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Purpose: Arthrodesis of the first ray metatarsophalangeal joint (MPJ) is the gold standard in iatrogenic hallux varus (IHV) in the presence of stiffness and osteoarthritis. The purpose of this study is to collect clinical and radiographic results and complications of MPJ arthrodesis in rigid iatrogenic HV., Methods: A retrospective evaluation of rigid iatrogenic HV undergoing arthrodesis with a minimum follow-up (FU) of two years was performed. The clinical parameters assessed were visual analog scale (VAS), the AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale score and the satisfaction scale. The radiological parameters evaluated the first to second metatarsal angle (IMA) and the angle of hallux valgus (HVA). Complications were also analysed., Result: A total of 18 patients (19 procedures) with a mean FU of 5.5 ± 2.5 years were included. The mean VAS improved from 7.3 ± 1.6 to 1.3 ± 1.2 (p < 0.05) at the last FU. Similarly, the AOFAS Hallux Metatarsophalangeal-Interphalangeal scale score significantly improved to 82 ± 9.2 (p < 0.05). Radiological evaluation demonstrated a 1-2 IMA improvement from 4.4 ± 2.2° preoperatively to 8.9 ± 2.4° at 3 months post-operatively. Similarly, there was a significant (p < 0.05) improvement of the HVA from - 22.7 ± 4.1° to 13.1 ± 4.1° at three months post-operative (p < 0.05). No signification loss of correction was noted at the last follow-up (p > 0.05). In one case, a delayed fusion at the arthrodesis site required surgical revision to promote fusion. No patient experienced pain with stress from the first MTP joint arthrodesis site or identified the arthrodesis site as a source of pain. No patient required implant removal. Re-operation and revision rates were 5.3%. The overall complications rate was 15.8%., Conclusions: MPJ fusion effectively corrects Iatrogenic Hallux Varus in cases of rigid and fixed deformities in the medium- to long-term follow-up, with lasting improvements in AOFAS and VAS scores. The procedure is characterised by a non-negligible risk of complications, reoperations and revisions., Level of Evidence: Level IV, case series., (© 2024. The Author(s).)

Acquired hallux varus deformity secondary to postburn contracture is a rare condition. It causes cosmetic disfigurement, pain, and inability to wear a shoe. Soft-tissue procedures and tendon transfers have been described for correction; however, these may require multiple operations and the outcome may be poor. We report a 6-year-old neglected case of hallux varus deformity secondary to burn contracture successfully managed by contracture release with pivotless distraction technique using a biplanar distractor and skin grafting with Z-plasty in the same procedure. The deformity was corrected to a lesser extent and with good functional outcomes. The scar was excised and Z-plasty was performed. The medial joint capsule was released. We used gradual differential distraction with monitoring on sequential radiographs. Pain-free flexion of 45° and extension of 40° were achieved and the patient was able to wear shoes after 4 weeks postoperatively. Hallux varus is a multidimensional deformity. A severe and rigid deformity might not respond well to tendon transfers in a single stage. Our described technique can be used to correct rigid hallux varus deformity with preservation of joint function.

Iatrogenic hallux varus is formed due to an imbalance between the bone, tendon, and ligamentous-articular structures in the first metatarsophalangeal joint (MJ), with the progression of the medial deviation of the big toe. A secondary factor is an imbalance between excessive medial tension and weakness or excessive soft tissue release of lateral capsular-ligamentous structures. The article is devoted to a rare but no less complex postoperative complication of hallux valgus deformity, acquired hallux varus. Based on the literature data on this topic, in the work, the clinical anatomy of the first metatarsophalangeal joint, the pathogenesis of the development of tendon-muscle imbalance in the above joint, and the leading causes of hallux varus are described. Also, the issues of the clinic, X-ray diagnostics, and classification of this type of foot pathology are considered with a description of the appropriate surgical tactics for different types of deformity., Competing Interests: The authors declare that they have no conflict of interest.

