Abstract
Background: There have been few prospective studies that have
documented the outcome of surgical treatment of hallux valgus deformities. The
purpose of this investigation was to evaluate the effect of operative
treatment of hallux valgus with use of a proximal crescentic osteotomy and
distal soft-tissue repair on the first metatarsophalangeal joint.
Methods: All adult patients in whom moderate or severe subluxated
hallux valgus deformities had been treated with surgical repair between
September 1999 and May 2002 were initially enrolled in the study. Those who
had a hallux valgus deformity treated with a proximal crescentic osteotomy and
distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy)
were then invited to return for a follow-up evaluation at a minimum of two
years after surgery. Outcomes were assessed by a comparison of preoperative
and postoperative pain and American Orthopaedic Foot and Ankle Society scores;
objective measurements included ankle range of motion, Harris mat imprints,
mobility of the first ray (assessed with use of a validated calibrated
device), and radiographic angular measurements.
Results: Of the 108 patients (127 feet), five patients (five feet)
were unavailable for follow-up, leaving 103 patients (122 feet) with a
diagnosis of moderate or severe primary hallux valgus who returned for the
final evaluation. The mean duration of follow-up after the surgical repair was
twenty-seven months. The mean pain score improved from 6.5 points
preoperatively to 1.1 points following surgery. The mean American Orthopaedic
Foot and Ankle Society score improved from 57 points preoperatively to 91
points postoperatively. One hundred and fourteen feet (93%) were rated as
having good or excellent results following surgery. Twenty-three feet
demonstrated increased mobility of the first ray prior to surgery, and only
two feet did so following the bunion surgery. The mean hallux valgus angle
diminished from 30° preoperatively to 10° postoperatively, and the
mean first-second intermetatarsal angle decreased from 14.5°
preoperatively to 5.4° postoperatively. Plantar gapping at the first
metatarsocuneiform joint was observed in the preoperative weight-bearing
lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in
one-third (nine) of them after hallux valgus correction. Complications
included recurrence in six feet. First ray mobility was not associated with
plantar gapping. There was a correlation between preoperative mobility of the
first ray and the preoperative hallux valgus (r = 0.178) and the first-second
intermetatarsal angles (r = 0.181). No correlation was detected between
restricted ankle dorsiflexion and the magnitude of the preoperative hallux
valgus deformity, the post-operative hallux valgus deformity, or the magnitude
of hallux valgus correction.
Conclusions: A proximal crescentic osteotomy of the first metatarsal
combined with distal soft-tissue realignment should be considered in the
surgical management of moderate and severe subluxated hallux valgus
deformities. First ray mobility was routinely reduced to a normal level
without the need for an arthrodesis of the metatarsocuneiform joint. Plantar
gapping is not a reliable radiographic indication of hypermobility of the
first ray in the sagittal plane.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
The theory of hypermobility of the first ray was initially introduced by
Morton in 19281.
However,
Lapidus2,3
later suggested that increased mobility at the first metatarsocuneiform joint
leads to hallux valgus. However, neither Morton nor Lapidus ever quantified
the mobility of either the first ray or the first metatarsocuneiform joint in
any of their
reports1-8.
Klaue et al.9 and
others10-12
have demonstrated an association between increased mobility of the first ray
and hallux valgus. While hypermobility of the first metatarsocuneiform joint
is one of the most frequent indications listed for hallux valgus deformities
treated with a Lapidus
procedure13-19,
the mobility of the first ray was not quantified either preoperatively or
postoperatively in any of those studies. The first metatarsal-medial cuneiform
angle20, which
measures the dorsiflexion, or plantar wedging, or gapping at the first
metatarsal-medial cuneiform joint, has been proposed as a parameter to define
the presence of sagittal plane instability at the first metatarsocuneiform
joint in patients with hallux valgus, but it has not been assessed in
relationship to quantified mobility of the first ray.
The association of restricted ankle dorsiflexion and pes planus deformities
of the hindfoot has been implied by
Morton5, and other
investigators21,22
have suggested the influence of these factors on the presence, progression,
and correction of hallux valgus deformities. The outcome of hallux valgus
surgery in the presence of restricted ankle dorsiflexion has not been
delineated.
The purposes of this study were to assess the mobility of the first ray and
other associated clinical findings prospectively in a group of patients with
moderate or severe hallux valgus deformities undergoing a distal soft-tissue
reconstruction with a proximal osteotomy of the first metatarsal, as well as
to evaluate Morton's notions regarding pes planus, restricted ankle
dorsiflexion, and hypermobility of the first ray in relationship to the
success of hallux valgus surgery. Furthermore, we assessed the radiographic
characteristics of the first metatarsocuneiform joint both prior to and after
the index surgery.
Approval
All subjects participating in this study received a thorough explanation of
the risks and benefits of inclusion and gave informed consent. Approval from
the hospital institutional review board was obtained prior to the initiation
of the study.
Inclusion and Exclusion Criteria
The indications for surgical intervention were intractable pain isolated to
the region of the first or second metatarsophalangeal joint associated with a
hallux valgus deformity that was refractory to shoe modifications,
nonsteroidal anti-inflammatory medications, or modification of activities. To
be included in the study, patients also had to be adults (over twenty-one
years of age) with a symptomatic primary idiopathic hallux valgus deformity.
Radiographic criteria included a moderate or severe hallux valgus deformity (a
hallux valgus angle of
=20°)23,24
with a subluxated or noncongruent metatarsophalangeal joint. Patients with
underlying ankle deformity or arthropathy, or pathologic hindfoot or midfoot
deformities, were also eliminated from the cohort.
All patients in whom moderate or severe hallux valgus deformities were
treated with surgical repair between September 1999 and May 2002 were
initially enrolled in the study. During the study period, 159 consecutive
patients (189 feet) were treated. Forty-nine patients (fifty-nine feet) were
excluded because of a diagnosis of mild, recurrent, congruent, or juvenile
hallux valgus or because of concurrent degenerative or inflammatory arthritis
involving the first metatarsophalangeal joint. Two patients (three feet) died,
leaving 108 patients (127 feet) available for follow-up evaluation. Five
patients (five feet) either moved away or were unavailable for follow-up,
leaving 103 adult patients (122 feet; 96%) with a diagnosis of moderate or
severe primary hallux valgus who returned for the final evaluation.
All subjective data were recorded by the individual patient; objective data
were obtained and recorded over the thirty-three-month enrollment period and
at the twenty-four-month follow-up evaluation by one of the current foot and
ankle fellows.
