HV Patients Show Greater Pronation of the First Metatarsal than Normals

Category: Basic Sciences/Biologics, Bunion, Midfoot/Forefoot Introduction/Purpose: The progression of the hallux valgus (HV) deformity demonstrates dorsiflexion and abduction; concomitant pronation has not received adequate documentation and the extent of pronation in the pathology is unknown even though correction of the deformity may need to address all three angles. To overcome the inability of standard radiographs to capture pronation, we have developed a means to assess the three dimensional deformity using CT scans. Our goal was to document the extent of pronation/supination both of the first phalanx with respect to the first metatarsal and of the first metatarsal with respect to the second metatarsal. Furthermore, we wanted to regress pronation against the intermetatarsal (IMA) angle of hallux valgus patients. Methods: Three-dimensional models were reconstructed from loaded and unloaded CT files of patients (10 HV, 10 normal). The orientations of specific bones, in anatomic directions, were determined by selecting landmarks on the surface of the phalanx and of the first and second metatarsals. The resulting calculations output a set of angles to determine the pronation/supination of the first metatarsal relative to the second and of the first phalanx relative to the first metatarsal. A regression analysis was conducted to extrapolate any relationship between adduction and pronation (known intermetatarsal and pronation). Results: The average pronation of the first metatarsal relative to the second metatarsal was 19.8 ± 7.1 and 28.3 ± 10.8 in the normal and HV groups respectively (p < 0.05). The influence of weightbearing demonstrated pronation angle differences that were greater in the normal group than in the HV group for both the IM pronation and the HV pronation (p < 0.05) (Figure 1). The differences in HV angles and IM angles between normal and HV patients were 22° and 7° respectively. The regression analysis of the pronation and intermetatarsal angle was not found to be significant, with a weak correlation (r2 = 0.26). Conclusion: The pronation of the first metatarsal relative to the second metatarsal between normal and HV patients is significantly different. While the first metatarsal had measurable pronation in patients with hallux valgus but that value was not predicted by the IMA. The findings of this study indicate pronation should be considered in any surgical technique that seeks to restore native configurations.

Download Full-text

Pilot Study of a 3-Dimensional Method for Analysis of Pronation of the First Metatarsal of Hallux Valgus Patients

Foot & Ankle International ◽

10.1177/1071100718793391 ◽

2018 ◽

Vol 39 (12) ◽

pp. 1449-1456 ◽

Cited By ~ 13

Author(s):

Bradley Campbell ◽

Mark Carl Miller ◽

Lance Williams ◽

Stephen F. Conti

Keyword(s):

Hallux Valgus ◽

Computer Aided Design ◽

Proximal Phalanx ◽

Three Dimensional ◽

Great Toe ◽

3 Dimensional ◽

First Metatarsal ◽

Second Metatarsal ◽

Three Dimensional Models ◽

Aided Design

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.

Download Full-text

Hallux valgus correction using Scarf-Osteotomy leads to shortening of the first metatarsal

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00320 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0032

Author(s):

Christopher Lenz ◽

Paul Borbas

Keyword(s):

Hallux Valgus ◽

Consecutive Series ◽

Hallux Valgus Angle ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Valgus Angle ◽

