Radiographic analysis of hallux valgus in women on weightbearing and nonweightbearing

To investigate changes in the radiographic appearance during weightbearing in hallux valgus and to examine the importance of a weightbearing view, a comparative study was performed of accurate dorsoplantar radiographs of 108 symptomatic hallux valgus feet in 73 female patients and 100 normal feet in 69 females, which were taken weightbearing and nonweightbearing. The hallux valgus angle in the hallux valgus group increased on weightbearing, whereas that in the normal group decreased. The intermetatarsal angle between the first and second metatarsals increased on weightbearing in both groups. The degree of the changes of the angles was closely related with the degree of the hallux valgus deformity. The intermetatarsal angle between the fourth and fifth metatarsals decreased on weightbearing in the both groups. A weightbearing view is necessary to evaluate the structural configuration of hallux valgus, because muscle imbalance around the first metatarsophalangeal joint in hallux valgus causes an increase of a hallux valgus angle on weightbearing.     

Metatarsophalangeal and intermetatarsal angle: different values and interpretation of postoperative results dependent on the technique of measurement

For measurement of the first metatarsophalangeal angle and intermetatarsal angle I-II, five different methods for drawing the axis of the first metatarsal have been published. This study aimed to evaluate differences in the resulting angles that depend on the method of drawing this axis. Using pre- and postoperative radiographs of 20 patients who had surgery on the hallux (chevron procedure), highly significant differences were found: mean values for the preoperative metatarsophalangeal angle ranged from 27.3 degrees to 31.9 degrees; the mean postoperative values were calculated at 8.6 degrees to 20.3 degrees. The preoperative mean of intermetatarsal angle I-II showed values from 13.0 degrees to 17.6 degrees; the postoperative mean ranged from 5.2 degrees to 16.7 degrees. These differences--especially in the postoperative evaluation--resulted in a postoperative improvement between 11.6 degrees and 20.8 degrees for the metatarsophalangeal angle and between 0.9 degrees and 10.0 degrees for the intermetatarsal angle. These wide differences seem to be unacceptable for angles as a criterion of success in surgery on the hallux. The reason for these discrepancies can be found in the different relations of the points of reference to the anatomical outline of the metatarsal and the site of osteotomy. As a consequence of this study, defining the axis of the first metatarsal as a line connecting the center of the articular surface of the metatarsal head and the center of the proximal articulation can be recommended as the most appropriate method. The resulting angles are independent of the type of surgery performed on the hallux.     

Potency and hourly maintenance requirement of combinations of mivacurium and pancuronium in adults

The purpose of this study was to evaluate retrospectively outcomes of the Mau osteotomy for hallux abducto valgus deformity. Twenty-two patients were evaluated by the senior author on an average of 14 months (range, 3-34 months) following their surgery. Preoperative and postoperative intermetatarsal (IM) and hallux abductus (HA) angles were evaluated as well as range of motion of the first metatarsophalangeal joint and patient satisfaction. The mean preoperative IM and HA angles were 16.1 degrees and 35.8 degrees. The mean reduction in IM and HA angles was 10.5 degrees and 23.5 degrees, respectively. Joint range of motion was 58 degrees of dorsiflexion (range, 42 degrees-80 degrees) and 11 degrees of plantarflexion (range, 0 degree-20 degrees). There were no cases of delayed healing or avascular necrosis. There were two patients (9%) with radiographic values consistent with hallux varus; however, neither patient had a clinical appearance of hallux varus and neither patient was displeased with the outcome. Ninety-one percent of patients returned to a soft shoe or sneakers in an average of 5.1 weeks following surgery. Eighty-two percent of patients had no pain at the time of their evaluation, and 96% of patients stated they were satisfied or very satisfied with the surgery. Comparing the subgroup of patients who underwent a Mau-Reverdin procedure with another subgroup undergoing a Mau-Reverdin fibular sesamoidectomy, there was a 3.7 degrees greater reduction of IM angle and 6.7 degrees greater reduction in HA angle in the subgroup with the fibular sesamoidectomy.     

