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Background: Operative treatment is indicated for patients who have symptomatic hallux valgus (HV) with moderate to severe metatarsus adductus (MA). However, there is limited information available on the operative procedures and outcomes for the treatment of HV with MA. We aimed to investigate the average 10-year follow-up clinical and radiologic outcomes., Methods: Seventeen patients (21 feet, average age: 60.1 years) with symptomatic HV with moderate to severe MA were operatively treated. Mean postoperative follow-up duration was 114.4 (24-246) months. All feet had metatarsus adductus angle ≥20 degrees on dorsoplantar weight-bearing radiograph. The procedure included a proximal crescentic osteotomy of the first metatarsal and abduction osteotomy of the proximal third of the second and third metatarsals., Results: The mean American Orthopaedic Foot & Ankle Society scale score improved significantly postoperatively ( P < .001). The mean postoperative visual analog scale score (17 feet) was 2.0 (0-6). Preoperative metatarsalgia was severe in 2 feet, moderate in 17, and mild in 2. At the most recent follow-up evaluation, 11 feet had no pain, 9 had mild pain, and 1 had moderate pain. The mean hallux valgus angle, intermetatarsal angle, and metatarsus adductus angle significantly decreased postoperatively ( P < .001 for all). Recurrence of HV (HV angle ≥ 20 degrees) was observed in 4 feet., Conclusion: The clinical and radiologic results indicated that our novel operative treatment for HV with moderate to severe MA can achieve significant correction of HV with MA deformities and significant improvement in pain and function., Level of Evidence: Level IV, retrospective case series.

Background: Metatarsus adductus (MA) is a congenital condition in which there is adduction of the metatarsals in conjunction with supination of the hindfoot through the subtalar joint. It is generally believed that MA precedes the development of hallux valgus. Historically, studies have demonstrated that patients with a history of MA were ~3.5 times more likely to develop hallux valgus. The purpose of this study was to identify the relative prevalence of MA in patients undergoing surgery for symptomatic hallux valgus., Methods: Between 2002 and 2012, 587 patients who underwent hallux valgus surgery were retrospectively identified following IRB approval and parameters including the hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the metatarsus adductus angle (MAA) were recorded. The MAA was considered abnormal if the value was greater than 20 degrees. Interobserver and intraobserver reliability studies for the measurement of the MAA were completed as well., Results: Using the modified Sgarlato technique for measurement of the MAA, there was a high interobserver and intraobserver reliability. The interclass and intraclass coefficients were greater than .90. The prevalence of MA in this patient population was found to be 29.5%. Of those patients with MA, 23 males and 150 females were identified. This gave a male to female ratio of 1:6.5 (P < .00001). Lesser toe deformities (claw toes, hammertoes) were the most commonly associated diagnoses identified. When stratified by severity, 113 (65%) patients had an MAA between 21 and 25 degrees, 41 (23.7%) had an MAA between 26 and 30 degrees, 8 (4.6%) patients had an MAA between 31 and 35 degrees, and 11 (6.3%) patients had an MAA greater than 36 degrees., Conclusion: Historically the prevalence of MA in patients with hallux valgus has been reported to be 35%. The data in this study indicate a comparable prevalence at 29.4%. The presence of concomitant MA may portend different outcomes for operative treatment of hallux valgus. Further research needs to delineate rates of persistence of deformity in this patient population to guide operative management., Level of Evidence: Level IV, case series., (© The Author(s) 2014.)

Background: The occurrence of musculoskeletal foot disorders differs by race and obesity, and these disorders may be related to pronated (low arch) or supinated (high arch) foot structure. This cross-sectional analysis examined relationships of foot disorders and foot function by race and obesity in a community-based observational study of adults 50+ years old with and without osteoarthritis., Methods: Members of a prospective cohort study in North Carolina were included in this analysis (N = 1466, 67.2% women, 29.5% African American, mean age 68.5 years). Foot disorders were identified with a validated assessment tool, and each foot was categorized as overpronated, oversupinated, and referent using the center of pressure excursion index from foot pressure scans during normal-paced walking. Logistic regression models estimated associations between foot function and each foot disorder with age, body mass index (BMI), gender, and race as covariates., Results: Compared to referent, an overpronated foot was associated with hallux valgus (adjusted odds ratio [aOR] 1.36, 95% confidence interval [CI] 1.13-1.65) and overlapping toes (aOR 1.36, 95% CI 1.12-1.64), especially in the obese. An oversupinated foot was inversely associated with hallux valgus (aOR 0.85, 95% CI 0.74-0.97). An oversupinated foot was less likely to be associated with bunionettes among the obese and was more likely to be associated with plantar fasciitis in Caucasians., Conclusion: Foot function was related to hallux valgus and overlapping toes, especially among the obese. In clinical patients as well as in the community of older adults, treatments for both the foot disorder and the pronated/supinated foot may be needed., Level of Evidence: Level II, comparative cohort study., (© The Author(s) 2014.)