Initial Evaluation
History
A routine evaluation that consisted of an established protocol was
performed on all patients. Pain was quantified with a 10-point visual analog
scale (with 0 points indicating no pain and 10 points, severe pain). A score
was also determined with use of the hallux-interphalangeal joint scale of the
American Orthopaedic Foot and Ankle Society
(AOFAS)25. This
100-point unvalidated scale assesses both subjective and objective factors.
The numerical score is composed of separate sections for pain (0 to 40
points), function (0 to 45 points), and alignment (0 to 15 points). These
scores were calculated both preoperatively and at the time of final follow-up
for all patients.
Physical Examination
Patients were examined to ascertain the location of pain in the forefoot.
Special attention was directed to the first metatarsocuneiform joint during
this examination. The patients were examined in a seated and supine position
(with the knee flexed and extended) with attention to gastrocnemius-soleus
tightness. Care was taken to ensure that the foot was maintained in a neutral
position (with the talonavicular joint reduced to eliminate transverse tarsal
or subtalar motion) with respect to the forefoot and
hindfoot26-28
during the assessment of Achilles or gastrocnemius-soleus tightness. Ankle
dorsiflexion was measured with a hinged goniometer (5° increments) placed
on the lateral aspect of the ankle, with the plantar aspect of the foot and
the longitudinal axis of the fibula used as
landmarks12.
Results of ankle range of motion were recorded with the knee extended. A right
angle was considered the neutral position. Ankle range of motion was measured
once at the preoperative visit and at the final visit.
The method and device described by Klaue et
al.9 were used for
objective measurement of the sagittal motion of the first ray. The handheld
caliper has an adjustable micrometer that is attached to a modified
ankle-foot-orthosis, which holds the foot and ankle at a right angle; the
micrometer is positioned on the dorsal aspect of the first metatarsal head
(see Appendix). With the lesser metatarsals immobilized by the opposite hand
of the examiner, the first ray is dorsiflexed in the sagittal plane. The
manual force exerted beneath the first metatarsal head uses the same manual
technique that
Morton5 and
others29 have
described. When the dorsal end point is reached, the displacement of the first
ray is measured with the micrometer, and the measurement is then recorded as
the value of the mobility of the first ray. With the Klaue device, =8 mm of
excursion in the sagittal plane is considered to be normal motion for the
first ray9.
Harris mat imprint studies were performed on all patients to assess arch
height. Patients were asked to stand 18 in (46 cm) from the Harris mat and
then walk forward placing the foot on the center of the prepared mat. They
then continued walking farther forward beyond the mat, leaving an imprint of
the foot and the
hallux30-32
(see Appendix).
Radiographic Examination
Standardized anteroposterior and lateral weight-bearing radiographs of all
feet were made and
reviewed33. All
angular measurements of the first and second ray were made according to the
guidelines set forth by the AOFAS Committee on Angular
Measurements33 (see
Appendix). On weight-bearing anteroposterior radiographs, the hallux valgus
and first-second intermetatarsal angle were measured with use of
mid-diaphyseal reference points.
The first metatarsal-medial cuneiform angle (see Appendix) is the angle
subtended by the lines drawn along the superior and inferior edges of the
articular surfaces of the medial cuneiform and first metatarsal. It measures
dorsiflexion or plantar wedging (or gapping) of the first metatarsal-medial
cuneiform joint in degrees on the lateral weight-bearing
radiograph20. The
first metatarsal-medial cuneiform joint angle was calculated on all
preoperative radiographs. Any angular divergence was considered abnormal
(Figs. 1-A, 1-B,
1-C, 1-D,
2-A, 2-B,
2-C, 2-D).
The first metatarsocuneiform joint was inspected on the preoperative
anteroposterior and lateral radiographs for evidence of degenerative
arthritis. The narrowest articular width was determined on either radiograph,
and this value was subtracted from the mean preoperative width (2 mm) to
determine the magnitude of joint space narrowing on the preoperative and
postoperative radiographs. Electronic digital calipers (721 A-6/150; L.S.
Starrett, Athol, Massachusetts) were used to measure the joint width. The
calipers had a measuring error of 0.03 mm. The joint was classified as Grade
1, indicating no degenerative changes; Grade 2, <0.5 mm of joint space
narrowing; Grade 3, =1.0 mm of joint space narrowing; or Grade 4, complete
loss of joint
space34
(Table I).
The anteroposterior and lateral radiographs were inspected for evidence of
pes planus. On the anteroposterior radiographs, the talonavicular coverage
angle was measured. On the lateral radiographs, the lateral talometatarsal
angle (Meary's line), the lateral talocalcaneal angle, and the calcaneal pitch
angle were measured. These radiographic measurements were all compared with
the Harris mat imprints (see Appendix).
Description of Surgical
Procedure35
A distal soft-tissue realignment with a proximal crescentic osteotomy was
performed in each patient and, if necessary, a proximal phalangeal
closing-wedge osteotomy was performed at the discretion of the surgeon either
to diminish remaining hallux valgus interphalangeus deformity or to correct
residual pronation of the hallux. Through a longitudinal incision in the first
metatarsal web space, the conjoined adductor tendon, transverse
intermetatarsal ligament, and lateral joint capsule were released. No sutures
were placed between the first and second metatarsophalangeal joint capsules.
Through a separate medial incision, the medial eminence was resected and a
medial capsulorrhaphy was performed. Through a third incision centered over
the dorsal aspect of the proximal part of the first metatarsal, a crescentic
osteotomy was performed 1.0 to 1.5 cm distal to the metatarsocuneiform joint
with use of a curved blade with the concavity of the saw blade facing
proximally. With the proximal metatarsal fragment shifted medially with a
Freer elevator, the osteotomy was then displaced by rotating the distal
fragment approximately 3 mm in a lateral direction to achieve parallelism
between the first and second metatarsals. The osteotomy and first
metatarsocuneiform joint were then stabilized by the placement of a 0.062-in
(1.57-mm) Kirschner wire across the osteotomy site and joint. A 3.5-mm
small-fragment compression screw was then placed as perpendicular to the
osteotomy site as possible to achieve compression (as opposed to a more
vertical orientation, which tends to displace the distal fragment in a plantar
direction). In many cases, the screw crossed the first metatarsocuneiform
joint. If necessary following the medial capsulorrhaphy, a medially based
closing-wedge or transverse rotational proximal phalangeal (Akin) osteotomy
was performed through a distal extension of the medial incision to correct any
residual hallux valgus interphalangeus or pronation deformity. This triplanar
osteotomy was then secured with two 0.062-in (1.57-mm) Kirschner wires.
