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Background: Bunionette deformity is described as a painful bony prominence on the lateral aspect of the fifth metatarsal head. The present study prospectively assessed the clinical, functional, and radiographic outcomes of sliding distal metatarsal minimally invasive osteotomy (S-DMMO) used in a large series of patients with a midterm follow-up period. Methods: From December 2015 to December 2018, we evaluated 74 feet (57 patients). Radiologic (4-to-5 intermetatarsal angle, fifth metatarsophalangeal angle, the fifth metatarsal head width, lateral deviation angle, fifth metatarsal length, medial displacement, and elevation), clinician-reported scores (AOFAS score, visual analog scale [VAS]) and patient-reported outcomes measure (Foot and Ankle Ability Measure [FAAM] activities of daily living [ADL], FAAM sports, Manchester-Oxford Foot Questionnaire [MOXFQ], and patient satisfaction survey) were included in the analysis. The time to bone union was also assessed. Results: The average 4-to-5 intermetatarsal angle improved from 11.1 degrees preoperatively to 4.5 degrees postoperatively ( P < .001), whereas the average fifth metatarsophalangeal angle improved from 15.7 degrees preoperatively to 4.8 degrees postoperatively ( P < .001). The lateral deviation angle was found to be 2.2 degrees. The fifth metatarsal length decreased from 66.6 to 64.3 mm postoperatively. The average initial medial displacement was 4.67 mm preoperatively and 4.54 mm at final follow-up. The elevation of the fifth metatarsal head was 1.08 mm. The American Orthopaedic Foot & Ankle Society score improved from 54.3 ± 20.86 points preoperatively to 93.4 ± 17.3 ( P < .001). VAS score decreased from 7.9 to 0.7 ( P < .001). Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences ( P < .001) between preoperative and postoperative periods. Patients found the procedure excellent in 89.1% of cases, very good in 5.4%, and good in 5.4%. Bone union was obtained at 8.1 weeks. Conclusion: The most important finding of the present study is that S-DMMO showed improvement in function and pain associated with a high satisfaction rate. Also, we found substantial capacity to correct deformities and a low incidence of complications. Level of Evidence: Level IV, case series.

Background: Classification of fifth metatarsal base fractures has been a source of confusion since originally described by Jones in 1902. Zone classifications have been described but never evaluated for reliability. The most recent classification, metaphyseal vs meta-diaphyseal, may be unknown to many surgeons. The purpose of this study was to evaluate reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fifth metatarsal base fractures and current management of these fractures. Methods: A survey was emailed to AOFAS members including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the radiographs. Interrater reliability was assessed for each measurement: presence of Jones fracture, zone classification, and metaphyseal vs metaphyseal-diaphyseal, using Fleiss kappa. After 3 weeks, a second email was sent to the members asking to retake the survey to evaluate intrarater reliability. Respondents were asked which region is a Jones fracture, which classification is used, if symptomatic zone 2 and 3 fractures are treated similarly, and what fractures are operative in healthy symptomatic acute fractures. Results: A total of 223 AOFAS members, with a median time in practice of 12 years (range 0-50), completed the initial survey. Eighty members (36%) repeated the survey for intrarater comparison. Interrater reliability was moderate for Jones and zone classification but substantial for the 2-zone metaphyseal/meta-diaphyseal classification. The median intrarater kappa was 0.78, 0.75, and 0.78 for Jones, zone, and metaphyseal/meta-diaphyseal respectively. Seventy percent of respondents treat zones 2 and 3 similarly, and approximately 60% consider an acute symptomatic fracture identified as Jones, zone 2 or zone 3 operative. Conclusion: A 2-zone system may be the best available classification for fifth metatarsal base fractures given high interrater reliability and 70% of AOFAS members treat zones 2 and 3 in similar fashion. Level of Evidence: Level III, diagnostic study.

Background: A previous study defined the normal first metatarsal pronation angle (MPA) as Methods: MPA and α angles were measured on standardized coronal weightbearing computed tomography slices. Paired t tests were used to test significance of mean side-to-side differences in a population of 63 normal, asymptomatic individuals. Results: The mean side-to-side difference in first metatarsal pronation was 4.3 degrees (95% CI 3.3, 5.2 degrees) for MPA and 4.9 degrees (95% CI 3.8, 6.0 degrees) for α angle. The normative range for side-to-side difference was calculated as 12 degrees for MPA and 14 degrees for α angle, as defined by 2 SDs from the mean. Conclusion: In a cohort of normal patients, the mean difference in first metatarsal pronation between sides was approximately 4 to 5 degrees based on MPA and α angle. However, considerable variation in differences was observed. These findings may be considered when assessing first metatarsal pronation using population-based values as it may influence thresholds for identifying pathology in an individual.

Background: The dorsalis pedis artery (DPA) usually branches into the arcuate artery (AA) from its lateral side which in turn crosses the bases of the lateral four metatarsals. The DPA then passes into the first interosseous space, where it divides into the first metatarsal artery and the deep plantar artery. In this study, we aimed to determine the extent of variation in the DPA and the distance between the AA and the tarsometatarsal (TMT) joint with the aim of reducing the risk of vascular complications arising from dorsal midfoot surgery. Methods: In 29 fresh cadaveric feet, we examined the course of the DPA and the distance between the AA and the TMT joint on computed tomography images with barium sulfate contrast. Results: The DPA was observed to have a standard course in 11 of the 29 cases (37.9%) but did not give rise to the AA and lateral tarsal artery or branches of the plantar arterial arch supplying to the second to fourth metatarsal spaces in 10 of 29 cases (34.5%). The mean closest distance from the TMT joint to the AA at the second, third, and fourth metatarsal level in the sagittal plane was 11.4, 14.6, and 17.1 mm, respectively. Conclusion: We found substantial variation in the arterial anatomy of the DPA system across the dorsal midfoot. Clinical Relevance: The risk of pseudoaneurysm and frank arterial disruption may be mitigated if the surgeon is aware of the variations of the course of the DPA when performing dorsal midfoot surgery.

Background: Recent work has reported a significant association between first metatarsal (M1) rotation and hindfoot alignment, with the finding of a moderate association between the calcaneal moment arm (CMA) and 2 M1 pronation angular measures: Saltzman ( r = 0.641, P < .01) and Kim ( r = 0.615, P < .01). The aim of the current post hoc investigation was to determine if this association is related with Meary angle. Methods: We reanalyzed previously published data set separating patients into 2 groups: (1) those with normal Meary angle (n = 128) and (2) those with abnormal Meary angle (n = 147). Hindfoot alignment and M1 rotation were measured on weightbearing computed tomography. Statistical analyses were performed to evaluate for association between these variables among the groups. Results: The correlation between CMA and M1 rotation of the entire cohort was r = 0.577 (Saltzman ankle) and r = 0.540 (Kim angle). For the subset with a normal Meary angle, this association was negligible (Saltzman and Kim angles, r = 0.194 and 0.240, respectively). Conversely, for the abnormal Meary angle subset, the association was substantial (Saltzman and Kim angles, r = 0.733 and 0.675, respectively). Conclusion: Patients presenting with an abnormal Meary angle and hindfoot deformity have a high likelihood of manifesting a proportionate degree of M1 rotation. Level of Evidence: Level III, Retrospective Cohort Study.

Background: Malposition of the sesamoids relative to the first metatarsal head may relate to intersesamoid crista underdevelopment or erosion. Using 3-dimensional models created from weightbearing CT (WBCT) scans, the current work examined crista volume and its relationship to first metatarsal pronation and sesamoid station. Methods: Thirty-eight hallux valgus (HV) patients and 10 normal subjects underwent weightbearing or simulated WBCT imaging. The crista was outlined by the inferior articular surface, and a line was drawn to connect the lowest point of each sulcus on either side of the intersesamoidal crista throughout the length of the crista. The volume was calculated. Sesamoid station and first metatarsal pronation were calculated from the 3D reconstructions. The mean crista volumes between HV and normal patients were statistically compared, as were the crista volume and pronation angle between sesamoid stations. Results: The mean crista volume in HV patients was 80.10 ± 35 mm3 and in normal subjects was 150.64 ± 24 mm3, which differed significantly between the 2 groups ( P < .001). Mean crista volumes were found to be statistically significantly different between the sesamoid stations ( P < .001) with decreasing crista volumes significantly and strongly correlated with increasing sesamoid station ( r = −0.80, P < .001). There was no difference in the mean pronation angle between the 4 sesamoid stations ( P = .37). The pronation angle was not associated with crista volume ( P = .52). Conclusion: HV patients have lower mean crista volume than normal patients. Crista volume is correlated with sesamoid station. Pronation of the first metatarsal was not associated with crista volume. Clinical Relevance: Crista volume may offer an additional determinant for the severity of hallux valgus.

