- Email: [email protected]
Distal Akin osteotomy for hallux valgus interphalangeus
Accepted Manuscript Title: Distal Akin Osteotomy for Hallux Valgus Interphalangeus Authors: N. Martinelli MD, PhD, A. Giacalone, A. Bianchi, M. Hosseinzadeh, C. Bonifacino, F. Malerba PII: DOI: Reference:
S1268-7731(17)30040-1 http://dx.doi.org/doi:10.1016/j.fas.2017.02.003 FAS 1006
To appear in:
Foot and Ankle Surgery
Received date: Revised date: Accepted date:
3-10-2016 28-12-2016 7-2-2017
Please cite this article as: Martinelli N, Giacalone A, Bianchi A, Hosseinzadeh M, Bonifacino C, Malerba F.Distal Akin Osteotomy for Hallux Valgus Interphalangeus.Foot and Ankle Surgery http://dx.doi.org/10.1016/j.fas.2017.02.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Distal Akin Osteotomy for Hallux Valgus Interphalangeus N. Martinelli,1 A. Giacalone,1 A. Bianchi,1 M. Hosseinzadeh,1 C. Bonifacino,1 F. Malerba1 1.
Department of Foot and Ankle Surgery, Galeazzi Hospital, via R. Galeazzi 4, 20161
Milan, Italy. Tel: 003902/662141 Fax: 003902/66214800
Corresponding author: Nicolò Martinelli, MD, PhD [email protected]
Highlights
Distal Akin osteotomy is safe and effective for HVI
High satifaction rate can be achieved after distal Akin osteotomy for HVI
Abstract Background The aim of this study was to assess clinical and radiological outcomes in patients who underwent distal Akin osteotomy for hallux valgus interphalangeus (HVI). Methods A series of 15 consecutive patients (17 feet) was retrospectively reviewed. All the patients were preoperatively and post-operatively evaluated with a physical and radiographic assessment (HVI angle). Satisfaction has been assessed through a satisfaction survey, the scale used consisted in three possible choice: very satisfied, satisfied, not satisfied. Results Among 15 patients the 52.9 % (9 patients) stated to be “very satisfied”, the 41.2 % (7 patients) “satisfied” and just a 5.9 % (one patient) was “not satisfied”. The mean HVI value decreased from 24.9°± 7.8° preoperatively to 13.1°± 5.8° 1
postoperatively at last follow up (p<0.05). Conclusions Based on these findings we can conclude that the distal Akin osteotomy can be considered safe and effective in the surgical correction of symptomatic HVI deformities.
Keywords: Hallux Valgus Interphalangeus, osteotomy, correction, pain, disability.
Introduction Hallux valgus interphalangeus (HVI) is a complex deformity involving the joint as well as the neighboring soft tissue influences. The deformity usually presents early in life and can rapidly progress during growth spurts. Older patients typically present a more rigid deformity and arthrodesis of the interphalangeal joint is often recommended to provide reliable and long-lasting correction. Possible etiologies of HVI reported by Barnett included obliquity of the articular surface of the proximal phalangeal head and an asymmetrical shape of the distal phalanx [1]. Sorto et al found a deviation of the articular surfaces of the interphalangeal joint in patients with HVI [2]. Cansü cited lateralization of the extensor hallucis longus (EHL) tendon insertion as an influencing factor [3]. Many reports have focused on the existence of concomitant hallux pathology predisposing to an interphalangeal valgus deformity, Coughlin and Shurnas reported an average HVI angle of 18° in patients with hallux rigidus [4]. Only few studies, involving a limited number of cases, reported on the treatment of this deformity [5, 6]. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate clinical and radiological outcomes in patients who underwent distal Akin osteotomy for hallux valgus interphalangeus. 2
Material and methods Patient population We retrospectively reviewed a series of 15 consecutive patients (17 feet), which have been treated for a hallux valgus interphalangeus deformity between 2008 and 2016. At surgery, the mean age of the patients was 36.2 ± 20.5 years with a median age of 25 years. Four patients were males and eleven were females. All patients gave an informed consent to participate in the study. The study was carried out in accordance with the World Medical Declaration of Helsinki.