A gauze-and-tape compression dressing was applied at the conclusion of the
surgery and was changed every ten days for eight weeks following surgery. A
stiff-soled postoperative shoe was used following surgery, and protected
walking was allowed with weight-bearing on the heel and the lateral aspect of
the involved foot for six weeks postoperatively. Under local anesthesia in an
office setting, the internal fixation used to stabilize the first metatarsal
osteotomy site was routinely removed six weeks following surgery. Plantigrade
weight-bearing was then permitted. All surgical procedures were performed by
the senior author (M.J.C.).
Follow-up Evaluation
History
At the time of the follow-up visit, the patients were assessed with a
standardized questionnaire and examination. Patients were again asked to rate
the pain on a 10-point visual analog scale and were also asked to localize the
pain, if they had any, to a specific area and were specifically asked about
pain at the first metatarsocuneiform joint. An AOFAS hallux-interphalangeal
joint score25 was
again obtained. Patients were asked to rate their satisfaction with the result
of the surgery according to a previously published
scale36. With this
scale, a result is considered excellent if the patient has no problem related
to the foot, is very satisfied, has mild or no pain, walks with mild or no
difficulty, and would have the surgery again under similar circumstances. A
result is considered good if the patient has a few problems, is satisfied, has
mild pain, walks with no or mild difficulty, and would have the surgery again
under similar circumstances. A fair result means that the patient has moderate
pain, some difficulty with walking, and reservations about the success of the
surgery. A poor result indicates that the patient has continued pain, has
little or no improvement in walking, and regrets having had the surgery.
Physical Examination
The physical examination included inspection and palpation of the foot with
attention to either new areas or continued areas of pain. Ankle range of
motion was measured with a goniometer with use of the same method previously
described, and the mobility of the first ray was again assessed with use of
the Klaue device9.
Attention was also directed to the first metatarsocuneiform joint in regard to
localization of pain.
Radiographic Examination
On weight-bearing anteroposterior and lateral radiographs, the hallux
valgus and first-second intermetatarsal angle and the first metatarsal-medial
cuneiform angle were again measured with use of the previously described
techniques. The amount of degenerative arthritis in the first metatarsal
cuneiform was also reassessed and recorded with use of the four-grade scale.
The anteroposterior and lateral postoperative radiographs were inspected to
assess whether either the Kirschner wire and/or small-fragment screw used to
stabilize the osteotomy site entered or crossed the first metatarsocuneiform
joint prior to hardware removal.
Statistical Analysis
Descriptive and comparative statistical analyses were performed with use of
SPSS software (version 11.5; SPSS, Chicago, Illinois). Contingency tables and
the Fisher exact and chi-square tests were used to assess associations among
categorical variables. Pearson and Spearman rho rank correlation coefficients
were used to assess bivariate relationships among continuous variables.
Correlation coefficients (r values) closer to ±1 indicate a strong
correlation, while values closer to zero indicate a weak correlation or no
correlation. Mann-Whitney, independent samples t tests, and paired samples t
tests were performed to analyze differences between continuous variables.
Selection of the test statistic was based on the level of data and the
characteristics of the distribution. For all tests, significance was set at p
< 0.05.
One hundred and three patients (122 feet) treated with a distal soft-tissue
reconstruction and proximal crescentic osteotomy of the first metatarsal
returned for final evaluation at a minimum of two years (mean, twenty-seven
months; range, twenty-four to thirty-seven months) following the index
procedure.
All 103 patients (122 feet) were treated with a distal soft-tissue
reconstruction and a proximal crescentic osteotomy of the first metatarsal. In
addition, fifty-seven feet (47%) also had a phalangeal osteotomy performed at
the time of the index surgery to treat concurrent hallux valgus
interphalangeus (>10°) or residual pronation of the hallux. Although
eighty-seven patients (84%) had bilateral deformity, only nineteen patients
underwent correction of both hallux valgus deformities within the time frame
of the study. All contralateral procedures were staged except for those in two
patients who requested simultaneous surgical correction. Ninety-five (92%) of
the 103 patients were female. The average age at the time of surgery was fifty
years (range, twenty-two to seventy-eight years). The average duration of
symptoms prior to surgery was 5.3 years (range, 0.3 to twenty-five years).
Sixty-eight right feet and fifty-four left feet were included in the study.
Hardware was removed at a mean of 6.4 weeks (range, five to sixteen weeks)
following surgery.
The most common primary location of pain leading to surgery was over the
medial eminence of the first metatarsal (ninety-three feet) or the first
metatarsophalangeal joint itself (eight feet). The mean preoperative pain
score was 6.5 points (range, 0 to 10 points). The mean score on the 10-point
visual analog scale postoperatively was significantly reduced to an average of
1.1 points (range, 0 to 8 points) (z = —6.154, p < 0.01). At the time
of the final follow-up, no patient reported pain over the medial eminence; in
twelve feet, mild pain was noted at the first metatarsophalangeal joint (a
score of <3 points on the visual analog scale). Pain was localized to the
first metatarsocuneiform joint in five feet. The pain was mildly symptomatic
(a mean score of 2 or 3 points on the visual analog scale) in four feet and
moderately symptomatic in one foot (8 points). These five feet were rated
subjectively as good (two feet) and excellent (three feet).
The subjective assessment of the success of the surgery as rated by the
patients was excellent for eighty-three feet (68%), good for thirty-one feet
(25%), fair for seven feet (6%), and poor for one foot (1%). The mean
preoperative AOFAS score of 57 points (range, 29 to 83 points) improved
significantly to 91 points (range, 60 to 100 points) (z = —6.301, p <
0.01). The relationship between postoperative satisfaction and the AOFAS total
score was significant (r = 0.573, p < 0.01). The reasons given for a
subjective satisfaction rating of fair or poor were recurrence (one foot),
numbness (two feet), hallux varus (two feet), joint stiffness (one foot), and
pain in the first metatarsophalangeal joint (two feet). Of the thirty-one feet
with good results, the reasons for dissatisfaction (more than one issue may
have been mentioned by patients) included swelling (six feet), stiffness
(thirteen feet), first metatarsophalangeal joint pain (seven feet), first
metatarsocuneiform joint pain (two feet), and hallux varus (five feet).
Physical Examination
Ankle Range of Motion
The mean ankle dorsiflexion was 11° (range, 0° to 25°)
preoperatively and 10° postoperatively. Only fourteen feet had =5°
of ankle dorsiflexion, and no patient had less than neutral dorsiflexion. No
Achilles tendon lengthening or gastrocnemius recession was performed either at
the time of the index surgery or during the postoperative follow-up period.
The average amount of mobility of the first ray for this subgroup with limited
ankle dorsiflexion decreased from 7.6 mm preoperatively to 4.3 mm
postoperatively. The association between preoperative hypermobility and the
magnitude of preoperative ankle dorsiflexion was not significant (p =
0.731).
