Midterm outcomes of the modified Lapidus arthrodesis using the Phantom® Intramedullary Nail System for the treatment of hallux valgus.

BACKGROUND: Lapidus arthrodesis is one of the most commonly used techniques in the correction of moderate and severe hallux valgus. We analyzed the clinical and radiological outcomes after using the Phantom® Lapidus intramedullary nail to find an effective technique with low complications. METHODS: We retrospectively analyzed data of 52 patients who underwent a modified Lapidus arthrodesis with an intramedullary nail at our center from November 2019 to September 2022. The mean follow-up period was 27 (range, 18-34) months. Clinical results were evaluated using the visual analog scale (VAS), the European Foot and Ankle Society score (EFAS) and the American Orthopaedic Foot and Ankle Society score (AOFAS); three different radiological measures were analyzed. RESULTS: The mean AOFAS score increased from 44.8 to 82 points. The mean EFAS score increased from 11.2 to 20.1 points. The mean VAS score decreased by 4.7 points. The mean EFAS Sport score was increased from 9.2 (SD 4.6) to 12.6 (SD 5.4) points. The intermetatarsal angle decreased from 15° to 6.9° and the hallux valgus angle by a mean of 17.9°. The forefoot width reduced from 93.6 to 84.7 mm. All results were statistically significant (p < .001). One case of nonunion was recorded. No implant-related complications were observed. CONCLUSIONS: This device was effective in correcting moderate to severe hallux valgus, with significant patient satisfaction. Its complication rate was not higher than that of other fixation devices. Correct compression of the arthrodesis, absence of extraosseous material, and multidirectional stability are important qualities of this implant for the correct treatment of this pathology. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Impact of Vitamin D Receptor Genotypes on Taiwan Hallux Valgus.

BACKGROUND/AIM: Hallux valgus (HV) is the most prevalent deformity affecting the forefoot; however, its genetic etiology remains unclear. In the literature, vitamin D receptor (VDR) genotypes have been reported to be associated with the risk of skeletal malformations accompanied by inflammation. This study aimed to examine the hypothesis that VDR genotypes are associated with the risk of HV. MATERIALS AND METHODS: The VDR rs731236, rs1544410, rs2228570 and rs7975232 genotypes of 150 HV patients and 600 non-HV subjects were determined using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) methodology and examined regarding their associations with HV risk. RESULTS: The results showed that none of the genetic frequency distributions of VDR rs731236, rs1544410, rs2228570, or rs7975232 were significant between the HV cases and non-HV controls (p for trend=0.4055, 0.2170, 0.7220, 0.5509, respectively). Additionally, allelic frequency analysis showed that none of the allelic frequencies of VDR rs731236, rs1544410, rs2228570, or rs7975232 were significantly distributed (p=0.2285, 0.1572, 0.9278, and 0.5547, respectively). Furthermore, stratified analysis showed that no correlation was observed between VDR rs731236 and different age groups (either younger or older than 51) or sex (p=0.3953 and p=0.9576). Moreover, no correlation was found between VDR rs731236 genotype and the risk of HV in individuals within subgroups of height, weight, or body mass index (BMI) (p=0.8317, 0.5346, and p=0.8783, respectively). CONCLUSION: VDR rs731236, rs1544410, rs2228570, and rs7975232 may not serve as indicators for a higher risk of HV.

Preoperative Degenerative Changes at the Tibial Sesamoid-Metatarsal Joint in Hallux Valgus: Association With Postoperative Patient-Reported Outcomes After Modified Lapidus Procedure.