The nonfixated Austin bunionectomy: a retrospective study of one-hundred procedures

A retrospective evaluation of 64 randomly selected patients with 100 nonfixated Austin bunionectomy procedures was performed. A radiographic and a clinical evaluation were performed, including an analysis of preoperative and postoperative angles as well as postoperative complications. This study demonstrates a similar complication rate for nonfixated Austin bunionectomies as compared with previous studies with internal fixation. Removal of the fibular sesamoid was performed in 90% of the cases and did not increase the incidence of hallux varus. The nonfixated Austin bunionectomy is an acceptable alternative to the correction of hallux valgus. If internal fixation is utilized, the most cost-effective device should be used.     

Avoiding common mistakes in APA style: the briefest of guidelines

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 degrees (range, 4-14 degrees), the average hallux valgus angle was 11 degrees (range, 4 degrees of varus to 30 degrees 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 < or = 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.     

Avascular necrosis of the first metatarsal head: incidence in distal osteotomy combined with lateral soft tissue release

The incidence of avascular necrosis of the metatarsal head following distal first metatarsal osteotomy combined with adductor tendon release has not been documented in a large series of patients. Of 82 consecutive procedures in 64 patients performed between 1986 and 1988, 42 patients (58 procedures) were available for clinical and radiographic examination. Average follow-up was 2.5 years (range 1.0-4.2 years). There were 35 L-shaped and 23 chevron osteotomies which were combined with a lateral soft tissue release that included adductor tenotomy. Preoperative hallux valgus angle averaged 25 degrees (range 15-40 degrees), and intermetatarsal angle averaged 12 degrees (range 5-24 degrees). Follow-up amount of correction averaged 13 degrees and 5 degrees, respectively. Eighty-four percent of patients were satisfied with their result. There was one case of avascular necrosis. The patient was asymptomatic at 4.2 years' follow-up, and the remaining patients included two with infections, one hallux varus, and no nonunions.     

Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment

In an 11-year retrospective study of 45 patients (60 feet) with juvenile hallux valgus, a multiprocedural approach was used to surgically correct the deformity. A Chevron osteotomy or McBride procedure was used for mild deformities, a distal soft tissue procedure with proximal first metatarsal osteotomy was used for moderate and severe deformities with MTP subluxation, and a double osteotomy (extra-articular correction) was used for moderate and severe deformities with an increased distal metatarsal articular angle (DMAA). The average hallux valgus correction was 17.2 degrees and the average correction of the 1-2 intermetatarsal angle was 5.3 degrees. Good and excellent results were obtained in 92% of cases using a multiprocedural approach. Eighty-eight percent of patients were female and 40% of deformities occurred at age 10 or younger. Early onset was characterized by increased deformity and an increased DMAA. Maternal transmission was noted in 72% of patients. An increased distal metatarsal articular angle was noted in 48% of cases. With subluxation of the first MTP joint, the average DMAA was 7.9 degrees. With a congruent joint, the average DMAA was 15.3 degrees. In patients where hallux valgus occurred at age 10 or younger, the DMAA was increased. First metatarsal length was compared with second metatarsal length. While the incidence of a long first metatarsal was similar to that in the normal population (30%), the DMAA was 15.8 degrees for a long first metatarsal and 6.0 degrees for a short first metatarsal. An increased DMAA may be the defining characteristic of juvenile hallux valgus. The success of surgical correction of a juvenile hallux valgus deformity is intimately associated with the magnitude of the DMAA. Moderate and severe pes planus occurred in 17% of cases, which was no different than the incidence in the normal population. No recurrences occurred in the presence of pes planus. Pes planus was not thought to have an affect on occurrence or recurrence of deformity. Moderate and severe metatarsus adductus was noted in 22% of cases, a rate much higher than that in the normal population. The presence of metatarsus adductus did not affect the preoperative hallux valgus angle or the average surgical correction of the hallux valgus angle. Constricting footwear was noted by only 24% of patients as playing a role in the development of juvenile hallux valgus. There were six recurrences of the deformities and eight complications (six cases of postoperative hallux varus, one case of wire breakage, and one case of undercorrection).     

