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This study aims to investigate the influence of lumbar spine disorders on the development of asymmetric hallux valgus (HV). Data from the fifth survey of the Osteoarthritis/Osteoporosis Against Disability (ROAD) study, a nationwide prospective study in Japan, were analyzed. HV severity was categorized into 4 grades based on the radiographic HV angle, and asymmetric HV was defined as having at least one HV on either side, with a difference of two or more severity grades between the left and right. Controls were matched from both the Normal group (without HV on both sides) and the Symmetric group (HV on at least one side with a difference of one or less severity grades). Univariate analysis assessed lumbar conditions, and multinomial logistic regression analysis explored the association between lumbar spine disorders and asymmetric HV. Among 1997 participants, 27 had asymmetric HV. Univariate analysis revealed a higher incidence of L5 spondylolisthesis and scoliosis in the Asymmetric group. Multinomial logistic regression analysis revealed that scoliosis independently increased the likelihood of asymmetrical HV (Odds ratio [OR] = 3.586, 95%Confidence interval [CI] 1.111-11.582), but showed no significant impact on symmetrical HV (OR 0.910, 95% CI 0.355-2.334). Asymmetric HV is rare but may be associated with lumbar spine disorders, particularly scoliosis., (© 2024. The Author(s).)

A 19-year-old girl presented with symmetric and bilateral hyperpigmentation, an indurated lesion that initially appeared on the axillary fold at the age of 14, which then extended to the lower back, anterior aspect of both thighs, and popliteal fold. No hypertrichosis was observed (Figure 1).The patient was the youngest of the four children, born from the first-degree consanguineous marriage. She was born at full term and weighed 2,420 g at birth. No similar patient was present in the family. The patient experienced delayed motor acquisition and stature growth (3rd percentile) until the age of 4. Right hypoacusis was diagnosed at the age of 6. She developed hallux valgus, flexion contracture of the fin-gers and toes, barrel deformity of the anterior thorax, and recurrent fever. The laboratory tests, including fasting blood glucose, -triglycerides, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were normal. Her abdominal, pelvic, and transthoracic ultrasound scans were normal, with no hepatosplenomegaly, lymphadenopathy, or cardiac abnormalities. Histologic analysis demonstrated patchy acanthosis of the epidermis, with orthokeratotic hyperkeratosis. Keratinocyte hyperpigmentation and spongiosis at certain areas were observed with moder-ate inflammation because of the infiltration of lymphocytes, histiocytes, and plasma cells. Immunohistochemical analysis showed macrosialin (CD68+) and common gamma chain (γ c ) CD132. Germline mutations in the SLC29A3 gene were not analyzed. The patient was prescribed dermocorticoids with depigmentation therapy, which demonstrated moderate clinical evolution.

Background: Hallux valgus (HV) is a complex deformity, with many associated risk factors. The flexor hallucis longus (FHL) tendon is a dynamic and potentially deforming force as it bowstrings laterally with HV. We hypothesized that FHL is more laterally inserted in the distal phalanx in cadavers with HV; therefore, it might be also a primary destabilizing force. We aim to compare the FHL distal insertion morphology and its relationship with osseous structures in cadavers with and without HV., Methods: Sixteen cadaver specimens, 8 with HV and 8 without (N-HV) were dissected. We evaluated FHL distal morphology in terms of its insertional footprint location and FHL long-axis position in relation to osseous anatomy., Results: Both the HV and N-HV groups displayed a laterally inserted footprint at the distal phalanx, with the HV group exhibiting median lateral translation of the footprint 6% greater than the N-HV group ( P  < .01). Both groups also demonstrated a laterally displaced position for the FHL long axis. The median FHL long axis for HV vs N-HV specimens 1 cm proximal to the IP joint was 9% more laterally displaced from the midaxis ( P  < .01), and at 1 cm proximal to the MTP joint was measured to be 15% more laterally displaced from the midaxis ( P  < .01)., Conclusion: FHL demonstrated an eccentric position in terms of insertion and trajectory in both the HV and N-HV groups, with greater lateralization in specimens exhibiting HV deformity. This eccentricity potentially creates a greater deforming force vector contributing to the development of HV., Clinical Relevance: The etiology and progression of HV deformity may include a lateralized insertion of the FHL tendon. Treatment implications remain unknown at this time., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Introduction: Foot morphology in the general population has been shown to change with age, and active older adults have reported a need for wide-fitting footwear., Methods: This study recruited 374 women active in racket sports and team sports in the UK who had their feet scanned while 50% weight bearing. Participants were grouped into 10-year age bands ranging from 18-29 years to 70-79 years. Data analysis was performed on the widths, heights, and circumferences of participants' right feet normalised to foot length, as well as an assessment of hallux valgus angle and deformity., Results: The 18-29-year group had significantly smaller measures of foot width, ball of foot circumference and short heel circumference (p < 0.05, η2 = 0.042, η2 = 0.056) compared to the older groups. The foot dorsum height and circumference at 50% foot length were significantly less in the oldest age groups compared to the middle age groups (p = 0.0001, η2 = 0.055 and p = 0.0007, η2 = 0.044, respectively). There was some evidence of increased hallux valgus deformity with age., Conclusion: Designers and manufacturers of athletic footwear should be aware of the changes in foot morphology with age in order to provide more inclusive footwear., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Bone morphology is one of the factors involved in hallux valgus development. However, previous studies have not evaluated the overall bone shape in three dimensions. This study aimed to compare the overall shape of the first proximal phalanx and first metatarsal in hallux valgus with those of normal feet.Homologous models were created from computed tomography data of the first proximal phalanx and first metatarsal of 75 healthy men and 53 women in the control group and 10 men and 71 women in the hallux valgus group. Principal component analysis was performed to examine the differences in bone morphology between the control and hallux valgus groups. In men and women with hallux valgus, the proximal articular surface of the first proximal phalanx was characterized by a more lateral inclination and torsion of the pronated first metatarsal. Additionally, the first metatarsal head was characterized by a more lateral inclination in male hallux valgus. This study is the first to reveal the morphological characteristics of the first metatarsal and first proximal phalanx in hallux valgus as a whole bone using a homologous model technique. These characteristics are considered possible causes of hallux valgus development. The shapes of the first proximal phalanx and first metatarsal in hallux valgus were different from those in normal feet. This finding should be useful when considering the pathogenesis and treatment development for hallux valgus., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Medial column instability is a frequent finding in patients with flatfeet and hallux valgus, within others. The etiology of hallux valgus is multifactorial, and medial ray axial rotation has been mentioned as having an individual role. Our objective was to design a novel cadaveric foot model where we could re-create through progressive medial column ligament damage some components of a hallux valgus deformity., Methods: Ten fresh-frozen lower leg specimens were used, and fluorescent markers were attached in a multisegment foot model. Constant axial load and cyclic tibial rotation (to simulate foot pronation) were applied, including pull on the flexor hallucis longus tendon (FHL). We first damaged the intercuneiform (C1-C2) ligaments, second the naviculocuneiform (NC) ligaments, and third the first tarsometatarsal ligaments, leaving the plantar ligaments unharmed. Bony axial and coronal alignment was measured after each ligament damage. Statistical analysis was performed., Results: A significant increase in pronation of multiple segments was observed after sectioning the NC ligaments. Damaging the tarsometatarsal ligament generated small supination and varus changes mainly in the medial ray. No significant change was observed in axial or frontal plane alignment after damaging the C1-C2 ligaments. The FHL pull exerted a small valgus change in segments of the first ray., Discussion: In this biomechanical cadaveric model, the naviculocuneiform joint was the most important one responsible for pronation of the medial column. Bone pronation occurs along the whole medial column, not isolated to a certain joint. Flexor hallucis longus pull appears to play some role in frontal plane alignment, but not in bone rotation. This model will be of great help to further study medial column instability as one of the factors influencing medial column pronation and its relevance in pathologies like hallux valgus., Clinical Relevance: This cadaveric model suggests a possible influence of medial column instability in first metatarsal pronation. With a thorough understanding of a condition's origin, better treatment strategies can be developed.