Correction Technique ◽

Second Metatarsal ◽

First Ray ◽

Akin Osteotomy

Category: Bunion Introduction/Purpose: In hallux valgus deformity less weight can be borne by the first ray which may lead to transfer metatarsalgia and lesser toe deformities. Depending on the exact configuration of the bone cuts during the scarf procedure, an iatrogenic shortening of the first metatarsal may occur which may diminish weightbearing ability of the first ray as well, causing transfer metatarsalgia. The aim of the present study was therefore to determine preoperative and postoperative changes in length of the first metatarsal by using different methods of measuring metatarsal length. Methods: A consecutive series of 118 feet in 106 patients (89% female, 11% male) was enrolled, who underwent correctional osteotomy (Scarf-with/without Akin-Osteotomy) from May 2015 to July 2017 at a single institution. Patients, who underwent additional shortening osteotomy of the metatarsals, were excluded. Average age at the time of surgery was 51 years (range, 14 to 83 years). Pre- and postoperative angle measurement of hallux valgus- and intermetatarsal angle was assessed at between six weeks and three months postoperatively on standardized weight-bearing radiographs in dorsoplantar plane. We also identified early complications in hallux valgus surgery. An assessment and comparison of different methods of measuring metatarsal length (length of first metatarsal, ratio first to second metatarsal, Coughlin method) postoperatively was performed to identify the amount of shortening with this technique. Results: Hallux valgus angle was statistically significant reduced by an average of 18.6° (28.3° preoperatively to 9.7° postoperatively, p < 0.001), intermetatarsal angle by 7.7° (12.8° to 5.1°, p < 0.001). Measuring the length of the first metatarsal, in all three methods a statistically significant reduction of the first metatarsal length could be detected. Mean absolute shortening of 1.8 mm was measured (p < 0.001). The ratio of the first metatarsal to the second metatarsal averaged -0.03 (p = 0.02). The mean relative lengthening of the second metatarsal, using the method described by Coughlin, was 0.42 mm (from 4.51 to 4.89 mm, p < 0.001) on average. Of those three methods, the Coughlin method showed the highest correlation. 6 minor complications were observed (5%). Conclusion: In the current study we could demonstrate a significant reduction of hallux valgus angle and intermetatarsal angle with hallux valgus correction using Scarf-/Akin-Osteotomy, with a low complication rate. However, statistically significant shortening of the first metatarsal could be detected as well. Further research is required to improve and establish a hallux valgus correction technique without shortening of the first metatarsal.

Download Full-text

Comparison of Transverse and Coronal Plane Stability at the First Tarsal-Metatarsal Joint With Multiple Screw Orientations

Foot & Ankle Specialist ◽

10.1177/1938640016666920 ◽

2016 ◽

Vol 10 (2) ◽

pp. 104-108 ◽

Cited By ~ 7

Author(s):

Mindi Feilmeier ◽

Paul Dayton ◽

Merrell Kauwe ◽

Andrea Cifaldi ◽

Britney Roberts ◽

...

Keyword(s):

Hallux Valgus ◽

Therapeutic Level ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Force Application ◽

Second Metatarsal ◽

First Ray ◽

Multiple Levels ◽

With Screws ◽

Improve Stability

Intercuneiform instability has been recognized as a potential cause of hallux valgus recurrence following tarsal-metatarsal joint (TMTJ) fusion. Recommendations have been made for additional screw placement between the metatarsals and/or the cuneiforms to improve stability. The screw orientation that provides the best stability has not been documented. Twelve cadavers with the first TMTJ fixated were used for testing. Using a consistent force application of 15 pounds in both the transverse and coronal planes, we measured the change in intermetatarsal angle on radiographs. Force testing was repeated with screws deployed individually in the following orientations: first to second cuneiform (CC), first to second metatarsal (MM), and first metatarsal to middle cuneiform (MC). Our results indicate that stability of the first ray in the transverse and coronal planes is not improved with TMTJ fixation alone or with an additional CC screw. The MM screw consistently reduced first metatarsal instability in both planes. The MC screw had intermediate results. These findings strengthen the notion that first ray instability is complex and involves the tarsal and metatarsal articulations at multiple levels outside of the TMTJ alone. Levels of Evidence: Diagnostic and Therapeutic, Level IV: Cadaveric Study

Download Full-text

Correlative Study Between the Sesamoid Bones under the Head of the First Metatarsal and the Development of Hallux Valgus Determined with Radiographs

10.21203/rs.3.rs-411401/v1 ◽

2021 ◽

Author(s):

Xiaozhong Li ◽

Dongxue Liu ◽

Xufang Wang

Keyword(s):

Hallux Valgus ◽

Metatarsal Head ◽

Sesamoid Bone ◽

Hallux Valgus Angle ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Valgus Angle ◽

Second Metatarsal ◽

Sesamoid Bones ◽

The Absolute

Abstract Objective. To study the correlative between the sesamoid bones under the head of the first metatarsal and the development of hallux valgus determined with radiographs.Methods.The measurements were performed on the X-ray of 300 normal feet and 300 cases of hallux valgus. The following parameters were measured: hallux valgus angle(HVA); the first-second intermetatarsal angle(IMA) between the axes of the first and second metatarsal;the length of the second metatarsal（CD）;the position of tibial sesamoid(TSP ) measured the percent formed between the tibial sesamoid and the centreline of the first metatarsal;the position of fibular sesamoid(FSP) measured tangent value between fibular sesamoid bone and lateral cortex of first metatarsal bone ; the absolute distances (AB) from the centre of the tibial sesamoid to the long axis of the second metatarsal, the absolute distances (EF) from the centre of the fibular sesamoid to the long axis of the second metatarsal and the absolute distance (GH) from the centre of the tibial sesamoid to the centre of the fibular sesamoid. Then calculate the ratio of AB to CD (K1), EF to CD (K2) and GH to CD (K3). Results.HVA moderately positively correlates with TSP and moderately negatively correlates with FSP in subjects with HVA ≥ 20°. HVA and FSP are strongly negatively correlated in the hallux valgus group. Conclusion.The dislocation of sesamoid bone under the first metatarsal head is an important pathological factor leading to valgus. HVA is positively correlated with TSP and negatively correlated with FSP.

