Ultrasonography-Based Quantitative Evaluation of Second Metatarsophalangeal Joint Instability in Female Patients With Hallux Valgus.

BACKGROUND: Patients with moderate to severe hallux valgus (HV) sometimes exhibit second metatarsophalangeal (MTP) joint dislocation. Second MTP joint instability due to plantar plate (PP) injury has been suggested as one of the causes. However, there have been no reports that quantitatively evaluate this instability. This study aimed to evaluate second MTP joint instability in patients with HV without dislocation via ultrasonography and investigate its relationship with the presence of PP injury or foot form. METHODS: Between May 2018 and July 2023, symptomatic female patients with HV without any lesser toe deformity were included in this study. Second MTP joint instability was defined as the dorsal displacement ratio (DDR) of the passively subluxated proximal phalangeal articular surface on the metatarsal head articular surface. The presence of PP injury was assessed using ultrasonography. Foot "form" was determined by measuring standard foot bony angles on weight-bearing foot-ankle radiographs. The relationship between DDR or PP injury and radiographic measurements was investigated. RESULTS: Sixty-four patients (100 feet) were included. The average DDR of the second MTP joint in patients with HV without dislocation was 35.7%. There was an increase in the probability of PP injury, above a cutoff DDR value r of 35.4% (area under the curve = 0.712). The sensitivity, specificity, positive predictive value, and negative predictive value for the presence of PP injury based on this cutoff level were 63.9%, 74.4%, 79.6%, and 56.9%, respectively. Metatarsalgia was reported in 21 feet (21.0%), of which 15 feet (71.4%) showed PP injury. An increase in DDR was weakly associated with increased metatarsus adductus angle and decreased second metatarsal height. CONCLUSION: In female patients with HV without second MTP dislocation, we found ultrasonographic evidence of second MTP plantar plate injury and joint instability to be a relatively common finding with a high prevalence in those with localized metatarsalgia. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria based on consecutive patients.

Low-Intensity Pulsed Ultrasound for Symptomatic Pseudarthrosis After Toe Fracture with Symphalangism: A Report of 2 Cases.

CASE: Distal phalangeal fractures are often treated conservatively. However, some patients experience residual pain. We report 2 cases of patients who underwent low-intensity pulsed ultrasound (LIPUS) therapy for pseudarthrosis after fracture of the distal phalanx of the fifth toe with symphalangism. Both patients (female, 63 and 33-year-old, respectively) underwent conservative treatment with buddy-taping fixation; however, bone union failed, and LIPUS therapy was initiated. In both cases, bone union was achieved and pain resolved after 3 months. CONCLUSION: Bone union occasionally fails after conservative treatment of distal phalangeal fractures. LIPUS is a useful treatment of symptomatic pseudarthrosis after such fractures.

Plantar Pressure Distribution Before and After Surgery for Lesser Metatarsophalangeal Joint Dislocation With Hallux Valgus.

Hallux valgus surgery and open reduction of the lesser metatarsophalangeal joints with metatarsal shortening osteotomy help treat severe hallux valgus concomitant with the lesser metatarsophalangeal joint dislocation; however, pre- and postoperative plantar pressure distribution and its effect on the foot remain unclear. The pre- and postoperative groups comprised 16 patients with moderate-to-severe symptomatic hallux valgus with lesser metatarsophalangeal joint dislocation. All feet underwent open reduction and collateral ligament reconstruction of the second metatarsophalangeal joint and proximal metatarsal shortening osteotomy under the second metatarsal with proximal osteotomy of the first metatarsal. Twenty healthy participants (20 feet) were included in the control group. The plantar pressure distribution was determined by measuring the peak pressure, maximum force, contact area, and force-time integral for 12 regions. Under the second toe, all measurements in the preoperative group were significantly lower than those of the control group. The peak pressure, maximum force, and contact area of the postoperative group were significantly greater than those of the preoperative group. However, no differences were observed between the postoperative and control groups. Under the second metatarsal head, the peak pressure of the preoperative group was significantly higher than that of the control group. The peak pressure of the postoperative group was significantly lower than that of the preoperative group and showed no differences from the control group. Open reduction and collateral ligament reconstruction of the lesser metatarsophalangeal joints and proximal metatarsal shortening osteotomy with proximal osteotomy of the first metatarsal in hallux valgus with lesser metatarsophalangeal joints dislocation cases may improve operative outcomes, including favorable foot function.

Morphology of the asymptomatic Αchilles tendon: Measurement of tendon length and shape using magnetic resonance imaging, and investigation of related factors.