Mobility
With use of the Klaue device, the mean mobility of the first ray was 7.2 mm
(range, 2 to 10 mm) preoperatively and significantly diminished to 4.5 mm
(range, 2 to 14 mm) at the time of the final follow-up (p < 0.01).
Twenty-three feet had =9 mm of mobility, which is consistent with recent
definitions of first ray
hypermobility9,29.
There was a correlation between increased first ray mobility and the magnitude
of the hallux valgus angle (r = 0.178, p = 0.052) and between the preoperative
first-second intermetatarsal angle and first ray mobility (r = 0.181, p =
0.048). Following surgical correction, only two feet had demonstrable
hypermobility of the first ray. To assess the relationship between
preoperative increased mobility of the first ray and the hallux valgus angle,
we arbitrarily divided the feet into two similarly sized subgroups: those with
<7 mm of mobility and those with =7 mm of mobility. Prior to surgery,
there were fifty-six feet with <7 mm of mobility (subgroup 1) and
sixty-four feet with =7 mm of first ray mobility (subgroup 2). The mean
postoperative hallux valgus angle (and standard deviation) was 9.1°
± 8.5° for subgroup 1 and 11.0° ± 6.6° for subgroup
2. With these numbers, there was no difference in preoperative hallux valgus
angle between subgroups 1 and 2 (p = 0.18).
Pes Planus
Preoperative assessment of the arch of the 122 feet with use of a Harris
mat imprint identified eighty-five feet with a normal or high medial arch and
thirty-seven feet with a low medial arch. Of the latter group, the low medial
arch was mild (+1) in nineteen feet and moderate (+2) or severe (+3) in
eighteen feet. The mean preoperative hallux valgus angle was 31° for the
eighteen feet with a moderately or severely low medial arch and 30° for
the entire cohort. The mean postoperative hallux valgus angle for the subgroup
of eighteen feet with a low medial arch was 9°, while it was 10° for
the entire cohort of 122 feet. Thus, with the numbers studied, we did not
identify a correlation between arch height and hallux valgus angle (p =
1.000).
Radiographic Data
Preoperatively, the mean hallux valgus angle was 30° (range, 20° to
53°) and the mean first-second intermetatarsal angle was 14.5° (range,
7° to 23°). There was a correlation between the magnitude of the
preoperative hallux valgus deformity and the first-second intermetatarsal
angle (r = 0.190, p < 0.01). The mean preoperative hallux valgus angle of
30° was significantly reduced to a mean of 10° at the time of the
final follow-up (p < 0.01). The mean first-second intermetatarsal angle was
corrected from 14.5° preoperatively to 5.4° at the time of the final
follow-up (p < 0.01). With the numbers studied, there was no correlation
between postoperative satisfaction and either the preoperative hallux valgus
deformity (p = 0.666) or the magnitude of the hallux valgus correction (p =
0.672).
When we compared the feet with moderate or severe pes planus (+2 or +3
arch), as determined by the Harris mat imprints, and those without pes planus
(+1, 0, —1, —2, or —3 arch), significant differences were
found in the lateral talometatarsal angle (Meary's line) (p < 0.01), the
anteroposterior talonavicular coverage (p = 0.048), and the calcaneal pitch (p
< 0.01); but, with these numbers, no such difference was found between the
subgroups when the lateral talocalcaneal angle (p = 0.069) was measured
(Table II). With the numbers
studied, no significant difference was found in the relationships between the
preoperative mobility of the first ray and the anteroposterior talonavicular
coverage (p = 0.866), calcaneal pitch (p = 0.497), lateral talocalcaneal angle
(p = 0.288), and lateral talometatarsal angle (p = 0.918).
Recurrence
Recurrence or undercorrection was defined as a postoperative hallux valgus
deformity of >20° with <10° of angular correction. Six feet were
classified as having a recurrent deformity by these criteria. Two feet were
measured and found to have the same angular deformity as that before surgery,
and both were rated as fair by the patient. The other four feet had an average
hallux valgus angle of 22° and were rated as excellent (one foot), good
(two feet), and fair (one foot). Preoperatively, the mobility of the first ray
was increased (12 mm) in only one of the six feet, while it was normal (4, 5,
7, 7, and 8 mm) in the other five feet.
Plantar Gapping
Twenty-eight feet (23%) demonstrated plantar gapping of the first
metatarsocuneiform joint with a divergence of >0°. The average plantar
gapping in these twenty-eight patients was 2.9° (range, 1.5° to
6.0°). With the numbers studied, there was no difference in either age or
gender distribution between those with and those without plantar gapping.
Gapping was eliminated in nine of the twenty-eight feet after the surgical
correction (Figs. 2-A, 2-B,
2-C, 2-D).
A significant difference was detected in the mean preoperative hallux
valgus deformity for the twenty-eight feet with plantar gapping (33°
± 8.6°) and the ninety-four without gapping (29° ±
5.8°) (p = 0.024). Of the twenty-eight feet with preoperative
hypermobility (mobility of =9 mm) of the first ray, only seven demonstrated
gapping at the first metatarsocuneiform joint. No significant difference in
mobility of the first ray was found between patients who had and those who did
not have plantar gapping (p = 0.842). For the twenty-eight feet with plantar
gapping at the first metatarsocuneiform joint, no substantial difference was
demonstrated between those in which gapping remained and those in which it
resolved with regard to the average preoperative hallux valgus angle, average
preoperative first-second intermetatarsal angle, average amount of
preoperative mobility of the first ray, or average postoperative hallux valgus
angle.
Arthritis of the First Metatarsocuneiform Joint
The average preoperative width of the first metatarsocuneiform joint was 2
mm on both the anteroposterior and lateral radiographs although obliquity of
the radiographs and overlap of bones on occasion obscured the joint space. Ten
(8%) of the 122 first metatarsocuneiform joints had radiographic evidence of
arthritis preoperatively, but forty-two (34%) had such evidence
postoperatively and it was symptomatic in five feet
(Table I). The postoperative
lateral radiographs commonly demonstrated penetration of the
metatarsocuneiform joint with an internal fixation device. In the 122 feet,
the joint had been penetrated by 118 Kirschner wires and fifty-five screws.
The severity of the preoperative hallux valgus deformity correlated with the
degree of metatarsocuneiform joint arthritis both preoperatively (r = 0.232, p
= 0.011) and postoperatively (r = 0.246, p < 0.01). On the other hand, with
the numbers studied, progression of arthritis in the first metatarsocuneiform
joint did not appear to be associated with the severity of the preoperative
angular deformity (p = 0.089), plantar gapping (p = 0.063), increased mobility
of the first ray (p = 0.0830), or placement of a screw and/or wire across the
metatarsocuneiform joint at surgery (p = 0.092).