Hallux varus is a rare foot deformity due to iatrogenic, post-traumatic, idiopathic, inflammatory, spontaneous, or congenital pathologies. Acquired hallux varus, in particular, iatrogenic type, is the commonest. The primary pathology is the abnormal musculotendinous forces secondary to soft tissue or bony imbalance exerting varus deforming force. Understanding the anatomy of the hallux stabilisers and the pathophysiology of hallux varus is vital in its management. It would be helpful to understand the potential surgical pitfalls leading to iatrogenic hallux varus. This literature review summarises all the published facts about hallux varus, focussing on anatomy, pathophysiology, clinical and radiological assessment, and management., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Purpose: Hallux varus is a classical complication of hallux valgus surgery with a medium rate of 6%., Material and Methods: Methods of treatment are MTP1 fusion or conservative joint operations. Hallux varus results from imbalance between excessive medial capsule retraction or tensioning and excessive lateral laxity or soft-tissue release but also and mainly from an over displacement of the first metatarsal which reduces the intermetatarsal angle and thus leads to medial displacement of the great toe. A majority are well tolerated, but few need to be re-operated upon., Results: Factors guiding choice are mainly range of motion and reducibility of the first metatarsophalangeal joint and tendon balance. Joint sparing could be decided for a mobile and well balancesd MTP1 with two options, soft-tissue repairing such as tendon and ligament transfer and reverse osteotomies. The choice depends mainly on the radiological features as an unduly closed intermetarsal angle which leads to a reverse scarf or chevron osteotomy whatever previous surgery was or was not with an osteotomy., Conclusion: Conservative treatment is tricky, and MTP1 fusion is still a reliable procedure which can be used widely., (© 2021. SICOT aisbl.)

Longitudinal epiphyseal bracket is a rare ossification disorder of the short tubular bones. The affected bone becomes deformed as a result of the bracket. The normal growth pattern cannot occur, and when it affects the first metatarsal bone, hallux varus may develop with the abnormal growth pattern. We present such a 6-year-old patient who had undergone surgery at 6 months of age for hallux varus and polydactyly. The deformity had worsened gradually after the initial operation because of the overlooked longitudinal epiphyseal bracket. The patient was treated with surgical excision of the epiphyseal bracket, with corrective medial open wedge osteotomy and split transfer of the extensor hallucis longus tendon. The result was excellent at the 20-month follow-up. At an early age, patients who present with hallux varus must be checked for the epiphyseal bracket, which can be invisible on radiographs because of the chondral structure. Untreated or overlooked patients with epiphyseal bracket will need revision operations for recurrent deformities.

Iatrogenic hallux varus is a dreaded complication of hallux valgus surgery, consisting in 1st-ray deformity in the form of medial malalignment of the 1st phalanx with respect to the metatarsal axis. Such over-correction results from imbalance between excessive medial capsule retraction or tensioning and excessive lateral laxity or soft-tissue release. There may be loss of medial stability of bone origin due to excessive "exostosectomy" or excessive intermetatarsal angle closure. Following excessive lateral release, the imbalance gradually induces a varus deformity of the 1st phalanx due to traction by the medial muscles: abductor hallucis and medial head of flexor hallucis brevis inserting to the medial sesamoid. The deformity comprises 3 components, of varying importance: medial deviation of the hallux at the 1st metatarsophalangeal joint, supination of the phalanx, and interphalangeal flexion (i.e., claw deformity of the hallux). Treatment strategy is determined by the various clinical and radiological data explaining the postoperative hypercorrection. The clinical analysis is decisive, while radiology contributes more technical factors once the treatment option has been decided on. There are two main options for surgical revision to restore 1st ray propulsion: 1) static or dynamic reconstruction of the ligamentous structures, conserving metatarsophalangeal motion; or 2) metatarsophalangeal and/or interphalangeal fusion. Factors guiding choice are mainly range of motion, and reducibility of the metatarsophalangeal and interphalangeal deformity. We describe the procedures in detail, emphasizing the essential points for success. Joint sparing is to be sought in flexible deformities and young patients. Ligament reconstruction can be anatomic or palliative by tenodesis effect, which makes adjustment difficult. Alongside soft-tissue reconstruction, the metatarsal osteotomy should also be revised if the intermetatarsal angle has been unduly closed. Metatarsophalangeal fusion is the most reliable solution and is unavoidable if the joint is stiff or degenerative; it undoubtedly reduces risk of failure. LEVEL OF EVIDENCE: V, expert opinion., (Copyright © 2019. Published by Elsevier Masson SAS.)