Background: Degenerative changes at the sesamoid-metatarsal joints (SMJs) may be a source of pain following hallux valgus surgery. The aims of this study were to describe degenerative changes at the SMJs on weightbearing computed tomography (WBCT) scans and, secondarily, investigate their association with 1-year patient-reported outcome scores following a modified Lapidus procedure for hallux valgus. We hypothesized that reduced joint space in the SMJs would correlate with worse patient-reported outcomes. Methods: Fifty-seven hallux valgus patients who underwent a modified Lapidus procedure had preoperative and minimum 5-month postoperative WBCT scans, and preoperative and at least 1-year postoperative PROMIS physical function (PF), pain interference, and pain intensity scores were included. Degenerative changes at the SMJs were measured using distance mapping between the sesamoids and first metatarsal head on preoperative and postoperative WBCT scans. The minimum and average distances between the first metatarsal head and tibial sesamoid (tibial-SMJ) for each patient preoperatively and postoperatively were measured. Sesamoid station was measured on WBCT scans using a 0 to 3 grading system. Linear regression was used to investigate the correlations between minimum preoperative and postoperative tibial-SMJ distances and 1-year postoperative PROMIS scores. Results: The median minimum and average tibial-SMJ distances increased from 0.82 mm (interquartile range [IQR] 0.40-1.03 mm) and 1.62 mm (IQR 1.37-1.75 mm) preoperative to 1.09 mm (IQR 0.96-1.23 mm) and 1.73 mm (IQR 1.60-1.91 mm) postoperative (P < .001 and P < .001), respectively. In a subset of patients with complete sesamoid reduction, we found an association between preoperative minimum tibial-SMJ distance and 1-year postoperative PROMIS PF scores (coefficient 7.2, P = .02). Conclusion: Following the modified Lapidus procedure, there was a statistically significant increase in the tibial-SMJ distance. Additionally, in patients with reduced sesamoids postoperatively, reduced preoperative tibial-SMJ distance correlated with worse PROMIS PF scores. Level of Evidence: Level IV, case series.

Onychomycosis in Foot and Toe Malformations.

Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.

Secondary Surgery Following Lapidus Bunionectomy.

While the Lapidus bunionectomy is a common procedure utilized to address hallux valgus, the incidence of secondary surgery is not well established. Our primary goal was to determine the incidence of revision surgery and hardware removal following the Lapidus bunionectomy in addition to the risk factors associated with each. A retrospective nested case-control study of adult patients who underwent a Lapidus bunionectomy for symptomatic hallux valgus over a nine-year period was performed. The incidence rates and 95% confidence intervals (CI) of secondary surgery in the three years following the procedure along with the estimated independent associations and odds ratios between baseline demographic, clinical, and radiographic characteristics were calculated. Of the original cohort of 2,540 patients, 127 were identified (5.0%; CI: 4.1%, 5.8%) who underwent revision surgery and 165 (6.5%; CI: 5.5%, 7.5%) who underwent hardware removal following Lapidus bunionectomy. Initially, the hallux valgus angle, intermetatarsal angle, and tibial sesamoid position were risk factors for revision surgery. However, in adjusted analyses for revision surgery, using a screw for third point of fixation emerged as the only independent risk factor (odds ratio [OR]=3.01; CI: 1.59, 5.69). In adjusted analyses for hardware removal, female sex (OR=2.33; CI: 1.08, 5.00) and third point of fixation (OR=2.92; CI: 1.82, 4.69) emerged as independent risk factors. While the overall risks associated with Lapidus bunionectomy are low and the need for revision surgery are low, this study helps to identify specific risk factors for secondary surgery and hardware removal to help in evaluation and discussion with patients. LEVEL OF EVIDENCE: : 4.

Biomechanical consequences of proximal screw placement in minimally invasive surgery for hallux valgus correction.

Hallux valgus is one of the most common surgically corrected forefoot deformities. Studies evaluating clinical outcomes of minimally invasive chevron and akin (MICA) procedure have shown shorter operation time, faster recovery, and smaller scars compared to the open approach. Previous biomechanical cadaveric studies have largely focused on the open approach with minimal on MICA. To our knowledge, no studies have compared different proximal screw placements in MICA which can either be three-point fixation or intramedullary. This study aims to compare the biomechanical properties of fixation between these two techniques in MICA. Six matched pairs of human fresh frozen cadaveric feet were randomized to either three-point fixation or intramedullary groups. Both procedures were performed by a single fellowship-trained orthopaedic foot and ankle surgeon. Using a material testing machine, each specimen underwent 1000 cycles of plantar-to-dorsal uniaxial loads from 0 to 31 N in cantilever configuration while monitoring bending stiffness and distal fragment dorsal angulation. They were then subjected to load until failure at a compression rate of 10 mm/min. Specimens from both groups tolerated the walking fatigue test. Mean bending stiffness of three-point fixation was 84% higher than intramedullary constructs (P=0.002). Mean dorsal angulation of intramedullary was thrice that of three-point fixation constructs (P=0.008). Mean load to failure of three-point fixation was 30% higher than intramedullary constructs (P=0.001). Three-point fixation provide superior biomechanical stability compared to intramedullary proximal screw placement. The surgical technique using three-point proximal screw fixation can offer robust fixation and lead to better clinical outcomes. LEVEL OF CLINICAL EVIDENCE: 5.