While several reports have detailed the experience with a distal
soft-tissue procedure and proximal osteotomy of the first metatarsal, many of
them have been complicated by the inclusion of adolescent
patients37 or
recurrent hallux valgus
deformities37,38,
a large number of patients who were lost to
follow-up39,
follow-up by telephone
interview37, and
inclusion of more than one surgical procedure within the
study39-41.
Only two studies have described prospective results, and both were small
series39,42
(less than forty-five feet).
Pain relief has been reported consistently following hallux valgus repair
with use of a proximal osteotomy of the first metatarsal and distal
soft-tissue
repair38-40,42,43.
Brodsky et al.42
reported postoperative reduction in the mean score on the 10-point visual
analog scale from 4.4 to 1.5 points. In the current study, the mean pain
scores were significantly reduced from 6.5 to 1.1 points at the time of the
final follow-up, which is consistent with previously reported findings.
The reported mean AOFAS scores at the time of the final follow-up in both
retrospective and prospective studies of the evaluation of the crescentic
osteotomy have ranged from 91 to 94
points38-40,42,43,
results similar to those in the current study. Prior retrospective studies
have described good and excellent subjective results, ranging from 90% to 95%
(in studies involving twenty to seventy-five
patients)37,38,43,
similar to the 93% satisfactory results in the current series. Although the
AOFAS scores were used at the initial and final follow-up evaluations, we
acknowledge that this instrument has yet to be validated. For some patients in
this study, pain scores on the visual analog scale and subjective satisfaction
scores differed substantially from the AOFAS scores. Also, the AOFAS scoring
system does not address cosmetic concerns, often an issue with subjective
patient satisfaction.
Physical Examination
Restricted Ankle Dorsiflexion
Morton6 suggested
that a gastrocnemius contracture plays a major biomechanical role in chronic
foot and ankle problems. While some have suggested that restricted ankle
dorsiflexion may be associated with the development of hallux
valgus21,23,24,44,45,
others43,46
have reported, in series ranging in size from twenty to thirty patients, that
this association is uncommon. We acknowledge the weakness of using a
goniometer (with 5° increments) to assess ankle motion in this study.
These measurements were primarily a clinical assessment at the preoperative
and final follow-up examinations; we suggest that this method is far superior
than making a visual estimate of ankle dorsiflexion. In the current study,
with the numbers available, we found no correlation between limited
preoperative ankle dorsiflexion and the magnitude of the preoperative or
postoperative hallux valgus deformity, the magnitude of the angular
correction, the postoperative AOFAS score, or the postoperative subjective
satisfaction of the patient. No Achilles tendon lengthening or gastrocnemius
recessions were performed before, during, or following the index surgery.
While a triceps surae lengthening has been recommended for patients with a
limitation of =5° of ankle
dorsiflexion22,27,
we find it quite difficult to recommend this for an otherwise asymptomatic
patient with a hallux valgus deformity.
Pes Planus
Beatty47 defined
pes planus (flatfoot) in general as a loss of the normal medial longitudinal
arch of the foot. While many other components, including heel valgus,
subluxation of the subtalar joint, eversion of the calcaneus, abduction at the
transverse tarsal joint, or forefoot supination, may be considered, these
physical and radiographic findings are difficult to quantify numerically.
Furthermore, the Harris mat imprint has shortcomings in quantifying the
deformity as well. We compared pertinent angular measurements (Meary's line,
anteroposterior talonavicular coverage, calcaneal pitch, and lateral
talocalcaneal angle) on anteroposterior and lateral weight-bearing radiographs
with Harris mat imprints and found a good correlation with three of the
angular measurements (Table
II). However, we chose the Harris mat as our primary means of
describing the posture of the foot, as
Morton5 had used a
similar method. Furthermore, we believed that the imprints accurately defined
the plantar footprint, which was the criterion we had also chosen to assess
the height of the medial arch. The technique of Harris mat imprints was
described by both Harris and
Beath32 and Hardy
and Clapham31 and
has been used to analyze arch height in several
reports12,30,31.
The notion that pes planus is associated with the development of hallux valgus
is not
new12,21,22,30,47-49.
On the other hand, Kilmartin and
Wallace50 and
others30,34,51
have reported that pes planus is no more common in those with hallux valgus
than in the normal population. In the current study, we noted a 15% prevalence
of a moderately or severely low medial arch, results consistent with those
reported previously by both Grebing and
Coughlin12 and
Harris and Beath
32. With the
numbers studied, we found no association between a low arched foot and
increased mobility of the first ray on either Harris mat imprints or on
angular measurements on radiographs. While
Morton7 and others
8,21,22
have linked pes planus to hypermobility of the first ray, we cannot support
this notion on the basis of the findings in the current study.
Radiographic Examination
Hallux Valgus and First-Second Intermetatarsal Angle
Hardy and
Clapham31 reported
an association between the magnitude of the hallux valgus angle and the
first-second intermetatarsal angle, a finding we confirm in this study. We
believe that the metatarsocuneiform joint is the key to the development and
the progression of a hallux valgus deformity. Without mobility in this joint,
a progressive concomitant increase in the hallux valgus and the first-second
intermetatarsal angle cannot occur.
Metatarsocuneiform Joint Plantar Gapping
It has been suggested that the development of a plantar gap between the
articular surfaces of the first cuneiform and first metatarsal, as seen on the
lateral radiographs in subjects with hallux valgus, is indicative of first
metatarsocuneiform joint
instability20,49.
King and Toolan20
evaluated a small cohort of fifteen patients with moderate and severe hallux
valgus deformities and described the first metatarsal-medial cuneiform angle
as a reliable measure of the dorsiflexion or plantar wedging of the first
metatarsocuneiform joint. While those patients were considered to have
instability of the first ray when assessed by a manual
examination5,29,
the magnitude of mobility was not quantified and the specifics of the manual
examination were not described. In the current study, 23% of the feet
demonstrated preoperative plantar gapping; those with gapping had, on the
average, a significantly greater hallux valgus deformity (+4°) than those
without preoperative gapping. There was, however, no significant difference
between those with and those without preoperative plantar gapping with respect
to the mobility of the first ray. In this study group, the gapping resolved
following realignment of the first ray in one-third of the feet. There was no
difference in the mean preoperative hallux valgus angle between the feet with
residual gapping and those in which the gapping resolved. The group with
residual gapping trended toward having a larger angular correction compared
with those in which gapping resolved. The mean mobility of the first ray was
slightly higher both preoperatively and postoperatively in the group in which
gapping resolved.