Hallux varus is most commonly seen iatrogenically following overaggressive lateral release, removal of the fibular sesamoid, or overaggressive removal of the medial eminence. There are several reported cases of traumatic hallux varus, although this is much less common. We present a case of traumatic hallux varus in a patient who was later found to have bilateral absence of her fibular sesamoids. We postulated that lack of her fibular sesamoid led to weakness of her lateral capsular ligaments, thereby making her more susceptible to this injury. We performed a repair using a split extensor hallucis longus tendon transfer that was transected proximally, rerouted the tendon under the deep transverse intermetatarsal ligament, and secured it to the first metatarsal with a Bio-Tenodesis (Arthrex, Inc, Naples, Florida) screw. At 22 months postoperatively, she has demonstrated maintenance of correction and has resumed use of normal shoe gear and participation in activities. Our goal was to demonstrate a repair for this condition that successfully maintained correction over time while still allowing for functionality of the first metatarsophalangeal joint.

Longitudinal epiphyseal bracket (LEB) is a rare bone dysplasia of the tubular bones. Owing to an abnormal secondary ossification center, the affected bones can develop progressive shortening and angular deformity. The aim of our study was to provide an overview of the reported data regarding epidemiology and surgical procedures available for LEB of the first metatarsal bone in a pediatric population combined with a small case series. We report a retrospective case series of 3 nonsyndromic pediatric patients with different ages and with confirmed dysplasia of the first metatarsal bone. All patients presented with unilateral congenital hallux varus deformity and underwent surgical treatment. The radiographs and medical records were reviewed to evaluate the deformity characteristics, treatment, and clinical results. The mean patient age at initial surgery was 34 (range 12 to 63) months, and the median follow-up period was 46 (range 31 to 75) months. Almost all specific radiographic measurements showed correction of the deformity, and each foot demonstrated functional and cosmetic improvement. A standardized literature search was performed to obtain studies of LEB of the first metatarsal bone in the pediatric population. From on our results and the current data available, surgical treatment should be tailored to the patient's age and radiographic stage of LEB. However, monitoring until skeletal maturity of the feet is necessary to assess the final results., (Copyright © 2018 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Hallux varus is a deformity of acquired and less commonly congenital etiologies. It can present secondary to the release of the soft tissues surrounding the first metatarsophalangeal joint surfaces during bunion surgery. If the condition is left untreated, it can be debilitating, with progressive pain and destruction of joint surfaces. Many procedures have been described for the treatment of iatrogenic causes of hallux varus; however, little has been reported regarding the success of procedures when used for less typical traumatic causes. In the present report, a case is presented of surgical repair of a traumatic hallux varus using a suture and button fixation device and 3-year patient follow-up data., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Pfeiffer syndrome is a rare hereditary condition with an autosomal dominant transmission caused by a mutation that affects fibroblast growth factor receptors. It is one of the acrocephalosyndactyly diseases causing cranial malformations owing to early suture fusion. In the foot, it is typically associated with hallux varus, first ray hyperplasia, and partial lesser digit syndactyly. We report a clinical case of a 10-year-old patient with Pfeiffer type I syndrome with bilateral severe hallux varus due to a hypoplastic trapezoidal shaped proximal phalanx, a distal, medial-facing articular surface, and interphalangeal instability. This deformity was addressed by minimally invasive hallux interphalangeal joint arthrodesis with internal and external fixation. We report the results at the 2-year follow-up point., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Hallux varus is an uncommon condition and majority of the cases are iatrogenic. It can occur as a result of any type of hallux valgus correction surgery and in our cases scarf osteotomy is not an exception. Treatment of this complication can be challenging and it is important to understand the factors that cause this deformity before embarking on surgical correction. Four cases of hallux varus following Scarf osteotomy (1% of our total Scarf osteotomy cases) and discuss the salient features of these patients. The authors ascertained the factors that caused iatrogenic hallux varus and formulated a classification of the nature of the deformity. The management of iatrogenic hallux varus based on our experience and proposed classification system has also been outlined and discussed., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: The prevalence of hallux varus deformity in rheumatoid arthritis (RA) has been reported to be extremely rare. However, in South Asian Countries, where open-toed shoes are habitual footwear for the majority of people, we have found that hallux varus is a common deformity in patients with RA. This rate of occurrence is much more common than that in published hallux deformities in RA and reinforces the impact of footwear on the development of hallux deformities. In this report, we present 3 illustrative cases of hallux varus developed in patients with RA and review the etiology of hallux varus deformity., Levels of Evidence: Therapeutic, Level IV: Case Study., (© 2015 The Author(s).)