Background: Hallux valgus is a deformity of the forefoot involving a phalangeal valgus and a metatarsal adductus. In most cases its correction requires surgical treatment with different types of osteotomies. The best known is Scarf osteotomy., Aim: To study the effet of Scarf osteotomy on distal metatarsal articular angle (DMAA) as well as the validitiy of this angle and the value of its correction after review of the literature., Methods: It was a retrospective study including patients operated on for severe hallux valgus by a Scarf osteotomy. The clinical assessment was based on the the American-Orthopedic-Foot-and-Ankle-society (AOFAS) score. Radiologically, we calculated the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA. This assessment was performed preoperatively and one year postoperatively., Results: We collected 37 cases of evolved hallux valgus. The average AOFAS score went from 60.7 to 85.8 / 100 postoperatively with a gain of 25 points. We've noted a significant correction of the 3 angular measurements at one year postoperatively (the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA) which went from 38.8° to 20.5°, from 17° at 10° and 13.5° to 8.5° respectively (p<0.05)., Conclusion: The literature has shown that there is no consensus regarding the effect of HV surgery on the DMAA. As for the accuracy, reproducibility and interest of correcting this angle we deduce that the DMAA is an interesting measure in the pathology of HV. Its correction seems not to be necessary in order not to hamper the correction of metatarsus varus. But in cases where the preoperative DMAA is high (> 15 °), efforts should be made to correct it to avoid recurrence.

To examine the influence of the configuration of the first and second metatarsal (MT) bones on the development of hallux valgus deformity. To determine the extent to which the difference in the lengths of the first and second MT bones, measured distal to the Maestro line, contribute to the severity of the hallux valgus (HV) deformity defined by the size of the hallux valgus angle (HVA) and inter-metatarsal angle (IMA). On a sample of 319 feet with HV deformity the difference of measured lengths R = d (I MT) - d (II MT) was calculated The influence of differences (R) on the values of IMA and HVA as well as on the severity of deformities according to the formed groups was investigated. The influence of age on the development of deformities was examined separately as well as in conjunction with the determined difference in lengths. In 203 feet or 63.7%, a shorter MT bone was measured, while in 80 feet or 25.1% the first MT bone was longer than second ones and only in 36 feet or 11.3% there is no difference in the length of the 1st and 2ndMT bones distal to the Maestro line. A statistically significant correlation was found between the difference between the measured lengths of 1st and 2nd MT bones and IMA, while this correlation with HVA was not statistically significant. There is no statistically significant correlation or the effect of the difference in measured lengths (R) on the severity of hallux valgus deformity classified into three groups. A statistically significant correlation and impact of the age on the intensity of the deformity are established. A shorter 1st MT bone in correlation to the 2nd MT bone is accompanied by an increase in IMA and this correlation and impact are statistically significant. It was not established that there was a statistically significant influence of the length of the first and second metatarsal bone measured distal from Maestro line upon the values of HVA and severity of HV deformity. Age significantly contributes to the severity of the deformity.

The pathogenesis of hallux valgus is not clearly understood. However, genetics research about hallux valgus is rare. Therefore, the present study aimed to explore the pathogeny of hallux valgus from the perspective of genetics. Human samples were collected from normal bone tissue and hallux valgus region bone tissue. The bone samples were studied using real time-PCR, western blot and immunohistochemical. Lentivirus-mediated miR-182 transfected osteoblasts and tested the expression of FGF9 mRNA with real time-PCR. To test alkaline phosphatase activity, number of calcium nodules and proliferation of osteoblast with enzymatic activity analysis, calcium nodules stained and MTT assay. We found that (1) FGF9 expressed in hallux valgus region bone tissue was significantly higher than normal bone tissue. (2) miR-182 expression levels in hallux valgus region bone tissue were notably lower than those of normal bone tissue. (3) miR-182 could negatively regulate the expression of FGF9 in osteoblasts. (4) FGF9 may enhance osteoblasts proliferation. We have demonstrated that miR-182 promotes the formation of bone by targeting FGF9, implicating an essential role of miR-182 in the etiology of hallux valgus. Moreover, miR-182 might potentially be a therapeutic target for hallux valgus treatment., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Background: Mechanical stress can induce multiple functional changes in vascular endothelial cells, including proliferation, differentiation, and migration. Furthermore, human fibroblasts are susceptible to external mechanical stress. In this work, we investigated whether mechanical stress can induce exosome secretion from fibroblasts to modulate angiogenesis., Methods: A CCK-8 cell proliferation assay was used to determine mechanical parameters. Then, exosomes from fibroblasts were isolated and characterized with regard to concentration and markers. We subsequently explored the effect of exosomes on proliferation, migration, and angiogenesis. Additionally, high-throughput sequencing was used to screen differentially expressed miRNAs in the mechanical stress-induced exosomes., Results: A static stretching of 15% significantly enhanced the cell viability of the fibroblasts (p < 0.05) and significantly induced the secretion of exosomes from the fibroblasts, which had a stronger internalization ability. Further experiments demonstrated that the presence of static stretching-induced exosomes significantly increased cell proliferation, migration, and angiogenesis by regulating the Erk1/2 signaling pathway. Additionally, 12 up-regulated and 12 down-regulated candidate miRNAs were discriminated in the static stretching-induced exosomes., Conclusion: Our findings conclusively demonstrate that static stretching-derived exosomes from fibroblasts promote angiogenesis through differentially expressed miRNAs, providing novel insights into the molecular mechanism by which mechanical stress influences angiogenesis., Competing Interests: Declaration of competing interest There is no conflict of interest in this manuscript., (Copyright © 2020. Published by Elsevier Inc.)

Background: Little attention has been paid to foot structural factors and ground reaction force in hallux valgus. Investigating the structural factors in detail and determining their biomechanical effects can help to better manage hallux valgus., Methods: In this case-control study, 120 females, 90 hallux valgus and 30 healthy, were recruited. Hallux valgus grades (mild, moderate, severe), first metatarsal mobility, foot pronation, hallux rotation, and pain were assessed by clinical tests. Ground reaction forces were measured in barefoot and shod conditions for both feet and analyzed using mixed within-between MANOVA. The association between structural factors and pain with force was analyzed using Spearman correlation coefficient., Results: The frequency of foot structural factors and pain severity were reported in hallux valgus grades. A significant difference was seen in the force values between groups (P<0.001). Bonferroni post hoc test indicated that the mean of the first peak for the severe group was significantly higher than the mild group (P=0.013) and the mean of second peak for the moderate group was higher than that of the healthy group (P=0.009). The force values were affected by wearing shoe (P<0.001) but not by foot side (P=0.086). There was a medium, positive correlation between the hallux rotation and force in the moderate group (r=0.39, P=0.03) and also between the pronation and force in the severe group (r=0.36, P=0.04)., Conclusion: Foot structural factors, pain, and force were different in each hallux valgus grads. Similar force in both feet, and increased force by wearing shoe were seen. The relationship between the pronation and hallux rotation with force revealed the importance of these factors from the biomechanical viewpoint., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The intrinsic foot muscles are vital for maintaining normal foot function. This study was conducted to systematically review the literature on the functional capacity and morphological characteristics of the intrinsic foot muscles in subjects with Hallux Valgus (HV) deformity., Methods: A search was carried out in all available electronic databases, including Pub Med, Scopus, Embase and Web of Science, for identifying any relevant studies published from 1990 to October 2018., Results: Three studies had investigated intrinsic foot muscle size using ultrasound imaging; two had reported electromyography parameters and four had measured the muscle force capacity. The results of the present review suggested that the functional capacity and morphological characteristics of intrinsic foot muscles are different in subjects with HV compared to those without this deformity., Conclusion: This review found scientific evidence on muscle performance impairment in the abductor hallucis and flexor hallucis brevis in subjects with HV deformity., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Hand hyperphalangism leading to shortened index fingers with ulnar deviation, hallux valgus, mild facial dysmorphism and respiratory compromise requiring assisted ventilation are the key features of Chitayat syndrome. This condition results from the recurrent heterozygous missense variant NM&#95;006494.2:c.266A>G; p.(Tyr89Cys) in ERF on chromosome 19q13.2, encoding the ETS2 repressor factor (ERF) protein. The pathomechanism of Chitayat syndrome is unknown. To date, seven individuals with Chitayat syndrome and the recurrent pathogenic ERF variant have been reported in the literature. Here, we describe six additional individuals, among them only one presenting with a history of assisted ventilation, and the remaining presenting with variable pulmonary phenotypes, including one individual without any obvious pulmonary manifestations. Our findings widen the phenotype spectrum caused by the recurrent pathogenic variant in ERF, underline Chitayat syndrome as a cause of isolated skeletal malformations and therefore contribute to the improvement of diagnostic strategies in individuals with hand hyperphalangism., (© 2020 The Authors. American Journal of Medical Genetics Part A published by Wiley Periodicals LLC.)