The Ludloff osteotomy: a critical analysis

Fourteen Ludloff (oblique shaft) osteotomies were performed to reduce the first intermetatarsal angle on 12 female patients whose average age was 47 years. Average reduction of the first intermetatarsal angle was 6.5 degrees (postoperative average, 9.4 degrees). Average hallux abductus angle reduction was 16.7 degrees (postoperative average, 13.4 degrees). These reductions were statistically significant (P < or = 0.05). Average first metatarsal shortening was 1.4 mm. No transfer lesions nor lesser metatarsal stress fractures were noted. One patient (a 30+ pack/year smoker) sustained a delayed union. The average American Orthopedic Foot and Ankle rating score was 92.3 out of 100. Average follow-up was 48 months. This procedure is a viable alternative to closing base wedge osteotomies.     

Mitchell's osteotomy of hallux valgus

45 patients were included in a prospective study to evaluate the results of Mitchell's osteotomy of hallux valgus. 43 patients complained of pain preoperatively. 44 patients were reviewed after one year, and excellent results were achieved in alleviating pain for 35 of these patients. Four patients developed metatarsalgia after surgery. There was a mean improvement in the hallux valgus angle of eight degrees. The mean shortening of the first metatarsal was 6 mm (1-12 mm). This shortening showed no correlation with postoperative pain. Signs of osteoarthrotic changes in the metatarsophalangeal joint were found in one patient and early signs of osteonecrosis of the first metatarsal head in two. We conclude that in spite of some serious complications this method produces satisfactory results and can be recommended when pain over the medial prominence is the main indication.     

Juvenile hallux abducto valgus association with metatarsus adductus

The authors evaluated the radiographs of 40 patients (72 feet) under 21 years of age who underwent surgery for symptomatic hallux abducto valgus deformity at Northlake Regional Medical Center. Forty-eight of 72 feet had metatarsus adductus angles greater than 15 degrees. A statistically significant correlation was found between an increasing metatarsus adductus angle and an increasing hallux abductus angle.     

The Kalish osteotomy. A review and retrospective analysis of 265 cases

One hundred seventy-two patients (265 feet) were reviewed following correction of hallux abducto valgus surgery, using the Kalish modification of the Austin bunionectomy. Fifty-three cases were followed up on an average of 2.5 years from 1986 through 1992. The statistical results support the use of this osteotomy with rigid internal fixation for the reduction of the intermetatarsal angle, hallux abductus angle, and tibial sesamoid position. Patients are weightbearing immediately and are usually back in soft shoes or sneakers 2 weeks after surgery. Surgical techniques and complications of this procedure are discussed to help surgeons use this procedure in correcting hallux abducto valgus deformities.     

Fryns syndrome: prenatal diagnosis and pathologic correlation

From 1988 to 1995, 96 patients (161 feet) underwent a modified Mitchell distal metatarsal osteotomy performed for mild-to-moderate hallux valgus. On AP x-rays of the standing foot, the average intermetatarsal angle was corrected from 15 degrees to 9 degrees, and the first metatarsophalangeal angles were corrected from an average of 41 degrees to 15 degrees. Criteria for evaluation of clinical results included relief of pain, appearance of foot, and shoe wear. After an average follow-up of 38 months, the overall satisfaction rate was 92.5%. Complications included 13 pin tract infections, two delayed unions, and two correction losses. The most common late sequela was transfer metatarsalgia of the lesser toes, which occurred in 20 feet (12.4%), leading to some dissatisfaction. The Mitchell osteotomy can be used on cases with less than 20 degrees of intermetatarsal angle, offering a stable construct with easy postoperative care.     