Background The Distal Metatarsal Articular Angle (DMAA) was previously described as an increase in valgus deformity of the distal articular surface of the first metatarsal (M1) in hallux valgus (HV). Several studies have reported poor reliability of this measurement. Some authors have even called into question its existence and consider it to be the consequence of M1 pronation resulting in projection of the round-shaped lateral edge of M1 head. Our study aimed to compare the DMAA in HV and control populations, before and after computer correction of M1 pronation and plantarflexion with a dedicated weightbearing CT (WBCT) software. We hypothesized that after computerized correction, DMAA will not be increased in HV compared to controls. Methods: We performed a retrospective case-control study including 36 HV and 20 control feet. In both groups, DMAA was measured as initially described on conventional radiographs (XR-DMAA) and WBCT by measuring the angle between the distal articular surface and the longitudinal axis of M1. Then, the DMAA was measured after computerized correction of M1 plantarflexion and coronal plane rotation using the α angle (3d-DMAA). Results: The XR-DMAA and the 3d-DMAA showed higher significant mean values in HV group compared to controls (respectively 25.9 ± 7.3 vs 7.6 ± 4.2 degrees, P < .001, and 11.9 ± 4.9 vs 3.3 ± 2.9 degrees, P < .001). Comparing a small subset of precorrected juvenile HV (n=8) and nonjuvenile HV (n=28) demonstrated no significant difference in the measure DMAA values. On the other hand, the α angle was significantly higher in the juvenile HV group (21.6 ± 9.9 and 11.4 ± 3.7 degrees; P = .0046). Conclusion: Although the valgus deformity of M1 distal articular surface in HV is overestimated on conventional radiographs, comparing to controls showed that an 8.6 degrees increase remained after confounding factors’ correction. Clinical Relevance: After pronation computerized correction, an increase in valgus of M1 distal articular surface was still present in HV compared to controls. Level of Evidence: Level III, retrospective case-control study.

Background: Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus. Methods: We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas’s stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies. We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134). Results: The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively ( P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001. The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees ( P < .001). The mean first metatarsal shortening rate (SRpo) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SRpo influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SRpo. Conclusion: Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications. Level of Evidence: Level III, retrospective cohort study.

Background: We compare the clinical and radiographic outcomes of the interdigital approach vs the medial transarticular approach for lateral release combined with scarf osteotomy. Methods: Seventy-seven feet with moderate to severe hallux valgus underwent scarf osteotomy and lateral soft tissue release, using an interdigital approach (n = 36) vs medial transarticular approach (n = 41). The clinical measurements (range of motion, American Orthopaedic Foot & Ankle Society [AOFAS] score) and radiographic data were evaluated preoperatively and at final follow-up (93-124 months postoperatively). Additionally, the numeric pain rating scale and Foot and Ankle Outcome score [FAOS] were assessed postoperatively. Results: The AOFAS score improved from 60 (q1 = 54, q3 = 70) to 93 (q1 = 85, q3 = 98) in the transarticular group, and from 59 (q1 = 50, q3 = 64) to 95 (q1 = 85, q3 = 100) in the interdigital group. The hallux valgus angle improved from 35.7±6.5 degrees to 15.5±7.6 degrees in the transarticular group, and from 36.0±6.8 degrees to 12.9±13.0 degrees in the interdigital group. The intermetatarsal angle improved from 16.5±2.5 degrees to 6.5±2.7 degrees within the transarticular group and from 17.2±2.5 degrees to 7.3±4.3 degrees in the interdigital group. None of the clinical or radiographic parameters showed any significant differences between the treatment groups. Conclusion: Comparison of outcomes between the interdigital approach and the transarticular approach for lateral soft-tissue release with scarf osteotomy are equally successful. The transarticular approach can thus be considered safe and effective, with the additional benefits of just one scar as opposed to 2. Level of Evidence: Level III, therapeutic.

Background: Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort. Methods: All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded. Results: A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2. Conclusion: MICA is good method to correct hallux valgus deformity with low postoperative narcotic use. Level of Evidence: Level III, restrospective cohort study of a single surgeon practice.

Background: The importance of the rotational profile of the first metatarsal is increasingly recognized in the surgical planning of hallux valgus. However, rotation in the normal population has only been measured in small series. We aimed to identify the normal range of first metatarsal rotation in a large series using weightbearing computed tomography (WBCT). Methods: WBCT scans were retrospectively analyzed for 182 normal feet (91 patients). Hallux valgus angle, intermetatarsal angle, anteroposterior/lateral talus–first metatarsal angle, calcaneal pitch, and hindfoot alignment angle were measured using digitally reconstructed radiographs. Patients with abnormal values for any of these measures and those with concomitant pathology, previous surgery, or hallux rigidus were excluded. Final assessment was performed on 126 feet. Metatarsal pronation (MPA) and α angles were measured on standardized coronal computed tomography slices. Pronation was recorded as positive. Intraobserver and interobserver reliability were assessed using intraclass correlation coefficients (ICCs). Results: Mean MPA was 5.5 ± 5.1 (range, –6 to 25) degrees, and mean α angle was 6.9 ± 5.5 (range, –5 to 22) degrees. When considering the normal range as within 2 standard deviations of the mean, the normal range identified was −5 to 16 degrees for MPA and −4 to 18 degrees for α angle. Interobserver and intraobserver reliability were excellent for both MPA (ICC = 0.80 and 0.97, respectively) and α angle (ICC = 0.83 and 0.95, respectively). There was a moderate positive correlation between MPA and α angle (Pearson coefficient 0.68, P < .001). Conclusion: Metatarsal rotation is variable in normal feet. Normal MPA can be defined as less than 16 degrees, and normal α angle can be defined as less than 18 degrees. Both MPA and α angle are reproducible methods for assessing rotation. Further work is needed to evaluate these angles in patients with deformity and to determine their significance when planning surgical correction of hallux valgus. Level of Evidence: Level III, retrospective comparative study.

Background: Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known. Methods: A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction. Results: Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement ( P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%. Conclusion: Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence. Level of Evidence: Level IV, case series.

Background:Weightbearing cone beam computed tomography (WBCT) has been gaining traction as a useful imaging modality in the diagnosis and follow-up of foot and ankle musculoskeletal pathologies due to the ability to perform quick, low-dose, 3-dimensional (3D) scans. However, the resulting wealth of 3D data renders daily clinical use time-consuming. The aim of this study was to evaluate a new artificial intelligence (AI)–based automatic measurement for the M1-M2 intermetatarsal angle (IMA) in hallux valgus (HV). We hypothesized that automatic and manual measurements would have a strong correlation, and that the AI software would yield better reproducibility and would be faster compared with manual measurements.Methods:This was a multicenter retrospective comparative case-control study in which a total of 128 feet were included from 93 patients who underwent WBCT scans as part of their routine follow-up: 59 feet with symptomatic HV and 69 controls. The IMA was measured automatically using the AI software and manually on digitally reconstructed radiographs (DRRs). The AI software produced both an automatic 2D (auto 2D) and 3D (auto 3D) measurement.Results:There were strong intermethod correlations between the DRR IMA and the auto 2D (HV, r = 0.61; control, r = 0.60; all P < .0001) and auto 3D (HV, r = 0.63; control, r = 0.52; all P < .0001) measurements, respectively. The intrasoftware reproducibility was very close to 100%. Measurements took 23.6 ± 2.31 seconds and 14.5 ± 1.18 seconds, respectively, when taken manually on DRRs and automatically. Controls demonstrated a mean DRR IMA of 8.6 (95% CI, 8.1-9.1), mean auto 2D of 11.2 (95% CI, 10.7-11.7), and mean auto 3D IMA of 11.0 (95% CI, 10.5-11.5). The HV group demonstrated significantly increased IMA compared with controls ( P < .0001), with a mean DRR IMA of 15.4 (95% CI, 14.8-16.1), mean auto 2D of 17.8 (95% CI, 17.2-18.4), and mean auto 3D IMA of 16.8 (95% CI, 16.8-17.4).Conclusion:Measurements generated by the WBCT AI-based automatic measurement system for IMA demonstrated strong correlations with manual measurements, with near-perfect reproducibility. Further developments are warranted in order to make this tool more usable in daily practice, particularly with respect to its use in the presence of hardware in the foot.Level of Evidence:Level III, retrospective comparative study.