Traumatic hallux varus associated with osseous deformity, especially in the case of a decreased distal metatarsal articular angle, is an extremely challenging, but rewarding, deformity to treat. To the best of our knowledge, no previous reports have referred to surgical correction of traumatic hallux varus using first metatarsal hemicallotasis. We report the case of a 54-year-old male with traumatic hallux varus associated with medial subluxation of the second metatarsophalangeal joint and second metatarsocuneiform joint arthrosis. The patient was successfully treated with metatarsal hemicallotasis with medial soft tissue release, a proximal second metatarsal shortening osteotomy, and second metatarsocuneiform joint arthrodesis. After 1 year and 6 months, the correction had been maintained in a suitable position, no discomfort or pain was present, and the patient was completely satisfied with the surgical results. Metatarsal hemicallotasis can safely determine the angle of correction and minimize the risk of avascular necrosis of the metatarsal head even in deformed halluces with previous traumatic injuries and/or surgical treatment. This technique should be indicated only for hallux varus with a decreased distal metatarsal articular angle, an angular-type metatarsal head, and good metatarsophalangeal joint congruence., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Unlabelled: All reported rheumatoid arthritis (RA) forefoot deformities in the literature thus far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod population with an unshod population. A population comparison was undertaken in 2 specialized foot and ankle units, one in India and one in the United Kingdom. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity, and 90 hallux valgus deformities. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the fifth toe in a varus position. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. In the non-shoe wearing population, intrinsic muscle forces and weight bearing forces are the most likely determinants of the deformity, with hallux varus being a more common presenting problem. In the shod population, the external forces of shoe wear dictate the direction of deformity., Levels of Evidence: Prognostic, Level III: Case control study., (© 2015 The Author(s).)

Purpose: To determine survivorship and functional results of medial open-wedge high tibial osteotomy (HTO) combined with a chondral resurfacing procedure (abrasion/microfracture) in patients with Kellgren-Lawrence grade 3 and 4 osteoarthritis with full-thickness cartilage defects and varus malalignment., Methods: From September 2005 to December 2008, all cases of HTO (fixation with an angular-stable internal fixator) combined with a chondral resurfacing procedure performed at our institution were prospectively surveyed, with a minimum follow-up of 5 years, regarding survival (not requiring arthroplasty), functional outcome (subjective International Knee Documentation Committee [IKDC] score), and subjective satisfaction (whether patients would undergo the operation again). Clinical evaluation (according to objective IKDC parameters), radiologic evaluation, and revision arthroscopy for evaluation of regenerated cartilage were performed between 1 and 2 years., Results: A total of 91 knees (85 patients; mean age, 50.4 ± 8.0 years; age range, 28.3 to 67.7 years) were included. The survival rate was 95.2% (95% confidence interval, 90.7% to 99.7%) at 5 years, with 4 conversions to arthroplasty (3 unicondylar and 1 total knee arthroplasty; follow-up rate, 87.9%). Subjective IKDC scores significantly improved from 45.1 ± 11.6 points preoperatively to 69.1 ± 14.2 points after 1 year, 66.4 ± 14.5 points after 3 years, and 67.2 ± 14.4 points after 5 years (P < .001). In 94.9% of the cases patients were satisfied with the result after 5 years, including those with arthroplasty. Revision arthroscopy was performed in 80 cases (87.9%) at 1.5 ± 0.8 years: Cartilage regeneration was graded good in 50.0% and excellent in 25.8% on the tibial side compared with 48.1% and 39.0%, respectively, on the femoral side (P < .001). The overall complication rate was 6.6%., Conclusions: HTO in combination with a chondral resurfacing procedure is effective in the treatment of severe medial osteoarthritis and varus malalignment. The effect of the chondral resurfacing in this combined approach remains unclear., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Patients with ankle arthritis often present with concomitant hindfoot deformity, which may involve the tibiotalar and subtalar joints. However, the possible compensatory mechanisms of these two mechanically linked joints are not well known., Questions/purposes: In this study we sought to (1) compare ankle and hindfoot alignment of our study cohort with end-stage ankle arthritis with that of a control group; (2) explore the frequency of compensated malalignment between the tibiotalar and subtalar joints in our study cohort; and (3) assess the intraobserver and interobserver reliability of classification methods of hindfoot alignment used in this study., Methods: Between March 2006 and September 2013, we performed 419 ankle arthrodesis and ankle replacements (380 patients). In this study, we evaluated radiographs for 233 (56%) ankles (226 patients) which met the following inclusion criteria: (1) no prior subtalar arthrodesis; (2) no previously failed total ankle replacement or ankle arthrodesis; (3) with complete conventional radiographs (all three ankle views were required: mortise, lateral, and hindfoot alignment view). Ankle and hindfoot alignment was assessed by measurement of the medial distal tibial angle, tibial talar surface angle, talar tilting angle, tibiocalcaneal axis angle, and moment arm of calcaneus. The obtained values were compared with those observed in the control group of 60 ankles from 60 people. Only those without obvious degenerative changes of the tibiotalar and subtalar joints and without previous surgeries of the ankle or hindfoot were included in the control group. Demographic data for the patients with arthritis and the control group were comparable (sex, p=0.321; age, p=0.087). The frequency of compensated malalignment between the tibiotalar and subtalar joints, defined as tibiocalcaneal angle or moment arm of the calcaneus being greater or smaller than the same 95% CI statistical cutoffs from the control group, was tallied. All ankle radiographs were independently measured by two observers to determine the interobserver reliability. One of the observers evaluated all images twice to determine the intraobserver reliability., Results: There were differences in medial distal tibial surface angle (86.6°±7.3° [95% CI, 66.3°-123.7°) versus 89.1°±2.9° [95% CI, 83.0°-96.3°], p<0.001), tibiotalar surface angle (84.9°±14.4° [95% CI, 45.3°-122.7°] versus 89.1°±2.9° [95% CI, 83.0°-96.3°], p<0.001), talar tilting angle (-1.7°±12.5° [95% CI, -41.3°-30.3°) versus 0.0°±0.0° [95% CI, 0.0°-0.0°], p=0.003), and tibiocalcaneal axis angle (-7.2°±13.1° [95% CI, -57°-33°) versus -2.7°±5.2° [95% CI, -13.3°-9.0°], p<0.001) between patients with ankle arthritis and the control group. Using the classification system based on the tibiocalcaneal angle, there were 62 (53%) and 22 (39%) compensated ankles in the varus and valgus groups, respectively. Using the classification system based on the moment arm of the calcaneus, there were 68 (58%) and 20 (35%) compensated ankles in the varus and valgus groups, respectively. For all conditions or methods of measurement, patients with no or mild degenerative change of the subtalar joint have a greater likelihood of compensating coronal plane deformity of the ankle with arthritis (p<0.001-p=0.032). The interobserver and intraobserver reliability for all radiographic measurements was good to excellent (the correlation coefficients range from 0.820 to 0.943)., Conclusions: Substantial ankle malalignment, mostly varus deformity, is common in ankles with end-stage osteoarthritis. The subtalar joint often compensates for the malaligned ankle in static weightbearing., Level of Evidence: Level III, diagnostic study.