In the last decade, minimally invasive or percutaneous surgery has evolved rapidly through the development of novel techniques. Treatment of hallux valgus deformity is one of the indications for percutaneous surgery, both for bony and soft tissue correction. The release of the structures on the lateral part of the first metatarsophalangeal joint (lateral release) is one of the best indications for percutaneous surgery in the forefoot. In this article, a detailed description of the anatomy of the metatarsophalangeal joint is provided, along with the indications and tips to perform a safe percutaneous lateral release., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Hallux valgus is one of the most common and painful deformities, occurring due to adductor/abductor imbalance of the big toe. Many structural foot disorders have been suggested as the cause of hallux valgus deformity. In this study, we aimed to show the relationship between hallux valgus and pes planus in adult males. A total of 213 patients were included in this study between May 2013 and May 2014. 54 patients with hallux valgus angle (HVA) >20° and intermetatarsal angle (IMA) >9° were evaluated in the case group and 159 patients randomly selected from those admitted for a recent foot ankle trauma with the HVA <15° and IMA <9° were the control group. All patients' HVA, IMA, and talonavicular coverage angle on anteroposterior (AP) foot radiographs and talar-first metatarsal angle (Meary's angle), calcaneal pitch angle, and lateral talocalcaneal angle on lateral foot radiographs were measured. There was no significant difference in talonavicular and Meary's angles between the groups. Calcaneal pitch angle was significantly lower in the case group, whereas talonavicular angle was higher in the control group. Calcaneal pitch angle and lateral talocalcaneal angle showed significant negative correlation with HVA and IMA. There are few reports in the literature about the relationship between pes planus and hallux valgus. Our results strongly showed a high correlation between pes planus and hallux valgus. Further larger patient cohort studies are needed to support our results., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

To date, we could find no study concerning the relationship between mechanoreceptors in the joint capsule of the first metatarsophalangeal joint and hallux valgus deformity. We aimed to investigate the presence of mechanoreceptors in samples obtained from the first metatarsophalangeal joint capsules of patients with hallux valgus deformity to improve our understanding of the clinical and histopathological features of the disease. Samples were taken from the first metatarsophalangeal joint capsules of 13 fresh-frozen cadavers with normal anatomy (controls) and 29 patients undergoing surgery for hallux valgus (cases). For light microscopy, excised specimens were fixed in 10% formaldehyde and processed for routine histopathological investigation. All samples were dehydrated in a series of ethanol, cleared in xylene, and embedded in paraffin. Orientation of collagen fibers was determined on Masson's trichrome-stained sections, and mechanoreceptors were evaluated on S-100-immunostained sections. In the sections stained with Masson's trichrome, the orientation of collagen fibers was regular in the control group. However, coarse and disoriented collagen bundles were observed in the hallux valgus cases (P ≤ .05). S-100 immunostaining was positive in the sections of both the cases and controls. Finally, free nerve endings were more abundant in the samples obtained from the capsules of hallux valgus cases than from the control group (P ≤ .05). An increase in the number of free nerve endings within the capsules of the first metatarsophalangeal joints in feet with hallux valgus deformity might have a role in the development of clinically relevant joint pain and instability., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The prevalence of foot pathologies, such as flatfoot deformity and hallux valgus, is higher in women and increases with age. It has been reported that these types of foot disorders may also be linked to excessive mobility of the subtalar joint to the eversion direction during weight bearing. Given that the mobility of the joint is determined by its articular morphology, sex- and age-related variations in the subtalar articular surface morphology are possible. The purpose of this study was to investigate the orientation and the curvature radii of the talar articular facets of the calcaneus in relation to age and sex using three-dimensional computer tomography., Methods: Fifty-six feet without subtalar injuries or disorders were included in this study. The orientations of the talar articular surfaces of the calcaneus were quantified in the sagittal and coronal planes. The curvature radii of the articular surfaces of the calcaneus were also assessed based on the approximations of the sphere surfaces., Results: The talar articular surface was oriented more anteriorly and medially in the females than in the males. The curvature radius of the calcaneal posterior facet in the females exhibited a positive correlation with age, indicative of increased articular surface flattening., Conclusions: The morphological features of the female calcaneus could induce excessive eversion and could lead to a higher prevalence of foot disorders, including flatfoot and hallux valgus, in elderly females. This study contributes to an understanding of the sexual dimorphism of the articular surfaces of the calcaneus and provides insight into the mechanisms that underline various foot disorders., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Introduction: The loss of correct relationships between the sesamoid and the first metatarsal is one of the architectural consequences of the hallux valgus (HV). The reduction of this dislocation by lateral soft tissue release (LSTR) is one of the objectives of surgery., Aim: To study the relationship between postoperative position of sesamoid and clinical outcome at one-year postoperative follow-up., Methods: It's a retrospective study including patients operated for evolved HV performed in la Rabta orthopedic department in Tunis. These patients had a Scarf osteotomy associated with at least one Weil osteotomy. The functional evaluation was based on the AOFAS score (American-orthopedic-foot-and-ankle-society). We classified the sesamoid position according to 3 scores: Hardy & Clapham , RCAOFAS and the Agrawal. We compared each score of the sesamoid position to the clinical outcome., Results: We collected 46 cases of HV in 45 patients. The mean AOFAS score increased from 60,9 to 85,5/100 postoperatively. Our patients were divided into 2 groups: group A whose result was excellent and group B whose result was good, fair and poor. The analytical study of this work concluded that there was no relationship between the postoperative sesamoid position and the clinical outcome, regardless of the radiological classification used (p=0,361, p=0,222, p=0,260)., Conclusion: Sesamoids that remain in postoperative dislocation are not necessarily predictive of a poor clinical outcome at one year of the surgical cure.

Background: We hypothesized that the cause of second-ray pathology with hallux valgus is excessive relative length of the second metatarsal and performed Weil osteotomy to shorten it, with correction of hallux valgus. The purpose of this study is to evaluate the outcome of second-ray pathology after distal chevron osteotomy (DCO) with Weil osteotomy to correct metatarsal parabola. Methods: We performed concomitant Weil osteotomy of the second metatarsal with DCO of the first metatarsal as part of hallux valgus with second-ray pathology correction surgery in 45 feet (40 patients). Second-ray pathologies were claw toe deformity, painful plantar callosity, second metatarsophalangeal joint (MTPJ) dislocation, and osteoarthritis (OA) of the second MTPJ. We measured projection of the second metatarsal (PSM), metatarsal protrusion index (MPI), and metatarsal protrusion distance (MPD). The second-ray surgery outcome was assessed by patient satisfaction. Results: Patient satisfaction was good in claw toe deformity and OA (satisfaction rate: 60% [23 patients] and 71% [7 patients], respectively) and fair in painful plantar callosity and second MTP joint dislocation (satisfaction rate: 44% [9 patients] and 33% [6 patients], respectively). Total patient satisfaction rate was higher when the PSM, MPI, and MPD ranged between 7 and 12 mm, -5 and 0 mm, and 0 and 4 mm, respectively. Conclusions: We concluded that simultaneous performance of hallux valgus correction and Weil osteotomy in patients with second-ray pathologies associated with hallux valgus was safe as well as effective. Correcting the metatarsal parabola within the appropriate range after surgery is associated with second-ray pathology outcome. Levels of Evidence : Therapeutic studies, Level VI: Case series.

Background: The aim of the present study was to investigate the morphologic features and mechanical properties of plantar fascia (PF), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and abductor hallucis (AbH) muscles in individuals with halluks valgus (HV) and to compare the results with individuals without HV., Methods: A total of 30 participants (27 female, 3 male) between the ages of 19-58 years with HV deformity and 30 individuals without HV (27 female, 3 male) between the ages of 20-58 years were included in the study. AbH, PF, FHB, and FDB thickness, cross-sectional area and stiffness were measured with an ultrasonography device. For stiffness measurements, Shear Wave Velocity (SWV) of the assessed soft tissues was calculated using a customized software program., Results: Mean and standard deviation of SWV of PF, AbH, FHB, FDB, and thickness of PF, AbH, FHB, FDB, and cross-sectional area of AbH, FHB, FDB in individuals with HV were 7.6 ± 1.0 m/sec, 2.8 ± 0.3 m/sec, 2.6 ± 0.4 m/sec, and 3.4 ± 0.2 m/sec, 3.3 ± 0.5 mm, 11.4 ± 2.2 mm, 16.5 ± 1.9 mm, 8.9 ± 1.8 mm, 2.4 ± 0.5 cm 2 , 2.7 ± 0.5 cm 2 , 1.9 ± 0.6 cm 2 , respectively. Mean and standard deviation of SWV of PF, AbH, FHB, FDB and thickness of PF, AbH, FHB, FDB, and cross-sectional area of AbH, FHB, FDB in controls groups were 7.6 ± 1.2 m/sec, 2.3 ± 0.3 m/sec, 2.3 ± 0.4 m/sec, and 3.4 ± 0.4 m/sec, 3.3 ± 0.5 mm, 9.7 ± 2.1 mm, 14.5 ± 1.4 mm, 9.7 ± 1.2 mm, 2.1 ± 0.3 cm 2 , 2.3 ± 0.4 cm 2 , 2.1 ± 0.4 cm 2 , respectively. Individuals with HV had lower AbH and FHB thickness, cross-sectional area and SWV, however FDB thickness and cross-sectional area were higher in individuals with HV compared to that of individuals without HV (p < 0.05). PF thickness (p = 0.273), SWV of PF (p = 0.979) and FDB (p = 0.295) were similar in both groups., Conclusion: Our results suggest that individuals with HV had lower AbH and FHB stiffness, however PF and FDB stiffness were similar in HV and control group. In addition, AbH and FHB thickness and cross-sectional area were lower in individuals with HV; however, FDB thickness and cross-sectional area were higher in individuals with HV compared to that of individuals without HV., Level of Evidence: Level III, Diagnostic Study., (Copyright © 2019 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.)