Category: Bunion; Midfoot/Forefoot; Other Introduction/Purpose: Previous studies have demonstrated success in using autogenous bone graft for arthrodesis in patients with previously failed surgeries of the hallux. These patients have several causes for pain and dysfunction preoperatively, including shortened first ray, nonunions, and poor hallux alignment. In this study, a consecutive series of 36 patients (38 procedures) were treated with a patellar wedge interposition structural allograft to salvage bone loss from great toe arthrodesis malunion, painful joint replacement, failed osteotomy, or infection of the great toe metatarsophalangeal (MP) joint with shortening of the first ray. The goals of the surgery were to restore length to the first ray and provide a stable MP joint fusion to relieve pain. Methods: The 38 treated toes were followed for at least one year and were evaluated for preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) MP scores, subjective patient outcome scores, and clinically successful fusion of the hallux. Results: At a minimum one-year follow-up, all but two feet healed with a solid fusion, and all patients reported good or excellent outcomes. AOFAS MP scores averaged 43.5 preoperatively and 77.2 postoperatively. Three patients with infection as cause for nonunion of the initial procedure were treated with staged procedures, including the use of a temporary antibiotic spacer and mini external fixator; all three healed without recurrent infection. One patient had a fracture of her allograft following her interposition arthrodesis, but fused successfully after a second interposition arthrodesis surgery. Two patients developed a nonunion of the revision arthrodesis. Conclusion: In conclusion, the use of an interposition patellar wedge allograft can restore length to the first ray and provide successful salvage of arthrodesis nonunions and bone loss from failed hemi and total joint implants of the great toe MP joint. [Table: see text]

Background: First metatarsal (M1) axial rotation is recognized as a clinically relevant component of hallux valgus deformity. Methods to realign the M1 in 3 dimensions have been developed. One goal of these operations is to restore normal rotation of the first ray. The aim of this study is to provide estimates for the normal distribution of M1 rotation in patients without relevant anatomic pathology. Methods: Using stringent clinical and radiographic criteria, we evaluated a set of plain radiograph and weightbearing computed tomography (WBCT) images of 62 feet from a consecutive patient database. Subjects included had normal foot alignment without bunion symptoms. M1 rotation of each foot was measured using 2 unique methods (Saltzman et al and Kim et al methods). Measurement of rotation was performed by 2 observers from coronal WBCT images. Mean values and confidence intervals (CIs) of M1 rotation were calculated for each method. Inter- and intraobserver reliability values were also reported. Results: Mean M1 rotation values of 2.1 degrees (95% CI: 0.9-3.4) and 6.1 degrees (95% CI: 4.4-7.8) were identified using the Saltzman et al and Kim et al methods, respectively. Inter- and intraobserver reliability values were interpreted as excellent for both methods. Conclusion: In this study, we describe the natural distribution of the M1 axial rotation in subjects without bunion or other identifiable bony foot deformities. This information should provide a normative reference for surgeons correcting rotational issues of the first metatarsal. Level of Evidence: Level III.

Background: There is no consensus in the foot and ankle literature regarding how to measure pronation of the first metatarsal in patients with hallux valgus. The primary purpose of this study was to compare 2 previously published methods for measuring pronation of the first metatarsal and a novel 3-dimensional measurement of pronation to determine if different measurements of pronation are associated with each other. Methods: Thirty patients who underwent a modified Lapidus procedure for their hallux valgus deformity were included in this study. Pronation of the first metatarsal was measured on weightbearing computed tomography (WBCT) scans using the α angle with reference to the floor, a 3-dimensional computer-aided design (3D CAD) calculation with reference to the second metatarsal, and a novel method, called the triplanar angle of pronation (TAP), that included references to both the floor (floor TAP) and base of the second metatarsal (second TAP). Pearson’s correlation coefficients were used to determine if the 3 calculated angles of pronation correlated to each other. Results: Preoperative and postoperative α angle and 3D CAD had no correlation with each other ( r = 0.094, P = .626 and r = 0.076, P = .694, respectively). Preoperative and postoperative second TAP and 3D CAD also had no correlation ( r = 0.095, P = .624 and r = 0.320, P = .09, respectively). However, preoperative and postoperative floor TAP and α angle were found to have moderate correlations ( r = 0.595, P = .001 and r = 0.501, P = .005, respectively). Conclusion: The calculation of first metatarsal pronation is affected by the reference and technique used, and further work is needed to establish a consistent measurement for the foot and ankle community. Level of Evidence: Level III, retrospective cohort study.

Background: We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe. Methods: We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months. Results: At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain. Conclusion: The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively. Levels of Evidence: Level IV, retrospective case series.

Background: Isolated shear fractures of a metatarsal head in the lesser toes are rare in clinical practice. We report the clinical and imaging characteristics, and treatment results, of these fractures. Methods: A retrospective consecutive case-series study was performed on 7 patients with symptomatic isolated shear fracture of a metatarsal head in the lesser toes who were operatively treated using open reduction and internal fixation (ORIF). Radiographs and computed tomographic (CT) scans of the patients were analyzed. The American Orthopaedic Foot & Ankle Society–lesser metatarsophalangeal-interphalangeal (AOFAS-LMI) score, visual analog scale (VAS) score, and passive dorsiflexion range of motion (ROM) of the metatarsophalangeal (MTP) joint were determined preoperatively and at final follow-up. Postoperative complications were also recorded. Results: There were 5 males and 2 females, with a mean age of 21 years (range, 16-36) at the time of surgery. Four fractures occurred at the fourth metatarsal. There were 3 chronic cases, 1 was not diagnosed initially; the other 2 failed conservative treatment. The main symptom of the chronic fractures was limited dorsiflexion at the MTP joint. Preoperative radiographs and CT scans revealed dorsal displacement of the fragment without dislocation of the MTP joint. At the final follow-up (mean, 17.4 months; range 9-27), the AOFAS-LMI scores had improved from 70.6 (range, 59-79) preoperatively to 93.3 (range, 92-100) ( P = .001). VAS scores showed a decrease in pain from 4.0 to 0.0 ( P = .016). Mean passive dorsiflexion ROM of the MTP joint improved significantly from 8.6 degrees preoperatively to 35.7 degrees at final follow-up ( P < .001). All patients returned to their respective preinjury activity levels. Conclusion: Patients with an acute or chronic isolated shear fracture of a metatarsal head in the lesser toes treated by ORIF achieved good short-term clinical and radiologic outcomes. Level of Evidence: Level IV, retrospective case series.

Background: Previous studies have found an increased rate of deformity recurrence in hallux valgus (HV) patients with concomitant metatarsus adductus (MA) undergoing metatarsal osteotomies. The purpose of this paper was to determine if there were radiographic or clinical outcome differences between HV patients with and without MA undergoing a modified Lapidus procedure. Methods: One hundred forty-seven feet that underwent a modified Lapidus procedure for HV were divided into 2 groups based on their preoperative modified Sgarlato’s angle: (1) the MA group had an angle ≥20 degrees and (2) the HV-only group had an angle Results: Patients in the MA group had a significantly higher mean postoperative HVA (10.8 vs 7.5 degrees; P = .038). There was a trend toward higher PROMIS PI scores in the MA group at 1 year postoperatively (51.9 vs 47.6; P = .088). Patients in the MA group were more likely to have a revision surgery (7.3% vs 0%; P = .021), and there was a trend toward those patients having a higher recurrence rate (17.1% vs 6.6%; P = .064). Conclusion: Despite potentially worse postoperative outcomes in patients with HV and MA who undergo a modified Lapidus procedure, the recurrence rates reported here are lower than those reported in the literature for patients with MA undergoing metatarsal osteotomies, indicating that a modified Lapidus procedure may be an acceptable choice in these patients. Level of Evidence: Level III, retrospective comparative series.