We believe that the plantar gapping as seen on the lateral radiograph may
be indicative of sagittal plane instability just as metatarsus primus varus is
indicative of axial plane instability. In the current study, with a much
larger cohort than that of King and
Toolan20, we found
no evidence to support the notion that an increase in the first
metatarsal-medial cuneiform angle was associated with increased mobility of
the first ray.
Degenerative Arthritis of the First Metatarsocuneiform Joint
Degenerative arthritis of the first metatarsocuneiform joint can precede
surgical realignment or develop following a bunion repair. Ten (8%) of the 122
feet in the study demonstrated degenerative changes prior to surgery, and 34%
demonstrated such changes at longer-term follow-up, but only five feet were
symptomatic.
In the current study, almost all first metatarsocuneiform joints were
penetrated with a Kirschner wire and almost half were penetrated with a small
fragment screw. Internal fixation was removed at a mean of 6.4 weeks following
the index surgery. There was no significant difference in arthritis
progression at the time of the two-year follow-up between those who did and
those who did not have implant penetration of the joint. Only the passage of
time will determine whether there is further progression of arthritis in the
first metatarsocuneiform joint. We acknowledge that the method we used to
assess metatarsocuneiform arthritis and metatarsocuneiform joint gapping has
limitations; if the x-ray beam is not perpendicular to the joint, overlap of
osseous surfaces may obscure the joint space. Computed tomography scanning
would give a better view of the amount of joint degeneration or gapping, but
it would have had a prohibitive cost for this study. In the current study, a
small percentage of the feet had progression of arthritis by more than one
grade, but only two of these first metatarsocuneiform joints were symptomatic.
We suggest that perhaps stress on the metatarsocuneiform joint with a
progressive hallux valgus deformity may lead to an incongruent articulation
and predispose the joint to degenerative arthritis.
Recurrence
Johnson and
Kile16 and Coetzee
et al.52 associated
hallux valgus deformities with hypermobility of the first ray and suggested
that, because of this inherent instability, there would be substantial
recurrence of hallux valgus without an arthrodesis of the first
metatarsocuneiform joint. On the other hand, Faber et
al.53 found no
significant difference in the results of patients either with or without
hypermobility of the first ray who underwent treatment with an arthrodesis of
the first metatarsocuneiform joint or with a distal realignment to correct a
hallux valgus deformity. Dreeben and
Mann54, and later
Veri et al.43,
using a surgical technique similar to that used in the current study, reported
low recurrence rates at both
intermediate54 and
long-term follow-up
43 after a distal
soft-tissue realignment with a proximal osteotomy of the first metatarsal as
treatment for hallux valgus deformity. With the number of patients in the
present study, no difference was found in the residual hallux valgus angle
between those with more preoperative mobility (=7 mm) and those with less
preoperative mobility (<7 mm). Likewise, only one of the six feet with
recurrent deformity had increased mobility of the first ray following surgery.
We believe it is unlikely that recurrence is the result of residual
hypermobility of the first ray.
Hypermobility of the First Ray
The concept of hypermobility of the first ray was initially proposed by
Morton1,5,
but it was
Lapidus2,3
who suggested the association of hallux valgus with hypermobility of the
metatarsocuneiform joint and advocated an arthrodesis of the first
metatarsocuneiform joint to realign and stabilize the first ray. Klaue et
al.9 and
others15,21,22,55,56
have implicated hypermobility of the first ray as a major cause of hallux
valgus. While hypermobility of the first ray is probably the most frequently
listed indication for which a Lapidus procedure is
performed13-19,21,22,
none of those reports quantified and reported the preoperative or
postoperative mobility of the first ray. Klaue et
al.9 designed an
external caliper for the measurement of first ray mobility, which was later
validated by Jones et
al.57. On the basis
of their analysis of normal subjects and those with hallux valgus, Klaue et
al. defined a first ray as hypermobile if there was =9 mm of sagittal
motion as measured with this device.
The Klaue device was used to quantify the mobility of the first ray in two
retrospective reports on the surgical treatment of hallux
valgus34,46.
In both of those studies, only postoperative measurements of mobility of the
first ray were performed. In both series, normal postoperative first ray
mobility was demonstrated following realignment of the first ray. Following
arthrodesis of the first metatarsophalangeal joint as treatment for moderate
and severe hallux valgus
deformities34, the
mean mobility of the first ray has been reported to be 4.0 mm; after a distal
soft-tissue procedure with a proximal crescentic
osteotomy45, the
mean mobility of the first ray was 4.9 mm. To date, other than the current
series, we are unaware of any clinical study on the correction of hallux
valgus deformities in which both preoperative and postoperative first ray
mobility has been quantified. In a cadaver study of specimens with hallux
valgus deformities, Coughlin et
al.58 demonstrated
a 50% reduction in sagittal plane mobility (from 11 to 5.2 mm) following a
surgical procedure identical to the one performed in the current study. In the
current study, the increased preoperative mobility of the first ray was
regularly and consistently reduced to a normal range following a surgical
procedure that did not fuse the first metatarsocuneiform joint. If increased
sagittal motion of the first ray was a primary factor predisposing to the
onset of hallux valgus, we would not have expected a significant reduction in
first ray mobility after a surgical correction distal to the first
metatarsocuneiform joint. While we recognize that arthrofibrosis or
degenerative changes occurring at the first metatarsocuneiform joint or
scarring between the first and second metatarsals may contribute
postoperatively to reduced first ray mobility, we believe that increased
sagittal mobility of the first ray occurs as a result of the hallux valgus
deformity and not as a primary cause of that deformity.
Sarrafian59 and
others11,60
have identified the plantar aponeurosis as a key component of first ray
stability. We suggest that realignment of the first ray restores the normal
anatomic relationships and function of the intrinsic muscles, the extrinsic
muscles, and the plantar aponeurosis and that this leads to a reduction in
first ray mobility. It is our belief that the stability of the first ray is a
function of the alignment of the first ray and is not an intrinsic
characteristic of the first metatarsocuneiform joint. We found little clinical
evidence to substantiate the theories on the hypermobility of the first ray
described by Morton1
and those later presented by
Lapidus2,3
who suggested that increased mobility at the first metatarsocuneiform joint
can lead to hallux valgus.
Lapidus2,3
advocated an arthrodesis of the first metatarsocuneiform joint to correct and
stabilize the first ray, which we consistently achieved in this study with
realignment of the first ray.
The weaknesses of this study are that the average duration of follow-up was
only twenty-seven months, that Harris mat studies quantify the height of the
medial arch but do not define all components of pes planus deformities, and
that the AOFAS scoring system has yet to be validated. On the contrary, the
AOFAS scoring system is widely used and allows comparison with other published
studies.