The choice of treatment of hallux valgus deformity is influenced by angles measured on radiographs. Angles of interest are the hallux valgus angle (HVA), 1,2-intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA), as well as the presence of first metatarsophalangeal joint (MTPJ) subluxation. Guidelines for measuring those angles have been distributed by American Orthopaedic Foot and Ankle Society (AOFAS), although the influence of weightbearing on these angles and its clinical relevance is not clear. We conducted a study to determine the influence of weightbearing and the inter- and intraobserver agreement in the measurement. A total of 104 patients were enrolled in this study. Both weightbearing and non-weightbearing radiographs were obtained. In 2 rounds, 2 orthopedic surgeons and 2 musculoskeletal radiologists measured the angles in blinded digital radiographs according to AOFAS guidelines. Agreement on measurement of HVA, IMA, and DMAA in both weightbearing and non-weightbearing radiographs, as well as the presence of MTPJ subluxation, was calculated using the linear-weighted kappa coefficient and the intraclass correlation coefficient (ICC). Examiner agreement strength was defined according to the guidelines of Landis and Koch. HVA decreases significantly with weightbearing, whereas IMA significantly increases. The change in magnitude was 1° to 2° on average. No significant influence on DMAA could be noted. Interobserver agreement was excellent in both weightbearing and non-weightbearing radiographs for HVA (ICC 0.99 and ICC 0.99, respectively), IMA (ICC 0.98 and ICC 0.86, respectively), and DMAA (ICC 0.95 and ICC 0.97, respectively). The agreement on presence of subluxation was moderate to good (Fleiss kappa 0.50 to 0.63). Weightbearing alters forefoot geometry significantly. Adhering to AOFAS guidelines yields excellent interobserver agreement on HVA, IMA, and DMAA. First MTPJ subluxation presence is not an alternative for DMAA. The magnitude of change in IMA and HVA is small and therefore not clinically important. Both weightbearing and non-weightbearing radiographs can be used for determination of the correct treatment of hallux valgus deformity., (Copyright © 2018 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Peripheral vascular disease is the rarest vascular complication in systemic lupus erythematosus. Some theories propose that immune complexes may promote inflammation in the vessel, and disrupt it in a manner that may cause ischemia., Case Presentation: A 14-year-old Asian girl presented with intermittent claudication as the chief complaint followed by discoloration of her left big toe for 2 weeks prior to admission. Her medical history showed that 1 month prior to admission she had photosensitivity, rash, and arthralgia, with positive antinuclear antibody test, positive anti-double-stranded DNA test, positive anti-ribosomal protein P, and complement C4 (7.4 mg/dL); she was diagnosed as having systemic lupus erythematosus and started therapy. A local examination of her left toe showed black discoloration, low pulsation, localized tenderness, and decreased sensation. Laboratory results showed C-reactive protein of 1.16 mg/dL and D-dimer of 2.28 uG/mL. A computed tomography angiogram showed near total occlusion of her popliteal artery; critical limb ischemia was confirmed. Peripheral arteriography was performed with invasive strategy. After the procedure, the flow was improved to distal, but there was inflammation in the vessel, so we decided to stop the procedure because of the risk of dissection. Our patient was given atorvastatin and warfarin, and we maximized her systemic lupus erythematosus therapy with prednisone. There were two follow-ups. The first follow-up was 1 week after the procedure. Our patient attended her first follow-up at our out-patient department with no symptoms and improvement in her toe's discoloration; warfarin was stopped, and clopidogrel and cilostazol were added for thrombus prevention therapy, she was then scheduled for debridement. The second follow-up was done 2 months after the first follow-up and discoloration was improved. The third follow-up, 5 months after the second follow-up, showed improvement., Conclusion: Critical limb ischemia is a rare complication of systemic lupus erythematosus that requires immediate treatment. Due to our limited resources, we improvised a strategy to achieve the best possible outcome in our patient by using a combination of invasive treatment and medication.

Aim: Radiographs (X-rays) are used for the preoperative assessment of hallux valgus (HV). Our purpose was to determine how well quantitative measurements of HV on radiographs and MRI correlate with the qualitative soft tissue and internal derangement findings on MRI., Materials and Methods: After IRB approval, 56 consecutive patients with MRI and radiographs of the foot were retrospectively reviewed. Two trained readers independently evaluated radiographs, measuring hallux valgus angle (HVA) and intermetatarsal angle (IMA). Two separate readers assessed qualitative MRI data by evaluating 21 different soft tissue and bony features. Statistical analysis included inter-reader reliability (IRR) and correlation of quantitative and qualitative findings., Results: Excellent IRR (ICC = 0.89-0.96) was observed for radiograph and MRI measurements of the hallux valgus severity. For qualitative assessments on MRI, IRR was good to excellent for all features (ICC = 0.63-0.9). No significant difference was found for HVA or IMA between normal and abnormal qualitative MRI features. No statistically significant correlation between the severity of hallux valgus and injury to hallux joints and supporting structures was found., Conclusion: Hallux valgus measurements are reliable on x-rays and MRI and qualitative findings of 1st MTP joint show good to excellent inter-reader agreement on MRI. No statistically significant correlations exist between the severity of hallux valgus and qualitative MRI findings., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Radiographs of the feet are the reference standard for measuring the hallux valgus angle. However, the availability and use of radiographs are constrained due to cost and radiation exposure. Less invasive, nonradiographic assessments have been proposed, although measurement using self-photography has not been reported., Objectives: To determine (1) reliability of photographic hallux valgus angle (pHVA) measurement using the same photographs of the feet, (2) reliability of repeated self-photography trials, and (3) measurement error when the radiographic hallux valgus angle (rHVA) is estimated using the pHVA., Methods: In this reliability study, participants took photographs of their own feet using a digital camera. The intrarater and interrater reliability of pHVA measurements were then assessed using the intraclass correlation coefficient (ICC) and 95% minimum detectable change (MDC). The participants took photographs twice, and the reliability of repeated self-photography trials was examined. Participants also received radiographs of their feet, from which the rHVA was measured. The measurement error was assessed using the mean difference and 95% limits of agreement., Results: The intrarater and interrater ICC of pHVA measurement was 0.99, with MDCs less than 2°. The ICC of pHVA measurement for repeated self-photography was 0.96, and the MDC was 6.9°. The pHVA was systematically lower than the rHVA, by 5.3°., Conclusion: Measurement of the pHVA using self-photography was reproducible, although pHVA measurement underestimated the rHVA. The pHVA can be a useful nonradiographic method to quantify hallux valgus deformity. J Orthop Sports Phys Ther 2019;49(2):80-86. Epub 12 Sep 2018. doi: 10.2519/jospt.2019.8280.