Iatrogenic hallux varus is a relatively rare complication of corrective hallux valgus surgery that has multiple pathologic facets. It requires a comprehensive assessment that focuses on joint flexibility, joint integrity, soft tissue balance, and bony deformity. A step-wise treatment approach is used to address all elements of the deformity. The literature on hallux varus treatments consists mainly of retrospective case series, with several proposed procedures addressing various degrees of deformity. Comparison of these procedures is a challenging endeavor and each case should be considered on an individual basis., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The proximal oblique sliding closing wedge osteotomy (POSCOW) technique was developed to address moderate to severe hallux valgus deformity. We present a retrospective multicenter study to analyze the midterm radiological and clinical outcomes of patients treated with this type of proximal osteotomy fixed with plates., Materials and Methods: One hundred and forty-four patients (187 feet) were operated on between May 2005 and June 2010 in 2 separate centers. Inclusion criteria were symptomatic moderate to severe incongruent hallux valgus deformity, no significant restriction in the first metatarsophalangeal joint movement, none to minimal degenerative changes in the first metatarsophalangeal or the tarsometatarsal joints, and no hypermobility. The median age was 60 years. The preoperative hallux valgus angle (HV) was 35.6 degrees, intermetatarsal angle (IM) was 15.3 degrees, AOFAS score was 53 points. The median follow-up was 35 months (range, 12-73). A POSCOW osteotomy was performed in all patients and fixed with plates. We recorded the satisfaction rate, postoperative clinical and radiological results, and complications., Results: The patient satisfaction rate was 87%. The mean postoperative HV angle was 12.3 degrees, IM angle 4.8 degrees, AOFAS score 89 points. The mean decrease in the first metatarsal length was 2.2 mm (range, 0-8). Twelve feet (6.4%) with recurrence of the deformity required revision surgeries. Removal of complete or partial hardware was needed in 23 feet (12.3%) for symptomatic hardware. Five feet (2.6%) developed hallux varus but only 2 required surgery. Transfer metatarsalgia was noted in 9 feet (4.8%)., Conclusions: The POSCOW osteotomy was an effective and reliable method for relieving pain and improving function. A learning curve was present, as most of the complications happened in the initial cases. To our knowledge, this is the largest reported series of proximal closing wedge osteotomy for hallux valgus deformities., Level of Evidence: Level IV, case series.