BACKGROUND: One of the severe complications of Achilles tendon (AT) rupture is muscle weakness due to tendon lengthening. It is very important to prevent tendon lengthening during treatment; however, data on the length, thickness, and width of normal ATs are scarce. Furthermore, no studies have investigated the factors related to the AT length and shape. We aimed to determine the normal AT length and shape and to investigate any correlating factors. METHODS: We measured the AT length, thickness, and width of 100 asymptomatic patients using magnetic resonance imaging. We also investigated the correlation between the AT length, thickness, and width and factors including age, sex, height, body weight, body mass index, history of sports activities, and the area of Kager's fat pad. RESULTS: The mean AT length was 42.1 ± 12.9 mm. The AT length in 73% of the patients was within the range of 30-55 mm. Individual differences in the tendon length were large, but there was no correlation between the tendon length and patient height (P = 0.505). There was a strong correlation between the AT length and area of Kager's fat pad on magnetic resonance imaging (r = 0.734, P < 0.001). Furthermore, the correlation coefficient between the area of Kager's fat pad on magnetic resonance imaging and the area of Kager's triangle on radiography was extremely high (r = 0.851, P < 0.001). CONCLUSIONS: The AT length can be predicted based on the area of Kager's triangle of the unaffected ankle on radiography. If the AT length is > 55 mm or longer than the length measured directly or calculated from the estimated area of Kager's triangle, tendon lengthening should be suspected. Our findings could provide an important indicator for the evaluation of AT lengthening not only in daily clinical situations but also in clinical studies.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints.

BACKGROUND: Hallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint. METHODS: Fifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft. RESULTS: The mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0-3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints). CONCLUSIONS: The clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Joint preserving procedures for painful plantar callosities in patients with flexible cavovarus foot.

BACKGROUND: The outcome of a constant joint preserving procedure for painful plantar callosities with cavovarus foot remains unclear. METHODS: Eleven patients (11 feet) who underwent lateral displacement calcaneal osteotomy (LDCO), dorsiflexion first metatarsal osteotomy (DFMO), and plantar fasciotomy (PF), simultaneously were included. The presence of painful callosities, heel alignment of standing (HA), and the Japanese Society for Surgery of the Foot ankle/hindfoot (JSSF) score were evaluated. Radiographically, the talonavicular coverage angle (TNCA), lateral talo-first metatarsal angle (LTMA), calcaneal pitch angle (CPA), and heel alignment angle (HAA) were measured. RESULTS: Postoperatively, painful plantar callosities disappeared in 10 patients and remained in one patient. The postoperative HA and JSSF score significantly improved. The postoperative TNCA, LTMA, CPA, and HAA significantly improved. CONCLUSIONS: In patients with flexible cavovarus foot, LDCO, DFMO, and PF yielded good outcomes at mid-term follow-up with preservation of the foot and ankle joints.

Dislocations of the second and third metatarsophalangeal joints after local steroid injection in patients with refractory metatarsalgia: A case report.

Local steroid injections are frequently administered to patients with refractory metatarsalgia. No reports have described dislocation of the second and third metatarsophalangeal joints after local steroid injections. A 46-year-old woman had suffered from metatarsalgia and received multiple local steroid injections for over 2 years. The second and third metatarsophalangeal joints revealed dorsal dislocations on the lateral radiograph. Therefore, collateral ligament reconstruction of the metatarsophalangeal joints was performed. Intraoperative findings suggested that the rupture of the plantar plate may have caused dorsal dislocation of both joints. Thus, unnecessary multiple steroid injections around the lesser metatarsophalangeal joint should be avoided.

Extensor hallucis longus muscle contracture after distal tibial physeal injury: A report of two cases.

Few studies have reported about isolated contracture in the extensor hallucis longus (EHL) muscle, but none of the EHL muscle contracture after distal tibial physeal injury. Two such cases in 16- and 14-year-old boys who underwent surgeries for distal physeal injury of the tibia at a previous hospital are presented. Extension contracture of the hallux appeared 1-2 months post-surgery. Physical examinations revealed that the extension contracture of the first metatarsophalangeal joint was aggravated in plantar flexion of the ankle due to a tenodesis effect, and magnetic resonance imaging showed atrophy and signal changes in the anterior compartment muscles. This was diagnosed as EHL muscle contracture due to anterior compartment syndrome (ACS) after distal tibial physeal injury. The EHL tendon transfers were performed in both cases, with favorable short-term results. Therefore, the EHL tendon transfer might be preferable in case of the EHL muscle contracture due to partial ACS.

Plantar pressure distribution in hallux valgus feet after a first metatarsal proximal crescentic osteotomy with a lesser metatarsal proximal shortening osteotomy.