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: It is still unknown whether the excessive length of the first ray is a risk factor for hallux valgus recurrence. The purpose of this study is to clarify the relationship between the excessive length of the first ray and the recurrence of hallux valgus., Methods: Between 2008 and 2011, a total of 186 feet (left 105, right 81) who underwent chevron osteotomy combined with distal soft tissue procedure in our foot and ankle center were retrospectively reviewed. A postoperative hallux valgus angle(HVA) ≥20° was defined as recurrence. Patients were divided into two groups: recurrence and non-recurrence group. Weight-bearing radiographs were evaluated preoperatively and at the time of last follow-up for both groups. Radiographic parameters including the length of the great toe(P1), the length of the second toe(P2), the length distance between the first and second metatarsal(D), the hallux valgus angle(HVA) were obtained. The excessive length of the first ray(EL) was calculated using the equation of EL = P1-P2-D., Results: A total of 45 patients (24.2%) had hallux valgus recurrence at the time of last follow-up with a mean follow-up of 83.7 ±12.1 months (range, 66-110). The mean postoperative P1 was 5.06±0.39cm for recurrence group and 4.84±0.34cm for no recurrence group(p<0.001). The mean post operative EL was 5.71±5.01mm for recurrence group and 1.61±4.09mm for no recurrence group(p<0.001). The predictive cutoff value of postoperative P1 and postoperative EL for hallux valgus recurrence was 4.9cm [odds ratio (OR) = 8.67, p = 0.03] and 0.4cm (OR = 6.79, p = 0.001) respectively., Conclusions: Significant relationships between postoperative P1, postoperative EL and hallux valgus recurrence were identified according to our radiographic results. A postoperative P1>4.9cm and postoperative EL>0.4cm can be risk factors for hallux valgus recurrence. The appreciation of the excessive length of the first ray prior to surgery may help to improve the surgical outcome., Competing Interests: The authors have declared that no competing interests exist.

The role of lateral release is widely accepted and regarded as a key step in the management of hallux valgus. There remains however debate in the literature in regards to which structures should be divided and the method of approach. As such, a technique of lateral release using a curved blade placed inferior to the metatarsal head to divide the lateral metatarsosesamoid suspensory ligament and incise the lateral joint capsule has been developed. This technique was performed on fourteen fresh frozen cadaveric specimens which were then dissected. In all cases the lateral metatarsosesamoid suspensory ligament was divided and the lateral capsule incised to the joint line. One case of iatrogenic injury to the oblique head of adductor hallucis tendon was noted. No cases of neurovascular injury were noted. The authors conclude that this method of lateral release to be safe and reproducible in a cadaveric model in achieving lateral release for the management of hallux valgus., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: It has been suggested that atrophied or weak toe flexor muscles are associated with the formation of toe deformities, but there is little evidence to support this theory. This study aimed to determine whether the size of the toe flexor muscles differed in older adults with and without toe deformities., Methods: Forty-four older adults (>60 years) were recruited for the study. Each participant had their feet assessed for the presence of hallux valgus or lesser toe deformities. Intrinsic and extrinsic toe flexor muscles were imaged with an ultrasound system using a standardized protocol. Assessor-blinded measurements of muscle thickness and cross-sectional area were taken using Image J software., Results: Participants with lesser toe deformities (n = 20) were found to have significantly smaller quadratus plantae (P = 0.003), flexor digitorum brevis (P = 0.013), abductor hallucis (P = 0.004), and flexor hallucis brevis (P = 0.005) muscles than the participants without any toe deformities (n = 19). Female participants with hallux valgus (n = 10) were found to have significantly smaller abductor hallucis (P = 0.048) and flexor hallucis brevis (P = 0.013) muscles than the female participants without any toe deformities (n = 10; P < 0.05)., Conclusion: This is the first study to use ultrasound to investigate the size of the toe flexor muscles in older adults with hallux valgus and lesser toe deformities compared to otherwise healthy older adults. The sizes of the abductor hallucis and flexor hallucis brevis muscles were decreased in participants with hallux valgus, whereas the quadratus plantae, flexor digitorum brevis, abductor hallucis, and flexor hallucis brevis muscles were smaller in the participants with lesser toe deformities., (© 2017, American College of Rheumatology.)

Background: Arthrodesis of the first metatarsophalangeal (MTP) joint has been recommended for severe hallux valgus deformity in patients with rheumatoid arthritis (RA). However, with the progress of medical treatment of RA, joint preservation surgery has recently been performed. The aim of this study was to investigate the clinical and radiographic outcomes of modified Scarf osteotomy with medial capsule interposition for RA cases including severe destruction of the first MTP joint and to evaluate risk factors for recurrence., Methods: A retrospective observational study of 76 cases (60 patients) followed for a mean of 35.3 months (range, 24 to 56 months) after a modified Scarf osteotomy was performed. Scores on the Japanese Society for Surgery of the Foot (JSSF) RA foot and ankle scale, the JSSF hallux scale, and a self-administered foot evaluation questionnaire (SAFE-Q) were determined along with preoperative and postoperative radiographic parameters., Results: There was a significant improvement, from preoperatively to final follow-up, in the mean JSSF RA foot and ankle score (from 52.2 to 76.9 points) and the mean JSSF hallux score (from 38.2 to 74.5 points). There was a recurrence (hallux valgus angle [HVA] of >20°) in 12 feet (16%). The preoperative DAS28-CRP score (disease activity score [based on 28 joints in the body]-C-reactive protein score) and intermetatarsal angles between the first and second metatarsals (M1M2A) and between the first and fifth metatarsals (M1M5A) were significantly greater in the recurrence group, as were the HVA, M1M2A, M1M5A, and Hardy grade at 3 months after surgery. There was a significant negative correlation between the preoperative DAS28-CRP score and the JSSF RA foot and ankle score at final follow-up (β = -0.39, p = 0.02) and a significant positive correlation between the preoperative DAS28-CRP score and the HVA at final follow-up (β = 0.44, p = 0.001)., Conclusions: The modified Scarf osteotomy with medial capsule interposition for hallux valgus deformity improved clinical and radiographic outcomes in RA cases with severe destruction of the first MTP joint. Increased preoperative M1M2A and M1M5A; incomplete reduction of the sesamoid bone; and the HVA, M1M2A, and M1M5A at 3 months after surgery should be evaluated as they are associated with recurrence of the deformity. The preoperative DAS28-CRP score was associated with the clinical and radiographic outcomes after surgery., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Incomplete sesamoid reduction is a potential risk factor for the recurrence of hallux valgus. The purpose of this study was to radiologically investigate changes in sesamoid position after chevron osteotomy and the open lateral soft tissue procedure., Methods: Sixty-eight feet that underwent operative correction for hallux valgus deformity were reviewed consecutively. The hallux valgus angle (HVA), first to second intermetatarsal angle (IMA), tibial sesamoid position (TSP), distance of the fibular sesamoid (DFS), and translation of the metatarsal head (TMH) were evaluated preoperatively and at final follow-up., Results: While most parameters were significantly decreased after surgery, no significant change in DFS (correction - 1.45 mm, p = 0.08) was noted. The difference between preoperative and postoperative TSP values (ΔTSP) has a moderately positive correlation with difference in TMH values (ΔTMH) (Rho 0.475, p = .000). Other parameters were similarly correlated., Conclusions: First, metatarsal bone realignment reduced the sesamoid, but its position, relative to the second metatarsal axis (DFS), was unchanged. The sesamoid is reduced by the lateral translation of the first metatarsal but not by medial sesamoid migration.

Objective: Hallux valgus (HV) and gout are common pathologies of the first metatarsophalangeal joint (MTP1) leading to pain and deformation. In this study, we aimed to determine the correlation between tophus size and characteristics of HV in gouty patients., Methods: In this case-control study, we included patients with gout (the presence of monosodium urate crystals in synovial fluid) and control patients with spondyloarthritis, without crystal disease disorders. Radiographic assessment and ultrasound (US) assessment were performed by two blinded operators. US features of gout (double contour [DC] sign and/or tophus) were collected. HV was defined by hallux abductus (HA) angle ≥20° and/or intermetatarsal angle (IM) ≥10°. Correlation between US findings and HV angles was estimated by Spearman correlation coefficient., Results: We included 56 gouty patients (87.5% males, mean age of 63.9 ± 12.2 years) and 41 control patients (90% males, mean age of 59.0 ± 12.8 years). HV was more frequent in patients with gout than controls (62% vs 37%, P = .0007). Regardless of HV status, correlations were found between the size of US tophi and IM (r = .3381, P = .003) and HA angles (r = .2344, P = .043)., Conclusions: Our results confirm a high prevalence of HV in gouty patients. We also observed a correlation between the size of the US tophus and the angles defining HV, which suggests a link between urate deposition load and HV. Early urate-lowering therapy for gout could limit the occurrence of HV., (© 2017 Stichting European Society for Clinical Investigation Journal Foundation.)