Background: Hallux valgus (HV) is frequently associated with other forefoot disorders, but its influence on preoperative quality of life (QOL) has not been well characterized. The main purpose of this study was to assess the influence of common associated forefoot disorders (metatarsalgia and lesser toe deformities) on preoperative QOL in patients with HV., Methods: Preoperative QOL assessed through the Short Form-36 (SF-36, version 2) was obtained from 94 patients with HV from a database. Patients were classified according to their condition: HV alone, HV and metatarsalgia, HV and lesser toe deformities, and HV and both metatarsalgia and lesser toe deformities. Values of each domain were compared among groups. In addition, a correlational study between SF-36 and radiographic severity of HV was performed. The mean age of the 94 patients was 62.6 ± 12.3 years. There were 42.6% patients with HV alone, 30.8% with HV and metatarsalgia, 16% with HV and lesser toe deformities, and 10.6% with HV and both metatarsalgia and lesser toe deformities., Results: Patients with HV and associated metatarsalgia and lesser toe deformities had significantly worse physical function (P = .029), role-physical (P = .017), bodily pain (P = .045), role-emotional (P = .016), mental health (P = .001), and mental component summary (P = .003) compared to patients with HV alone. There were no significant correlations between radiographic HV and intermetatarsal angles and any of the domains or summaries of the SF-36., Conclusion: Patients with HV and both metatarsalgia and lesser toe deformities have significantly worse QOL compared to patients with HV alone. The presence of associated forefoot deformities may be a discriminating factor for the prioritization of surgical treatment of HV., Level of Evidence: Level III, cross-sectional study.

Background: The standard treatment for hallux valgus in rheumatoid arthritis has been arthrodesis of the first metatarsophalangeal (MTP) joint. There is limited literature regarding the results of hallux valgus procedures which preserve the first MTP joint in rheumatoid patients. We investigated the radiographic and clinical outcomes of joint-preserving surgery for hallux valgus in a series of rheumatoid patients to evaluate the result of nonarthrodesis reconstruction., Methods: Thirty-seven feet with hallux valgus in 27 patients with RA treated with a joint-preserving procedure of the first MTP joint were analyzed radiographically and clinically. Average follow-up was 42 (range, 12-111) months. Twenty feet had Ludloff osteotomies, 15 had scarf osteotomies, and 2 had chevron osteotomies. Radiographs were evaluated preoperatively and postoperatively for hallux valgus angle, 1-2 intermetatarsal angle, and degenerative narrowing of the first MTP joint based the Sharp score and the Larsen grade. Narrowing of the first interphalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson. Operative complications and required secondary surgeries were tabulated. Clinical outcomes were measured using preoperative and postoperative Short Form-36 (SF-36), AOFAS forefoot scale, and Visual Analogue Scale (VAS) pain questionnaires., Results: The average hallux valgus angle improved from 37 degrees preoperatively to 15 degrees postoperatively. The average 1-2 intermetatarsal angle improved from 14 degrees preoperatively to 5 degrees postoperatively. The average Sharp score of the first MTP joint was 0.9 preoperatively and 1.6 postoperatively. The average Larsen grade of the first MTP joint was 0.6 preoperatively and 1.4 postoperatively. Range of motion of the first MTP joint was essentially unchanged between preoperative and postoperative measurements. Seven of 37 feet had progression of first IP joint space narrowing, but none were symptomatic. The AOFAS score improved from 45.2 preoperatively to 82.6 at final follow-up (P value < .01). The VAS decreased from 4.8 preoperatively to 1.5 at final follow-up (P value < .02). The SF-36 physical component score decreased from 40.3 preoperatively to 37.4 at final follow-up, and the mental component score remained unchanged, and neither was statistically significant. There were 7 feet (19%) that required a return to surgery: 3 wound infections, 2 arthrodeses for progression of deformity, and 1 each for revision for recurrence and hardware removal., Conclusion: Rheumatoid arthritis patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have satisfactory clinical and radiographic outcomes. This procedure appeared to be a reasonable alternative to first MTP arthrodesis in patients with relatively preserved joints., Level of Evidence: Level IV, retrospective case series.

