went on to heal with local wound care. Smokers accounted for six of the seven patients (OR 24.62, p<.05), and one of seven patients had Charcot (OR 2.08, p<.05). Deep wound complications, which required return to the operating room for formal irrigation and debridement, were seen in 3% (2 of 62). Both patients were active smokers and had removal of hardware at the time of debridement. Both underwent definitive coverage with split-thickness skin grafts and went on to successful arthrodesis and wound healing. Conclusion: One advantage of applying a plate and screw construct plantarly for midfoot arthrodesis is biomechanical stability. Multiple studies have indicated this plantar construct may be superior. Another benefit may be less hardware prominence due to increased soft-tissue coverage. Subcutaneous positions of dorsal plates have been reported to contribute to incisional irritation and symptomatic hardware. Tibialis anterior tendon damage has been suggested as a limitation of the plantar approach for midfoot arthrodesis, and the tendon insertion must be released to prepare the joint adequately to apply implants. This series shows tendon release can be safely accomplished without any deleterious effects. [Table: see text]

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The Modified Lapidus Procedure for Hallux Valgus: A Clinical and Radiographic Analysis

Foot & Ankle International ◽

10.1177/107110070502601103 ◽

2005 ◽

Vol 26 (11) ◽

pp. 913-917 ◽

Cited By ~ 60

Author(s):

Franz J. Kopp ◽

Mihir M. Patel ◽

David S. Levine ◽

Jonathan T. Deland

Keyword(s):

Hallux Valgus ◽

Valgus Deformity ◽

Hallux Varus ◽

Hallux Valgus Deformity ◽

Age At Surgery ◽

First Ray ◽

Foot Function ◽

Visual Analog Pain Score ◽

Radiographic Data ◽

Subjective Sensation

Background: Historically, the modified Lapidus procedure has been considered technically challenging, with high rates of complications, including nonunion and malunion. The purpose of this study was to review the clinical and radiographic results of this technique for the treatment of hallux valgus associated with first ray hypermobility, specifically examining patient satisfaction and the incidence of complications. Methods: We retrospectively reviewed the results of the modified Lapidus procedure in 32 patients (38 feet). Evaluation included preoperative and postoperative questionnaires, physical examination, and radiographs. Results: Complete clinical data was available for 29 patients (35 feet) and complete radiographic data for 29 patients (34 feet). Average age at surgery was 54 (range 27 to 84) years. Average followup was 42 months (range 29 to 93) months. Average preoperative visual analog pain score was 7.2 and postoperative 2.3 ( p < 0.001). Average preoperative AOFAS Hallux MTP-IP Score was 44.8 and postoperative 87.3 ( p < 0.001). Average preoperative intermetatarsal (IM) angle was 16 degrees, and the hallux valgus (HV) angle was 34 degrees. Postoperatively, the average IM angle was 6 degrees, the HV angle 11 degrees. There were no cases of nonunion or malunion. Complications included symptomatic hallux varus in two, recurrence of hallux valgus deformity in one, deep venous thrombosis in one, and failure of fixation in one patient. Twenty-four percent of patients (7 of 29) noted the subjective sensation of midfoot stiffness and 34% (10 of 29) noted forefoot stiffness. None of these patients thought that the stiffness was a disability. Ninety percent of patients (26 of 29) were satisfied with their foot function, and 86% (25 of 29) were satisfied with the cosmetic appearance of their foot. Conclusions: The modified Lapidus procedure results in a satisfactory clinical outcome in most patients. With meticulous operative technique, rigid internal fixation, and strict postoperative weightbearing restrictions, successful union can be achieved and complications can be minimized. Care should be taken to avoid hallux varus, and patients need to be counseled regarding a potentially long convalescent period and possible postoperative stiffness.