Surgical technique Planning of the operation was performed by the senior author. The direction and the angulation of the bone cut, was carried out in order to correct the HVI. Surgery was performed under regional anesthesia, with patients in supine position. A medial approach through a two centimeter medial transverse incision at the middle of the proximal hallux phalanx was used to expose the bone. The first osteotomy is performed parallel to the phalangeal base, at 5 to 8 mm from the interphalangeal joint surface and the second osteotomy is performed parallel to the articular surface of the phalangeal head at about 60° of inclination. It is crucial that the distal cut leave enough bone to place the screw head. The bony wedge thickness removed was decided in order to correct the HVI angle. Fixation is accomplished with one mini-Herbert screw from distal to proximal. All patients were dismissed the same day or one day after surgery. Postoperative ambulation was allowed immediately using a weight bearing hindfoot shoe. After 30 days, X-rays was performed. Progressive rehabilitation with passive and active exercises, cycling, and swimming are 3
advised. Gradual recovery of normal walking wearing comfortable shoes was supported.
Clinical and radiological assessment All the patient were preoperatively and post-operatively evaluated with a physical and radiographic assessment. At the preoperative evaluation all the patients reported pain and limitation in shoes-wearing during daily activities. The hallux–interphalangeal scale of the American Orthopaedic Foot and Ankle Society (AOFAS) [7] was used for the clinical evaluation. Pain was quantified with a visual analog scale (VAS) from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. The hallux valgus interphalangeous angle (HVI) were analyzed on standing dorso-plantar radiographs of the forefoot [8]. The radiographs were obtained at the last follow-up and independently evaluated by an orthopedic surgeon. Satisfaction has been assessed through a satisfaction survey, the scale used consisted in three possible choice: very satisfied, satisfied, not satisfied.
Statistical analysis All continuous data were expressed in terms of mean and standard deviation of mean. Data were analyzed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA), with a paired t-test after checking normal distribution of samples with the Kolmogorov–Smirnoff z test. The level of significance was considered as p<0.05.
Results The mean follow up was 28.9 ± 10.7 months after surgery. The average AOFAS score 4
significantly improved at last follow-up to an average of 85 ± 13 , while preoperatively it was 38 ± 45 (p<0.05). Among 15 patients, the 52.9 % (9 patients) stated to be “very satisfied”, the 41.2 % (7 patients) “satisfied” and just a 5.9 % (one patient) was “not satisfied”. The mean HVI value decreased from 24.9°± 7.8° preoperatively to 13.1°± 5.8° postoperatively at last follow up (p<0.05). Recurrence was observed in one case. VAS for pain decreased significantly from 4.1 ± 0.6 before treatment to 0.5 ± 1.0 at the last follow-up (p<0.05). No patients reported sensory loss or alterations after the procedure. The 52.9 % of patients underwent an isolated distal Akin osteotomy, correction of hammer toes of the lateral rays was performed in the 23.5 % the patients, osteotomy of the first metatarsal head for correction of hallux valgus was performed in the 17.6% of the patients, one patient (5,9 %) underwent a subtalar arthroreisis for correction of a flat foot deformity.