Background: The high frequency of hallux valgus deformities in females is well known and has been widely reported in the literature. This finding tends to obscure the importance and the characteristic details of hallux valgus deformities in males. The severity of the deformity, its onset at an earlier age, and its inheritability seem to be more frequent in males, but there are no reports in the literature to substantiate these concepts. The purpose of this study was to analyze these questions in regard to males with hallux valgus., Methods: The records and plain radiographs of 31 males (53 feet) with a diagnosis of hallux valgus that were treated over a 20-year period (1985-2005) were analyzed. During that same period, the senior author (CN) performed 812 procedures for the correction of hallux valgus deformities in women. In order to compare gender-related differences associated with this deformity, 31 women's charts-paired by age and affected side-were randomly selected and both clinical and radiological data were statistically compared., Results: The onset of the complaints of first ray pain in males was equally distributed by decades, indicating that the deformity begins earlier in this group. Among males, we found 68% of the subjects had a familial history of bunion deformities-58% were maternal and 10% were fraternal. In the control group of females, only 35% of the women reported inheritance of the deformity. No correlation with footwear was found among males. The radiographic measurements were significantly higher in the male group, which included the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the tarsal metatarsal angle (TMA). The main gender difference was found to be the DMAA with first metatarsophalangeal (MTP) joint congruence being much more common in males (males = 57%, females = 30%). No correlations were found for metatarsus primus varus or pes planus., Conclusion: Based on our observations, we conclude that hallux valgus in males is commonly hereditary in nature and is mainly transmitted by the mother, with early onset and higher severity when compared to women. We report a female/male ratio of 15:1. The main intrinsic factor associated with a hallux valgus deformity in males is a high DMAA., Level of Evidence: Level III, retrospective comparative series.

Background: The premise of this study was that after the correction of hallux-metatarsophalangeal pronation, the intraoperative interphalangeal angle (HIA) increases significantly, and that an additional Akin osteotomy (AO) is often needed. Therefore, the purpose of this study was to evaluate whether HIAs in hallux valgus (HV) feet were underestimated, and to assess the need for AO during HV correction., Method: This study was conducted on 54 feet with moderate to severe HV treated from June 2007 to December 2008. HIAs and medial sesamoid subluxations (MSS) were measured initially and intraoperatively after a distal soft tissue procedure (DSTP) and proximal chevron metatarsal osteotomy (PCMO). An intraoperative technique was used to evaluate the incongruency of the metatarsophalangeal joint (MTPJ) to determine the need for additional AO., Results: After performing DSTP and PCMO, HIAs significantly increased from an average of 9 to 13.3 degrees and MSS reduced from average grade 2.5 to 0.5 (p < 0.05). AO was added in 44 (81%) feet. After an average followup of 13.2 months in Akin group, average VAS pain score decreased from 5.7 to 1.2 and average AOFAS score increased from 57.8 to 90.2 (p < 0.05). Final hallux MTPJ dorsiflexion in the Akin group was significantly larger than in the without-Akin group (p < 0.05)., Conclusion: Average HIA significantly increased after DSTP and PCMO for moderate to severe HV necessitating additional AO, to achieve ideal HV correction and, to preserve MTPJ motion.

Background: There are many forefoot deformities, including hallux valgus, forefoot overload, and hammertoe that are treated as unrelated problems with multiple different techniques. Currently, there has been renewed interest in the role of a gastrocnemius contracture on foot deformities. Our objective was to review a specific surgical treatment plan for forefoot deformities classified by us as Type 2 arch collapse and evaluate the outcomes., Materials and Methods: We retrospectively reviewed the charts of 374 patients who underwent foot procedures to treat deformity classified as a Type 2 arch collapse. Data was collected regarding complications and need for secondary surgery. A phone survey was performed to assess patient satisfaction, pain level, and Foot Function Index (FFI) scores., Results: Of the 374 patients (412 feet), there was a 96% (357 of 371 feet) union rate at the first tarsometatarsal joint and 98% (227 of 232 feet) union rate at metatarsal shortening osteotomy sites. Recurrence of hallux valgus was 2.7% (7 of 256 feet), while hallux varus occurred in 1.6% (4 of 256 feet). There were 292 patients (78%) available for phone interview. Of those patients, 88% were satisfied with the results of the procedure. The subset of procedures relating to the highest mean FFI was hammertoe correction (22.2) and the highest mean pain score was related to metatarsal shortening osteotomy (2.6)., Conclusion: Utilizing the arch collapse model, operative treatment of forefoot deformities with a combination of procedures including gastrocnemius recession, first TMT fusion, modified McBride, hammertoe correction, and metatarsal shortening osteotomy can produce good satisfaction rates with low complication rates.