Follow-up results 17 years after resection arthroplasty of the great toe

Resection arthroplasty of the first metatarsophalangeal joint is a well-known operation. The follow-up results more than 17 years after arthroplasty for hallux valgus are reported and discussed. Between 1971 and 1980, 335 resection arthroplasties were performed on 205 patients. The sole indication for resection arthroplasty of the great toe in this study was hallux valgus. The technique involved removal of the proximal one-third of the phalanx with interposition of a capsular flap, occasionally including temporary Kirschner wire fixation. After 17.6 years on average, 102 patients were re-examined clinically and radiographically. Questionnaire assessment revealed a significantly prolonged walking distance, and 70% of the patients were pain-free at follow-up investigation, whereas 67% suffered from severe pain before the operation. Clinical evaluation showed diminished weight-bearing of the great toe during walking and a reduced range of motion of the resected first metatarsophalangeal joint. Radiographic shortening of the proximal phalanx was 37%. The average hallux valgus angle was 23 degrees at follow-up and 34 degrees prior to surgery. The unacceptably high rate of hallux valgus relapse, especially due to a high intermetatarsal angle, emphasizes the unsatisfactory long-term results of the resection arthroplasty. We now recommend this operation for older patients only, and a differentiated approach using reconstructive procedures according to the clinical and radiographical situation for younger patients.     

Preventing loss of the great toe with the hallux interphalangeal joint arthroplasty

Chronic ulcerations of the hallux may result in amputation if infection becomes uncontrolled. Salvage of the hallux often requires surgical intervention when conservative measures fail. Many authors have described various procedures to prevent recurrent ulceration and the potential for loss of the great toe. The authors have reviewed their experience with the hallux interphalangeal joint arthroplasty for chronic neuropathic ulcers of the great toe. Between August 1988 and July 1991, the authors performed 46 hallux interphalangeal joint arthroplasties on 40 patients (22 males, 18 females). Of the 40 original patients, one patient was lost to follow-up in the immediate postoperative period, leaving 45 procedures on 39 patients. Thirty-six feet were noted to heal both the procedure and ulceration uneventfully (80%). There were five minor complications (11%). Four cases were deemed failures (9%). Overall, 41 feet (91%) healed and had no evidence of recurrence in the follow-up period. Follow-up was an average of 23.6 months (range 4-44 months). The hallux interphalangeal joint arthroplasty has been a valuable procedure for chronic ulcerations of the hallux. By allowing these ulcers to heal, loss of the great toe has been avoided. Function and structure of the foot has been maintained.     

Radiographic course after acetabuloplasty and femoral osteotomy in hip dysplasia

The radiographic course of 101 hips with residual dysplasia treated with roof plasty combined with intertrochanteric varus derotation osteotomy using the osteotomy wedge as a roof graft after Mittelmeier were reviewed. The average followup period was 8.8 years. The acetabular angle was improved by an average of 16 degrees (postoperative mean, 19 degrees; average at followup, 18 degrees). The center edge angle also was improved by 16 degrees and was stable at 25 degrees average at followup. The neck shaft angle, abnormal in 70% of hips preoperatively, was reduced by the varus osteotomies to a mean of 111 degrees and showed a spontaneous postoperative increase to normal values of an average of 129 degrees. There was no correlation of the postoperative of the neck shaft angle to patient age, preoperative valgus extension, correction angle, or length of followup. In nearly all cases, an almost anatomic joint shape was achieved. With a complication rate of only 1%, especially regarding the rate of necroses of the femoral head, the presented surgical technique can be recommended as highly effective, reliable, and safe for the treatment of congenital hip dislocation.     

Flexor tendon transfer for metatarsophalangeal instability of the second toe

Flexor to extensor transfer was used to treat painful second metatarsophalangeal joint instability in thirteen feet in eleven patients. All patients had their pain reproduced with vertical stress motion of 50% to 100% at the metatarsophalangeal joint. Seven feet had concomitant hallux valgus correction, two feet had no hallux valgus, and four feet underwent no correction for asymptomatic hallux valgus. Results at an average of 33.4 months followup showed that all patients had substantial pain relief, with eight patients becoming pain-free, and five patients experiencing mild pain. All but one were satisfied with their result. Stiffness appeared to be the source of the mild residual pain. All toes, including six toes with preoperative medial crossover toe deformity, were corrected into valgus alignment with adjacent toes. All toes operated on for the first time were able to touch the ground with grasp postoperatively. Flexor to extensor transfer is successful in reducing the second toe and relieving pain caused by instability of the second metatarsophalangeal joint, but may require rapid postoperative mobilization to ensure passive dorsiflexion equal to that of the adjacent toes to reduce postoperative uncomfortable stiffness.     