Finally, we conclude that the distal soft-tissue realignment combined with
a proximal osteotomy of the first metatarsal is a highly reliable way to
correct a hallux valgus deformity and leads to high levels of patient
satisfaction, minimal recurrence, successful angular correction, and
significantly diminished mobility of the first ray at two years of
follow-up.
Figures demonstrating the Klaue device and measurement technique, the
Harris mat measurements, and the measurements of radiographic angles are
available with the electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
Note: The authors thank Troy G. Pinsonneault, MD, Robert C.
Schenck Jr., MD, Michael P. Kennedy, MD, Paul S. Shurnas, MD, and Brett R.
Grebing, MD, for their contributions to the patient evaluations in this study.
They also thank Allison Williams for her assistance in the statistical
analysis.
Morton DJ. Hypermobility of the first
metatarsal bone: the interlinking factor between metatarsalgia and
longitudinal arch strains. J Bone Joint Surg.1928;10:
187-96.10187
1928
Lapidus PW. A quarter of a century of
experience with the operative correction of the metatarsus varus primus in
hallux valgus. Bull Hosp Joint Dis.1956;17:
404-21.17404
1956
[PubMed]
Lapidus PW. The author's bunion
operation from 1931 to 1959. Clin Orthop Relat Res.1960;16:
119-35.16119
1960
Lapidus PW. Operative correction of
metatarsus varus primus in hallux valgus. Surg Gynecol Obstet.1934;58:
183-91.58183
1934
Morton DJ. The human foot; its
evolution, physiology and functional disorders. New York:
Columbia University Press; 1935.
1935
Morton DJ. Mechanism of the normal foot
and of flat foot: part 1. J Bone Joint Surg Am.1924;6:
368-86.6368
1924
Morton D. Metatarsus ativicus. The
identification of a distinctive type of foot disorder. J Bone Joint
Surg Am.1927;9:
531-44.9531
1927
Morton DJ. Significant characteristics
of the Neanderthal foot. Nat History.1926;26:
310-4.26310
1926
Klaue K, Hansen ST, Masquelet AC.
Clinical, quantitative assessment of first tarsometatarsal mobility in the
sagittal plane and its relation to hallux valgus deformity. Foot Ankle
Int.1994;15:
9-13.159
1994
Glasoe WM, Allen MK, Saltzman CL. First
ray dorsal mobility in relation to hallux valgus deformity and first
intermetatarsal angle. Foot Ankle Int.2001;22:
98-101.2298
2001
[PubMed]
Grebing BR, Coughlin MJ. The effect of
ankle position on the exam for first ray mobility. Foot Ankle
Int.2004;25:
467-75.25467
2004
Grebing BR, Coughlin MJ. Evaluation of
Morton's theory of second metatarsal hypertrophy. J Bone Joint Surg
Am.2004;86:
1375-86.861375
2004
Bacardi BE, Boysen TJ. Considerations
for the Lapidus operation. J Foot Surg.1986;25:
133-8.25133
1986
[PubMed]
Bednarz PA, Manoli A 2nd. Modified
Lapidus procedure for the treatment of hypermobile hallux valgus. Foot
Ankle Int.2000;21:
816-21.21816
2000
Clark HR, Veith RG, Hansen ST Jr.
Adolescent bunions treated by the modified Lapidus procedure. Bull Hosp
Jt Dis Orthop Inst.1987;47:
109-22.47109
1987
Johnson KA, Kile TA. Hallux valgus due
to cuneiform-metatarsal instability. J South Orthop Assoc.1994;3:
273-82.3273
1994
[PubMed]
Myerson M, Allon S, McGarvey W.
Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus
primus varus. Foot Ankle.1992;13:
107-15.13107
1992
[PubMed]
Myerson MS, Badekas A. Hypermobility of
the first ray. Foot Ankle Clin.2000;5:
469-84.5469
2000
[PubMed]
Sangeorzan BJ, Hansen ST Jr. Modified
Lapidus procedure for hallux valgus. Foot Ankle.1989;9:
262-6.9262
1989
[PubMed]
King DM, Toolan BC. Associated
deformities and hypermobility in hallux valgus: an investigation with
weightbearing radiographs. Foot Ankle Int.2004;25:
251-5.25251
2004
[PubMed]
Hansen ST Jr. Hallux valgus surgery.
Morton and Lapidus were right! Clin Podiatr Med Surg.1996;13:
347-54.13347
1996
[PubMed]
Hansen ST Jr. Functional
reconstruction of the foot and ankle. Philadelphia: Lippincott
Williams and Wilkins; 2000. p
221.221
2000
Coughlin MJ. Hallux valgus. J
Bone Joint Surg Am.1996;78:
932-66.78932
1996
Mann RA, Coughlin MJ. Adult hallux
valgus. In: Coughlin MJ, Mann RA, editors. Surgery of the foot and
ankle. Vol 1. 7th ed. St. Louis: Mosby;
1999. p 150-269.1150
1999
Kitaoka HB, Alexander IJ, Adelaar RS,
Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the
ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle
Int.1994;15:
349-53.15349
1994
Bordelon RL. Surgical and
conservative foot care: a unified approach to principles and practice.
Thorofare, NJ: Slack; 1988. p
13-14.13
1988
DiGiovanni CW, Kuo R, Tejwani N, Price
R, Hansen ST Jr, Cziernecki J, Sangeorzan BJ. Isolated gastrocnemius
tightness. J Bone Joint Surg Am.2002;84:
962-70.84962
2002
[PubMed]
Pinney SJ, Hansen ST Jr, Sangeorzan BJ.
The effect on ankle dorsiflexion of gastrocnemius recession. Foot Ankle
Int.2002;23:
26-9.2326
2002
Voellmicke KV, Deland JT. Manual
examination technique to assess dorsal instability of the first ray.
Foot Ankle Int.2002;23:
1040-1.231040
2002
[PubMed]
Coughlin MJ. Juvenile hallux valgus:
etiology and treatment. Foot Ankle Int.1995;16:
682-97.16682
1995
[PubMed]
Hardy RH, Clapham JC. Observations on
hallux valgus; based on a controlled series. J Bone Joint Surg
Br.1951;33:
376-91.33376
1951
Harris RI, Beath T. Hypermobile
flat-foot with short tendo Achillis. J Bone Joint Surg Am.1948;30:
116-38.30116
1948
Coughlin MJ, Saltzman CL, Nunley JA 2nd.
Angular measurements in the evaluation of hallux valgus deformities: a report
of the ad hoc committee of the American Orthopaedic Foot and Ankle Society on
angular measurements. Foot Ankle Int.2002;23:
68-74.2368
2002
[PubMed]
Coughlin MJ, Grebing BR, Jones CP.