Background:Proper implant selection and placement is crucial during fixation of zone II and III fifth metatarsal fractures to avoid postoperative complications. This study examined the effects of screw parameters and placement on malreduction, delayed union, nonunion, and refracture rate.Methods:A retrospective review of zone II and proximal zone III fifth metatarsal fractures managed with intramedullary screw fixation was conducted. Comparisons were made between cortex distraction (gap) and ratios of screw length, diameter, and entry point. Further analysis was carried out between time to union and distraction in the lateral and plantar cortices.Results:The plantar and lateral gaps were both associated with the mean entry point ratio on the lateral and anteroposterior (AP) views ( P < .001 for both views). No association between the plantar and lateral gaps and the screw diameter ratio ( P = .393 for AP and P = .981 for lateral) or the screw length ratio ( P = .966 for AP and P = .740 for lateral) was identified. The ratio of postoperative to preoperative apex height on AP and lateral views was correlated with the presence of lateral and plantar fracture gaps ( P < .001). The presence of a plantar gap was associated with increased time to union ( P = .022). A majority of fractures showed radiographic union at 12 weeks (38/43). Only 5 of 38 patients had delayed union. There were no refractures or nonunions as per available records.Conclusion:Plantar or lateral fracture site distraction (gap) was not influenced by screw diameter ratio or screw length ratio. The entry point ratio had a significant effect on plantar and lateral gaps on postoperative radiographs, with lateral and inferior placement leading to fracture site distraction. Patients with a plantar gap did have an increased risk of delayed union. The results of this study emphasize the significance of the entry point when managing zone II and III fifth metatarsal base fractures.Level of Evidence:Level IV, case series.

Background: Jones fractures of the proximal fifth metatarsal are predisposed to delayed union and nonunion due to a tenuous blood supply. Solid intramedullary (IM) screw fixation is recommended to improve healing, traditionally followed by delayed weightbearing (DWB). However, early weightbearing (EWB) postoperatively may facilitate functional recovery. The purpose of this study was to compare union rates and time to union after solid IM screw fixation of Jones fractures in patients treated with an EWB protocol to those treated with a DWB protocol, as well as to identify any factors that may be predictive of delayed or nonunion. Methods: True Jones (zone 2 fifth metatarsal base) fractures treated from April 2012 through January 2018 with IM screw fixation and 6 months follow-up were identified (41 fractures in 40 patients; mean ± SD age, 45.3 ± 17.9 years). Patients were divided into EWB and DWB cohorts (within or beyond 2 weeks, respectively). Delayed union (12.5 weeks) was statistically derived from established literature. Union times were compared between cohorts. Regression analyses were conducted to investigate possible confounders contributing to delayed union. There were 20 fractures in the EWB cohort and 21 fractures in the DWB cohort. Results: There was no significant difference in healing times (EWB: 25% by 6th week, 55% by the 12th week, 20% delayed; DWB: 33% by 6th week, 43% by 12th week, 24% delayed; P = .819) or delayed unions (EWB, 20% vs DWB, 24%; P > .999). There were no nonunions. No significant confounding risk factors were identified. Conclusion: Postoperative protocols using early weightbearing following solid IM screw fixation of Jones fractures appear to be safe and do not delay fracture healing or increase the risk of delayed union. Older age may be a risk for delayed union, but larger studies are needed to evaluate this with appropriate power in light of possible confounders. EWB protocols may allow better functional recovery without compromising outcomes by increasing the risk of delayed union. Level of Evidence: Therapeutic level III, retrospective comparative study.

Background: Shortening and dorsiflexion of the first metatarsal are known potential side effects of metatarsal osteotomies for hallux valgus (HV) with the potential to cause transfer metatarsalgia. We compared the effect of the first tarsometatarsal joint arthrodesis (Lapidus procedure), 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 105 feet in 99 patients with 30 weeks of follow-up. The average age was 54 years. Seventy-four feet had a Lapidus procedure, 12 had a PLCWO, and 19 had intermetatarsal suture button fixation. Digital radiographic measurements were made for the 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 > .05 for each). Similar corrections of HVA (30.5-13.5 degrees) were achieved between all groups ( P > .05). The IMA was improved more in the Lapidus group (14.3-6.5 degrees) compared with the suture button fixation group (14.2-8.1 degrees) ( P = .045). There were significant differences in the change in absolute first cuneiform–metatarsal length (FCML) between the Lapidus (–1.6 mm), PLCWO (–2.3 mm), and intermetatarsal suture button fixation (+1.9 mm) procedure ( P = .004). There were also significant differences in relative first metatarsal shortening between the Lapidus (0.1 mm relative shortening), PLCWO (1.1 mm relative shortening), and intermetatarsal suture button fixation (1.3 mm lengthening) procedure ( P < .001). The average dorsiflexion differed between the Lapidus (1.8 degrees) and suture button fixation (0.4 degrees) groups ( P = .004). Conclusion: Intermetatarsal suture button fixation relatively lengthened the first ray, the Lapidus procedure maintained length, and the PLCWO relatively and absolutely shortened it. Dorsiflexion may be higher with the Lapidus and osteotomy procedures. Level of Evidence: Level III, retrospective comparative series.

Background: Fractures of the fifth metatarsal base (5th MT) are common foot injuries, but their treatment remains a subject of debate. The aim was to assess the midterm outcome of functionally treated epi-metaphyseal fractures (Lawrence and Botte types I and II) of the 5th MT. Methods: This study was a longitudinal retrospective database study with prospective follow-up. Included were all patients with an acute, isolated fracture to the 5th MT base (types I and II). All patients were treated functionally: weightbearing as tolerated without immobilization. Fracture types and fracture characteristics (displacement 2 mm, articular involvement, number of fragments) were assessed retrospectively. Patient-reported outcome measures (PROMs) including the visual analog scale for foot and ankle (VAS FA) and the quality-of-life score (QoL) SF-12 were collected prospectively at 2- and 5-year follow-up. Out of 95 patients, 43 patients (45%) were included with a median follow-up of 5.7 (1.5) years. Results: For both the VAS FA and SF-12, excellent scores were observed. For 30 patients (77%), longitudinal 2- and 5-year follow-up was available. No significant longitudinal changes could be observed for the VAS FA and SF-12. For both time points, neither fracture type nor characteristics significantly influenced any outcome parameter assessed. Conclusion: Functional treatment by full weightbearing and free range of motion led to excellent 5-year results for both type I and II fractures. Neither fracture location nor characteristics had a significant influence on the 5-year PROMs. Level of Evidence: Level III, comparative study.

Background: Weakness of evertor strength is controversial in chronic ankle instability (CAI). Ankle evertor muscles are attached to the toe joints as well as to the metatarsal bone. Therefore, it is necessary to consider toe joint position for the measurement of evertor strength. The purpose of this study was to compare ankle evertor strength and muscle activity during eversion with and without toe flexion (TF) in individuals with CAI and individuals in a healthy group. Methods: Fifteen subjects with CAI and 15 healthy subjects participated in this study. Isometric ankle evertor strength and muscle activity of the peroneus longus (PL), peroneus brevis (PB), and extensor digitorum longus (EDL) were measured during eversion with and without TF. Results: The results indicated a significant interaction effect in evertor strength ( P = .03) and no significant interaction effect on EMG of the PL ( P = .08), PB ( P = .12), and EDL ( P = .28). However, measurements of muscle activity of the PL and PB between eversion with and without TF revealed a significant difference in the CAI group ( P < .01) and no significant difference in the healthy group (PL: P = .07; PB: P = .13). Conclusion: The results indicated that subjects with CAI had increased EDL compensation and reduced selective activation of the PL and PB during eversion. Clinical Relevance: Our findings suggest that clinicians should consider the activation of EDL when training the evertor of patients with CAI.