Discussion In 1935 Daw established the term hallux valgus interphalangeus, to describe an outward deflection of the great toe at the interphalangeal (IP) joint [9]. Lateral deviation that exceeds 10 degrees should be considered a pathologic hallux valgus interphalangeal deformity [8]. The criteria and performance of the actual procedure to perform the distal Akin are very similar to those described regarding the proximal Akin procedure. Important exceptions are surgical indication that have to be an abnormal (10°-15° ranged) HAI value accompanied by discomfort symptoms [2, 10, 11] and the shape of the osteotomy that is essentially identical to that of the proximal Akin but placement of this wedge is approximately 5-8 mm proximal to the interphalangeal joint. In literature there is a lack of studies on HVI and the articles regarding the management or the etiology of HVI are only case reports. 5
More recently just few authors described the management of HVI . Kubo et al. [5] reported a case of HVI treated by reversed sliding osteotomy of the proximal phalanx. Göksel et al. [12] reported a case of an idiopathic HVI with an HVA of 26° on anterior-posterior standing X-ray in a 14-year-old girl, which had been asymptomatic for 4 years before starting to enlarge and cause discomfort. Treatment consisted in medial closing wedge osteotomy and fixation with a double compression headless bone screw. Postoperative HVA was 14°. Grawe et al. [6] described three cases (four feet) of hallux valgus interphalangeus deformity in a pediatric population. All patients had a deformity that was not consistent with a traumatic etiology. They concluded that surgical correction appears to be a reliable option for symptom relief for patients who present with a painful symptomatic HVI deformity. On the contrary a pain free deformity that does not impact functionality of toe, or impair shoe ware may be treated successfully with conservative measures. Others case reports published on the HVI, place attention mainly on the etiology of this deformity that is not still completely known. Some authors hypothesized osteochondral injury to the distal phalanx of the great toe, or an osseous lesion, such as an enchondroma [8, 13, 14]. Some authors proposed iatrogenic causes: Dixon et al. [15] showed an increased incidence and severity of postoperative radiographic HVI with surgical correction of hallux valgus. Castillo-Lopez et al. [16] demonstrated that deviation of the distal phalanx with respect to the proximal was similar in normal feet and feet with early stages of hallux limitus or hallux valgus deformities. Parker et al. [17] considered the possibility of a more serious underlying syndrome with other accompanying abnormalities of organogenesis. They reported a case of a 13-year-old female with Hand-Foot-Genital syndrome presenting tarsal coalition and HVI, an unusual variation on the previously reported hallux varus usually 6
associated with the syndrome. The patient was subsequently found to have a novel mutation in the HOXA13 gene. Proximal or midshaft closing osteotomies are generally more familiar to the orthopedic surgeons. However, osteotomies should be performed as close to the center of rotation and angulation (CORA) as possible to maximize correction and avoid creation of an additional deformity [18]. Opening wedge osteotomy requires either bone graft for acute corrections or an external fixator for gradual distraction, which for hallux seems technically difficult. In HVI, the CORA is almost always at the level of the joint or just proximal to the joint. Therefore, arthrodesis may be considered as an option, but due to the age of the patients should be reserved as a salvage procedure. Concomitant pathologies were addressed in the same surgical procedure. A limitation of this approach is that correction of these deformities may have been closely associated with patient improvement after surgery. Concomitant procedures represent confounding variables, making it more difficult to compare the results between patients. However, we did show a high satisfaction rate after the procedures with very few complications. Due to the low number of patients, no subgroup analyses was performed. The aim of our study is to demonstrate that distal Akin osteotomy with internal fixation can be an effective and predictable method of correcting an HVI deformity. Clinical evaluations showed an improvement in terms of pain, functional capacity and hallux alignment. Most patients, 14 on 15, were satisfied with the surgical correction. Radiographic evaluation showed a good correction in terms of HVA significantly correlated with symptoms improvement. No complication was recorded postoperatively in terms of infection, hallux elevates, delayed/non-union of the osteotomy, sensory loss, pain at the interphalangeal or 7
metatarsophalangeal joints, ipercorrection of the deformity, shortened hallux. One patient reported a worsening of symptoms and discomfort due to a clinical and radiographic recurrence of the deformity.
Conclusions Based on this findings we would conclude that the distal Akin osteotomy play a definite role in the surgical correction of HVI proving to be able to correct symptomatic deformities either isolated or associated with other forefoot deformities.
Founding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare no conflict of interests related to this manuscript.
Competing interests The authors declare no conflict of interests related to this manuscript.
