JBJS | Article

The Journal of Bone & Joint Surgery, Volume 81, Issue 12

Articles | December 01, 1999

Application of Bone Graft to the Medial Side of the First Metatarsal Head in the Treatment of Hallux Varus*

A. ROCHWERGER, M.D.†; G. CURVALE, M.D., PROF.†; P. GROULIER, M.D., PROF.†, MARSEILLE, FRANCE

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Investigation performed at Hôpital de la Conception, Marseille

The Journal of Bone & Joint Surgery. 1999; 81:1730-5

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Abstract

Background: Hallux varus deformity is not frequent, is usually acquired, and is poorly tolerated by patients. A common cause is the resection of an excessive amount of the head of the first metatarsal during an operation performed to correct a hallux valgus deformity. The purpose of this study was to evaluate the results of application of bone graft to the medial aspect of the first metatarsal head in order to restore missing bone after resection of an excessive amount of bone during a bunionectomy.Methods: Of thirty patients who had a hallux varus deformity that was treated operatively, eight (ten feet) had bone-grafting to the medial aspect of the first metatarsal head. Six patients (seven feet) were available for evaluation at an average of 8.6 years (range, two to twenty-two years) postoperatively. The original reasons for the consultation for the hallux varus deformity were pain in the great toe, discomfort with shoewear, and the cosmetic appearance of the deformity. The pain typically was located on the medial aspect of the great toe and was caused by the pressure of the shoe; the pain usually was aggravated by walking. Preoperatively, the passive range of dorsiflexion averaged 72 degrees (range, 60 to 80 degrees); the passive range of plantar flexion, 12 degrees (range, 10 to 20 degrees); and the varus deformity, 18 degrees.Results: Six of the seven feet had a satisfactory result. The pain associated with the varus deformity had disappeared in all patients. One patient was dissatisfied because of 20 degrees of valgus angulation. The passive range of dorsiflexion averaged 63 degrees (range, 60 to 70 degrees), and all patients had 10 degrees of plantar flexion. Overall, the valgus angulation of the metatarsophalangeal joint averaged 19 degrees (range, 16 to 22 degrees). There was no recurrence or persistence of the varus deformity. In three feet, the joint space was reduced, but this did not jeopardize the clinical result.Conclusions: A bone graft screwed onto the medial aspect of the metatarsal head provided a good result. This technique is indicated when the varus deformity is related to a previous resection of an excessive amount of bone during a bunionectomy and when the deformity is passively reducible to neutral.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Hallux varus is most often iatrogenic, occurring as a complication of operative correction of a hallux valgus deformity when an excessive amount of the metatarsal head is resected. The hallux varus deformity is uncomfortable and unsightly, creates a problem with shoewear, and is disappointing to both the patient and the surgeon. In series ranging from thirty-one to 1100 procedures, the prevalence of acquired hallux varus deformity ranged from 1 percent (three of 300) to 5 percent (eleven of 210)^5,8,10,11. Contraction of scar tissue in the intermetatarsal space and on the medial aspect of the first metatarsophalangeal joint is common in all patients who have hallux varus.

Isolated release of the metatarsophalangeal joint is rarely performed^13,19 because it does not totally solve the problem. However, it is part of other operative procedures. Several authors have described different techniques^2,4,9,11,18 with use of tendon transfer to correct the muscular imbalance related to the transfer of the conjoined tendon of the adductor hallucis. Arthrodesis is suggested by most authors^1,6,13,16 as the standard treatment for patients who have stiffness and degenerative arthritis involving the metatarsophalangeal joint. In some patients, hallux varus may be attributable to resection of an excessive amount of the metatarsal head during a bunionectomy. Repair with a medial bone graft screwed into place has been proposed for such patients¹⁵; however, to our knowledge, the long-term results of this technique have not been reported in the literature. In our orthopaedic department, we have used three different techniques: a soft-tissue procedure consisting of release of the metatarsophalangeal joint capsule, arthrodesis, and use of a bone graft screwed medially onto the metatarsal head. The purpose of this study was to evaluate the results of the third technique.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, The Marseille School of Medicine, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille CEDEX 05, France.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, The Marseille School of Medicine, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille CEDEX 05, France.