Background:The treatment of fifth metatarsal stress fractures can be challenging. Various operative fixation methods have been reported for fracture management. Among them, intramedullary screw fixation has become increasingly popular. However, recent reports have described failures after screw fixation in athletes. The aim of this study was to determine the rates of clinical and radiographic healing, time to return to sport, and complications of elite athletes with proximal fifth metatarsal fractures treated with plantar plating.Methods:Thirty-eight athletes with fifth metatarsal stress fractures treated using a plantar plating technique in 3 hospitals from 2013 to 2018 were evaluated retrospectively. Demographic data, radiographic evaluation, and the time until union and return to sports activities were collected and analyzed. A total of 38 patients underwent the plantar plating for a fifth metatarsal stress fracture with a mean follow-up of 23 (range, 12-49) months.Results:The mean time to the radiologic union, as determined by plain radiography, was 9.3 (range, 8-16) weeks. Although there were no nonunions or delayed unions during follow-up, 4 refractures developed (10.5%). All but 1 patient were able to return to their previous levels of sporting activity at 22.2 ± 4.5 (range, 12-40) weeks.Conclusion:With a minimum of 1-year follow-up, the described plantar plating technique could be an alternative method for the operative treatment of fifth metatarsal stress fractures without nonunion problems.Level of Evidence:Level IV, case series.

Background: Despite the importance of shoe wear to patients with hallux valgus (HV), few studies have investigated changes in foot width following surgery in this population. The purpose of our study was to determine if the modified Lapidus procedure would effectively decrease foot width in patients with HV. Methods: Thirty-one feet (19 left, 12 right) in 30 patients (29 females, 1 male) who underwent a modified Lapidus procedure in combination with a modified McBride and Akin osteotomy for treatment of HV were included in the study. All patients had preoperative and at least 5-month postoperative imaging, consisting of both weightbearing radiographs and computed tomography (WBCT) scans, which were used to measure bony and soft tissue foot widths pre- and postoperatively by 2 independent observers. Results: Intraclass correlation coefficients (ICCs) demonstrated high interobserver reliability (all ICCs >0.90). Bony foot width decreased significantly, by a mean of 8.9 mm (9.1%) on radiographs and 7.9 mm (8.4%) on WBCT scans ( P < .001). The soft tissue foot width also decreased significantly, by a mean of 6.9 mm (6.3%) on radiographs and 6.7 mm (6.4%) on WBCT scans ( P < .001). Changes in the hallux valgus angle and intermetatarsal angle correlated with changes in bony foot width on WBCTs (both r > 0.4, P < .02). Conclusions: The modified Lapidus procedure in combination with a modified McBride and Akin osteotomy resulted in statistically significant changes in both bony and soft tissue foot width. Patients should be counseled that foot width decreases, on average, by 0.5 to 1 cm. Level of Evidence: Level III, comparative series.

Background: Hallux valgus (HV) is a triplanar deformity of the first ray including pronation of the first metatarsal with subluxation of the sesamoids. The purpose of this study was to investigate if a first tarsometatarsal fusion (modified Lapidus technique), without preoperative knowledge of pronation measured on weightbearing computed tomographic (CT) scans, changed pronation of the first metatarsal and determine if reduction of the sesamoids was correlated with changes in first metatarsal pronation. Methods: Thirty-one feet in 31 patients with HV who underwent a modified Lapidus procedure had preoperative and at least 5-month postoperative weightbearing CT scans and radiographs. Differences in preoperative and postoperative pronation of the first metatarsal using a 3-dimensional computer-aided design, HV angle, and intermetatarsal angle (IMA) were calculated using Wilcoxon signed-rank tests. After dividing patients into groups based on sesamoid station, Kruskal-Wallis H tests were used to compare first metatarsal pronation between the groups. Results: The mean preoperative and postoperative pronation of the first metatarsal was 29.0 degrees (range 15.8-51.1, SD 8.7) and 20.2 degrees (range 10.4-32.6, SD 5.4), respectively, which was a mean change in pronation of the first ray of −8.8 degrees ( P < .001). There was no difference in pronation of the first ray when stratified by postoperative sesamoid position ( P > .250). The average preoperative and postoperative IMA was 16.7 degrees (SD 3.2) and 8.8 degrees (SD 2.8), which demonstrated a significant change ( P < .001). Conclusions: The modified Lapidus procedure was an effective tool to change pronation of the first ray. Reduction of the sesamoids was not associated with postoperative first metatarsal pronation. Level of Evidence: Level IV, case series.

Background:Hallux valgus is a multiplanar deformity of the first ray. Traditional correction methods prioritize the transverse plane, a potential factor resulting in high recurrence rates. Triplanar first tarsometatarsal (TMT) arthrodesis uses a multiplanar approach to correct hallux valgus in all 3 anatomical planes at the apex of the deformity. The purpose of this study was to investigate early radiographic outcomes and complications of triplanar first TMT arthrodesis with early weightbearing.Methods:Radiographs and charts were retrospectively reviewed for 57 patients (62 feet) aged 39.7 ± 18.9 years undergoing triplanar first TMT arthrodesis at 4 institutions between 2015 and 2017. Patients were allowed early full weightbearing in a boot walker. Postoperative radiographs were compared with preoperative radiographs for hallux valgus angle (HVA), intermetatarsal angle (IMA), tibial sesamoid position (TSP), and lateral round sign. Any complications were recorded.Results:Radiographic results demonstrated significant improvements in IMA (13.6 ± 2.7 degrees to 6.6 ± 1.9 degrees), HVA (24.2 ± 9.3 degrees to 9.7 ± 5.1 degrees), and TSP (5.0 ± 1.3 to 1.9 ± 0.9) from preoperative to final follow-up ( P < .001). Lateral round sign was present in 2 of 62 feet (3.2%) at final follow-up compared with 52 of 62 feet (83.9%) preoperatively. At final follow-up, recurrence was 3.2% (2/62 feet), and the symptomatic nonunion rate was 1.6% (1/62 feet). Two patients required hardware removal, and 2 patients required additional Akin osteotomy.Conclusion:Early radiographic outcomes of triplanar first TMT arthrodesis with early weightbearing were promising with low recurrence rates and maintenance of correction.Level of Evidence:Level IV, retrospective case series.

Background: The optimal techniques for Lisfranc open reduction and internal fixation techniques remain debated. The purpose of the current study was to describe the joints involved in Lisfranc fixation and to determine if nonarticular transosseous internal fixation would be possible. Methods: Twenty cadaver Lisfranc joints were dissected and the articular cartilage was quantified by calibrated digital imaging software. Utilizing CT data, a computational model of the foot was developed and the mean joint surface was mapped and nonarticular screw paths between bones was determined. Results: For the medial-middle cuneiform (C1-C2) connection, 27.3% of the lateral face of C1 and 43.7% of the medial face of C2 was articular cartilage. Three variations of articular morphology were observed on C1 and 2 on C2. From the 3D models, it was determined that a joint-sparing, transosseous screw trajectory was possible between C1 and the second metatarsal and between C1 and C2. These screw paths were large enough to accommodate clinically useful screw diameters (>5 mm). The screw trajectories were roughly perpendicular to the long axis of the foot and take a plantar-medial to dorsal-lateral orientation. Conclusion: The articular surface of the Lisfranc joint was quantified for the first time and may be smaller than some surgeons realize. This study demonstrated the orientation required to minimize articular damage. Clinical Relevance: The clinical significance of the current study was that a nonarticular screw trajectory was possible, and this information may help guide the placement of these screws.