The efficacy of shoes modification and orthotics in hallux valgus deformity: a comprehensive review of literature.

Hallux valgus (HV) is a frequent forefoot deformity affecting about 23% of adults and 35.7% of people over 65. The exact etiology is not fully understood. The first ray plays a significant role in walking cause it bears the principal amount of weight and maintains the position of the medial arch. Several factors that deteriorate the integrality of the first ray, such as foot deformities, restrictive footwear, and pes planus, may be ascribed to the HV occurrence. Before any surgical correction, conservative treatment should always be initiated first. Currently, there is no consensus that conservative management by shoe modification and foot orthoses could correct the pathology or terminate the clinical worsening of the condition.From a careful analysis of the literature, proper footwear should be a shoe with an adequate length, wide toe box, cushioned sole, and a lowered heel to not increase the load on the metatarsal heads and cause pain. Personalized 3D printed customized toe spreaders may be applied in patients with HV, improving symptoms and bringing pain relief. Compensating the subtalar joint hyperpronation through foot orthoses plays a fundamental role in the HV development, preventing or at least controlling the condition's progress; this, along with weight reduction and regular physical activity.Data obtained suggest that dynamic foot orthoses prefer a biomechanical type with 3/4-length, which is less likely to negatively affect the dorsal or medial pressures, which instead were noted to increase with the sulcus- and full-length orthoses.Although some studies suggest that foot orthoses would favor the correction of HV deformity, results have been very variable and just in few studies appear to correct HV or reduce its progression, improving symptoms and bringing pain relief. In the case of HV surgical correction, orthoses seem to maintain the correct position acquired over time.

Relationship between the medial cuneiform bone morphology and the severity of hallux valgus.

BACKGROUND: It has been reported on the relationship between the medial cuneiform bone morphology, especially in terms of obliquity, and the severity of hallux valgus (HV), however, no consensus has been obtained. On the other hand, there are no reports on the relationship between the difference in height between the medial and intermediate cuneiforms and the severity of hallux valgus. The purpose of this study was to clarify the relationship between the medial cuneiform bone morphology and the severity of HV. METHODS: The authors retrospectively analyzed 200 feet of 116 patients who had a weightbearing anteroposterior foot radiograph taken between April 2017 and July 2022 and diagnosed with HV. Measurements included the hallux valgus angle (HVA), the intermetatarsal angle (IMA), the distal medial cuneiform angle (DMCA) and the cuneiform first-second length (C1-2D). HV groups were classified into one of three groups: mild (15 ≦ HVA<30°, 9 < IMA<13°), moderate (30 ≦ HVA<40°, 13 ≦ IMA≦20°) and severe groups (HVA≧40°, IMA>20°), and the relationship to DMCA or the difference in height between the medial and intermediate cuneiforms was analyzed. RESULTS: A total of 163 feet of 93 patients were included in this study. There were significant correlations between the HVA and the DMCA (r = 0.47, p <0.001) or the C1-2D (r = 0.64, p <0.001). There was no significant difference in DMCA between the mild and moderate groups (p = 0.14). On the other hand, significant differences in C1-2D were observed between the three groups (mild-moderate; p <0.001, moderate-severe; p = 0.03, mild-severe; p <0.001). IMA was also positively correlated with the DMCA (r = 0.30, p <0.001) or the C1-2D (r = 0.47, p <0.001). However, the DMCA (p = 0.07) and the C1-2D (p = 0.39) did not differ significantly from IMA between the moderate and severe groups. CONCLUSIONS: The difference in height between the medial and intermediate cuneiforms, referred to as C1-2D, is closely associated with the HVA. The C1-2D may influence the progression of HV and be a novel radiographic parameter that indicates severity of HV.

Radiological and functional outcomes of Reverdin Isham osteotomy in moderate Hallux Valgus: a systematic review and meta-analysis.