Download Full-text

Hallux Valgus Correction Using a Novel 3D Printed Plate: Retrospective Case Series with Two Year Follow-Up Data: Surgical Technique Guide and Outcomes

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00119 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0011

Author(s):

Justin Brohard ◽

Ryan Callahan ◽

Jason Lin

Keyword(s):

Surgical Technique ◽

Hallux Valgus ◽

Chart Review ◽

Intermetatarsal Angle ◽

Operative Complication ◽

First Metatarsal ◽

Second Metatarsal ◽

3D Printed ◽

Initial Correction

Category: Bunion Introduction/Purpose: Over 130 techniques have been described for the treatment of hallux valgus, ranging from bunionectomies, osteotomies, and arthrodesis. Modern attempts at bunion correction with less invasive joint sparing approaches, such as suture-button techniques, have introduced additional complications like second metatarsal fracture. Suture fixation techniques have evolved in an attempt to avoid these complications. We present our results, with up to 26 months of radiographic follow up including initial correction and complications, with a novel device which utilizes a 3D printed titanium plate on the lateral cortex of the second metatarsal without bony violation, and reduces the 1-2 intermetatarsal angle using suture tape passed through drill holes in the first metatarsal with PEEK interference screw fixation. Methods: This study includes 33 feet in 31 patients. A single board certified and fellowship trained orthopedic foot and ankle surgeon performed all operations over the course of 18 months at a single institution. He utilized a dual incision approach and followed previously described surgical technique for the application of the device. We retrospectively reviewed radiographs including pre-operative AP, lateral, and oblique images, along with another set at the two and six week post operative periods, and another at the last available follow up visit. Using standard technique we measured the 1-2 intermetatarsal angle (IMA), as well as the hallux valgus angle (HVA), which were used as the primary outcomes. Chart review was performed to determine patient satisfaction with the outcome. All secondary procedures and complications were recorded based on the chart review and radiographs. Results: Average radiographic follow up was 15 months. The average initial HVA was 31.4º and IMA was 16.0º. Two-week average HVA was 11.3º and IMA was 7.1º. At six weeks, weight-bearing radiographs showed an average HVA 14.5º and IMA 8.2º. Final radiographic measurements, accounting for either the latest available image or the final image prior to revision, showed average HVA of 24.3º and IMA of 13.7º. Six patients had revision for recurrence or fracture. One underwent removal of symptomatic hardware. Seventeen patients had at least mild radiographic recurrence, without revision. Two patients had an intraoperative fracture of the first metatarsal, and one had an intraoperative fracture of the second metatarsal shaft. There were no infections or wound healing issues. Conclusion: Although this device allows a minimally invasive hallux valgus correction, and provides a powerful initial correction with little bony manipulation, results presented in this study suggest a high rate of radiographic recurrence, and relatively high rates of intra-operative complication, post-operative complication, and revision surgery. We found that more severe deformity had a higher rate of recurrence, suggesting it may be more beneficial in mild deformity, but even in many of these patients we found recurrence and other complications. As a result, this technique has since been abandoned at our local institution with the last procedure being performed in 2016.