Background: Fractures of the proximal fifth metatarsal are one of the most common foot injuries in athletes. Repetitive stresses endured by the fifth metatarsal can lead to stress fracture, delayed union, and refracture, making optimal treatment challenging. A radiographic analysis of fifth metatarsal morphology and foot type in National Football League (NFL) players was performed to investigate morphologic risk factors for these injuries. Methods: This was a case-control study that looked at NFL players treated between 1992 and 2012, as well as participants at the NFL Combine. Ninety-six feet (51 athletes) were included. Fractures were present in 15 feet. Two reviewers assessed fifth metatarsal morphology and foot type on anteroposterior, lateral, and oblique radiographs. Differences in foot type and metatarsal morphology between athletes with and without fractures were determined. Results: On anteroposterior radiographs, significant differences in apex medullary canal width, 4-5 intermetatarsal angle, fifth metatarsal angle, and talar head uncovering were observed between fractured and non-fractured feet ( P = .001, .003, .004, .008, respectively). On lateral radiographs, significant differences in the fifth metatarsal length, distance to apex, apex height, fifth metatarsal angle, and talocalcaneal angle were observed between fractured and nonfractured feet ( P = .04, .01, .02, .01, .01, respectively). On oblique radiographs, a significant difference was observed in apex height between fractured and nonfractured feet ( P = .002). Conclusion: Individuals with long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for fifth metatarsal fractures. With this insight, attempts at fracture prevention can be implemented via footwear modifications, orthoses, and off-loading braces that account for those aforementioned morphologic attributes that place athletes at risk. Level of Evidence: Level III, retrospective comparative study.

Background:The current work sought to quantify pronation of the first metatarsal relative to the second metatarsal and of the proximal phalanx of the great toe relative to the first metatarsal.Methods:Three-dimensional models were reconstructed from weightbearing computed tomography (CT) images (10 hallux valgus, 10 normal). The orientations of bones related to hallux valgus (HV) (ie, the phalanx, first and second metatarsals) were determined from coordinate systems established by selecting landmarks. After determining the hallux valgus and intermetatarsal angles, additional calculations geometrically determined the 3-dimensional (3D) angles using the aeronautical system of yaw-pitch-roll. The 3D geometrically determined angles were compared to the conventional plain radiographic angles.Results:HV measurements taken with CT and 3D computer-aided design (3DCAD) geometric methods were the same as measurements taken from plain radiographs (P > .05). The average pronation of the first metatarsal relative to the second metatarsal was 8.2 degrees greater in the hallux valgus group (27.3 degrees) than in the normal group (19.1 degrees) (P = .044). A regression analysis of pronation vs intermetatarsal angle (IMA) was not found to be significant. There was also no correlation between pronation of the great toe and first metatarsal in the HV group.Conclusions:The pronation angle of the first metatarsal relative to the second metatarsal between normal and hallux valgus patients was larger in HV patients but was not well correlated with the IMA.Clinical Relevance:The findings of this study indicate that pronation may need to be considered in the operative correction of hallux valgus for restoration of normal anatomy.

Background:Operative treatment of juvenile hallux valgus (JHV) has a high recurrence rate. The aim of this study was to better understand the pattern of radiographic deformity.Methods:Standing radiographs of 93 feet in 57 patients with JHV, and 50 feet in 36 normal patients were measured. Measurements included: hallux valgus angle (HVA), first metatarsal physis status (open or closed), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), Meary’s angle, medial cuneiform angle (MCA), relative first to second metatarsal length ratio (1:2 MT ratio), cuneiform obliquity (CO), and congruency of the metatarsophalangeal joint (MTPJ). JHV groups were defined as normal (HVA 0-15 degrees), mild-moderate (HVA 15-35), or severe (HVA > 35) and were analyzed.Results:Seventy of 93 feet (75%) with JHV presented with mild-moderate JHV (average HVA of 26.2 ± 5.6 degrees), and 23 feet (25%, 23/93) presented with severe JHV (average HVA of 41.9 ± 5.3 degrees). Multivariable analysis determined that DMAA ( P < .001), MCA ( P = .04), and congruency ( P < .001) were independently associated with JHV and its severity (normal vs mild-moderate vs severe). Severe JHV cases had larger DMAA ( P = .01), larger IMA ( P = .01), larger 1:2 MT ratio ( P = .02), and were less frequently congruent ( P = .03) compared with mild-moderate JHV cases.Conclusion:Deformity in JHV was highly correlated with both the proximal and distal morphology of the first metatarsal and medial cuneiform. Severe JHV was associated with increased bony deformity and increased incongruity of the MTPJ. Treatment should be individualized, but JHV treatment algorithms can take this information into account.Level of Evidence:Level III, comparative study.

Background: Percutaneous, transverse distal metatarsal osteotomy with K-wire fixation (the Bösch technique) is an established technique for hallux valgus correction. Nevertheless, the risk of damaging the anatomical structures during the operation is unknown. Methods: Forty fresh-frozen anatomical foot specimens with hallux valgus deformity underwent a percutaneous corrective procedure. Specimens of group A (n = 20) were operated by an experienced surgeon while specimens of group B (n = 20) were done by untrained residents. Results: The dorsal cutaneous nerve was injured in 1 of 20 cases in group A and 6 of 20 cases in group B ( P = .037). There was a significant difference in overall complication rate between specimens of group A and group B ( P = .043). Conclusions: The results show an increased risk of perioperative injury of the dorsal cutaneous branch of the deep peroneal nerve as well as a significant effect of the surgeon’s experience on the overall complication rate. Clinical Relevance: Results of this study are highly relevant for all surgeons who perform percutaneous, minimally invasive hallux valgus surgery to avoid damage to the peripheral nerves. In addition, the data suggest an intensive training for surgeons before minimally invasive hallux valgus surgery is performed without supervision.

Background: Hallux valgus (HV) adversely affects quality of life. Patients frequently express concerns regarding postoperative foot appearance, foot width and footwear anticipations. However, only scarce data are available regarding postoperative foot width. Materials and Methods: Seventy-one cases with moderate to severe HV treated with scarf osteotomy were included. The average age was 55.7 years (range, 20-76), with average follow-up of 20.7 months (range, 6-96). Patients’ medical records were reviewed for demographic, operative, and radiographic data. Foot width was assessed radiographically by measuring both bone (distance between the first and fifth metatarsal heads) and soft tissue width (maximal distance of the soft tissue outline). Results: Preoperative HV deformity (mean hallux valgus angle [HVA] 35.8 degrees, intermetatarsal angle [IMA] 14.1 degrees, and distal metatarsal articular angle [DMAA] 15.2 degrees) was successfully corrected (postoperative mean HVA 13.7 degrees, IMA 6.9 degrees, and DMAA 7.7 degrees). Overall bony foot width was reduced by 5% and soft tissue foot width by 2%. Further analysis showed that 13 feet (18.3%) had increased (>5%) bone width, 26 feet (36.6%) with no change (±5%), and 32 feet (45.1%) for which the width decreased (>5%) postoperatively. Angular deformity (HVA, IMA, and DMAA) showed low correlation with postsurgery foot width. Conclusion: HV surgery effect on foot width was very limited, overall reducing foot width by 2%. Furthermore, in only about half of the patients, the postoperative foot width decreased, regardless of angular deformity magnitude. Patients with the widest feet had a decrease in foot width following surgery, whereas patients with the narrowest feet had an increase in foot width. Level of Evidence: Level III, comparative series.

Background: There have been very few studies related to the treatment of first, second, third, and fourth (MT) metatarsal shaft and neck fractures. In order to reduce metatarsal fracture malunion, many surgeons have turned from K-wire to plate fixation of these fractures. This study reports the healing rates, final fracture angulation, and need for hardware removal of operatively treated first to fourth MT shaft and neck fractures with plate fixation. Methods: A retrospective review was performed on all metatarsal fractures at our institution between 2008 and 2014 to identify all first to fourth MT shaft and neck fractures. Medical records and radiographs were reviewed for evidence of union, sagittal, and coronal fracture angulation (degrees), time to full weight bearing, plate size, fracture location (neck vs shaft), and number of screws on each side of the fracture. Multiple linear regression analysis was used to make calculations of statistical significance. Results: Forty-five patients with a total of 75 first to fourth MT fractures treated with plate fixation were included in this study. All fractures went on to union and full weight bearing. The average time to union and time to full weight bearing was 10.9 ± 2 weeks and 7.5 ± 1.6 weeks, respectively. The average coronal and sagittal plane angulation was 3.9 and 2.2 degrees, respectively. Fractures located in the neck were found to have higher coronal plane angulation malunion compared with fractures in the shaft ( P = .019). No variable was found to be related to final sagittal plane angulation. No patient had a plate removed, and 26 of 27 of patients did not want to have the plate removed. Conclusion: Metatarsal fractures fixed with plates had high rates of union and low final fracture angulation. No patient included in this study underwent hardware removal. Level of Evidence: Level III, comparative study.