This systematic review and meta-analysis addresses the effects of minimally invasive surgical techniques, specifically the Reverdin Isham osteotomy, on functional and radiological outcomes in patients with moderate Hallux Valgus, a common foot deformity. The review included randomized and non-randomized controlled trials, as well as case reports, assessing the osteotomy in adults with moderate to severe Hallux Valgus. Searches were conducted in electronic databases such as MEDLINE and Web of Science up until July 2023, and the Joanna Briggs Institute's critical appraisal tool was used to assess the risk of bias. Meta-analytical analyses employed a random-effects model with small-sample correction, presenting results as standardized mean differences and mean differences with 95% confidence intervals. Seven studies involving 554 patients and 643 operated feet were included, showing significant improvements in AOFAS scores (an average improvement of 36 points from 28.61 to 45.16) and reductions in radiological angles such as the distal metatarsal angle and hallux valgus angle post-surgery (IMA improved by - 3.07° from - 4.68 to - 1.46, DMAA by - 6.12° from - 9.52 to - 2.71, and HVangle by - 15.27° from - 17.98 to - 12.57). Despite these positive outcomes, most studies exhibited risks of bias and other methodological limitations, impacting the generalizability of the results. Overall, the findings highlight the efficacy of the Reverdin Isham osteotomy in improving both functional and radiological parameters in patients with moderate Hallux Valgus, although further research is warranted to solidify these results. No specific funding was received for this study, and the protocol was registered on PROSPERO with the number CRD-42023445886.

Congenital hallux valgus occurs in Fibrodysplasia Ossificans Progressiva and BMPR1B-associated dysplasia: an important distinction.

BACKGROUND: Fibrodysplasia Ossificans Progressiva (FOP; OMIM #135100) is an ultrarare genetic disorder characterised by congenital bilateral hallux valgus (CBHV), intermittent soft tissue swellings and progressive heterotopic ossification. We report a three-month-old girl with great toe abnormalities similar to FOP, in whom comprehensive clinical workup and genetic investigations illustrates an alternative diagnosis. CASE PRESENTATION: A three-month-old girl presented with CBHV. The antenatal period was unremarkable, she was born by spontaneous vaginal delivery with an uneventful subsequent course, except for maternal concern of her bent toes which received reassurance from several health professionals. Her mother's persisting concerns were explored via the internet and social media leading her to request referral to an expert bone centre for consideration of FOP. On examination, she was thriving, there was no dysmorphism, subcutaneous lumps, skeletal or extra-skeletal deformity except for shortened great toes with lateral deviation of the proximal and distal phalanges. FOP was a feasible diagnosis, for which CBHV is highlighted as an early sign. A cautionary potential diagnosis of FOP was counselled, including advice to defer intramuscular immunisations until genetic results available. Genetic investigation was undertaken through rapid whole genomic sequencing (WGS), with analysis of data from a skeletal dysplasia gene panel, which demonstrated no ACVR1variants. The only finding was a heterozygous variant of unknown significance in BMPR1B (c1460T>A, p.(Val487Asp)), which encodes a bone morphogenic receptor involved in brachydactyly syndromes A1, A2 and D and acromesomelic dysplasia 3 (only the latter being an autosomal recessive condition). CONCLUSION: This report highlights that CBHV serves as a vital diagnostic indicator of FOP and affected infants should be considered and investigated for FOP, including precautionary management whilst awaiting genetic studies. The second educational aspect is that CBHV may not represent a generalised skeletal disorder, or one much less significant than FOP. Receptor-ligand BMP and Activins mediated interactions are instrumental in the intricate embryology of the great toe. Recognition of non-FOP conditions caused by alterations in different genes are likely to increase with new genomic technology and large gene panels, enhancing understanding of bone signaling pathways.