Hallux varus deformity typically results from soft-tissue overcorrection at the metatarsophalangeal joint during surgery for hallux valgus. There are several soft-tissue procedures available for flexible hallux varus deformity including transfer of the extensor hallucis longus or abductor hallucis. To our knowledge, there have not been any previous reports in the literature of bilateral hallux varus deformities in the setting of potential pregnancy-related ligamentous laxity combined with iatrogenic injury. We present the case of an isolated bilateral hallux varus deformity occurring after pregnancy and prior bunion surgery. The simultaneous operations using the Mini TightRope device (Arthrex Inc, Naples, Florida) were considered a success with the patient having pain relief and return to regular activities with normal shoewear.

Unlabelled: The objective of this study is to assess the clinical and radiologic results of patients with rheumatic forefoot who underwent metatarsophalangeal arthrodesis of the first ray and arthroplastic resection of the second to fifth metatarsal heads at the National Rehabilitation Institute., Material and Methods: This is a prospective comparative study of the clinical and radiological status before and after the surgical procedure; it is a descriptive, observational single-group study. From April 2006 to December 2011, 31 surgical procedures were performed in 29 female and two male patients. The SPSS 17.0 software was used for the statistical analysis. Efficacy and quality of life indicators were compared using mean comparison tests (Student t test), the indicator of patient safety by means of frequency analysis, and the comparative analysis of the occurrence of complications throughout time., Results: The mean preoperative visual analog scale score was 6.2 +/- 1.3, with an average of 1.6 +/- 2.5, with statistical significance, with p < 0.0001 and t = 7.97. Radiographic measurements of the hallux valgus angle showed a remarkable improvement., Conclusions: The surgical procedure described is reliable and efficacious, as patients had an important improvement in quality of life, with pain relief and adaptation to their activities of daily living after surgery.

Hallux valgus is a common forefoot pathology often requiring surgical intervention for symptomatic relief. One complication of hallux valgus correction is flexible hallux varus. Iatrogenic flexible hallux varus often requires surgical repair; however, the most advantageous surgical procedure for repair of iatrogenic flexible hallux varus and their sustainability remains unclear. Therefore, we performed a systematic review to determine the sustainability of soft-tissue release with tendon transfer for the correction of iatrogenic flexible hallux varus. Studies were eligible for inclusion only if they involved failure of soft-tissue release with tendon transfer for flexible iatrogenic hallux varus. Eight studies met our inclusion criteria, seven of which were evidence-based medicine level IV studies and one was level V. A total of 52 patients, all female, involving 68 feet, were included. All studies included soft-tissue release of the first metatarsal-phalangeal joint capsule and 1 of the following procedures: Johnson transfer of the extensor hallucis longus tendon with arthrodesis of the hallux interphalangeal joint (41 feet); Hawkins transfer of the abductor hallucis tendon (9 feet); reverse Hawkins transfer (7 feet); Valtin transfer of the first dorsal interosseous tendon (7 feet); and Myerson transfer of the extensor hallucis brevis tendon (4 feet). The weighted mean age of the patients was 50.4 years, and the weighted mean follow-up was 30.2 months. A total of 11 complications (16.2%) occurred. Of note, only 3 cases (4.4%) of recurrent hallux varus deformity developed, all of which occurred after Johnson transfer of the extensor hallucis longus tendon, with arthrodesis of the hallux interphalangeal joint. Our results support that sustainable correction of iatrogenic flexible hallux varus can be achieved with soft-tissue release of the first metatarsal-phalangeal joint combined with a variety of tendon transfer procedures. However, given the limited data available, potential areas for additional prospective investigation remain., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from -11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from -0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.