Download Full-text

Radiographic Assessment of the Second Metatarsal: Measure of First Ray Hypermobility

Foot & Ankle International ◽

10.1177/107110079601700606 ◽

1996 ◽

Vol 17 (6) ◽

pp. 331-333 ◽

Cited By ~ 34

Author(s):

David W. Prieskorn ◽

Roger A. Mann ◽

Germaine Fritz

Keyword(s):

Hallux Valgus ◽

Cortical Thickness ◽

Valgus Deformity ◽

Hallux Valgus Angle ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Hallux Valgus Deformity ◽

Valgus Angle ◽

Second Metatarsal

Hypermobility of the first metatarsal cuneiform joint has been implicated as a cause of the hallux valgus deformity. The objective definition of hypermobility at this joint, however, has not been clearly defined. We used a modified Coleman block test to accentuate motion at the first metatarsal cuneiform joint in order to measure physiologic limits of motion in vivo. This motion was compared with radiographic analysis of the feet, which included the hallux valgus angle, intermetatarsal angle, and medial cortical thickening at the midshaft of the second metatarsal. This assessment was performed on 100 feet (50 right feet and 50 left feet in 50 patients). The average intermetatarsal angle was 8.7° (range, 4–14°), the average hallux valgus angle was 11° (range, 4° of varus to 30° of valgus), and the average midshaft medial cortical thickness was 3.2 mm (range, 2.0–5.5 mm). Pearson's correlation coefficient was calculated to compare these factors. The relationship between variables was found to be small ( r ≤ 0.2). Motion was noted to occur in the normal foot at this joint and a range of normal values for medial cortical thickness was identified.

Download Full-text

Correlation of Different Methods of Measuring Pronation of the First Metatarsal on Weightbearing CT Scans

Foot & Ankle International ◽

10.1177/10711007211003090 ◽

2021 ◽

pp. 107110072110030

Author(s):

Matthew S. Conti ◽

Tamanna J. Patel ◽

Kristin C. Caolo ◽

Joseph M. Amadio ◽

Mark C. Miller ◽

...

Keyword(s):

Hallux Valgus ◽

Computer Aided Design ◽

Foot And Ankle ◽

Level Of Evidence ◽

3 Dimensional ◽

3D Cad ◽

First Metatarsal ◽

Hallux Valgus Deformity ◽

Second Metatarsal ◽

Α Angle

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

Download Full-text

Comparison of Postoperative Height Changes of the Second Metatarsal Among 3 Osteotomy Methods for Hallux Valgus Deformity Correction

Foot & Ankle International ◽

10.1177/1071100716666566 ◽

2016 ◽

Vol 38 (1) ◽

pp. 20-26 ◽

Cited By ~ 5

Author(s):

Jun Young Choi ◽

Yu Min Suh ◽

Ji Woong Yeom ◽

Jin Soo Suh

Keyword(s):

Hallux Valgus ◽

Deformity Correction ◽

Metatarsal Head ◽

Valgus Deformity ◽

Metatarsal Osteotomy ◽

Level Of Evidence ◽

First Metatarsal ◽

Scarf Osteotomy ◽

Hallux Valgus Deformity ◽

Second Metatarsal

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.

Download Full-text

Etiological factors in hallux valgus, a three-dimensional analysis of the first metatarsal

Journal of Foot and Ankle Research ◽

10.1186/s13047-017-0226-1 ◽

2017 ◽

Vol 10 (1) ◽

Cited By ~ 9

Author(s):

Tomohiko Ota ◽

Takeo Nagura ◽

Tetsuro Kokubo ◽

Masateru Kitashiro ◽

Naomichi Ogihara ◽

...

Keyword(s):

Hallux Valgus ◽

Dimensional Analysis ◽

Three Dimensional ◽

Etiological Factors ◽

First Metatarsal

Download Full-text

Mitchell Osteotomy for Hallux Valgus: Long-term Follow-up and Gait Analysis

Foot & Ankle ◽

10.1177/107110078300300402 ◽

1983 ◽

Vol 3 (4) ◽

pp. 189-196 ◽

Cited By ~ 70

Author(s):

Kurt D. Merkel ◽

Yoshihisa Katoh ◽

Einer W. Johnson ◽

Edmund Y. S. Chao

Keyword(s):

Retrospective Study ◽

Gait Analysis ◽

Hallux Valgus ◽

Age Groups ◽

Intermetatarsal Angle ◽

First Metatarsal ◽

Long Term Follow Up

In this retrospective study of 96 Mitchell first-metatarsal osteotomies performed on 69 patients with an average follow-up of 7 years, we found that more than 86% were completely satisfied and that the procedure was equally effective in all age groups. Excessive first metatarsal shortening, dorsiflexion of the osteotomy, and failure to correct the intermetatarsal angle to 10° or less correlated with poorer results. This study demonstrates a relationship between metatarsal shortening and osteotomy plan-tarflexion. Gait analysis demonstrated that these patients do not have normal foot mechanics postoperatively.

Download Full-text