Background: Different osteotomies have been proposed for the treatment of bunionette deformity. Minimally invasive surgery is now increasingly popular for a variety of forefoot conditions. The aim of this study was to evaluate the outcome following fifth minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) for bunionette deformity. Methods: Nineteen patients (21 feet) who had symptomatic bunionette deformity and failed conservative treatment between 2014 and 2016 were included in this retrospective study. Clinical data were recorded, and pre- and postoperative Manchester-Oxford Foot Questionnaire (MOXFQ) scores and visual analog scale (VAS) pain score were collected. The mean follow-up was 28 months (range, 12-47). Results: The mean MOXFQ summary index score decreased from 71 (range, 59-81) preoperatively to 10 (range, 0-30) postoperatively. All 3 MOXFQ domains also improved. The average improvement in VAS score was 7. Forefoot swelling and some painful symptoms took an average of 3 months to settle. There were no wound or nerve complications. One patient required a dorsal cheilectomy for a symptomatic prominent dorsolateral callus formation. Conclusion: The minimally invasive fifth DMMO for bunionette deformity was a safe and effective technique. It had relatively few complications and led to good clinical results. We believe it is important to warn patients that the forefoot swelling will take months to settle compared to an osteotomy with fixation, and there is a 10% chance of a prominent callus over the osteotomy site. Level of Evidence: Level IV, retrospective case series.

Background: The tibialis anterior tendon has its insertion sites on both the medial and plantar surfaces of the medial cuneiform and the base of the first metatarsal. Operative procedures near those areas, especially at the first metatarsocuneiform joint, may disturb tendon insertions and cause irritation or functional impairment of the tendon. Methods: Tibialis anterior tendons and their insertion sites were dissected and examined from 46 cadaveric feet (19 female and 27 male cadavers, aged between 33 and 86 years, with a mean of 68.5 ± 14.3 years). The greatest lengths and widths of the tendon attachments on the bony surface of the medial cuneiform and base of the first metatarsal, on both the medial and plantar surfaces, were measured and analyzed. The measurement reliability was evaluated by using the intraclass correlation coefficient. Results: Most of the tibialis anterior tendon insertions were found to be longer at the medial cuneiform than at the base of the first metatarsal (mean, 8.3 and 5.4 mm; P < .001), but the widths were almost similar (mean, 11.0 and 10.4 mm; P = .079). When focusing on each bone, the widths of the tendon attachments on the medial and plantar surfaces of the medial cuneiform were equivalent (mean, 5.4 and 5.6 mm; P = .584). At the base of the first metatarsal, the tendon attachment on the plantar surface was found to be wider than on the medial surface (mean, 7.0 and 3.4 mm; P < .001). Conclusion: The widths of the tibialis anterior tendon insertions on the medial and plantar surfaces of the medial cuneiform were equal, as were the total widths of insertions on the medial cuneiform and on the base of the first metatarsal. However, the width of insertions on the medial surface of the first metatarsal was significantly smaller than on the plantar surface, and the total length of insertions at the medial cuneiform was longer than at the first metatarsal. Clinical Relevance: This study provides information about characteristics of the tibialis anterior tendon insertions, particularly details of the dimensions on each surface of the bones. This knowledge enables surgeons to minimize the risk of irritation or tendon injuries during operations near the base of the first metatarsal and medial cuneiform area.

Background: Intramedullary screw fixation is a common method of treating proximal metadiaphyseal fifth metatarsal (ie, Jones) fractures. Fatigue failure is a complication of this fixation. There are many screw designs available, including Jones fracture specific fixation, but the optimal choice of screw design is unknown. The purpose of this study was to compare the fatigue strength of Jones fracture specific screw designs as well as other commonly used screw designs. Our hypothesis was that there would be no difference in fatigue strength for Jones fracture specific screw designs at similar screw diameters. Methods: A study was performed to determine the fatigue bending strength of 5 different screw designs including Jones fracture specific screw designs at 3 different screw diameters. Six screws of each size and design underwent cyclic fatigue testing, and a median fatigue limit (MFL) was determined for each screw design and size. Results: The Stryker Asnis JFX solid 4.0-mm, 5.0-mm, and 6.0-mm screws had a higher MFL than all other screws with similar diameter tested (all P < .0001). Both Jones fracture specific screw designs (Stryker Asnis JFX solid screws and Charlotte Carolina Jones screws) had higher MFLs than the other screw designs tested. Conclusion: This study provides comparative fatigue strength data on larger screw diameters, which have not been previously reported. There was a statistically significant difference in screw fatigue properties at the screw diameters tested. Clinical Relevance: The clinical significance of this study is that it provides surgeons with fatigue strength data to aid in screw selection for Jones fracture fixation.

Background:The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes.Methods:A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out ( P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%).Results:All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points ( P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time.Conclusion:Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications.Level of Evidence:IV, case series.

Background: Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs. Methods: We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed. Results: At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied. Conclusion: Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures. Level of Evidence: Level IV, retrospective case series.

Background: An association between hallux rigidus and metatarsus primus elevatus (MPE) has been suggested, although there remains no general consensus about the nature of this relationship. Past studies were limited due to inaccuracies of assessing MPE on 2-dimensional radiographs. The aims of this study were to (1) assess and compare foot alignment in patients with and without hallux rigidus using 3-dimensional (3D) reconstructions from weightbearing computed tomography (CT) and (2) assess intraobserver and interobserver reliability of these measurements. Methods: A prospective study was performed in 50 consecutive patients with symptomatic hallux rigidus and 50 control patients who underwent a weightbearing CT. Two investigators measured first and second metatarsal declination angles, first and second metatarsal lengths, first to second intermetatarsal angle (IMA), hallux valgus angle (HVA), and foot width on 3D CT reconstructions. Measurements were repeated after 1 month. Student t tests were performed to compare hallux rigidus and control groups. Intraclass and interclass correlation coefficients were calculated to evaluate reliability. Results: The first to second metatarsal declination ratio was less in patients with hallux rigidus (mean, 0.81) than controls (mean, 0.92; P < .001). Patients with Coughlin and Shurnas grade 3 and 4 hallux rigidus had greater first metatarsal declination than patients with grade 1 and 2 hallux rigidus. Last, IMA was higher (mean, 13 degrees) but HVA was lower (mean, 11 degrees) in patients with hallux rigidus than controls (IMA mean, 12 degrees; HVA mean, 15 degrees; P = .04). Intraobserver (ICC1,1 ≥ 0.93) and interobserver (ICC3,1 ≥ 0.85) reliability were good to excellent for all measured parameters. Conclusions: Patients with hallux rigidus had MPE. Patients with grade 3 and 4 hallux rigidus had more MPE than patients with grade 1 and 2 hallux rigidus. There was no clear correlation between hallux rigidus and bunions. Finally, weightbearing CT proved to be a reliable method of assessing all measured parameters. Level of Evidence: II, prospective comparative series.

Background: Identifying the optimal starting point for intramedullary fixation of tibia and femur fractures is well described in the literature using a retrograde or anterograde technique. This technique has not been applied to the fifth metatarsal, where screw trajectory can cause iatrogenic malreduction. The generally accepted starting point for the fifth metatarsal is “high and inside” to accommodate the fifth metatarsal’s dorsal apex and medial curvature. We used a retrograde technique to identify the optimal starting position for intramedullary fixation of fifth metatarsal fractures. Methods: Five matched cadaveric lower extremity pairs were dissected to the fifth metatarsal neck. An osteotomy was made to access the intramedullary canal. A retrograde reamer was passed to the base of the fifth metatarsal to ascertain the ideal entry point. Distances from each major structure on the lateral aspect of the foot were measured. Computed tomography scans helped assess base edge measurements. Results: In 6 of 10 specimens, the retrograde reamer hit the cuboid with a cuboid invasion averaging 0.7 mm. The peroneus brevis and longus were closest to the starting position with an average distance of 5.1 mm and 5.7 mm, respectively. Distances from the entry point to the dorsal, plantar, medial, and lateral edges of the metatarsal base were 8.3 mm, 6.9 mm, 9.7 mm, and 9.7 mm, respectively. Conclusion: Optimal starting position was found to be essentially at the center of the base of the fifth metatarsal at the lateral margin of the cartilage. Osteoplasty of the cuboid or forefoot adduction may be required to gain access to this site. Clinical Relevance: This study evaluated the ideal starting position for screw placement of zone II base of the fifth metatarsal fractures, which should be considered when performing internal fixation for these fractures.