BACKGROUND: Plantar pressure distribution after the first metatarsal proximal crescentic osteotomy (FMPCO) with lesser metatarsal proximal shortening osteotomy (LMPSO) for hallux valgus with metatarsalgia has not been previously described. METHODS: The pre- (Pre) and postoperative (Post) groups comprised of 18 patients who underwent unilateral FMPCO with LMPSO; fifteen healthy volunteers constituted the control (C) group. For each of the 10 regions, peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force-time integral (FTI) were measured. RESULTS: The mean Peak-P of the second metatarsal head was significantly lower in the Post group than the Pre group. The mean Peak-P, Max-F, Con-T, and FTI were not significantly different between the Post and C groups. The mean Con-A was significantly lower in the Post group than the C group. CONCLUSION: FMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.

Postural stability impairment in patients with bilateral hallux valgus: A case-control study using a stabilometer.

BACKGROUND: Hallux valgus (HV) is an important risk factor for falls (in older people); however, the detailed relationship is less understood. We aimed to evaluate postural stability in bilateral HV patients. METHODS: Two groups of 20 female patients-an HV group and a C (i.e., non-HV) group-participated in this study. Evaluations were made using the Timed Up and Go (TUG) test, the Berg Balance Scale (BBS), the Falls Efficacy Scale (FES), track length (LNG), velocity (VEL), enveloped area (ENV), and root mean square area (RMS). RESULTS: TUG and FES scores were significantly higher and BBS scores were lower in the HV group than in the C group. LNG was significantly longer, VEL was higher, and ENV and RMS were wider in the HV group than in the C group. CONCLUSIONS: The HV group exhibited impaired walking mobility, balance, and postural stability.

Effect of Toe Type on Static Balance in Ballet Dancers.

OBJECTIVES: Some forefoot shapes are ideal for pointe work in ballet. Egyptian-type, with the hallux being longest and the remaining toes decreasing in size, and Greek-type, with the second toe longer than the hallux, are considered less optimal for pointe work. Square-type, with the second toe the same length as the hallux, is considered optimal. This study compared postural stability in the bipedal stance, demi pointe, and en pointe between ballet dancers with the two toe types using a stabilometer. METHODS: This study included 25 Japanese ballet academy dancers who had received ballet lessons for at least 6 years. Toes were categorized into Egyptian-type (n=14) and square-type (n=11). Bipedal stance, demi pointe, and en pointe were tested. Center of pressure (COP) parameters were calculated from ground-reaction forces using two force plates: total trajectory length (LNG), velocities of anterior-posterior (VAP) and medial-lateral directions (VML), and maximum range displacement in the anterior-posterior (MAXAP) and medial-lateral directions (MAXML). Mann-Whitney U-tests were used to examine differences in COP parameters. RESULTS: There were no differences in parameters during bipedal stance or demi pointe. However, dancers with Egyptian-type toes had significantly greater LNG (p<0.01), VML (p=0.01), MAXML (p<0.01), and MAXAP (p=0.03) during en pointe. CONCLUSIONS: Ballet dancers with Egyptian-type toes demonstrated greater displacement in the medial-lateral and anterior-posterior directions during en pointe. Ballet dancers should be aware of toe types and sway character to optimize ballet training and balance.

Operative Treatment for Hallux Valgus With Moderate to Severe Metatarsus Adductus.

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

Comparison of Plantar Pressure Distribution Between Postoperative Hallux Valgus Feet and Healthy Feet.

BACKGROUND: Proximal crescentic osteotomy (PCO) in patients with moderate-to-severe hallux valgus (HV) is a well-established and effective procedure for correcting the deformity. However, there are no published studies comparing plantar pressure in postoperative HV feet with healthy feet. This study aimed to compare the plantar pressure distribution in postoperative HV feet with healthy feet. METHODS: Twenty-six patients were included in the HV group, and 24 healthy participants were included in the control (C) group. All patients in the HV group underwent unilateral PCO. After undergoing PCO, this group was defined as the OP group. All subjects were women with no significant differences in age, height, weight, and body mass index. There were no significant differences in demographic characteristics between patients in each group. We divided the subjects' feet into 8 regions and measured the peak pressure (Peak-P), maximum force (Max-F), contact time, contact area, and the force-time integral in each region. RESULTS: All parameters of the great toe were significantly higher in the OP group than in the HV group. All forefoot parameters were not significantly different between the 2 groups. No parameter of the great toe was significantly different between the OP and C groups. However, mean Peak-P and Max-F of the central forefoot were significantly higher in the OP group than in the C group. CONCLUSION: PCO can improve the plantar pressure of the great toe in patients with moderate-to-severe HV to a level similar to that in healthy subjects. LEVEL OF EVIDENCE: Level III, comparative study.