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Hallux Valgus in Men Part II: First Ray Mobility after Bunionectomy and Factors Associated with Hallux Valgus Deformity

Foot & Ankle International ◽

10.1177/107110070302400112 ◽

2003 ◽

Vol 24 (1) ◽

pp. 73-78 ◽

Cited By ~ 64

Author(s):

Michael J. Coughlin ◽

Paul S. Shurnas

Keyword(s):

Hallux Valgus ◽

Positive Family History ◽

Valgus Deformity ◽

Ankle Dorsiflexion ◽

Metatarsal Osteotomy ◽

Pes Planus ◽

Hallux Valgus Deformity ◽

First Ray ◽

Angular Measurements ◽

Standard Radiographs

Methods: A retrospective study of 30 men (35 feet) was performed. First ray mobility, ankle dorsiflexion, pes planus, and metatarsus adductus were evaluated at the final follow-up. All internal fixation was routinely removed at six to eight weeks postoperatively. Standard radiographs were evaluated and angular measurements were calculated on all feet. Conclusion: Hallux valgus in this group of male patients was not associated with limited ankle dorsiflexion or pes planus. Men with toe pronation and a positive family history had a greater hallux valgus deformity than those without after a distal soft tissue repair with proximal first metatarsal osteotomy. There was no evidence of first ray hypermobility after a DSTP-PMO.

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Dynamic First Tarsometatarsal Instability During Gait Evaluated by Pedobarographic Examination in Patients with Hallux Valgus

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00304 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0030

Author(s):

Byung Jo Min ◽

Seungbum Koo ◽

Won-keun Park ◽

Ki-bum Kwon ◽

Kyoung Min Lee

Keyword(s):

Hallux Valgus ◽

Joint Instability ◽

Weight Bearing ◽

Binary Logistic Regression ◽

Valgus Deformity ◽

Binary Logistic Regression Analysis ◽

Tarsometatarsal Joint ◽

Hallux Valgus Deformity ◽

Metatarsal Angle ◽

Radiographic Measurements

Category: Midfoot/Forefoot Introduction/Purpose: This study aimed to investigate the pedobarographic characteristics of tarsometatarsal instability and to identify factors associated with pedobarographic first tarsometatarsal instability in patients with hallux valgus deformity. Methods: Fifty-seven patients (mean age, 59.7 years; standard deviation, 11.4 years; 6 men and 51 women) with a hallux valgus angle (HVA) greater than 15° were included. All patients underwent a pedobarographic examination along with weight-bearing anteroposterior (AP) and lateral foot radiography. Radiographic measurements were compared between the two groups with and without pedobarographic first tarsometatarsal instability. The association between the radiographic and pedobarographic parameters of the first tarsometatarsal instability was analyzed using the chi-square test. Binary logistic regression analysis was performed to identify significant factors affecting pedobarographic first tarsometatarsal instability. Results: HVA (p<0.001), the intermetatarsal angle (p=0.001), and AP talo-first metatarsal angle were significantly different between the pedobarographically stable and unstable tarsometatarsal groups. There was no significant association between radiographic and pedobarographic instabilities of the first tarsometatarsal joint (p=0.924). HVA was found to be the only significant factor affecting pedobarographic tarsometatarsal joint instability (p=0.001). Conclusion: The pedobarographic examination has possible clinical utility in evaluating first tarsometatarsal joint instability in patients with hallux valgus deformity. Patients with greater HVA need to be carefully monitored for the presence of first tarsometatarsal instability, and the necessity of the Lapidus procedure should be considered.

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Clinical, Quantitative Assessment of First Tarsometatarsal Mobility in the Sagittal Plane and Its Relation to Hallux Valgus Deformity

Foot & Ankle International ◽

10.1177/107110079401500103 ◽

1994 ◽

Vol 15 (1) ◽

pp. 9-13 ◽

Cited By ~ 177

Author(s):

Kaj Klaue ◽

Sigvard T. Hansen ◽

Alain C. Masquelet

Keyword(s):

Hallux Valgus ◽

Sagittal Plane ◽

Metatarsophalangeal Joint ◽

Metatarsal Head ◽

Valgus Deformity ◽

Main Concern ◽

First Metatarsophalangeal Joint ◽

First Metatarsal ◽

Hallux Valgus Deformity ◽

First Ray

Today, bunion surgery is still controversial. Considering that a bunion deformity in fact may be a result of multiple causes, the rationale of the currently applied techniques of surgical treatment has not been conclusively demonstrated. In view of the known hypermobility syndrome of the first ray that results in insufficient weightbearing beneath the first metatarsal head, the relationship between this syndrome and hallux valgus deformity has been investigated. The results suggest a direct relationship between painful hallux valgus deformity and hypermobility in extension of the first tarsometatarsal joint. A pathological mechanism of symptomatic hallux valgus is proposed that relates this pathology with primary weightbearing disturbances in the forefoot where angulation of the first metatarsophalangeal joint is one of the consequences. The alignment of the metatarsal heads within the sagittal plane seems to be a main concern in many hallux valgus deformities. As a consequence, treatment includes reestablishing stable sagittal alignment in addition to the horizontal reposition of the metatarsal over the sesamoid complex. As an example, first tarsometatarsal reorientation arthrodesis regulates the elasticity of the multiarticular first ray within the sagittal plane and may be the treatment of choice in many hallux valgus deformities.