Background: Proximal opening wedge osteotomy (POWO) is an established procedure for moderate to severe hallux valgus. A common concern of this procedure is that it results in lengthening of the first metatarsal, which could cause increased intra-articular pressure of the first metatarsophalangeal joint (MTP) and may ultimately lead to arthritis because of these altered mechanics. The purpose of this study was to use a cadaveric model to compare intra-articular pressures and articulating contact properties of the MTP joint following either scarf osteotomy or POWO. Methods: Fresh-frozen cadaveric below-knee specimens with pre-existing hallux valgus (n = 12) and specimens without hallux valgus (n = 6, control group) were used. The hallux valgus specimens were stratified into 2 groups (n = 6 each): POWO or scarf osteotomy. The groups were matched based on the degree of deformity. Peak intra-articular pressure, force, and area were measured in all normal, preoperative, and postoperative specimens with a simulated weightbearing model. These measurements were made with a pressure transducer placed within the first MTP joint. Results: Postoperatively POWO group had slightly higher contact forces and pressures compared to the scarf group and lower contact forces and pressures than those of the normal group but were not statistically significant ( P > .05). Normal specimens had higher intra-articular force, pressure, and area than postoperative specimens but the difference was not found to be significant. First metatarsal lengthening was found in both the scarf and POWO specimens; however, neither increase was found to be significant ( P > .05). Conclusion: The results from this study show that after operative correction, contact properties of the fist MTP joint among normal, POWO, and scarf osteotomy groups revealed no significant differences. First MTP joints in those with hallux valgus had significantly lower contact force and pressure compared to those without hallux valgus. Clinical Relevance: With little long-term outcomes of proximal opening wedge osteotomy, this study will help predict the possibility of future MTP joint arthritis.

Background: Plantar plate pathology is common, yet it is unclear whether, and to what extent, the length of the second metatarsal contributes to this problem. Methods: We conducted a retrospective case-control (1:2) study to examine radiographic risk factors for plantar plate tears. One hundred patients (age 55.7 ± 12.3 years) with plantar plate injuries and 200 healthy controls (age 56.3 ± 11.3 years) were included. Cases were defined as patients with nonacute, isolated, plantar plate pathology of the second metatarsophalangeal joint confirmed by intraoperative inspection at a single foot and ankle specialty practice from June 1, 2007, to January 31, 2014. Patients presenting for pain outside of the forefoot served as the control group. Controls were matched on age (±2 years), gender, and year of presentation. Weight-bearing foot x-rays were assessed for several predetermined angular relationships by a single rater. Conditional logistic regression was used to identify risk factors for plantar plate injury. Results: A long second metatarsal, defined as a metatarsal protrusion index less than −4 mm, was the only significant risk factor for plantar plate pathology in both the univariate and multivariable analyses (multivariate odds ratio 2.5 [95% confidence interval 1.8 to 3.3], P = .002). Conclusion: We found that a long second metatarsal was a risk factor for developing second metatarsophalangeal joint plantar plate tears. This knowledge may aid foot and ankle surgeons when contemplating the need for second metatarsal shortening osteotomies (eg, Weil osteotomy) during plantar plate surgery and when deciding on the amount of shortening for second metatarsal osteotomies. Level of Evidence: Level III, retrospective comparative study.

Background:The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton’s neuroma (MN).Methods:Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author’s private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years.Results:When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location.Conclusion:We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence.Level of Evidence:Level III, case control study.

Background: Arthrodesis is a standard operative treatment for symptomatic arthritis of the first metatarsophalangeal (MTP) joint. Patients with degenerative joint disease (DJD), severe hallux valgus, and metatarsus primus varus may also require fusion of the first MTP joint. An important question in the latter group of patients is whether a proximal first metatarsal osteotomy is required, in addition to the first MTP joint fusion. Our hypothesis was that patients with severe hallux valgus and metatarsus primus varus, treated with first MTP joint arthrodesis alone, would have correction of the first-to-second intermetatarsal angle (1-2 IMA) and hallux valgus angle (HVA) to near population norms, without the addition of a proximal first metatarsal osteotomy. Methods: Preoperative and postoperative radiographs of 19 feet, in 17 patients, with preoperative IMA greater than 15 were analyzed. Weight-bearing radiographs were divided into pre- and postoperative cohorts. Three independent reviewers measured these radiographs and mean 1-2 IMA and HVA were calculated. Mean follow-up was 10 months. Results: The mean preoperative 1-2 IMA was 19.2 degrees (15.6-24.3). The mean preoperative HVA was 48.5 (36-56.6). The mean postoperative values for 1-2 IMA and HVA were 10.8 and 12.3 degrees, respectively. The mean change in IMA was 8.3 degrees and in the hallux valgus angle was 36.4 degrees. The differences between pre- and postoperative measurement for both angles were statistically significant ( P < .001). Seven of 19 (37%) feet were corrected to an IMA of less than 9 degrees (normal), whereas in 15/19 feet the postoperative IMA was 12.3 degrees or less. The postoperative HVA was less than 15 degrees in 15/19 (79%) feet. Conclusion: This pre- and postoperative radiographic analysis of patients with severe bunion deformity demonstrated that HVA and 1-2 IMA were acceptably corrected without the addition of a proximal first metatarsal osteotomy. Level of Evidence: Level III, retrospective comparative series.

Background: The purposes of this study were to compare the quality of life (QOL) of subjects who had untreated symptomatic hallux valgus with the QOL of the general population and to investigate factors associated with the QOL of the subjects. Methods: One hundred sixteen subjects with previously untreated and symptomatic hallux valgus were surveyed. QOL was assessed using the 36-item Short Form Health Survey (SF-36). Additionally, clinical evaluations (the visual analog scale for pain, Japanese Society for Surgery of the Foot Scale, lesser toe pain, and pain in other parts of the body) and radiographic evaluations (hallux valgus angle, intermetatarsal angle between the first and second metatarsals, and dislocation of the second metatarsophalangeal joint) were performed. Differences in the SF-36 between the subjects and the general population were tested using independent t tests. Correlations between the QOL measurements, clinical evaluations, and radiographic evaluations were assessed using Spearman rank correlation coefficient. Results: All SF-36 subscales and physical component summary scores for the subjects were significantly lower than those of the general population. Notably, the standardized physical function subscale (38.2 ± 15.8, P < .001) and physical component summary scores (38.9 ± 14.5, P < .001) were more than 10 points lower than those of the general population. Most QOL and clinical evaluation parameters were not correlated or were negligibly correlated with radiographic evaluations. Similarly, lesser toe pain or pain in other parts of the body was not correlated with QOL or clinical evaluations. Conclusion: The QOL of untreated and symptomatic hallux valgus subjects was lower than that of the general population. All QOL and clinical evaluation parameters were not significantly or negligibly correlated with the severity of toe deformities. Surgical decision making should not be based on the severity of the deformity alone, but rather patient QOL should also be carefully assessed. Level of Evidence: Level III, comparative series.

Hallux valgus is the most common disorder of the hallux and often results in pain, functional disability, and impaired gait patterns. The goals of surgical management are to correct the deformity while improving patients’ pain and function. Traditional treatment of moderate to severe hallux valgus deformities consist of proximal osteotomy and/or arthrodesis given their powerful corrective ability. Despite their corrective power, proximal osteotomies are more technically demanding, have a higher rate of complications, and require a more restricted post-operative recovery. We present an alternative technique for the treatment of moderate to severe hallux valgus. With this operation, a single distal medial incision is utilized to create a chevron osteotomy and lateral release. This procedure can achieve and maintain the desired correction and outcome without the need for a protracted recovery period. Level of Evidence: Level V, expert opinion.