Hallux varus can present as a congenital deformity or it can be acquired secondary to trauma, surgery, or neuromuscular disease. In the present report, we describe the presence of hallux varus as a sequela of calcaneal fracture with entrapment of the medial plantar nerve in the calcaneal tunnel and recommend that clinicians be wary of this when they clinically, and radiographically, evaluate patients after calcaneal fracture., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: [Corrected] Hallux varus is a complication of hallux valgus surgery. Historically the standard treatment has been to arthrodese the first metatarso-phalangeal (MTP) joint. More recently other options have come to light, including reverse osteotomies and tendon-transfer procedures., Objectives: This paper presents a small retrospective audit of patients who developed hallux varus following the combined rotation scarf and Akin osteotomy for hallux valgus, and their subsequent treatment with a stepwise approach of soft tissue release and ultimately reverse scarf osteotomy and opening wedge osteotomy of the proximal phalanx., Method: Five patients attended for a retrospective audit including reasons for revision surgery, review of intermetatarsal (IM) and first metatarso-phalangeal joint (MTPA) angles, AOFAS scores and patient satisfaction., Results: At a mean follow up of 38 months, mean IM angle and MTP joint angle improved from 5 to 9° and -10° to 11° respectively. Mean first MTP joint dorsiflexion and plantarflexion was 26° and 19° respectively. One patient was completely satisfied and four were satisfied with reservations with their surgical outcome and 100% felt they were better off as a result of their surgery., Conclusion: The stepwise approach to the reverse scarf and opening wedge osteotomy of the proximal phalanx for iatrogenic hallux varus is an alternative to first MTP joint arthrodesis for those with a viable joint., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Gradual correction of varus deformity of the proximal tibia is generally accepted and produces good results. However, most studies have used circular external fixators, which are complex and cause patient discomfort. This study was undertaken to determine the efficacy of hemicallotasis with a unilateral external fixator for correction of varus deformity of the proximal tibia., Methods: Thirteen patients (21 legs, 8 bilateral) were included in this study: 6 with constitutional bowing, 3 with a malunion, 2 with Blount's disease, and 2 with Turner syndrome. There were 7 males and 6 females of mean age 21 years (range 13-40). With an oblique osteotomy on the proximal tibia, a unilateral external fixator was placed on the medial side. Using a distraction of 1 mm/day, the external fixator was removed after consolidation of the callus., Results: Surgery corrected medial proximal tibia angle from a preoperative average of 75.1° (64°-81°) to 88.6° (86°-90°) at final follow-up. Average tibiofemoral angle improved from -7° to 6.8°. The duration of external fixation averaged 101.3 days and the external fixation index was 70 days/cm. No patient had a limited ambulation, and all recovered preoperative range of knee motion (mean 130.1°) at final follow-up. Seven minor complications (pin tract infection, clamp loosening) and 1 major complication (uncorrected genu procurvatum) were observed., Conclusions: Hemicallotasis using a unilateral external fixator was found to be a safe and simple corrective procedure for varus deformity of the proximal tibia, with few complications.

We describe an unusual cause of an acquired cavo-varus foot deformity produced by progressive enlargement of an accessory calcaneal ossicle. A 13-year-old boy with constitutional plano-valgus flat feet noted a gradual change in foot shape associated with lateral ankle pain on ambulation following an inversion injury 2 years earlier. CT and MRI scans confirmed a large accessory calcaneal ossicle lying within the sinus tarsi, with associated marrow oedema. Following surgical excision of the ossicle, the foot returned to its original shape and the symptoms were alleviated. This is the fifth reported case of an accessory calcaneal ossicle, but the only case that has occurred in a flatfooted individual. We also present the first reported MRI images of the lesion confirming pathological marrow oedema as a response to mechanical stress.

Complications with hallux valgus surgery can manifest in a variety of ways, but ultimately preventing them depends on the surgeon's expertise in patient and procedural selection, ability to perform the surgery selected, and knowledge in dealing with postoperative care and complications if present. In this article, the authors discuss common diagnostic and treatment dilemmas when dealing with recurrent hallux valgus, hallux varus, malunion, and avascular necrosis following bunion surgery.

Appropriate treatment for hallux varus requires comprehensive radiographic and systematic clinical assessment to identify the involved factors. A classification scheme must incorporate many variables in order to determine the best approach to correcting the deformity. This article focuses on iatrogenic hallux varus following bunion surgery, but the same principles apply to other causes of acquired hallux varus.