8
References [1] Barnett CH. Valgus deviation of the distal phalanx of the great toe. J Anat 1962;96:171-7. [2] Sorto LA Jr, Balding MG, Weil LS, et al. Hallux abductus interphalangeus. Etiology, xray evaluation and treatment. J Am Podiatric Medical Assoc 1992;82: 85-97. [3] Cansu E. L-shaped big toe: a case of severe hallux valgus interphalangeus. J Am Podiatric Medical Assoc 2009;99:244-6. [4] Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003;24:731-43. [5] Kubo M, Miyamoto W, Takao M, Yasui Y, Innami K, Matsushita T. Valgus deformity of the great toe interphalangeal joint treated by reversed sliding osteotomy of the proximal phalanx: a case report. Foot Ankle Int 2011;32:448-51. [6] Grawe B, Parikh S, Crawford A, Tamai J. Hallux valgus interphalangeus deformity: A case series in the pediatric population. Foot Ankle Surg 2012;18:e4-e8. [7] Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating system for the ankle-hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15:349-53. [8] Coughlin MJ, Saltzman CL, Nunley JA. 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. [9] Daw SW. An unusual type of hallux valgus (two cases). Br Med J 1935;2:580. [10] Gerbert J, Spector E, Clark J. Osteotomy procedures on the proximal phalanx for correction of a hallux deformity. J Am Podiatry Assoc 1974;64:617-29. [11] Segal D. Proximal and distal Akin procedures. J Foot Surg 1977;16:57-8. 9
[12] Göksel F, Ermutlu C, Gölge UH, Kaymaz B. Treatment of juvenile hallux valgus interphalangeus with a double compression headless bone screw. BMJ Case Rep 2015. [13] Shimizu A, Watanabe S, Kamada K, Tsuboi I, Yamamoto H. Hallux valgus interphalangeus following osteochondral fracture of the proximal phalanx: a case report. Foot Ankle Int 2005;26:994-6. [14] Nnene CO, Fernandez GN. Enchondroma causing Juvenile Hallux Interphalangeus. Foot 1998;8:173-5. [15] Dixon AE, Lee LC, Charlton TP, Thordarson DB. Increased Incidence and Severity of Postoperative Radiographic Hallux Valgus Interphalangeus With Surgical Correction of Hallux Valgus. Foot Ankle Int 2015;36:961-8. [16] Castillo-López JM, Ramos-Ortega J, Reina-Bueno M, Domínguez-Maldonado G, Palomo-Toucedo IC, Munuera PV. Hallux abductus interphalangeus in normal feet, early stage hallux limitus, and hallux valgus. J Am Podiatr Med Assoc 2014;104:169-73. [17] Parker L, Mangwani J, Wakeling E, Singh D. Hallux valgus interphalangeus and novel mutation in HOXA13. Part of the broadening spectrum of Hand-Foot-Genital syndrome. Foot Ankle Surg 2011;17:e28-e30. [18] Barksfield RC, Monsell FP. Predicting translational deformity following openingwedge osteotomy for lower limb realignment. Strategies Trauma Limb Reconstr 2015;10:167-73.
10
Figure Legends Figure 1. Pre and post-operative radiographic examination in a patient with HVI treated with the distal Akin osteotomy.
11
S1268-7731(17)30040-1 http://dx.doi.org/doi:10.1016/j.fas.2017.02.003 FAS 1006
To appear in:
Foot and Ankle Surgery
Received date: Revised date: Accepted date:
3-10-2016 28-12-2016 7-2-2017
Please cite this article as: Martinelli N, Giacalone A, Bianchi A, Hosseinzadeh M, Bonifacino C, Malerba F.Distal Akin Osteotomy for Hallux Valgus Interphalangeus.Foot and Ankle Surgery http://dx.doi.org/10.1016/j.fas.2017.02.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Distal Akin Osteotomy for Hallux Valgus Interphalangeus N. Martinelli,1 A. Giacalone,1 A. Bianchi,1 M. Hosseinzadeh,1 C. Bonifacino,1 F. Malerba1 1.
Department of Foot and Ankle Surgery, Galeazzi Hospital, via R. Galeazzi 4, 20161
Milan, Italy. Tel: 003902/662141 Fax: 003902/66214800
Corresponding author: Nicolò Martinelli, MD, PhD [email protected]
Highlights
Distal Akin osteotomy is safe and effective for HVI
High satifaction rate can be achieved after distal Akin osteotomy for HVI
Abstract Background The aim of this study was to assess clinical and radiological outcomes in patients who underwent distal Akin osteotomy for hallux valgus interphalangeus (HVI). Methods A series of 15 consecutive patients (17 feet) was retrospectively reviewed. All the patients were preoperatively and post-operatively evaluated with a physical and radiographic assessment (HVI angle). Satisfaction has been assessed through a satisfaction survey, the scale used consisted in three possible choice: very satisfied, satisfied, not satisfied. Results Among 15 patients the 52.9 % (9 patients) stated to be “very satisfied”, the 41.2 % (7 patients) “satisfied” and just a 5.9 % (one patient) was “not satisfied”. The mean HVI value decreased from 24.9°± 7.8° preoperatively to 13.1°± 5.8° 1
postoperatively at last follow up (p<0.05). Conclusions Based on these findings we can conclude that the distal Akin osteotomy can be considered safe and effective in the surgical correction of symptomatic HVI deformities.
