BACKGROUND: There have been few prospective studies that have
documented the outcome of surgical treatment of hallux valgus deformities. The
purpose of this investigation was to evaluate the effect of operative
treatment of hallux valgus with use of a proximal crescentic osteotomy and
distal soft-tissue repair on the first metatarsophalangeal joint.
METHODS: All adult patients in whom moderate or severe subluxated
hallux valgus deformities had been treated with surgical repair between
September 1999 and May 2002 were initially enrolled in the study. Those who
had a hallux valgus deformity treated with a proximal crescentic osteotomy and
distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy)
were then invited to return for a follow-up evaluation at a minimum of two
years after surgery. Outcomes were assessed by a comparison of preoperative
and postoperative pain and American Orthopaedic Foot and Ankle Society scores;
objective measurements included ankle range of motion, Harris mat imprints,
mobility of the first ray (assessed with use of a validated calibrated
device), and radiographic angular measurements.
RESULTS: Of the 108 patients (127 feet), five patients (five feet)
were unavailable for follow-up, leaving 103 patients (122 feet) with a
diagnosis of moderate or severe primary hallux valgus who returned for the
final evaluation. The mean duration of follow-up after the surgical repair was
twenty-seven months. The mean pain score improved from 6.5 points
preoperatively to 1.1 points following surgery. The mean American Orthopaedic
Foot and Ankle Society score improved from 57 points preoperatively to 91
points postoperatively. One hundred and fourteen feet (93%) were rated as
having good or excellent results following surgery. Twenty-three feet
demonstrated increased mobility of the first ray prior to surgery, and only
two feet did so following the bunion surgery. The mean hallux valgus angle
diminished from 30° preoperatively to 10° postoperatively, and the
mean first-second intermetatarsal angle decreased from 14.5°
preoperatively to 5.4° postoperatively. Plantar gapping at the first
metatarsocuneiform joint was observed in the preoperative weight-bearing
lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in
one-third (nine) of them after hallux valgus correction. Complications
included recurrence in six feet. First ray mobility was not associated with
plantar gapping. There was a correlation between preoperative mobility of the
first ray and the preoperative hallux valgus (r = 0.178) and the first-second
intermetatarsal angles (r = 0.181). No correlation was detected between
restricted ankle dorsiflexion and the magnitude of the preoperative hallux
valgus deformity, the postoperative hallux valgus deformity, or the magnitude
of hallux valgus correction.
CONCLUSIONS: A proximal crescentic osteotomy of the first metatarsal
combined with distal soft-tissue realignment should be considered in the
surgical management of moderate and severe subluxated hallux valgus
deformities. First ray mobility was routinely reduced to a normal level
without the need for an arthrodesis of the metatarsocuneiform joint. Plantar
gapping is not a reliable radiographic indication of hypermobility of the
first ray in the sagittal plane.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors
for a complete description of levels of evidence.
ORIGINAL ABSTRACT CITATION:"Hallux Valgus and First Ray Mobility. A
Prospective Study"
(2007;89:1887-98).