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Figs. 1-A, 1-B, and 1-C: Case 6. Dorsoplantar weight-bearing radiographs of a woman who had the index procedure when she was forty-five years old. Fig. 1-A: Radiograph showing a reducible 10-degree hallux varus deformity that occurred after excessive resection of bone during a bunionectomy and a varization osteotomy of the first metatarsal. Grafting of bone to the metatarsal head was performed in 1976.

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Fig. 1-B: One year postoperatively, the patient had had no recurrence of the deformity and there was correct articular congruence.

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Fig. 1-C Twenty-two years later, there was an excellent subjective result despite the reduced joint space seen on the radiograph. The hallux valgus was 16 degrees.

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Figs. 2-A and 2-B: Case 2. Dorsoplantar weight-bearing radiographs of a woman who had the index procedure when she was forty-six years old. Fig. 2-A: Radiograph showing the appearance of the foot resulting from excessive resection of bone during a bunionectomy. The angle between the first and second metatarsals is 8 degrees, and the metatarsophalangeal joint is in 10 degrees of varus angulation.

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Fig. 2-B: Five years after a bone graft was screwed onto the medial aspect of the metatarsal head, the angle between the first and second metatarsals was 12 degrees and there was a 22-degree valgus angulation of the metatarsophalangeal joint. The size of the screws used in this patient is more appropriate than that of the screws used in the patient in Figs. 1-A, 1-B, and 1-C, who was operated on in 1976.

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TABLE I CHARACTERISTICS OF THE PATIENTS

Case	Gender, Age (yrs.)	Interval from Onset of Hallux Varus to Operation (yrs.)	Etiology of Hallux Varus
1R	F, 19	5	Recentering
1L		4	Recentering
2	F, 46	8	McBride proc.
3	F, 38	2	McBride proc.
4R	M, 60	4	McBride proc.
4L		7	McBride proc.
5	F, 54	5	Recentering
6	F, 45	1	McBride proc.
7	F, 46	6	Petersen proc.
8	F, 34	12	Unknown

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TABLE I CHARACTERISTICS OF THE PATIENTS

Case	Gender, Age (yrs.)	Interval from Onset of Hallux Varus to Operation (yrs.)	Etiology of Hallux Varus
1R	F, 19	5	Recentering
1L		4	Recentering
2	F, 46	8	McBride proc.
3	F, 38	2	McBride proc.
4R	M, 60	4	McBride proc.
4L		7	McBride proc.
5	F, 54	5	Recentering
6	F, 45	1	McBride proc.
7	F, 46	6	Petersen proc.
8	F, 34	12	Unknown

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TABLE II PREOPERATIVE DATA

Case	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Reducibility of Deform.	Stiffness of Metatarso- phalangeal Joint	Hallux Varus (degrees)	Angle Between First and Second Metatarsals (degrees)	Degen. Changes of Metatarso- phalangeal Joint on Radiographs
1R	Yes	70/10	Yes	Daily	Yes	Yes	No	28	6	No
1L	Yes	80/10	Yes	Daily	Yes	Yes	No	16	6	No
2	Yes	70/20	Yes	Recreational	Yes	Yes	No	10	8	No
3	Yes	80/20	Yes	Daily	Yes	Yes	No	28	4	No
4R	Yes	80/10	Yes	Daily	Yes	Yes	No	18	6	No
4L	Yes	60/10	Yes	Daily	Yes	Yes	No	12	6	No
5	Yes	70/10	Yes	Daily	Yes	Yes	No	10	3	No
6	Yes	80/10	Yes	Daily	Yes	Yes	No	10	0	No
7	Yes	70/10	Yes	Daily	Yes	Yes	No	24	6	No
8	Yes	60/10	Yes	Daily	Yes	Yes	No	28	6	No

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TABLE II PREOPERATIVE DATA

Case	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Reducibility of Deform.	Stiffness of Metatarso- phalangeal Joint	Hallux Varus (degrees)	Angle Between First and Second Metatarsals (degrees)	Degen. Changes of Metatarso- phalangeal Joint on Radiographs
1R	Yes	70/10	Yes	Daily	Yes	Yes	No	28	6	No
1L	Yes	80/10	Yes	Daily	Yes	Yes	No	16	6	No
2	Yes	70/20	Yes	Recreational	Yes	Yes	No	10	8	No
3	Yes	80/20	Yes	Daily	Yes	Yes	No	28	4	No
4R	Yes	80/10	Yes	Daily	Yes	Yes	No	18	6	No
4L	Yes	60/10	Yes	Daily	Yes	Yes	No	12	6	No
5	Yes	70/10	Yes	Daily	Yes	Yes	No	10	3	No
6	Yes	80/10	Yes	Daily	Yes	Yes	No	10	0	No
7	Yes	70/10	Yes	Daily	Yes	Yes	No	24	6	No
8	Yes	60/10	Yes	Daily	Yes	Yes	No	28	6	No

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TABLE III POSTOPERATIVE DATA

*Two patients (Cases 3 and 4 [three feet]) were not included in this analysis.