Background: Hallux valgus (HV) is a metatarsophalangeal joint deformity that can be classified as mild, moderate, or severe. Treatment is recommended for pain or severe deformities. Recently, operative percutaneous correction techniques have been performed to treat mild deformities., Materials and Methods: A retrospective, single-surgeon, single-center study of 49 HV percutaneous correction using a modified Reverdin-Isham osteotomy was conducted. HV, intermetatarsal angle (IM), proximal articular set angles (PASA), and American foot and ankle functional score (AOFAS) were assessed pre- and postoperatively by a single operator. Statistical analysis was performed using a Wilcoxon rank test. Medium time of follow-up was 34 months., Results: HV mean value decreased from a preoperative medium value of 35.18° to 14.3° postoperatively, IM mean value decreased from 15.5° to 8.7°, and PASA from 7.2° to 5.25°(p<0.001 for HV and IM, p<0.125 for PASA reduction). Postoperatively AOFAS medium score was 95., Discussion: In our series, functional and clinical results of percutaneous osteotomy without osteosynthesis were comparable to other percutaneous and conventional techniques, both in clinical and radiological findings. High level of patient's satisfaction and improvement on pain-related symptoms are even better referred to traditional techniques. Modified Reverdin-Isham osteotomy technique differs from the others for translation of metatarsal head after osteotomy; we do not correct PASA angles, but we can obtain more HV and IM correction and include some severe HV. Our results suggest that translation of metatarsal head could give higher HV angle correction.

Background: Second metatarsophalangeal (MTP) joint dislocation is associated with hallux valgus, and the treatment of complete dislocation can be difficult. The purpose of this study was to radiographically clarify the characteristic foot shape in the presence of second MTP joint dislocation., Methods: Weight-bearing foot radiographs of the 268 patients (358 feet) with hallux valgus were examined. They were divided into 2 groups: those with second MTP joint dislocation (study group = 179 feet) and those without dislocation (control group = 179 feet). Parameters measured included the hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), second MTP joint angle, hallux interphalangeal angle (IPA), second metatarsal protrusion distance (MPD), metatarsus adductus angle (MAA), and the second metatarsal declination angle (2MDA). Furthermore, the dislocation group was divided into 3 subgroups according to second toe deviation direction: group M (medial type), group N (neutral type), and group L (lateral type)., Results: The IPA and the 2MDA were significantly greater in the study group than in the control group. By multiple comparison analysis, the IMA was greatest in group M and smallest in group L. The IPA was smaller and 2MDA greater in group N than in group L. The HVA and MAA in group L were greatest, and MPD in group L was smallest., Conclusions: The patients with second MTP joint dislocation associated with hallux valgus had greater hallux interphalangeal joint varus and a second metatarsal more inclined than with hallux valgus alone. The second toe deviated in a different direction according to the foot shape., Level of Evidence: Level III, retrospective comparative study.

Background: First metatarsal protrusion distance (MPD) has been commonly studied as a characteristic of hallux valgus deformity. To date, the majority of investigations have used radiographic methods, with most reporting first metatarsal (ray) protrusion to be associated with deformity. As an alternative, this study used a three-dimensional (3-D) image acquisition and data analysis method to quantify MPD., Methods: Magnetic resonance images were acquired in weightbearing on 29 women (19 with hallux valgus; 10 controls). After the 3-D images were reconstructed into virtual bone models, two examiners measured MPD in relation to the navicular. In addition to a reliability analysis, a t test assessed for group differences in demographics, foot posture (hallux valgus, intermetatarsal angles), and MPD., Results: Group demographics were not different, while measures of hallux valgus and intermetatarsal angles were different ( P < 0.01) between groups. The measurement of MPD was highly reliable (ICC [Formula: see text] 0.99; SEM [Formula: see text] 0.78 mm). Metatarsal protrusion averaged approximately -2.0 mm in both groups. There was no statistical group difference ( P = 0.89) in MPD., Conclusions: The reconstructed image datasets captured the 3-D spatial relationship of the anatomy. Measurements of MPD were reliable. The first ray measured 2 mm shorter than the second ray in both the hallux valgus and control groups. Though unexpected, this result may prompt future study of the pathokinematics associated with hallux valgus that include the quantification of metatarsal protrusion with 3-D methods, instead of relying solely on single-plane radiograph reports.

Background: Percutaneous surgery to correct deformities of the forefoot presents the advantages of using a minimal incision, which involves less soft tissue damage and less risk of wound complications. For severe deformities, percutaneous techniques have not been proven as effective. We propose a technique for the treatment of severe hallux valgus., Methods: In a sample of 52 feet operated on 48 patients, we performed a double percutaneous osteotomy (closure proximal osteotomy and a distal Akin) or triple when a Reverdin-Isham osteotomy was added. We measured preoperatively the American Orthopaedic Foot & Ankle Society (AOFAS) score at the 1-year and 2-year follow-up, as well as the values of hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular ankle (DMAA), and shortening and elevation of the first metatarsal. The presence of metatarsalgia was recorded before and after the surgery., Results: HVA, IMA, and DMAA improved from 39.3 ± 7.1, 17.0 ± 2.0, and 16 ± 8.7 to 11.2 ± 6.2, 8.4 ± 3.4, and 8.3 ± 6.2, respectively. In 5 cases (10%), there was an elevation of the distal metatarsal bone, but only in 2 cases did a transfer metatarsalgia develop. There were no significant correlations between the amount of shortening and the presence of postoperative metatarsalgia. Scores on the AOFAS scale improved from 47.6 ± 5.6 to 89.7 ± 10.1 points., Conclusion: The results are comparable to those reported with other more established techniques. Transfer metatarsalgia did not correlate with lifting or shortening of the metatarsal. We indicate the percutaneous technique for IMA above 15 degrees and increased DMAA or congruent joints., Level of Evidence: Level IV, retrospective case series.

Background: Operative correction of a symptomatic hallux valgus interphalangeus (HVI) deformity is often achieved with an osteotomy at the proximal end of the proximal phalanx (Akin osteotomy). However, the apex of the typical HVI deformity (center of rotation angle) is at the interphalangeal joint of the hallux. This study was done to evaluate the results of performing a medial closing wedge osteotomy at the distal end of the proximal phalanx., Methods: Thirty-three patients (33 feet) underwent an osteotomy at the distal end of the proximal phalanx for correction of HVI. All of the patients had other forefoot deformities which were corrected at the same time. Eight of these were revision procedures of prior forefoot operations. The length of follow-up was determined by the associated procedures with a minimum follow-up of 4 months., Results: The preoperative hallux valgus interphalangeus angle averaged 16 degrees of valgus (range 7-32 degrees) and was corrected to an average of 2 degrees of valgus (range 5 degrees valgus to 5 degrees varus). All of the patients were satisfied with the postoperative appearance and function of the first toe. Because of simultaneous correction of numerous other forefoot problems, it was not possible to specifically isolate or evaluate the effects and benefits of this osteotomy using outcomes measures. There was one intraoperative complication resulting in a fracture extending into the adjacent IP joint., Conclusions: Correction of an HVI deformity can be achieved with an osteotomy at the distal end of the proximal phalanx. This was a safe technique with few complications and with good results in terms of both correction and patient satisfaction., Level of Evidence: Level IV, retrospective case series.

Background: Hallux valgus is frequently associated with additional forefoot pathologies, including hammertoes and midfoot osteoarthritis (OA). However, the pathogenesis of these concurrent pathologies remains to be elucidated. We sought to determine whether there is a relationship between demographic and radiographic parameters and the incidence of secondary pathologies in the setting of a bunion, with an emphasis on second tarsometatarsal (TMT) OA and hammertoes., Methods: A total of 153 patients (172 feet) who underwent reconstruction for hallux valgus were divided into 3 groups: (1) bunion only (61 patients), (2) bunion with hammertoe without second TMT joint OA (78 patients), and (3) bunion with second TMT joint OA (14 patients). Preoperative age, sex, and body mass index (BMI) as well as hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsus adductus angle (MAA), ratio of second to first metatarsal length, and Meary's angle were recorded. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) tests were used to assess differences in continuous variables. Post hoc tests were conducted with the Bonferroni technique. Associations between discrete variables and the study groups were analyzed using χ 2 tests. Following the univariate analysis, multinomial logistic regression models were built to determine potential risk factors for hammertoe or TMT OA group placement., Results: Patients in the hammertoe and TMT OA groups were significantly older than patients in the bunion only group ( P < .001 for both pairwise comparisons) and had significantly higher BMIs ( P = .024 and P < .001, respectively). Patients in the TMT OA group had a significantly higher mean HVA than patients in the bunion-only group ( P = .004) and a significantly higher mean MAA relative to both other study groups ( P ≤ .001 for both comparisons). IMA, Meary's angle, and the ratio of second to first metatarsal length did not differ significantly between groups. In the multivariate analysis, hammertoe group assignment was predicted only by age and HVA, while midfoot OA group assignment was predicted by age, HVA, BMI, and MAA., Conclusion: Our data show that older age and increased HVA were predictors of both second ray pathologies studied. Higher BMI and MAA were predictive only of TMT joint OA. These data may help identify patients with hallux valgus who are at greater risk for developing secondary pathologies., Level of Evidence: Level III, retrospective comparative series.