Infantile tibia vara (infantile Blount's disease) is a condition in which progressive varus of the knee develops due to diminished physeal growth of the medial aspect of the proximal tibia. A 6-year-old boy with severe bilateral infantile tibia vara (Langenskiold stage V) underwent operative correction of his deformities. Surgery consisted of epiphyseolyses of the medial proximal tibiae and valgus-producing corrective tibial osteotomies. Nearly 5 years after symmetric growth, he again developed progressive varus involving his left knee. Usually, a repeat proximal tibial osteotomy is required along with consideration for completion of epiphyseodesis. In this case report, a simpler approach using staples was taken to successfully regain correction in a patient with recurrent deformity who was treated previously by a combination of epiphyseolysis and proximal tibial osteotomy. Stapling of the lateral aspect of the physis allowed the limited remaining growth potential within the abnormal medial physeal region to correct the angular deformity. A small overcorrection into valgus corrected after subsequent removal of the staple. At 14 years, with clinical and radiologic alignment normal, bilateral proximal tibial epiphysiodeses were performed. The patient returned to playing football at a high school level and had no functional limitations. To our knowledge, this is the first report of growth modulation (physeal stapling) resulting in successful correction of recurring genu varum in a knee that had previously undergone epiphyseolysis of the medial proximal tibial physis in advanced infantile tibia vara.

Sometimes a hallux varus occurs as a consequence of the treatment for a hallux valgus, determined by an alteration of the balance between the muscolo-ligamentous structure which crosses the first metatarso-phalangeal joint. This complication is poorly tolerated by patients. Various operations have been proposed to correct the varus, which includes the bone and the soft tissue. A clinical case has been presented which uses a split extensor hallucis longus transfer, distally sectioned and made to pass under the deep transverse intermetatarsal ligament, used as a pulley, and through a tunnel made in the bone at the proximal-lateral base of the proximal phalanx, and then tensioned and sutured to its medial side.

When facing revision surgery, the deformation of the femur must be considered for the important implications in the strategy of the operation and the choice of the implant. Deformation can occur in varus and retroversion, or both, in different degrees. For severe varus deformations a straightening osteotomy is generally indispensable and different types of distal fixations of the implant are necessary; in milder deformations other solutions are possible. Retroversion can be generally managed with proximally modular stems, stems without metaphyseal component, or, rarely, with a derotation osteotomy.

Whereas in the past resection arthroplasty was - in analogy to hallux valgus surgery - the preferred therapy to correct lesser toe deformities, the point of view has undergone a change. Much interest is directed toward functional aspects that require reconstructive management. Whenever possible the integrity of joint play should be saved. Above all the metatarsophalangeal joint of the lesser toes is worth being preserved to prevent a severe disturbance of the biomechanics of the foot. Tendon transfers and subtle corrective osteotomies such as the Weil procedure allow restricting resection procedures to contraction deformities.

Post-burn hallux varus is an extremely rare condition. A 22-year-old male, with a history of campfire burns in childhood, presented with secondary hallux varus of the left great toe. Surgical correction included medial soft tissue release, metatarsophalangeal joint arthrodesis, two-pin fixation of bones, metatarsophalangeal joint capsulorrhaphy, and coverage of the skin defect with a "Z" plasty of the skin and split thickness skin grafting. Follow up 20 months later showed satisfactory results.

The post operative iatrogenic hallux varus associates varus, big toe's dorsal flexion and supination. The pathogeny is dominated by musculo-tendinous lack of balance created by the initial operation and excessive exostosectomy. The authors have nineteen times surgically corrected this deformation. The procedure included in all cases, a medial arthrolysis; five times associated with a screwed capito-metatarsal osseous shelf (or graft) (when there was a metatarsal's head maiming); thirteen times associated with a metatarso-phalangeal arthrodesis (in cases of impaired joint surfaces). The authors analyse, besides, without excluding them the other surgical procedures for hallux varus, and particularly tendinous transfers. The results show the necessity of a perfect etiopathogenic analysis of the deformation.

Hallux varus is not uncommon after hallux valgus surgery. Through understanding of its cause, this deformity may be easily avoided with thorough preoperative evaluation, meticulous and deliberate intraoperative technique, and early postoperative diagnosis. By recognizing these factors, one can significantly reduce the predilection toward hallux varus. Once the diagnosis has been made, aggressive treatment is warranted, in the hope of minimizing the complexity of joint disorientation and surgical repair.