Case*	Durat. of Follow-up (yrs.)	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Hallux Valgus (degrees)	Markedly Reduced Joint Space	Angle Between First and Second Metatarsals (degrees)	Result	Patient Satisfied with Result
1R	6	Mild	60/10	Yes	Recreational	No	20	No	12	Fair	Wants less valgus of metatarso- phalangeal joint
1L	7	No	70/10	No	No	No	18	No	12	Good	Yes
2	5	No	70/10	No	No	No	22	No	12	Good	Yes
5	10	No	60/10	No	No	Yes	20	Yes	8	Good	Yes
6	22	No	60/10	No	No	No	16	Yes	2	Good	Yes
7	8	No	60/10	No	No	No	16	Yes	8	Good	Yes
8	2	No	60/10	No	No	No	18	No	12	Good	Yes

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TABLE III POSTOPERATIVE DATA

*Two patients (Cases 3 and 4 [three feet]) were not included in this analysis.

Case*	Durat. of Follow-up (yrs.)	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Hallux Valgus (degrees)	Markedly Reduced Joint Space	Angle Between First and Second Metatarsals (degrees)	Result	Patient Satisfied with Result
1R	6	Mild	60/10	Yes	Recreational	No	20	No	12	Fair	Wants less valgus of metatarso- phalangeal joint
1L	7	No	70/10	No	No	No	18	No	12	Good	Yes
2	5	No	70/10	No	No	No	22	No	12	Good	Yes
5	10	No	60/10	No	No	Yes	20	Yes	8	Good	Yes
6	22	No	60/10	No	No	No	16	Yes	2	Good	Yes
7	8	No	60/10	No	No	No	16	Yes	8	Good	Yes
8	2	No	60/10	No	No	No	18	No	12	Good	Yes

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Between June 1976 and January 1996, we managed thirty-seven patients who had a hallux varus deformity. The records and original radiographs of these patients were reviewed, and those who had complete documentation of acquired hallux varus deformity were identified. Two patients had congenital hallux varus, one had died, and four had been lost to follow-up or were excluded from the study because of a lack of documentation. Of the thirty patients who were available for the study, eight (ten feet) had had grafting of bone to the first metatarsal head (two patients had had the condition bilaterally). All deformities were iatrogenic; they occurred after correction of a bunion. Two patients (three feet) were not available for follow-up.

Release of the metatarsophalangeal joint capsule in conjunction with grafting of bone to the medial aspect of the first metatarsal head to compensate for a defect after extensive resection of bone during a bunionectomy was indicated when the deformity was reducible, no stiffening was present, and there was no arthritic involvement of the metatarsophalangeal joint.

Of the eight patients, seven were female and one was male; the average age at the time of the bone-grafting was forty-three years (range, nineteen to sixty years) (Table I). All patients had sought the consultation because of pain in the great toe, discomfort with shoewear, and the cosmetic appearance of the deformity. The pain typically was located on the medial aspect of the great toe and was caused by the pressure of the shoe. Usually, the pain was aggravated by walking.

Each patient had a detailed physical examination of the foot, including evaluation of the deformities of the toes and their reducibility and determination of the range of motion of the toes (Table II). Tenderness in the metatarsophalangeal joint, clawing of the great toe and the toe adjacent to it, and joint stiffening were evaluated. Dorsoplantar and lateral radiographs of the foot were made preoperatively with the patient bearing weight. The defect in the metatarsal head was determined by drawing the margin of the medial cortex of the metatarsus on the dorsoplantar radiograph.

The initial treatment was known for nine of the ten feet. A McBride procedure with a phalangeal osteotomy had been performed in five feet (four patients); recentering of the metatarsosesamoidal sling, in three feet (two patients); and a Petersen procedure, in one foot (Table I). A bunionectomy with excessive resection of bone had been performed in all feet.