Correlation between the prevalence of certain fungi and sick building syndrome

We retrospectively reviewed the results of using a biplanar chevron osteotomy performed on patients who presented with hallux valgus deformities with an increased distal metatarsal articular angle (DMAA). The study included 17 feet (14 patients) of 12 women and 2 men. The average follow-up was 33 months. The average American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Clinical Rating Score was 91. Ten of the 14 patients (13 of 17 feet) stated that they would choose to undergo the procedure again. The hallux valgus angle was improved from an average of 22 degrees to 18 degrees, the intermetatarsal angle from 11 degrees to 9 degrees, and the DMAA from 16 degrees to 9 degrees. We have demonstrated this procedure to be useful in the treatment of symptomatic bunion deformities with an increased DMAA.     

The "Z" osteotomy versus the Kalish osteotomy for the correction of hallux abducto valgus deformities: a retrospective analysis

A retrospective analysis of hallux abducto valgus surgery performed between 1990 and 1995 where the "Z" osteotomy and Kalish osteotomy were utilized was performed. Objective and subjective data were collected to determine the effectiveness of the Z osteotomy versus the Kalish osteotomy. Twenty cases of hallux abducto valgus where the Z osteotomy was utilized were evaluated on the basis of intermetatarsal angle correction and alleviation of preoperative symptoms. The same evaluation was performed on 21 cases where the Kalish osteotomy was utilized. There did not appear to be an appreciable difference in intermetatarsal angle correction between the two osteotomies; however, the Kalish osteotomy did alleviate preoperative symptoms to a greater degree compared with the Z osteotomy.     

Alternate method of reducing metatarsus primus adductus angle

Dr. Evins suggests a relatively simple technique to reduce the metatarsus primus adductus angle associated with hallux abducto valgus. It is used in conjunction with other bunionectomies--often with the modified McBride bunionectomy or the Reverdin osteotomy--with satisfactory results and often makes the Logroscino double osteotomy unnecessary.     

Evaluation of the efficacy of thiamine and pyridoxine in the treatment of symptomatic diabetic peripheral neuropathy

Our purpose in this study was to determine the effects of cheilectomy on the mechanics of dorsiflexion of the first metatarsophalangeal (MTP) joint. Ten fresh-frozen cadaver feet were utilized, of which two demonstrated radiographic evidence of hallux rigidus. Each specimen was rigidly mounted on a custom-made slide tray that was articulated with a hinge mechanism designed to dorsiflex the first MTP joint. Range-of-motion measurements were made on the first MTP joint. Cheilectomy of 30% of the metatarsal head diameter was performed. Lateral radiographs with the beam centered on the MTP joint were taken with the joint at neutral, 20 degrees, 40 degrees, and at the limits of dorsiflexion. This process was repeated after a 50% cheilectomy was performed. The radiographs were examined for changes in joint congruence and in patterns of surface motion as the hallux moved from neutral to full dorsiflexion. Instant centers of rotation were determined by a method first described by Rouleaux. We constructed surface velocity vectors to describe patterns of motion of the first MTP joint. The mean dorsiflexion of the first MTP joint was 67.9 degrees and increased to 78.3 degrees after 30% cheilectomy. The increase in dorsiflexion was significantly greater in the two specimens with hallux rigidus (33%) than in the other specimens (12.1%). After both levels of cheilectomy, the proximal phalanx demonstrated pivoting at the resection site on the metatarsal head. This pivoting resulted in abnormal motion patterns across the MTP joint. Normal sliding motion predominated in early dorsiflexion, with compression peaking at the end stage of dorsiflexion, producing jamming of the articular surfaces. Cheilectomy significantly increased dorsiflexion of the MTP joint, but resulted in abnormal motion patterns. The increase in dorsiflexion resulted from pivoting of the proximal phalanx on the metatarsal head, resulting in anomalous velocity vectors and compression across the MTP joint.