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Shortening of first metatarsalia after ReveL procedure depends on the osteotomy angle

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000397 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0003

Author(s):

Arnd Viehöfer ◽

Stephan Wirth ◽

Felix Waibel ◽

Philipp Fürnstahl

Keyword(s):

Hallux Valgus ◽

Valgus Deformity ◽

Clinical Impact ◽

Ct Scans ◽

Dimensional Model ◽

Intermetatarsal Angle ◽

3 Dimensional ◽

Hallux Valgus Deformity ◽

First Ray ◽

Severe Hallux Valgus

Category: Midfoot/Forefoot Introduction/Purpose: Recent studies have shown that Hallux valgus deformity can lead to transfermetatarsalgia due to an impairment and relative shortening of the first ray. During ReveL osteotomy the relative shortening of the MT I is not addressed. Furthermore, a posterior deviation of the osteotomy angle results in additional iatrogenic shortening of the MT I and might favor postoperative transfermetatarsalgia. Methods: A 3-dimensional model of a foot was obtained from CT scans of a cadaveric foot. The MT I of the 3-dimensional model was then pivoted medially to simulate a severe hallux valgus deformity of an intermetatarsal angle (IMA) of 18° and an intermediate hallux valgus deformity of an IMA of 13°. A ReveL operation was simulated to correct the IMA to 8° for the severe and the intermediate Hallux valgus. Therefore the osteotomy angle in the coronal plane (f=0) was chosen perpendicular to the axis of the second metatarsalia. Afterwards the length of MT I was measured. This procedure was repeated for an posterior altered osteotomy angle (f = 5°,10°, 15° and 20°). Results: The change in MT I length resulting from an osteotomy perpendicular to the axis of MT II was 0.6 mm for a severe hallux valgus (IMA correction from 18° to IMA 8°) and 0.3 mm for a moderate hallux valgus (IMA 13° to IMA 8°). A posterior deviation of the osteotomy angle led to additional shortening (max. 2.9 mm) with a total shortening of up to 3.5 mm (Figure 3). To avoid any shortening of MT I an osteotomy slightly pointing anterior (negative f) of 3.5° (IMA change of 10°) and 3° (IMA change of 5°) was found. Conclusion: ReveL procedure led only to a maximum shortening of 3.5 mm for a posterior deviation of 20°. Considering recently described MT I length cut off values of 2-3 mm for avoiding transfermetatarsalgia the osteotomy should be performed within an anterior directed cut angle of 4° and a posterior directed cut angle of 10° for the correction of a severe hallux valgus. However, further studies are needed to investigate the clinical impact of our findings.

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A Comparison of First Ray Length and Dorsiflexion after Arthrodesis, Osteotomy and Suture Button Procedures for Hallux Valgus Deformity

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00212 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0021

Author(s):

Ian Foran ◽

Nasima Mehraban ◽

Stephen K. Jacobsen ◽

Daniel D. Bohl ◽

Johnny L. Lin ◽

...

Keyword(s):