In order to restore the physiological valgus angulation, the surgeon began with removal of the medial contracted scar tissue, which caused medial deviation of the base of the first phalanx. Release also was performed on the lateral side of the first metatarsal in order to remove the fibrous knot that crowds the intermetatarsal space³ and to release the insertion of the transverse and oblique tendon of the adductor hallucis if it had been transferred onto the first metatarsal head. The freeing technique was carried out progressively and was stopped when valgus angulation was obtained spontaneously. Bone graft was obtained from the iliac crest. The graft was screwed into place and then was milled to eliminate overlapping edges that could prevent congruence of the metatarsophalangeal joint. Special postoperative shoes that resulted in weight-bearing on the heel were prescribed for all patients in order to avoid all weight-bearing on the forefoot for forty-five days.

The follow-up evaluation consisted of a clinical examination and a review of dorsoplantar and lateral radiographs of the foot, made with the patient bearing weight. The patients were also evaluated with use of a questionnaire, which included questions pertaining to pain, discomfort with shoewear, difficulty with activities of daily living because of problems with the foot, and overall satisfaction with the result of treatment. The result was considered good if the patient had no pain or limitation in daily or recreational activities while wearing shoes, fair if the patient had occasional mild pain and limitation in recreational but not daily activities, and poor if the patient had frequent pain and limitation in daily activities (Table III).

Results

Introduction | Materials and Methods | Results | Discussion | References

Preoperative examination showed a reducible varus deformity in all ten feet. This was a criterion for the operative procedure being performed. All ten feet had clawing of the great toe, but it was flexible and reducible. The preoperative passive range of motion averaged 72 degrees (range, 60 to 80 degrees) of dorsiflexion and 12 degrees (range, 10 to 20 degrees) of plantar flexion (Table II). The preoperative varus deformity averaged 18 degrees (range, 10 to 28 degrees). The angle formed by the first two metatarsal bones (metatarsus varus) averaged 5 degrees (range, 0 to 8 degrees). The medial sesamoid bone was clearly medial with respect to the first metatarsal in eight feet. A clinically excessive length of the first ray (that is, the so-called Egyptian pattern of the forefoot) was found in nine feet. All ten feet had had excessive resection of bone during a bunionectomy (Fig. 1-A). Two feet had a reducible varus deformity of the second toe. The average duration from the onset of the hallux varus to the operation was 5.4 years (range, one to twelve years) (Table I).

The results were evaluated for six patients (seven feet) at an average of 8.6 years (range, two to twenty-two years) postoperatively. Two patients (three feet) were not available for the long-term analysis: one did not answer our request for a repeat clinical examination, and one was lost to follow-up. Nevertheless, both patients had had a good clinical result (no recurrence of the varus deformity) at six months and acceptable hallux valgus and metatarsus varus as seen on radiographs. These results were not taken into account in the evaluation of the outcomes of the procedure for this study.

At the time of the latest follow-up, the result was considered good for six of the seven feet. The pain associated with the varus deformity had disappeared in all patients. One patient was dissatisfied with what she perceived to be an exaggeration of valgus angulation. Another patient had persistent, moderate clawing of the corrected great toe without clinical symptoms. The passive range of motion averaged 63 degrees (range, 60 to 70 degrees) of dorsiflexion, and all patients had 10 degrees of plantar flexion. On the dorsoplantar radiographs, valgus angulation averaged 19 degrees (range, 16 to 22 degrees) and the corresponding metatarsus varus averaged 9 degrees (range, 2 to 12 degrees). Varus of the second toe was completely reduced passively. In three feet, the joint space was markedly reduced, but this did not jeopardize the clinical result (Figs. 1-B and 1-C).