Arthrodesis of the first metatarsophalangeal joint for idiopathic hallux
valgus: intermediate results. Foot Ankle Int.2005;26:
783-92.26783
2005
[PubMed]
Coughlin MJ. Proximal first metatarsal
osteotomy. In: Kitaoka HB, editor. Master techniques in orthopaedic
surgery: The foot and ankle. 2nd ed. Philadelphia: Lippincott Williams
and Wilkins; 2002. p 71-98.71
2002
Coughlin MJ. Arthrodesis of the first
metatarsophalangeal joint with minifragment plate fixation.
Orthopedics. 1990;13:
1037-44.131037
1990
[PubMed]
Mann RA, Rudicel S, Graves SC. Repair of
hallux valgus with a distal soft-tissue procedure and proximal metatarsal
osteotomy. A long-term follow-up. J Bone Joint Surg Am.1992;74:
124-9.74124
1992
[PubMed]
Sammarco GJ, Russo-Alesi FG. Bunion
correction using proximal chevron osteotomy: a single-incision technique.
Foot Ankle Int.1998;19:
430-7.19430
1998
[PubMed]
Easley ME, Kiebzak GM, Davis WH,
Anderson RB. Prospective, randomized comparison of proximal crescentic and
proximal chevron osteotomies for correction of hallux valgus deformity.
Foot Ankle Int.1996;17:
307-16.17307
1996
[PubMed]
Markbreiter LA, Thompson FM. Proximal
metatarsal osteotomy in hallux valgus correction: a comparison of crescentic
and chevron procedures. Foot Ankle Int.1997;18:
71-6.1871
1997
[PubMed]
Pearson SW, Kitaoka HB, Cracchiolo A,
Leventen EO. Results and complications following a proximal curved osteotomy
of the hallux metatarsal. Contemp Orthop.1991;23:
127-32.23127
1991
[PubMed]
Brodsky JW, Beischer AD, Robinson AH,
Westra S, Negrine JP, Shabat S. Surgery for hallux valgus with proximal
crescentic osteotomy causes variable postoperative pressure patterns.
Clin Orthop Relat Res.2006;443:
280-6.443280
2006
[PubMed][CrossRef]
Veri JP, Pirani SP, Claridge R.
Crescentic proximal metatarsal osteotomy for moderate to severe hallux valgus:
a mean 12.2 year follow-up study. Foot Ankle Int.2001;22:
817-22.22817
2001
[PubMed]
Mann RA, Coughlin MJ. Hallux
valgus—etiology, anatomy, treatment and surgical considerations.
Clin Orthop Relat Res.1981;157:
31-41.15731
1981
[PubMed]
Coughlin MJ. Juvenile hallux valgus. In:
Coughlin MJ, Mann RA, editors. Surgery of the foot and ankle.
Vol 1. 7th ed. St. Louis: Mosby; 1999. p
270-319.1270
1999
Coughlin MJ, Shurnas PS. Hallux valgus
in men. Part II: First ray mobility after bunionectomy and factors associated
with hallux valgus deformity. Foot Ankle Int.2003;24:
73-8.2473
2003
[PubMed]
Beatty JH. Congenital foot deformities.
In: Coughlin RW, Mann RA, Saltzman CL, editors. Surgery of the
foot. 8th ed, vol 2. Philadelphia:
Mosby-Elsevier; 2007. p.
1744.21744
2007
Inman VT. Hallux valgus: a review of
etiologic factors. Orthop Clin North Am.1974;5:
59-66.559
1974
[PubMed]
Myerson MS. Hallux valgus. In: Myerson
MS, editor. Foot and ankle disorders. Volume
2. Philadelphia: Saunders; 2000. p
213-88.2213
2000
Kilmartin TE, Wallace WA. The
significance of pes planus in juvenile hallux valgus. Foot
Ankle. 1992;13:
53-6.1353
1992
Saragas NP, Becker PJ. Comparative
radiographic analysis of parameters in feet with and without hallux valgus.
Foot Ankle Int.1995;16:
139-43.16139
1995
[PubMed]
Coetzee JC, Resig SG, Kuskowski M, Saleh
KJ. The Lapidus procedure as salvage after failed surgical treatment of hallux
valgus: a prospective cohort study. J Bone Joint Surg Am.2003;85:
60-5.8560
2003
[PubMed]
Faber FW, Mulder PG, Verhaar JA. Role of
first ray hypermobility in the outcome of the Hohmann and the Lapidus
procedure. A prospective, randomized trial involving one hundred and one feet.
J Bone Joint Surg Am.2004;86:
486-95.86486
2004
[PubMed]
Dreeben S, Mann RA. Advanced hallux
valgus deformity: long-term results utilizing the distal soft tissue procedure
and proximal metatarsal osteotomy. Foot Ankle Int.1996;17:
142-4.17142
1996
[PubMed]
Ito H, Shimizu A, Miyamoto T, Katsura Y,
Tanaka K. Clinical significance of increased mobility in the sagittal plane in
patients with hallux valgus. Foot Ankle Int.1999;20:
29-32.2029
1999
[PubMed]
Lee KT, Young K. Measurement of
first-ray mobility in normal vs. hallux valgus patients. Foot Ankle
Int.2001;22:
960-4.22960
2001
Jones CP, Coughlin MJ, Pierce-Villadot
R, Golano P, Kennedy MP, Shurnas PS, Grebing BR, Teachout L. The validity and
reliability of the Klaue device. Foot Ankle Int.2005;26:
951-6.26951
2005
[PubMed]
Coughlin MJ, Jones CP, Viladot R, Glano
P, Grebing BR, Kennedy MJ, Shurnas PS, Alvarez F. Hallux valgus and first ray
mobility: a cadaveric study. Foot Ankle Int.2004;25:
537-44.25537
2004
[PubMed]
Sarrafian SK. Functional characteristics
of the foot and plantar aponeurosis under tibiotalar loading. Foot
Ankle.1987;8:
4-18.84
1987
Rush SM, Christensen JC, Johnson CH.
Biomechanics of the first ray. Part II: Metatarsus primus varus as a cause of
hypermobility. A three-dimensional kinematic analysis in a cadaver model.
J Foot Ankle Surg.2000;39:
68-77.3968
2000
[PubMed][CrossRef]
Shereff MJ. Radiographic analysis of the
foot and ankle. In: Jahss MH, editor. Disorders of the foot and ankle:
medical and surgical management. Vol 1. 2nd ed.
Philadelphia: WB Saunders; 1991. p
91-108.191
1991