Introduction and Aim: Down syndrome (DS) is associated with numerous developmental abnormalities, some of which cause dysfunctions of the posture and the locomotor system. The analysis of selected features of the foot structure in boys with DS versus their peers without developmental disorders is done., Materials and Methods: The podoscopic examination was performed on 30 boys with DS aged 14-15 years. A control group consisted of 30 age- and gender-matched peers without DS., Results: The feet of boys with DS are flatter compared to their healthy peers. The hallux valgus angle is not the most important feature differentiating the shape of the foot in the boys with DS and their healthy peers. In terms of the V toe setting, healthy boys had poorer results., Conclusions: Specialized therapeutic treatment in individuals with DS should involve exercises to increase the muscle strength around the foot joints, enhancing the stabilization in the joints and proprioception. Introducing orthotics and proper footwear is also important. It is also necessary to monitor the state of the foot in order to modify undertaken therapies.

Background: We aimed to compare the postoperative height of the second metatarsal head relative to the first metatarsal head using axial radiographs among 3 different commonly used osteotomy techniques: proximal chevron metatarsal osteotomy (PCMO), scarf osteotomy, and distal chevron metatarsal osteotomy (DCMO)., Methods: We retrospectively reviewed the radiographs and clinical findings of the patients with painful callosities under the second metatarsal head, complicated by hallux valgus, who underwent isolated PCMO, scarf osteotomy, or DCMO from February 2005 to January 2015. Each osteotomy was performed with 20 degrees of plantar ward obliquity. Along with lateral translation and rotation of the distal fragment to correct the deformity, lowering of the first metatarsal head was made by virtue of the oblique metatarsal osteotomy., Results: Significant postoperative change in the second metatarsal height was observed on axial radiographs in all groups; this value was greatest in the PCMO group (vs scarf: P = .013; vs DCMO: P = .008) but did not significantly differ between the scarf and DCMO groups ( P = .785). The power for second metatarsal height correction was significantly greater in the PCMO group (vs scarf: P = .0005; vs DCMO: P = .0005) but did not significantly differ between the scarf and DCMO groups ( P = .832)., Conclusions: Among the 3 osteotomy techniques commonly used to correct hallux valgus deformity, we observed that PCMO yielded the most effective height change of the second metatarsal head., Level of Evidence: Level III, retrospective comparative series.

Background and Aims: No deformity of the forefoot occurs more frequently than hallux valgus (HV), which is considered to be medial deviation of the first metatarsal and lateral deviation and rotation of the hallux, either with or without medial soft tissue enlargement of the metatarsal head. The HV deformity can lead to painful motion of the joint or difficulty in daily joint activity that often requires surgical correction. The aims of this study were to investigate the levels of foot pain and quality of life of patients with HV before and after surgery. Our study is focusing on imagistic investigations in HV, clinical aspects, specific treatment, foot pain levels, quality of life and general health before and after surgery., Patients, Materials and Methods: Our research was conducted in the period 2010-2015. We recruited 56 patients, 35 women and 21 men, age range 20 to 76 years, mean age 44.4 years, with HV (radiographic HV angle 25-40 and >40). We applied Visual Analogue Scales (VAS) for the foot pain and the Euro Quality of Life - five dimensions health questionnaire (EQ-5D)., Results: The results show statistically significant differences concerning the foot pain levels in VAS and also pain/discomfort, mobility and anxiety÷depression in the EQ-5D subscale in HV before and after surgery. The results prove high improvement of the scores of foot pain, discomfort, mobility and anxiety÷depression after surgery. Concerning the participation in usual activities and the self-care, the obtained results were not statistically significant., Conclusions: Our research was a proof that the surgery in HV represents a fruitful pathway of intervention and care and shows a high rate of success, favorable outcomes and improvement in quality of life of the patients.

Hallux valgus (HV) is a highly-prevalent forefoot deformity associated with progressive subluxation and osteoarthritis of the first metatarsophalangeal joint; it is believed to be associated with depression. The aim of the present study was to determine the association of patients with varying degrees of HV involvement to depression using the Beck Depression Inventory (BDI). The sample consisted of 102 participants (mean age: 45.1 ± 1.6), who attended an outpatient centre where self-report data were recorded. The degree of HV deformity was determined in both feet, and the scores on the BDI were compared. A total of 38.24% of the sample had depression, with an average BDI score of 10.55 ± 12.36 points. There was a statistically-significant association between the degree and presence of HV in both feet (P = 0.0001). People with a greater degree of HV deformity in any foot also have a significant increase in depression based on BDI scores, regardless of sex., (© 2016 Australian College of Mental Health Nurses Inc.)

Background: Although the tangential sesamoid view is used to visualize the sesamoid position relative to the first metatarsal head, correctly evaluating patients with severe varus of the first metatarsal is difficult. Computed tomography (CT) can be helpful due to its cross-sectional images in any plane. The purposes of this study were to evaluate the alignment of the tibial sesamoid and investigate the relationship between malalignment and degenerative change in the sesamoid metatarsal joint (SMJ) using simulated weight-bearing CT imaging in patients with hallux valgus., Methods: In total, 269 feet from 142 patients with hallux valgus were included. The mean age was 63.7 years (range, 33-87 years). An anteroposterior weight-bearing radiograph was assessed for sesamoid position into 3 grades: grade 1, the tibial sesamoid was medial to the axis of the first metatarsal; grade 2, the tibial sesamoid was located below the first metatarsal axis; and grade 3, the tibial sesamoid was lateral to the first metatarsal axis. The hallux valgus and intermetatarsal angles (HVA and IMA, respectively) were measured. The lateral shift of the tibial sesamoid relative to the first metatarsal was classified into 3 grades on simulated weight-bearing CT classification: grade 1, tibial sesamoid was entirely medial to the intersesamoid ridge; grade 2, tibial sesamoid was subluxated laterally but located below the intersesamoid ridge; and grade 3, tibial sesamoid was located entirely lateral to the intersesamoid ridge. The differences of HVA and IMA in each grade were confirmed by using 1-way analysis of variance with Bonferroni post hoc corrections. Furthermore, multiple linear regression analysis was used to predict the degenerative change in the SMJ for age, sex, sesamoid position determined by CT or plain radiography, HVA, and IMA. The χ 2 test was used for descriptive statistics to analyze the agreement between radiography or CT classifications of sesamoid position against degenerative change in the SMJ., Results: Based on the radiographic classification of the tibial sesamoid position, 7 feet were classified as grade 1, 72 were grade 2, and 190 were grade 3, respectively. Based on the CT classification, 34 feet were classified as grade 1, 116 were grade 2, and 119 were grade 3. Degenerative change in SMJ progressed according to the sesamoid shift relative to the first metatarsal using either radiography or CT. In radiography, statistically significant differences were found except for the difference in HVA between grades 1 and 2. In addition, statistically significant differences were found between HVA and IMA, along with the grades in CT.In multiple linear regression, degenerative change was correlated with age and sesamoid position in CT and radiographic classifications., Conclusion: Our study showed that lateral shift of the tibial sesamoid increased in association with progression of the hallux valgus deformity. Furthermore, increasing lateral shift of the tibial sesamoid was associated with worsening degenerative change within the SMJ., Level of Evidence: Level III, retrospective comparative study., (© The Author(s) 2016.)

Background: Hallux abducto valgus (HAV) is one of the most common forefoot deformities in adulthood with a variable prevalence but has been reported as high as 48%. The study proposed that HAV development involves a skeletal parameter of the first metatarsal bone and proximal phalanx hallux (PPH) to determine if the length measurements of the metatarsal and PPH can be used to infer adult HAV., Methods: All consecutive patients over 21 years of age with HAV by roentgenographic evaluation were included in a cross-sectional study. The control group included patients without HAV. The study included 160 individuals. We identified and assessed the following radiographic measurements to evaluate HAV: the distances from the medial (LDM), central (LDC), and lateral (LDL) aspects of the base to the corresponding regions of the head of the PPH. The difference between the medial and lateral aspect of PPH was also calculated., Results: The reliability of the variables measured in 40 radiographic films show perfect reliability ranging from 0.941 to 1 with a small error ranging from 0.762 to 0. Also, there were no systematic errors between the two measurements for any variable (P > 0.05). The LDM PPH showed the highest reliability and lowest error., Conclusion: It is more suitable to measure the LDM PPH instead of the LDC PPH when calculating the hallux valgus angle based on our reliability results. When the differences of the medial and lateral PPH are greater, the risk for developing HAV increases., Competing Interests: The authors have declared that no competing interests exist.