Joint-Preserving Surgery for Hallux Valgus Deformity in Rheumatoid Arthritis.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that frequently causes forefoot deformities. Arthrodesis of the first metatarsophalangeal joint is a common surgery for severe hallux valgus. However, joint-preserving surgery can maintain the mobility of the joint. This study aimed to investigate the clinical and radiographic outcomes of distal chevron metatarsal osteotomy (DCMO) for correcting hallux valgus deformity associated with RA. Methods: Between August 2000 and December 2018, 18 consecutive patients with rheumatoid forefoot deformities (24 feet) underwent DCMO for hallux valgus with/without lesser toe surgery. Radiological evaluations were conducted, assessing the hallux valgus angle, the intermetatarsal angle between the first and second metatarsals, and the Sharp/van der Heijde score for erosion and joint space narrowing. Clinical outcomes were quantified using a visual analog scale for pain and the American Orthopaedic Foot and Ankle Society forefoot scores to measure function and alignment. Results: The mean hallux valgus angle decreased from 38.0° (range, 25°-65°) preoperatively to 3.5° (range, 0°-17°) at the final follow-up (p < 0.05). The mean intermetatarsal angle decreased from 14.9° (range, 5°-22°) preoperatively to 4.3° (range, 2°-11°) at the final follow-up. (p < 0.05). Regarding the Sharp/van der Heijde score, the mean erosion score (0-10) showed no significant change, decreasing from 3.83 (range, 0-6) preoperatively to 3.54 (range, 0-4) at the final follow-up (p = 0.12). Recurrent hallux valgus was observed in 1 patient and postoperative hallux varus deformity was observed in 2 feet. Spontaneous fusion of the metatarsophalangeal joint developed in 1 case. Conclusions: DCMO resulted in satisfactory clinical and radiographic outcomes for correcting RA-associated hallux valgus deformity.

Percutaneous distal chevron osteotomy is associated with lower immediate postoperative pain and a greater range of motion than the open technique: A prospective randomized study.

PURPOSE: The results of past studies comparing percutaneous techniques with traditional open techniques for hallux valgus are controversial. Therefore, this study aimed to compare the radiologic and clinical outcomes of percutaneous and open distal chevron osteotomies. METHODS: Seventy-one patients with mild to severe hallux valgus deformity were randomized to undergo percutaneous distal chevron osteotomy (percutaneous group, n = 36) or open distal chevron osteotomy (open group, n = 35) between October 2019 and September 2020. Radiological and clinical outcomes were assessed preoperatively and postoperatively. Outcome measures included the foot and ankle outcome score, foot functional index, visual analogue scale (VAS) scores for pain, range of motion (ROM) of the first metatarsophalangeal (MTP) joint, hallux valgus angle, intermetatarsal angle, and first metatarsal shortening. Additionally, the first metatarsal declination angle was measured to evaluate sagittal malunion. RESULTS: The mean first metatarsal declination angle decreased significantly at 12 months postoperatively in both groups (p = 0.021 and p < 0.001 in the percutaneous and open groups, respectively), and the decrement was significantly greater in the open group (p = 0.033). The mean VAS score for pain on postoperative day one was 4.2 ± 1.9 and 5.3 ± 1.7 in the percutaneous and open groups, respectively (p = 0.019). The mean ROM of the first MTP joint did not change significantly after surgery, from 72.5 ± 7.5 preoperatively to 71.0 ± 9.5 at 12 months postoperatively in the percutaneous group (p = 0.215); however, it decreased significantly from 70.6 ± 7.3 preoperatively to 63.4 ± 10.4 at 12 months postoperatively in the open group (p < 0.001). There were no significant differences between the groups regarding other clinical outcomes. CONCLUSION: The percutaneous group showed a lower immediate pain level at postoperative day 1 and better ROM of the first MTP joint at 12 months postoperatively.

Sagittal Plane Alignment for First Metatarsal Phalangeal Arthrodesis Correlated with Postoperative Function: What is the Optimal Position?

There have been many reports describing the proposed alignment of a first metatarsal phalangeal arthrodesis to obtain optimum function. Most of these recommendations are based upon historical and anecdotal evidence. Furthermore, there are few reports directly comparing alignment to patient reported function. We studied radiographic sagittal plane alignment in a group of 60 patients (80 feet) who had undergone a first metatarsal phalangeal joint arthrodesis (20 of the 60 had bilateral arthrodesis) to better understand how this component of the arthrodesis position translates to real world function. The patients in this study had completed a functional survey in 2022 at a mean of 28.4 (median 27.8; range 13.2-45.7) months with very high satisfaction for return to activities of daily living and recreational sports. We measured the sagittal plane position of the first metatarsal relative to the proximal phalanx in this cohort with known post operative activity data. We found that a mean (standard of deviation) sagittal plane angle (angle between the anatomic axis of the first metatarsal and the proximal phalanx) of 15.4 (SD 7.4) degrees and a proximal phalanx head to ground height of 12.7 (SD 3.3) mm was present in this group. Comparing the functional and positional results we conclude that this sagittal plane position provides a good recommendation for alignment.