Keywords: Hallux Valgus Interphalangeus, osteotomy, correction, pain, disability.
Introduction Hallux valgus interphalangeus (HVI) is a complex deformity involving the joint as well as the neighboring soft tissue influences. The deformity usually presents early in life and can rapidly progress during growth spurts. Older patients typically present a more rigid deformity and arthrodesis of the interphalangeal joint is often recommended to provide reliable and long-lasting correction. Possible etiologies of HVI reported by Barnett included obliquity of the articular surface of the proximal phalangeal head and an asymmetrical shape of the distal phalanx [1]. Sorto et al found a deviation of the articular surfaces of the interphalangeal joint in patients with HVI [2]. Cansü cited lateralization of the extensor hallucis longus (EHL) tendon insertion as an influencing factor [3]. Many reports have focused on the existence of concomitant hallux pathology predisposing to an interphalangeal valgus deformity, Coughlin and Shurnas reported an average HVI angle of 18° in patients with hallux rigidus [4]. Only few studies, involving a limited number of cases, reported on the treatment of this deformity [5, 6]. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate clinical and radiological outcomes in patients who underwent distal Akin osteotomy for hallux valgus interphalangeus. 2
Material and methods Patient population We retrospectively reviewed a series of 15 consecutive patients (17 feet), which have been treated for a hallux valgus interphalangeus deformity between 2008 and 2016. At surgery, the mean age of the patients was 36.2 ± 20.5 years with a median age of 25 years. Four patients were males and eleven were females. All patients gave an informed consent to participate in the study. The study was carried out in accordance with the World Medical Declaration of Helsinki.
Surgical technique Planning of the operation was performed by the senior author. The direction and the angulation of the bone cut, was carried out in order to correct the HVI. Surgery was performed under regional anesthesia, with patients in supine position. A medial approach through a two centimeter medial transverse incision at the middle of the proximal hallux phalanx was used to expose the bone. The first osteotomy is performed parallel to the phalangeal base, at 5 to 8 mm from the interphalangeal joint surface and the second osteotomy is performed parallel to the articular surface of the phalangeal head at about 60° of inclination. It is crucial that the distal cut leave enough bone to place the screw head. The bony wedge thickness removed was decided in order to correct the HVI angle. Fixation is accomplished with one mini-Herbert screw from distal to proximal. All patients were dismissed the same day or one day after surgery. Postoperative ambulation was allowed immediately using a weight bearing hindfoot shoe. After 30 days, X-rays was performed. Progressive rehabilitation with passive and active exercises, cycling, and swimming are 3
advised. Gradual recovery of normal walking wearing comfortable shoes was supported.
Clinical and radiological assessment All the patient were preoperatively and post-operatively evaluated with a physical and radiographic assessment. At the preoperative evaluation all the patients reported pain and limitation in shoes-wearing during daily activities. The hallux–interphalangeal scale of the American Orthopaedic Foot and Ankle Society (AOFAS) [7] was used for the clinical evaluation. Pain was quantified with a visual analog scale (VAS) from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. The hallux valgus interphalangeous angle (HVI) were analyzed on standing dorso-plantar radiographs of the forefoot [8]. The radiographs were obtained at the last follow-up and independently evaluated by an orthopedic surgeon. Satisfaction has been assessed through a satisfaction survey, the scale used consisted in three possible choice: very satisfied, satisfied, not satisfied.
Statistical analysis All continuous data were expressed in terms of mean and standard deviation of mean. Data were analyzed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA), with a paired t-test after checking normal distribution of samples with the Kolmogorov–Smirnoff z test. The level of significance was considered as p<0.05.