One patient had difficulty in wearing shoes, had mild pain during recreational activities, and had hallux valgus of 20 degrees. The result was considered fair in this patient. The other six feet had a good result (Figs. 2-A and 2-B). In two of the ten feet, the bone graft fragmented proximal to the drill-hole during the operation because of excessive tightening of the screw, but this fragmentation did not adversely affect the clinical or radiographic result. Radiographs showed good union of the graft to the metatarsal head, with correct articular congruence.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The importance of hallux varus as a debilitating problem has generally not been emphasized in the medical literature. The decision to operate depends on the symptoms of the patient, the severity of the deformity, and the effect of the deformity on function. In the absence of symptoms and of progression of the deformity, moderate hallux varus should not be treated operatively. In a previous study⁵ of 300 patients who had been managed operatively because of a hallux valgus deformity, ten patients had a moderate hallux varus deformity (range, 2 to 8 degrees), which was very tolerable. No patient had discomfort, and all were satisfied with the result of the operation for the hallux valgus deformity. Trnka et al.¹⁷ reported on thirteen patients who had a moderate hallux varus deformity eighteen years after the operation, and they similarly concluded that additional operative intervention was not warranted.

In contrast, if a patient has pain and severe hallux varus deformity, then operative management is a reasonable choice. We recommend that the deformity be corrected with use of operative procedures that restore physiological valgus angulation and avoid recurrence of varus angulation, in order to ensure a long-lasting result. These procedures vary according to the severity of the deformity and the state of the metatarsophalangeal joint, especially if the joint is stiff or has arthritic involvement.

The findings on the preoperative clinical and radiographic workup should determine the choice of operative procedure. In addition to the usual findings (that is, severe hallux varus and axial deformity of the great toe), it is important to determine the reducibility of the hallux varus deformity and the interphalangeal clawing, the stiffness of the metatarsophalangeal joint, and the effect of tendinous contractures or hypertonia on the flexor hallucis longus or the extensor hallucis longus¹². If the deformity is severe and not reducible and if it is complicated by stiffness and arthritic lesions of the joint, arthrodesis of the metatarsophalangeal joint should be performed^1,6,7,13,16. If the deformity is reducible and there is no stiffness or arthritis, different procedures can be used¹⁴.

We did not use tendon transfer in this study even though some of our patients could have been managed with that technique^2,4,11,13. In order to restore the normal valgus angulation of the phalanx, release of the joint capsule must be complete. The release is first performed on the medial aspect of the joint; the insertion of the tendon of the abductor hallucis is released carefully as distal as possible, in order to allow it to be used for transplantation if necessary⁸. Wood¹⁹ suggested freeing of the distal half of the metatarsal and the proximal half of the first phalanx. Peeling or stripping of the first metatarsal along its distal half is more likely to be effective but is associated with the risk of eventual necrosis because of destruction of the vascular supply to the metatarsal head.

Since June 1976, we have considered excessive resection of bone during a bunionectomy, which destabilizes the joint, to be a common etiology of hallux varus. It seems logical to repair this loss of bone from the medial aspect of the first metatarsal head by screwing on a bone graft in order to stabilize the metatarsophalangeal joint. We obtained a good long-lasting result in six of seven feet in the current series with use of this procedure, which is very similar to that described by Roy-Camille et al.¹⁵ in 1978. To our knowledge, the current series represents the first report of long-term results with use of this technique.

Although only seven of ten feet were available for follow-up, our findings support use of this technique for the repair of iatrogenic loss of bone from the metatarsal head in patients who have a reducible hallux varus deformity. Nevertheless, the best strategy is prevention—that is, avoiding overcorrection of hallux valgus in the first place.

References

Introduction | Materials and Methods | Results | Discussion | References

Andreasi, A.: Il trattamento dell'aluce varo iatrogeno medicate arthrodesi della metatarso-phalangea. Arch. Putti chir. organi mov.,36: 123-135, 1986.36123 1986 [PubMed]

Clark, W. D.: Abductor hallucis tendon transfer for hallux varus. J. Foot Surg.,23: 146-148, 1984.23146 1984 [PubMed]

Feinstein, M. H., and Brown, H. N.: Hallux adductus as a surgical complication. J. Foot Surg.,19: 207-211, 1980.19207 1980 [PubMed]

Goldman, F. D.; Siegel, J.; and Barton, E.: Extensor hallucis longus tendon transfer for correction of hallux varus. J. Foot and Ankle Surg.,32: 126-131, 1993.32126 1993

Groulier, P.: Le traitement chirurgical de l'hallux valgus et des métatarsalgies associées du deuxième rayon. Rev. chir. orthop.,76 (Supplement I): 117-130, 1990.76 (Supplement I)117 1990