Cannulated screws versus nitinol staple for tarsometatarsal fusion: A cadaveric biomechanical comparison model.

BACKGROUND: The objective of this study was to evaluate the biomechanical stability of a medially placed nitinol staple compared to two crossed-screws in the first TMT-1 joint fusion in a cadaveric cyclic loading model. METHODS: Seven matched pairs (N = 7) of lower limb cadaveric specimens were utilized. TMT-1 joints from each donor were fixed with a medially placed nitinol staple or dorsally placed two 3.5 mm partially threaded cannulated crossed-screws. Specimens were tested in a 4-point bending setting with increasing cyclic forces. RESULTS: The mean plantar gapping was not significantly different between the two groups at any loading stage below 200 N. Specimens fixed with a nitinol staple failed at a mean load of 305 ± 57 N. Conversely, those fixed with crossed-screws failed at 373 ± 86 N. (P = .09). CONCLUSION: There was no statistical difference between a medially placed nitinol staple and dorsally placed crossed-screws in failure loads and plantar gapping under cyclic loads at the TMT-1 joint, however, the staple fixation was much more variable. LEVEL OF EVIDENCE: Level V, basic science study, biomechanics.

Developing Machine Learning-Based Predictive Models for Hallux Valgus Recurrence Based on Measurements From Radiographs.

BACKGROUND: Machine learning (ML) is increasingly used to predict the prognosis of numerous diseases. This retrospective analysis aimed to develop a prediction model using ML algorithms and to identify predictors associated with the recurrence of hallux valgus (HV) following surgery. METHODS: A total of 198 symptomatic feet that underwent chevron osteotomy combined with a distal soft tissue procedure were enrolled and analyzed from 2 independent medical centers. The feet were grouped according to nonrecurrence or recurrence based on 1-year follow-up outcomes. Preoperative weightbearing radiographs and immediate postoperative nonweightbearing radiographs were obtained for each HV foot. Radiographic measurements (eg, HV angle and intermetatarsal angle) were acquired and used for ML model training. A total of 9 commonly used ML models were trained on the data obtained from one institute (108 feet), and tested on the other data set from another independent institute (90 feet) for external validation. Optimal feature sets for each model were identified based on a 2000-resample bootstrap-based internal validation via an exhaustive search. The performance of each model was then tested on the external validation set. The area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model were calculated to evaluate the performance of each model. RESULTS: The support vector machine (SVM) model showed the highest predictive accuracy compared to other methods, with an AUC of 0.88 and an accuracy of 75.6%. Preoperative hallux valgus angle, tibial sesamoid position, postoperative intermetatarsal angle, and postoperative tibial sesamoid position were identified as the most selected features by several ML models. CONCLUSION: ML classifiers such as SVM could predict the recurrence of HV (an HVA >20 degrees) at a 1-year follow-up while identifying associated predictors in a multivariate manner. This study holds the potential for foot and ankle surgeons to effectively identify individuals at higher risk of HV recurrence postsurgery.

Radiographic Assessment of Transverse Tarsometatarsal Instability Complicated by Metatarsus Adductus in Hallux Valgus Patients.

Objective evaluations of transverse tarsometatarsal (TMT) hypermobility/instability are lacking. This study aims to radiographically explore the relationship between transverse TMT instability and metatarsus adductus (MA) in hallux valgus (HV). This study retrospectively analyzed 207 feet with varying degrees of HV, employing the distance between the first and second metatarsals (M1-2 distance) to assess transverse TMT instability of the first ray. Participants were categorized into MA and non-MA groups. It was found that the M1-2 distance significantly increased with the hallux valgus angle (HVA) and metatarsus adductus angle (MAA), demonstrating significant differences between the MA and non-MA groups. The measurement of M1-2 distance showed high reliability, and its cutoff value was determined to be 4.05 mm. Additionally, the results suggest that the widening of the M1-2 distance may be a predisposing factor for MA in HV patients, highlighting its role in the pathogenesis of this foot condition. These findings highlight the need for a comprehensive assessment of TMT instability on both the axial and sagittal planes for the surgical planning of HV, particularly when complicated by a large MAA. Based on these insights, reoriented first-TMT arthrodesis might be recommended for HV with significant MA to address potential multiplanar instability.