Comparison of plantar pressure distribution in patients with hallux valgus and healthy matched controls.

BACKGROUND: Detailed information regarding differences in plantar pressure distribution between hallux valgus and healthy feet is unavailable. The purposes of the present study were to clarify the characteristics of the plantar pressure distribution in patients with hallux valgus compared with healthy matched controls and to determine whether hallux valgus leads to dysfunction of the great toe during walking. METHODS: The study consisted of 25 patients with symptomatic moderate-to-severe hallux valgus (HV group) and 13 healthy matched volunteers (C group) without hallux valgus. All patients and volunteers were women. The HV and C groups did not differ significantly in age, height, weight, and body mass index. Plantar pressure during walking was measured using F-scan. The plantar aspect of the foot was divided into eight regions. The peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force time integral (FTI) were measured in each region. RESULTS: The Peak-P of the great toe did not differ significantly between the HV and C groups. However, all other parameters: Max-F, Con-T, Con-A, and FTI of the great toe in the HV group were significantly lower than in the C group. In the central forefoot, the Peak-P and Max-F in the HV group were significantly higher than in the C group. CONCLUSION: The present study demonstrated that a moderate-to-severe hallux valgus deformity leads to dysfunction of the great toe during walking and may increase mechanical loading on the central forefoot.

Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle.

BACKGROUND: Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments. HYPOTHESIS: Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated. RESULTS: Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation. CONCLUSION: MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.

The effect of platelet-rich plasma on Achilles tendon healing in a rabbit model.

OBJECTIVE: The aim of the present study was to evaluate the effects of PRP on Achilles tendon healing in rabbits during the inflammatory, proliferative, and remodeling phases by histological examination and quantitative assessments. METHODS: Fifty mature male Japanese albino rabbits with severed Achilles tendons were divided into two equal groups and treated with platelet-rich plasma (PRP) or left untreated. Tendon tissue was harvested at 1, 2, 3, 4, and 6 weeks after treatment, and sections were stained with hematoxylin-eosin and monoclonal antibodies against CD31 and type I collagen. RESULTS: Collagen fibers proliferated more densely early after severance, and subsequent remodeling of the collagen fibers and approximation of normal tendinous tissue occurred earlier in the PRP group than in the control group. The fibroblast number was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Similarly, the area ratio of CD31-positive cells was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Positive staining for type I collagen was more intense in the PRP group than in the control group after 3 weeks, indicating tendon maturation. CONCLUSION: Administration of PRP shortened the inflammatory phase and promoted tendon healing during the proliferative phase.

Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps.

BACKGROUND: Several surgical procedures for chronically ruptured Achilles tendons have been reported. Resection of the interposed scar tissue located between the tendon stumps and reconstruction using normal autologous tissue have been well described. We developed a direct repair procedure that uses scar tissue, which obviates the need to use normal autologous tissue. METHODS: Thirty consecutive patients with Achilles tendon ruptures with a delay in diagnosis of >4 weeks underwent removal of a section of scar and healing tissue with direct primary suture of the ends of the tendon without the use of allograft or autograft. Patients were followed for a mean time of 33 months. Preoperative and postoperative clinical outcomes were measured with the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, the patients underwent preoperative and postoperative functional measurements and magnetic resonance imaging. Lastly, we evaluated the histology of the interposed healing tissue. RESULTS: The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. At the time of the latest follow-up, none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Preoperative T2-weighted magnetic resonance imaging showed that 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative T2-weighted magnetic resonance imaging findings included fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers. CONCLUSIONS: Shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical reduction and ligament reconstruction for chronic dorsal dislocation of the lesser metatarsophalangeal joint associated with hallux valgus.