Hallux Valgus ◽

Valgus Deformity ◽

Wedge Osteotomy ◽

Treatment Groups ◽

Suture Button ◽

Hallux Valgus Deformity ◽

Radiographic Measurements ◽

Valgus Angle ◽

First Ray ◽

Postoperative Symptoms

Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Shortening and dorsiflexion of the first metatarsal are a known side effect of metatarsal osteotomies for hallux valgus (HV) deformity with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus), proximal lateral closing wedge osteotomy (PLCWO), and intermetatarsal suture button fixation procedures on the length and dorsiflexion of the first ray. Methods: We retrospectively evaluated 123 feet in 115 patients. The average age was 54. There were 106 females. Eighty-four feet had a Lapidus procedure, 14 had a PLCWO, and 24 had intermetatarsal suture button fixation. Digital radiographic measurements were made for pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA), absolute and relative shortening of the first ray, and dorsiflexion. Results: Preoperative HVA and IMA did not differ between treatment groups (p>0.05 for each). Similar corrections of HVA (30.1 to 12.3 degrees) and IMA (14.7 to 7.0 degrees) were achieved in all three groups (p>0.05). There were significant differences in absolute first-cuneiform-metatarsal length (FCML) between Lapidus (-1.5mm), PLCWO (-2.5mm), and intermetatarsal suture button fixation (+1.1mm) (p<0.05). There were also significant differences in relative 1st metatarsal shortening between Lapidus (0.32mm relative lengthening), PLCWO (1.05mm relative shortening), and intermetatarsal suture button fixation (1.24mm lengthening) (p<0.05). Average dorsiflexion differed between the Lapidus (1.95 degrees) and PLCWO groups (0.49 degrees) (p<0.05). Conclusion: The use of the intermetatarsal suture button fixation relatively lengthens the first ray, whereas the Lapidus and PLCWO shorten it. Dorsiflexion may be higher with Lapidus and osteotomy procedures. These findings may be helpful to explain postoperative symptoms of metatarsalgia and for the surgeon’s selection of the appropriate surgical technique for preoperative planning. [Table: see text]

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Stress Fractures of the Lesser Metatarsals After a Wilson Osteotomy for Correction of Hallux Valgus Deformity

Journal of the American Podiatric Medical Association ◽

10.7547/0960063 ◽

2006 ◽

Vol 96 (1) ◽

pp. 63-66 ◽

Cited By ~ 3

Author(s):

John M. Kirkos ◽

Margaritis J. Kyrkos ◽

George A. Kapetanos

Keyword(s):

Hallux Valgus ◽

Stress Fracture ◽

Valgus Deformity ◽

Stress Fractures ◽

Metatarsal Osteotomy ◽

Compression Stress ◽

First Metatarsal ◽

Hallux Valgus Deformity ◽

First Ray

This article describes a patient with lesser-metatarsal stress fractures resulting from an oblique Wilson displacement first metatarsal osteotomy. The shortening of the first metatarsal forces the lesser metatarsals to bear the weight previously borne by the first ray and increases the compression stress on the adjacent metatarsal heads. The proximal displacement of the osteotomy must be minimized in order to limit the risk of stress fracture of the lesser metatarsals. (J Am Podiatr Med Assoc 96(1): 63–66, 2006)

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First Tarsometatarsal Joint Derotational Arthrodesis for Flexible Hallux Valgus: Results from Follow-Up of 3–8 Years

Scandinavian Journal of Surgery ◽

10.1177/1457496916683095 ◽

2017 ◽

Vol 106 (4) ◽

pp. 325-331 ◽

Cited By ~ 1

Author(s):

T. Klemola ◽

O. Savola ◽

P. Ohtonen ◽

R. Ojala ◽

J. Leppilahti

Keyword(s):

Confidence Interval ◽

Hallux Valgus ◽

Valgus Deformity ◽

Term Outcome ◽

Long Term Outcome ◽

Tarsometatarsal Joint ◽

Hallux Valgus Deformity ◽

Valgus Angle ◽

The Mean

Purpose: We report 3- to 8-year follow-up results for the first tarsometatarsal joint derotational arthrodesis. Methods: A total of 70 patients (88 feet) with symptomatic flexible hallux valgus were operated between 2003 and 2009. In all, 66 patients (94.3%) with 84 (95.5%) feet were enrolled in retrospective analysis; of those, 58 (87.9%) patients with 76 (90.5%) feet were followed for a mean of 5.1 (range: 3.0–8.3) years. Preoperative, 6 week postoperative, and late follow-up weightbearing radiographs were evaluated along with clinical examination and questionnaires. Results: The mean hallux valgus angle improved 13.4° (95% confidence interval: 11.6–15.1, p < .001) at the latest follow-up, while the mean intermetatarsal angle correction was 4.5° (95% confidence interval: 3.7–5.2, p < .001). There were three (4.0%) nonunions, and seven (9.2%) feet needed reoperation during follow-up. Conclusion: First tarsometatarsal joint derotational arthrodesis is an effective procedure for correcting flexible hallux valgus deformity and provides a satisfactory long-term outcome.

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