Minimally Invasive Chevron Akin (MICA) Osteotomy Corrects Radiographic Parameters but Not Central Metatarsal Loading in Moderate to Severe Hallux Valgus without Metatarsalgia.

BACKGROUND: Central metatarsal pressure is increased in patients with hallux valgus, but the pedographic outcomes after hallux valgus (HV) correction are inconclusive. No known literature has reported the pedographic outcomes after HV correction with Minimally Invasive Chevron and Akin Osteotomy (MICA). METHODS: A prospective cohort of 31 feet from 25 patients with moderate-to-severe symptomatic HV but without metatarsalgia underwent MICA and was evaluated using radiographic parameters and pedographic measurements (Footscan®, RSscan International, Olen, Belgium). Data were collected preoperatively and 3 months after surgery. RESULTS: The radiographic parameters of the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, first metatarsal head lateral shape, and lateral sesamoid grade significantly improved after MICA. The corrected first metatarsal length was significantly shortened by 2.3 mm, with consistent second metatarsal protrusion distance, lateral Meary's angle, and calcaneal pitch angle. Max force, max pressure, cumulative force, and cumulative pressure on the central metatarsals did not show significant changes between pre- and post-operative measurements, while these parameters significantly decreased in the hallux and first metatarsal area. CONCLUSION: MICA effectively corrects radiographic parameters but does not reduce central metatarsal loading in patients with moderate-to-severe HV without metatarsalgia.

Minimally invasive hallux valgus surgery using 3D printed patient specific instrumentation.

In this technical report study, we describe technique for performing the osteotomy and screw passage in minimally invasive fourth-generation hallux valgus surgery with transverse and akin extra-articular metaphyseal osteotomy (META) using a 3D-printed patient-specific surgical instrumentation guide. In an effort to minimize the learning curve and address the variability associated with technical corrections and screw placement, we have initiated the creation of personalized patient-specific instrumentation guides using 3D printing. Our hypothesis is that this approach will enhance safety, precision, decrease surgical time, and reduce exposure to radiation. Level of Evidence: Level V, expert opinion.

The Effect of Therapeutic Approaches on Hallux Valgus Deformity.

Hallux valgus (HV) is a relatively frequent disease caused by a complicated structural malformation of the primary ray. The bunion or middle projection generated by the hallux's lateral displacement and pronation is merely one element of the three-dimensional abnormality. HV may trigger severe discomfort and affect joint kinematics. The specific kinematic cause is still unknown. Female age, gender, restrictive footwear, and heritage are risk indicators. HV frequently coexists along metatarsal adducts, equines contracture, hammertoe imperfection, and pes planus. HV is a frequent foot ailment with multiple, complicated, unknown etiology and course. HV has a preference for females. It is an ongoing condition for which there is no known treatment to reduce or prevent improvement. Fibrodysplasia ossificans progressiva (FOP) is distinguished by hereditary symmetrical HV deformities or symptoms that begin heterotopic calcification that is either idiopathic or caused by trauma, such as subcutaneous immunizations. Localized heterotopic calcification may be preceded by aggravating, recurring soft-tissue enlargements (flare-ups). Heterotopic calcification may happen anywhere; however, it most commonly impacts locations near the axial bone structure during the early/mild phases until advancing to the appendicular skeleton. As an effect of calcification affecting the flexibility of the joints, it might cause limitations in motion. The initial line of therapy focuses on non-surgical methods including night splinting, orthotics, and larger shoes. The next suggested line of action is surgical intervention if conservative therapy fails. Patients have good postoperative tolerance, and bone union often happens six to seven weeks after surgery. Stretching exercises help to restore function by extending shortened soft tissue and restoring range of motion (ROM). The goal of joint mobilization, a form of manual treatment method, is to extend the ligament, the soft tissue surrounding the limited joint, and the restricting joint capsule by applying modest amplitude passive movement to the joint components.