Results The mean follow up was 28.9 ± 10.7 months after surgery. The average AOFAS score 4
significantly improved at last follow-up to an average of 85 ± 13 , while preoperatively it was 38 ± 45 (p<0.05). Among 15 patients, the 52.9 % (9 patients) stated to be “very satisfied”, the 41.2 % (7 patients) “satisfied” and just a 5.9 % (one patient) was “not satisfied”. The mean HVI value decreased from 24.9°± 7.8° preoperatively to 13.1°± 5.8° postoperatively at last follow up (p<0.05). Recurrence was observed in one case. VAS for pain decreased significantly from 4.1 ± 0.6 before treatment to 0.5 ± 1.0 at the last follow-up (p<0.05). No patients reported sensory loss or alterations after the procedure. The 52.9 % of patients underwent an isolated distal Akin osteotomy, correction of hammer toes of the lateral rays was performed in the 23.5 % the patients, osteotomy of the first metatarsal head for correction of hallux valgus was performed in the 17.6% of the patients, one patient (5,9 %) underwent a subtalar arthroreisis for correction of a flat foot deformity.
Discussion In 1935 Daw established the term hallux valgus interphalangeus, to describe an outward deflection of the great toe at the interphalangeal (IP) joint [9]. Lateral deviation that exceeds 10 degrees should be considered a pathologic hallux valgus interphalangeal deformity [8]. The criteria and performance of the actual procedure to perform the distal Akin are very similar to those described regarding the proximal Akin procedure. Important exceptions are surgical indication that have to be an abnormal (10°-15° ranged) HAI value accompanied by discomfort symptoms [2, 10, 11] and the shape of the osteotomy that is essentially identical to that of the proximal Akin but placement of this wedge is approximately 5-8 mm proximal to the interphalangeal joint. In literature there is a lack of studies on HVI and the articles regarding the management or the etiology of HVI are only case reports. 5
More recently just few authors described the management of HVI . Kubo et al. [5] reported a case of HVI treated by reversed sliding osteotomy of the proximal phalanx. Göksel et al. [12] reported a case of an idiopathic HVI with an HVA of 26° on anterior-posterior standing X-ray in a 14-year-old girl, which had been asymptomatic for 4 years before starting to enlarge and cause discomfort. Treatment consisted in medial closing wedge osteotomy and fixation with a double compression headless bone screw. Postoperative HVA was 14°. Grawe et al. [6] described three cases (four feet) of hallux valgus interphalangeus deformity in a pediatric population. All patients had a deformity that was not consistent with a traumatic etiology. They concluded that surgical correction appears to be a reliable option for symptom relief for patients who present with a painful symptomatic HVI deformity. On the contrary a pain free deformity that does not impact functionality of toe, or impair shoe ware may be treated successfully with conservative measures. Others case reports published on the HVI, place attention mainly on the etiology of this deformity that is not still completely known. Some authors hypothesized osteochondral injury to the distal phalanx of the great toe, or an osseous lesion, such as an enchondroma [8, 13, 14]. Some authors proposed iatrogenic causes: Dixon et al. [15] showed an increased incidence and severity of postoperative radiographic HVI with surgical correction of hallux valgus. Castillo-Lopez et al. [16] demonstrated that deviation of the distal phalanx with respect to the proximal was similar in normal feet and feet with early stages of hallux limitus or hallux valgus deformities. Parker et al. [17] considered the possibility of a more serious underlying syndrome with other accompanying abnormalities of organogenesis. They reported a case of a 13-year-old female with Hand-Foot-Genital syndrome presenting tarsal coalition and HVI, an unusual variation on the previously reported hallux varus usually 6
associated with the syndrome. The patient was subsequently found to have a novel mutation in the HOXA13 gene. Proximal or midshaft closing osteotomies are generally more familiar to the orthopedic surgeons. However, osteotomies should be performed as close to the center of rotation and angulation (CORA) as possible to maximize correction and avoid creation of an additional deformity [18]. Opening wedge osteotomy requires either bone graft for acute corrections or an external fixator for gradual distraction, which for hallux seems technically difficult. In HVI, the CORA is almost always at the level of the joint or just proximal to the joint. Therefore, arthrodesis may be considered as an option, but due to the age of the patients should be reserved as a salvage procedure. Concomitant pathologies were addressed in the same surgical procedure. A limitation of this approach is that correction of these deformities may have been closely associated with patient improvement after surgery. Concomitant procedures represent confounding variables, making it more difficult to compare the results between patients. However, we did show a high satisfaction rate after the procedures with very few complications. Due to the low number of patients, no subgroup analyses was performed. The aim of our study is to demonstrate that distal Akin osteotomy with internal fixation can be an effective and predictable method of correcting an HVI deformity. Clinical evaluations showed an improvement in terms of pain, functional capacity and hallux alignment. Most patients, 14 on 15, were satisfied with the surgical correction. Radiographic evaluation showed a good correction in terms of HVA significantly correlated with symptoms improvement. No complication was recorded postoperatively in terms of infection, hallux elevates, delayed/non-union of the osteotomy, sensory loss, pain at the interphalangeal or 7
metatarsophalangeal joints, ipercorrection of the deformity, shortened hallux. One patient reported a worsening of symptoms and discomfort due to a clinical and radiographic recurrence of the deformity.