Hallux deformities other than hallux valgus, especially those in the sagittal plane, have not yet been elucidated in the feet of patients with rheumatoid arthritis. The objectives of the present study were to classify rheumatoid arthritis hallux deformity in both the horizontal and the sagittal planes and investigate its relationship with flatfoot. Using a cross-sectional study design, we assessed patients with rheumatoid arthritis (527 feet in 274 patients) using radiographs and classified the deformity patterns of the great toes using cluster analysis. Of the 274 patients, the range of motion in the metatarsophalangeal joint was clinically investigated in 44 (16.1%) patients. The great toes could be divided into 5 clusters according to the characteristic configuration as follows: cluster I (normal type), cluster II (hallux valgus type), cluster III (boutonniere type), cluster IV (boutonniere with hallux valgus type), and cluster V (swan-neck type). Radiographic measurements revealed the characteristic deformities of each cluster, including splayed foot for cluster II; flat foot, metatarsal primus elevatus, and plantar displacement of the proximal phalanx for cluster III; and a mixture of these characteristics for cluster IV. Plantar displacement of the proximal phalanx, which was a specific characteristic of the boutonniere deformity, correlated significantly with the decreased dorsiflexion in the metatarsophalangeal joint. Our classification method revealed the relationship of hallux deformity in the sagittal plane to flatfoot and also demonstrated the usefulness of measuring basal phalanx displacement in predicting the range of motion of the metatarsophalangeal joint., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Although the efficacy of Akin proximal phalanx closing wedge osteotomy as a sole procedure for correction of hallux valgus deformity is questionable, when used in combination with other osseous corrective procedures, the procedure has been believed to be efficacious. However, a limited number of comparative studies have confirmed the value of this additional procedure. We identified patients who had undergone osseous hallux valgus correction with first metatarsal osteotomy or first tarsometatarsal joint arthrodesis with (n = 73) and without (n = 81) Akin osteotomy and evaluated their radiographic measurements at 3 points (preoperatively, within 3 months after surgery, and ≥6 months after surgery). We found that those people who had undergone the Akin procedure tended to have a larger hallux abduction angle and a more laterally deviated tibial sesamoid position preoperatively. Although the radiographic correction of the deformity was promising immediately after corrective surgery with the Akin osteotomy, maintenance of the correction was questionable in our cohort. The value of additional Akin osteotomy for correction of hallux valgus deformity is uncertain., (Published by Elsevier Inc.)

The goal of distal chevron osteotomy for hallux valgus is to restore proper first-toe joint alignment by performing lateral translation of the distal first metatarsal fragment (the metatarsal head). We hypothesized that in some patients this procedure might also result in involuntary medial translation of the proximal first metatarsal fragment, which we called proximal intermetatarsal divergence. The aim of the present study was to compare the pre- and postoperative radiographs of patients with hallux valgus to determine whether we could identify proximal intermetatarsal divergence. We retrospectively compared the pre- and postoperative radiographs of 29 feet in 28 patients treated with distal chevron osteotomy. Two different methods were used to measure the intermetatarsal angles: the anatomic intermetatarsal angle (aIMA) and the mechanical intermetatarsal angle (mIMA). The maximum intermetatarsal distance (MID) was also measured. We defined proximal intermetatarsal divergence as a postoperative increase in the aIMA or MID, coupled with a decrease in the mIMA. For data analysis, we divided the patients into low-angle (mild deformity) and high-angle (severe deformity) groups, according to their preoperative mIMA. The mean ± standard deviation patient age was 41 ± 14 years. In the low-angle group, the mean mIMA decreased (from 10.91° to 7.00°), the mean aIMA increased (from 11.80° to 13.55°), and the mean MID increased (from 17.97 mm to 20.60 mm; p = .001, for all). In the high-angle group, the mean mIMA decreased (from 14.30° to 6.90°; p = .001), the mean aIMA decreased (from 14.77° to 13.54°; p = .06), and the mean MID decreased (from 20.74 mm to 20.37 mm; p = .64). The results of our study suggest that proximal intermetatarsal divergence might occur after distal chevron osteotomy for hallux valgus, primarily in patients with a low preoperative mIMA., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy., Patients and Methods: A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up., Results: The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx., Conclusion: Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement., Take Home Message: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion., (©2016 The British Editorial Society of Bone & Joint Surgery.)

Background: Clinicians base treatment decisions on measures of hallux and first ray motion in the management of first metatarsophalangeal joint disorders. Women account for a majority of the patients. This study assessed the reliability of a 2D approach for the measurements of sagittal motion, and compared the result to a Cardan (3D) angle criterion standard and evaluated how hallux valgus (bunion) deformity affected the comparisons., Methods: Twenty-nine women (controls n = 10; bunion n = 19) were examined using a retrospective repeated measures design. Weightbearing magnetic resonance (MR) images were acquired to replicate the position of the foot during the stance phase of gait. The images were reconstructed into virtual bone models using computer processes, whereby measures of hallux and first ray motion were represented by 2D and 3D methods of measurement. An examiner measured 2D motion on the image data sets using a goniometer, and reliability was assessed. The 3D Cardan angle result was derived from a matrix calculation. The 2D-3D comparison of measurements was evaluated with an analysis of variance (ANOVA) model across gait conditions, run separate for groups., Results: The 2D measurement was reliable (ICC ≥ 0.98, SEM ≤ 0.89 degrees). There was no method-by-condition interaction (F ≤ 1.37, P ≥ .25) between variables. No significant difference was detected between the 2D-3D measurements in the control group (F ≤ 1.24, P ≥ .30), but the measurements were statistically different (F ≥ 4.46, P ≤ .049) in the bunion group., Conclusion: This study described a reliable 2D approach for measuring hallux and first ray sagittal motion from weightbearing images. The 2D measurements were comparable to a Cardan angle component motion result in controls, but not in women with bunion., Clinical Relevance: Joint motion measurements may augment clinical decision making. These results suggest that a 2D image-based approach may be adequate to estimate hallux and first ray sagittal motion, although bunion deformity creates out-of-plane motions that may require 3D methods to accurately quantify. Further clinical study is required to assess the differences in clinical outcomes between measurement techniques., (© The Author(s) 2015.)

Background: Minimally invasive distal metatarsal osteotomy (MIDMO) is to be indicated for all patients with angles of IMA <20° and HV <40°, but many authors doubt whether this procedure is capable of correcting all types of hallux valgus deformities. The aims of this study were to perform a geometric analysis of MIDMO indications and to show which preoperative radiological parameters are necessary to achieve sufficient contact between bone fragments and sufficient correction with this operative technique., Methods: A geometric mathematical model in AP and lateral radiographic plane was created based on preoperative measurements of the intermetatarsal angle (IMA), subcapital metatarsal width, medial bunion eminence, and metatarsal length. MIDMO was simulated with possible dorsal/plantar fragment displacement in order to assess postoperative contact between fragments (either 4-5 mm or half of the metatarsal width) and sufficient correction (postoperative IMA 8°)., Results: The metatarsal neck should be at least 8 mm wider from the bunion eminence to achieve the minimally required contact between fragments. For sufficient correction, the metatarsal head translation should be at least 0.018 of the metatarsal length for every degree of IMA reduction. The medial bunion eminence, in comparison with metatarsal width/length size, determines whether MIDMO is a suitable procedure for a given patient., Conclusions: MIDMO cannot sufficiently correct all deformations within the boundaries of IMA angle <20° and HV angle <40°. In patients with large eminences and narrow metatarsals, complications related to insufficient postoperative fragment contact can be expected, while sufficient hallux valgus correction in patients with small eminences and long metatarsals is questionable.

We analyzed the effects of an anesthetic sciatic nerve block on the cutaneomuscular reflex (cMR) and the cutaneous silent period (cSP) of foot muscles, in order to investigate further the type of fibers involved in their generation. In 14 neurologically normal patients with indication for surgical treatment of hallux valgus, we recorded from the extensor digitorum brevis muscle the reflex responses elicited by high-intensity electrical stimulation of the big toe at various time periods, ranging from 0 to 20 min, after ultrasound-guided sciatic nerve popliteal anesthetic block. The first effect was a delay in cSP onset latency, with no changes in end latency. The cMR remained unaltered up to when subjects were no longer able to maintain the contraction. The effects of local anesthetics on peripheral nerves allow for recognition of the different types of fibers contributing to the cMR and the cSP in muscles of the lower limb.