Background: Painful plantar callosities under lesser metatarsal heads are commonly associated with hallux valgus. The purpose of the present study was to evaluate the prognosis of painful plantar callosities after hallux valgus correction without lesser metatarsal osteotomy in hallux valgus deformity., Materials and Methods: Between September 2004 and June 2007, 31 patients (40 feet) underwent proximal chevron first metatarsal osteotomy with a distal soft tissue procedure, with preoperatively painful plantar callosities under lesser metatarsal heads. Clinical results were evaluated using a visual analogue scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal interphalangeal scales, and a modified 70-point clinical scale. Radiographic evaluations included hallux valgus angle and intermetatarsal angle., Results: Thirty-two (80%) of the 40 feet had no pain and callosity and 5 (12.5%) had no pain but residual plantar callosities, and 3 (7.5%) were not improved at final evaluation. The mean VAS and AOFAS scores were improved from 7.8 +/- 1.6 to 1.9 +/- 1.5 points and from 53.8 +/- 14.2 to 92.6 +/- 15.3 points, respectively. In terms of the 70-point clinical scale, overall clinical results were good in 34 feet and fair in 6. The mean hallux valgus and intermetatarsal angles were improved from 36.6 +/- 6.2 to 12.5 +/- 5.9 degrees and from 17.5 +/- 3.9 to 8.6 +/- 3.5 degrees, respectively., Conclusion: Painful plantar callosities under the lesser metatarsals in patients with hallux valgus deformity can be improved by hallux valgus correction alone without lesser metatarsal osteotomy.

Background: Although surgical correction for hallux valgus and other toe deformities is one of the most common procedures in foot surgery, its incidence in the general population is not well-known., Materials and Methods: The study population comprised patients living in Sweden of a varied age group and both sexes who underwent forefoot surgery. We identified all inpatient cases from 1997 to 2000 and all ambulatory cases in 2000 registered in the National Swedish Patient Register (NSPR). Further, clinical data for the surgical treatment of hallux valgus deformity were extracted from medical records in patients treated in a geographically defined region (Stockholm)., Results: In total, 6956 patients with surgically treated forefoot deformities were identified from the adult population, equivalent to a cumulative incidence of 0.8 procedures per 1000 inhabitants for the whole analyzed group. There were regional variations and significant sex differences. The age distribution in both sexes was characterized by a peak in the fifth decade. Forefoot surgery was statistically more frequently performed in private clinics than in public hospitals (p < 0.001). Hallux valgus surgery was by far the most common procedure regarding forefoot surgery., Conclusion: The prevalence of forefoot- and hallux valgus surgery was not evenly distributed in the six major regions in Sweden. It is more common in urban than in rural regions. Furthermore, forefoot surgery is performed more frequently in private clinics than in community hospitals despite common financial sources.

Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.

The purpose of this study was to examine the prevalence of foot and ankle problems in 99 patients with clinically proven rheumatoid arthritis. Patients were recruited from outpatient rheumatology clinics; no attempt was made to select patients on the basis of the severity of their disease, duration of disease, or symptom constellation. Each patient was examined by an investigator utilizing a predesigned protocol to assess their functional status, functional capacity, and overall joint involvement. Ninety-three of 99 patients had complaints referable to the foot or ankle at some time since diagnosis of rheumatoid arthritis. Ankle problems were paramount in 42%, forefoot difficulties in 28%, and equal ankle and forefoot problems in another 14%. Only four patients had had any treatment involving foot orthotic devices or special shoe wear. The prevalence of foot and ankle symptoms was related to the duration of systemic illness, but was present in > 50% of patients at any time after diagnosis of rheumatoid arthritis. Patients with longstanding rheumatoid arthritis have a high prevalence of foot and ankle symptoms. Unlike previous reports, the present study found a high prevalence of ankle and hindfoot symptoms, as opposed to forefoot complaints. Despite this finding, the patients had been treated infrequently by either conservative nonoperative management directed at accommodating footwear or surgical intervention to favorably alter their foot and ankle mechanics.