Conclusions Based on this findings we would conclude that the distal Akin osteotomy play a definite role in the surgical correction of HVI proving to be able to correct symptomatic deformities either isolated or associated with other forefoot deformities.
Founding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare no conflict of interests related to this manuscript.
Competing interests The authors declare no conflict of interests related to this manuscript.
8
References [1] Barnett CH. Valgus deviation of the distal phalanx of the great toe. J Anat 1962;96:171-7. [2] Sorto LA Jr, Balding MG, Weil LS, et al. Hallux abductus interphalangeus. Etiology, xray evaluation and treatment. J Am Podiatric Medical Assoc 1992;82: 85-97. [3] Cansu E. L-shaped big toe: a case of severe hallux valgus interphalangeus. J Am Podiatric Medical Assoc 2009;99:244-6. [4] Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003;24:731-43. [5] Kubo M, Miyamoto W, Takao M, Yasui Y, Innami K, Matsushita T. Valgus deformity of the great toe interphalangeal joint treated by reversed sliding osteotomy of the proximal phalanx: a case report. Foot Ankle Int 2011;32:448-51. [6] Grawe B, Parikh S, Crawford A, Tamai J. Hallux valgus interphalangeus deformity: A case series in the pediatric population. Foot Ankle Surg 2012;18:e4-e8. [7] Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating system for the ankle-hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int 1994;15:349-53. [8] Coughlin MJ, Saltzman CL, Nunley JA. 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. [9] Daw SW. An unusual type of hallux valgus (two cases). Br Med J 1935;2:580. [10] Gerbert J, Spector E, Clark J. Osteotomy procedures on the proximal phalanx for correction of a hallux deformity. J Am Podiatry Assoc 1974;64:617-29. [11] Segal D. Proximal and distal Akin procedures. J Foot Surg 1977;16:57-8. 9
[12] Göksel F, Ermutlu C, Gölge UH, Kaymaz B. Treatment of juvenile hallux valgus interphalangeus with a double compression headless bone screw. BMJ Case Rep 2015. [13] Shimizu A, Watanabe S, Kamada K, Tsuboi I, Yamamoto H. Hallux valgus interphalangeus following osteochondral fracture of the proximal phalanx: a case report. Foot Ankle Int 2005;26:994-6. [14] Nnene CO, Fernandez GN. Enchondroma causing Juvenile Hallux Interphalangeus. Foot 1998;8:173-5. [15] Dixon AE, Lee LC, Charlton TP, Thordarson DB. Increased Incidence and Severity of Postoperative Radiographic Hallux Valgus Interphalangeus With Surgical Correction of Hallux Valgus. Foot Ankle Int 2015;36:961-8. [16] Castillo-López JM, Ramos-Ortega J, Reina-Bueno M, Domínguez-Maldonado G, Palomo-Toucedo IC, Munuera PV. Hallux abductus interphalangeus in normal feet, early stage hallux limitus, and hallux valgus. J Am Podiatr Med Assoc 2014;104:169-73. [17] Parker L, Mangwani J, Wakeling E, Singh D. Hallux valgus interphalangeus and novel mutation in HOXA13. Part of the broadening spectrum of Hand-Foot-Genital syndrome. Foot Ankle Surg 2011;17:e28-e30. [18] Barksfield RC, Monsell FP. Predicting translational deformity following openingwedge osteotomy for lower limb realignment. Strategies Trauma Limb Reconstr 2015;10:167-73.
10
Figure Legends Figure 1. Pre and post-operative radiographic examination in a patient with HVI treated with the distal Akin osteotomy.
11