BACKGROUND: Hallux valgus (HV) is occasionally associated with chronic dislocation of the lesser metatarsophalangeal (MTP) joints. We have developed a novel surgical procedure to treat dislocation of the lesser MTP joints. This study aimed to describe our procedure and investigate the outcomes of surgical intervention in the treatment of HV with dislocation of the lesser MTP joints. METHODS: Twenty-three patients (27 feet, average age: 63.6 years, average follow-up: 49.5 months; a minimum follow-up of 24 months) underwent surgical intervention for HV and dislocation of the lesser MTP joints. Twenty-three feet had dislocation (10 feet) or subluxation (13 feet) of the second MTP joint, whereas 4 feet had dislocation of the second and third MTP joints. The surgical procedure included a distal soft-tissue procedure combined with proximal osteotomy for correction of the HV, and reconstruction of the collateral ligaments (CL) following open reduction with complete release of the capsule and the CL at the metatarsal head for dislocation of the lesser MTP joints. Outcomes were assessed using the Japanese Society for Surgery of the Foot (JSSF) scale and radiological examinations. RESULTS: The JSSF score improved significantly from an average of 49.7 points preoperatively to 93.1 points postoperatively. The average HV angle and intermetatarsal angle decreased significantly from 44.6° and 18.1° preoperatively to 7.9° and 6.0° postoperatively, respectively. The average extension and flexion of the second MTP joint was 53.1° and 13.8° at the most recent follow-up, respectively. Postoperatively, no feet had dislocation of the second or third MTP joint, three had subluxation of the second MTP joint, and one had subluxation of the third MTP joint. Osteoarthritis of the lesser MTP joint had developed in two feet (7.4 %) at the time of the most recent follow-up. CONCLUSION: Our surgical procedure achieved significant correction of HV, a low rate of postoperative re-dislocation of the lesser MTP joints, and significant improvement of pain and function for symptomatic moderate-to-severe HV with dislocation of the lesser MTP joints. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Proximal supination osteotomy of the first metatarsal for hallux valgus.

BACKGROUND: Risk factors for hallux valgus recurrence include postoperative round-shaped lateral edge of the first metatarsal head and postoperative incomplete reduction of the sesamoids. To prevent the occurrence of such conditions, we developed a proximal supination osteotomy of the first metatarsal. Our aim was to describe this novel technique and report the outcomes in this report. METHODS: Sixty-six patients (83 feet) underwent a distal soft tissue procedure combined with a proximal supination osteotomy. After the proximal crescentic osteotomy, the proximal fragment was pushed medially, and the distal fragment was abducted, and then the distal fragment of the first metatarsal was manually supinated. Outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiographic examinations. The average follow-up duration was 34 (range, 25 to 52) months. RESULTS: The mean AOFAS score improved significantly from 58.0 points preoperatively to 93.8 points postoperatively (P < .0001). The mean hallux valgus and intermetatarsal angle decreased significantly from 38.6 and 18.0 degrees preoperatively to 11.0 and 7.9 degrees postoperatively, respectively (both, P < .0001). Sixty-nine feet (69/83, 83%) had a positive round sign preoperatively, and 66 feet (66/83, 80%) had a negative round sign postoperatively. According to the Hardy's classification of position of the sesamoids, all feet were classified as grade V or greater preoperatively, and 49 feet (49/83, 59%) were classified as grade IV or less postoperatively. Three feet (3/83, 4%) had recurrence of hallux valgus, defined as a hallux valgus angle ≥ 25 degrees. CONCLUSION: The rates of occurrence of a positive round sign and incomplete reduction of the sesamoids significantly decreased postoperatively, which may have contributed to the low hallux valgus recurrence rates. We conclude that a proximal supination osteotomy was an effective procedure for correction of hallux valgus and can achieve a low rate of hallux valgus recurrence. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Proximal abduction-supination osteotomy of the first metatarsal for adolescent hallux valgus: a preliminary report.

BACKGROUND: Surgical treatment of adolescent hallux valgus has been a challenging intervention because of high rates of postoperative recurrence. The purposes of this study were to describe a proximal abduction-supination osteotomy of the first metatarsal and prospectively review preliminary results of this procedure for correction of adolescent hallux valgus. METHODS: Eleven patients (12 feet) who had had a proximal abduction-supination osteotomy of the first metatarsal combined with a distal soft-tissue procedure to correct an adolescent hallux valgus deformity were prospectively reviewed clinically and radiologically. The average duration of follow-up was 22 months. The average age at the time of surgery was 17 years. RESULTS: The mean score on the Japanese Society for Surgery of the Foot standard rating system for hallux improved significantly, from 62.0 points preoperatively to 99.2 points postoperatively (p = 0.002). All patients were satisfied and would choose to have the same procedure again. The mean hallux valgus angle decreased significantly, from 32.3° preoperatively to 12.2° postoperatively (p = 0.002); mean intermetatarsal angle decreased significantly from 14.0° preoperatively to 6.2° postoperatively (p = 0.002). No feet had postoperative recurrence of hallux valgus (a hallux valgus angle ≥20°). There were no occurrences of nonunion or transfer lesions. CONCLUSIONS: The clinical and radiological results of this study demonstrate that a proximal abduction-supination osteotomy with a distal soft-tissue procedure, which described in this study, achieved significant correction of an adolescent hallux valgus deformity, significant improvement in pain and function, and reduction in rate of recurrence.