Groulier, P.; Curvale, G.; Coillard, J.-Y.; and Franceschi, J.-P.: Hallux varus acquis post-opératoire—traitement chirurgical. A propos de 19 cas. Rev. chir. orthop.,78: 449-455, 1992.78449 1992 [PubMed]

Groulier, P.; Curvale, G.; Piclet-Legre, B.; and Kelberine, F.: L'arthrodèse de la première articulation métatarso-phalangienne. Rev. chir. orthop.,80: 436-444, 1994.80436 1994 [PubMed]

Hawkins, F. B.: Acquired hallux varus: cause, prevention and correction. Clin. Orthop.,76: 169-176, 1971.76169 1971 [PubMed]

Hunter, W. N., and Wasiak, G. A.: Traumatic hallux varus correction via split extensor tenodesis. J. Foot Surg.,23: 321-325, 1984.23321 1984 [PubMed]

Janis, L. R., and Donick, I. I.: The etiology of hallux varus: a review. J. Am. Podiatry Assn.,65: 233-237, 1975.65233 1975

Johnson, K. A., and Spiegl, P. V.: Extensor hallucis longus transfer for hallux varus deformity. J. Bone and Joint Surg.,66-A: 681-686, June 1984.66-A681 1984

Joseph, B.; Jacob, T.; and Chacko, V.: Hallux varus—a study of thirty cases. J. Foot Surg.,23: 392-397, 1984.23392 1984 [PubMed]

Maynou, C.; Podglajen, J.; Delobelle, J. M.; and Metsdagh, H.: Conceptions thérapeutiques dans l'hallux varus post-opératoire. Med. chir. pied.,10: 243-248, 1994.10243 1994

Miller, J. W.: Acquired hallux varus: a preventable and correctable disorder. J. Bone and Joint Surg.,57-A: 183-188, March 1975.57-A183 1975

Roy-Camille, R.; Lelièvre, J.-F.; and Saillant, G.: Hallux valgus hypercorrigé: redressement et maintien par butée interne. Nouv. presse med.,7: 3357-3358, 1978.73357 1978 [PubMed]

Tourné, Y.; Saragaglia, D.; Picard, F.; De Sousa, B.; Montbarbon, E.; and Charbel, A.: Iatrogenic hallux varus surgical procedure: a study of 14 cases. Foot and Ankle Internat.,16: 457-463, 1995.16457 1995

Trnka, H.-J.; Zettl, R.; Hungerford, M.; Mühlbauer, M.; and Ritschl, P.: Acquired hallux varus and clinical tolerability. Foot and Ankle Internat.,18: 593-597, 1997.18593 1997

Valtin, B.: Le transfert du premier interosseux dorsal dans le traitement chirurgical de l'hallux varus iatrogénique. Med. chir. pied,7: 9-16, 1991.79 1991

Wood, W. A.: Acquired hallux varus: a new corrective procedure. J. Foot Surg.,20: 194-197, 1981.20194 1981 [PubMed]

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Fig. 1-B: One year postoperatively, the patient had had no recurrence of the deformity and there was correct articular congruence.

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Fig. 1-C Twenty-two years later, there was an excellent subjective result despite the reduced joint space seen on the radiograph. The hallux valgus was 16 degrees.

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TABLE I CHARACTERISTICS OF THE PATIENTS

Case	Gender, Age (yrs.)	Interval from Onset of Hallux Varus to Operation (yrs.)	Etiology of Hallux Varus
1R	F, 19	5	Recentering
1L		4	Recentering
2	F, 46	8	McBride proc.
3	F, 38	2	McBride proc.
4R	M, 60	4	McBride proc.
4L		7	McBride proc.
5	F, 54	5	Recentering
6	F, 45	1	McBride proc.
7	F, 46	6	Petersen proc.
8	F, 34	12	Unknown

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TABLE I CHARACTERISTICS OF THE PATIENTS

Case	Gender, Age (yrs.)	Interval from Onset of Hallux Varus to Operation (yrs.)	Etiology of Hallux Varus
1R	F, 19	5	Recentering
1L		4	Recentering
2	F, 46	8	McBride proc.
3	F, 38	2	McBride proc.
4R	M, 60	4	McBride proc.
4L		7	McBride proc.
5	F, 54	5	Recentering
6	F, 45	1	McBride proc.
7	F, 46	6	Petersen proc.
8	F, 34	12	Unknown

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TABLE II PREOPERATIVE DATA

Case	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Reducibility of Deform.	Stiffness of Metatarso- phalangeal Joint	Hallux Varus (degrees)	Angle Between First and Second Metatarsals (degrees)	Degen. Changes of Metatarso- phalangeal Joint on Radiographs
1R	Yes	70/10	Yes	Daily	Yes	Yes	No	28	6	No
1L	Yes	80/10	Yes	Daily	Yes	Yes	No	16	6	No
2	Yes	70/20	Yes	Recreational	Yes	Yes	No	10	8	No
3	Yes	80/20	Yes	Daily	Yes	Yes	No	28	4	No
4R	Yes	80/10	Yes	Daily	Yes	Yes	No	18	6	No
4L	Yes	60/10	Yes	Daily	Yes	Yes	No	12	6	No
5	Yes	70/10	Yes	Daily	Yes	Yes	No	10	3	No
6	Yes	80/10	Yes	Daily	Yes	Yes	No	10	0	No
7	Yes	70/10	Yes	Daily	Yes	Yes	No	24	6	No
8	Yes	60/10	Yes	Daily	Yes	Yes	No	28	6	No

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TABLE II PREOPERATIVE DATA

Case	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Reducibility of Deform.	Stiffness of Metatarso- phalangeal Joint	Hallux Varus (degrees)	Angle Between First and Second Metatarsals (degrees)	Degen. Changes of Metatarso- phalangeal Joint on Radiographs
1R	Yes	70/10	Yes	Daily	Yes	Yes	No	28	6	No
1L	Yes	80/10	Yes	Daily	Yes	Yes	No	16	6	No
2	Yes	70/20	Yes	Recreational	Yes	Yes	No	10	8	No
3	Yes	80/20	Yes	Daily	Yes	Yes	No	28	4	No
4R	Yes	80/10	Yes	Daily	Yes	Yes	No	18	6	No
4L	Yes	60/10	Yes	Daily	Yes	Yes	No	12	6	No
5	Yes	70/10	Yes	Daily	Yes	Yes	No	10	3	No
6	Yes	80/10	Yes	Daily	Yes	Yes	No	10	0	No
7	Yes	70/10	Yes	Daily	Yes	Yes	No	24	6	No
8	Yes	60/10	Yes	Daily	Yes	Yes	No	28	6	No

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TABLE III POSTOPERATIVE DATA

*Two patients (Cases 3 and 4 [three feet]) were not included in this analysis.

Case*	Durat. of Follow-up (yrs.)	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Hallux Valgus (degrees)	Markedly Reduced Joint Space	Angle Between First and Second Metatarsals (degrees)	Result	Patient Satisfied with Result
1R	6	Mild	60/10	Yes	Recreational	No	20	No	12	Fair	Wants less valgus of metatarso- phalangeal joint
1L	7	No	70/10	No	No	No	18	No	12	Good	Yes
2	5	No	70/10	No	No	No	22	No	12	Good	Yes
5	10	No	60/10	No	No	Yes	20	Yes	8	Good	Yes
6	22	No	60/10	No	No	No	16	Yes	2	Good	Yes
7	8	No	60/10	No	No	No	16	Yes	8	Good	Yes
8	2	No	60/10	No	No	No	18	No	12	Good	Yes

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TABLE III POSTOPERATIVE DATA

*Two patients (Cases 3 and 4 [three feet]) were not included in this analysis.

Case*	Durat. of Follow-up (yrs.)	Pain	Dorsiflex./ Plantar Flex. (degrees)	Discomfort with Shoewear	Limitation in Activities	Clawing of Great Toe	Hallux Valgus (degrees)	Markedly Reduced Joint Space	Angle Between First and Second Metatarsals (degrees)	Result	Patient Satisfied with Result
1R	6	Mild	60/10	Yes	Recreational	No	20	No	12	Fair	Wants less valgus of metatarso- phalangeal joint
1L	7	No	70/10	No	No	No	18	No	12	Good	Yes
2	5	No	70/10	No	No	No	22	No	12	Good	Yes
5	10	No	60/10	No	No	Yes	20	Yes	8	Good	Yes
6	22	No	60/10	No	No	No	16	Yes	2	Good	Yes
7	8	No	60/10	No	No	No	16	Yes	8	Good	Yes
8	2	No	60/10	No	No	No	18	No	12	Good	Yes