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Distal soft tissue realignment and proximal metatarsal countersinking osteotomy for moderate to severe hallux valgus
The Foot 22 (2012) 186–193
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The Foot journal homepage: www.elsevier.com/locate/foot
Distal soft tissue realignment and proximal metatarsal countersinking osteotomy for moderate to severe hallux valgus Mohamed F. Mostafa ∗ , Gamal El-Adl Department of Orthopaedic Surgery and Traumatology, Mansoura University Hospital, Mansoura, Egypt
a r t i c l e
i n f o
Article history: Received 2 October 2011 Received in revised form 14 March 2012 Accepted 15 March 2012 Keywords: Hallux valgus Countersinking Osteotomy
a b s t r a c t Background: Hallux valgus is a common condition and surgical correction has remained a challenge. Objective: To evaluate the results of distal soft tissue realignment and proximal 1st metatarsal countersinking osteotomy for the treatment of moderate to severe hallux valgus deformity. Materials and methods: This prospective study included 33 ft in 28 patients. The deformity was moderate in 27 ft (23 patients), severe in six ft (five patients) and bilateral in five patients. All operations were performed as a primary procedure with an average duration of follow-up of 28.2 months (range 10–45 months). Results: The average hallux valgus angle was improved from 32.5◦ to 8◦ and the first intermetatarsal angle from 16.5◦ to 7.7◦ . According to the symptomatic score of Broughton and Winson, 22 ft (18 patients) were rated excellent, nine good and two poor. The average American Orthopedic Foot Ankle Society score at the final follow-up was 89.3 (range 65–100). Recurrence of the valgus deformity was seen in three patients and hallux varus in two patients. Conclusions: The current procedure proved to be effective to correct all components of hallux valgus deformity regardless of its severity. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction The condition of hallux valgus (HV) includes not only the lateral deviation of the great toe, but also a medial deviation of the first metatarsal (metatarsus primus varus), with a close relationship between the degree of the two deformities. However, there is no agreement on which is the primary deformity [1,2]. Occasionally, there is a static deformity due to valgus angulation of the distal articular surface of the first metatarsal or proximal phalangeal articular surface [3]. McBride described the specific role of the adductor conjoined tendon as the “culprit” principally responsible for the valgus contracture and the advantages of transplanting it to an important position as the basic principle for surgical repair [4]. It has been observed that a distal soft tissue procedure alone does not always correct the deformity successfully and that an abnormal intermetatarsal angle persists [5]. Most authors agree that patients with HV and a wide first intermetatarsal angle require some procedure at the proximal first metatarsal bone. Basal osteotomies of
∗ Corresponding author at: Mansoura University Hospital, P.O. Box 35516 Mansoura, Egypt. Tel.: +20 115445384; fax: +20 502214715. E-mail address: [email protected] (M.F. Mostafa). 0958-2592/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2012.03.007
various kinds have been advocated: closed wedge [6], open wedge [7], crescentic [8] and chevron [9]. Distal metatarsal osteotomy in patients with splayed ft has led to high rates of patient dissatisfaction [10]. Mann [11] has warned that the potential complications of distal osteotomy include avascular necrosis, excessive shortening of the metatarsal, mal-alignment of the metatarsal head and overcorrection. The aim of this study was to evaluate the results of distal soft tissue realignment combined with basal first metatarsal countersinking osteotomy as an effective procedure for management of moderate to severe hallux valgus.
2. Materials and methods Between December 2005 and September 2009, twenty eight patients (33 ft) with moderate to severe HV deformity were treated by distal soft tissue realignment and proximal first metatarsal countersinking osteotomy. All operations were performed as a primary procedure at the King Saud Hospital, Unaizah, Kingdom of Saudi Arabia. Operations were indicated in patients with painful hallux valgus deformity and functional distabilities including the difficulty with shoe wear and activity restriction. Patients with hallux rigidus, marked arthrosis precluding realignment of the joint and underlying connective tissue disorders or neuromuscular diseases were excluded from this study.
M.F. Mostafa, G. El-Adl / The Foot 22 (2012) 186–193 Table 1 Main complaints of patients. Main complain
Number (%)
Pain Shoe wear problems Activity restriction Cosmetic reasons
18 (54.5%) 9 (27.3%) 3 (9.1%) 3 (9.1%)
There were twenty five females (30 ft) and three males (three ft) with an average age of 25.4 years (range, 17–38 years) at the time of surgery. The deformity was bilateral in five females, moderate in 27 ft (23 patients) and severe in six ft (five patients). Pain was the main complain in 18 patients (54.5%), twelve of them had the pain over the medial eminence of the first metatarsal head, five under the head of the second metatarsal, and one in the MTPJ itself (Table 1). 2.1. Operative procedure All patients were interviewed before operation and an informed consent was obtained. For patients with bilateral deformity, operations were performed in two sessions starting with the more symptomatic side (average interval, 10.8 months). Operations were done under general anaesthesia while the patient was in the supine position. A thigh pneumatic tourniquet was used. The ft were cleansed and draped in the usual fashion. The first incision was made between the first and second metatarsals in the line of the web space. The adductor hallucis tendon was released from its insertion into the base of the proximal phalanx and the fibular sesamoid after a stay suture was placed in the proximal end. With tension applied between the metatarsals using a self retaining retractor, the transverse intermetatarsal ligament was released from its attachment into the fibular sesamoid. Care was taken to avoid injury to the underlying common digital nerve. Then the lateral capsule and fibular sesamoid were freed from the first metatarsal head leaving a cuff of tissue that could be repaired. A second longitudinal incision was centered over the medial eminence. Care was taken to create a full thickness flap and to protect the medial dorsal and plantar sensory nerves while exposing the capsule. A V-shaped capsular flap was created with its broad base at the base of proximal phalanx. This allowed exposure of medial eminence and careful assessment of the sagittal sulcus. The medial eminence was then excised with the saw in line with the medial aspect of the metatarsal shaft. At this time, the flexibility of the metatarsocuneiform joint (MTCJ) was tested especially in patients with moderate deformity. A proximal metatarsal osteotomy was decided if intermetatarsal angle could not be corrected due to rigidity of the MTCJ in moderate deformity. An incision 3–4 cm was made along the dorsal aspect of the proximal part of the first metatarsal medial to extensor hallucis longus tendon and end just proximal to the MTCJ. An elevator was placed subperiosteally along the lateral aspect of the first metatarsal base to control displacement of the osteotomy and to protect the communicating artery in the first intermetatarsal space. The osteotomy was done 1.5–2 cm distal to MTCJ with the saw directed perpendicular to the metatarsal shaft and parallel to the joint. A preliminary glide-hole with a 3.5 mm drill-bit was made 1 cm distal to the planned osteotomy. The hole was directed proximally toward the plantar aspect of the proximal fragment, at a 45◦ angle in relation to the shaft of the metatarsal. After the osteotomy had been completed the metatarsal head was displaced laterally while supporting the proximal part of the distal fragment with an elevator. This allowed the distal fragment to be rotated along a point at the center or about 2 mm lateral to the center of the osteotomy and coutersinking the medial edge of the proximal fragment into
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the cancellous bone of the proximal fragment (Fig. 1). Then the proximal hole was made with 2.5 mm drill-bit over a sleeve and the osteotomy was secured with a 4 mm cancellous-bone screw. The head of the screw was countersunken to reduce subcutaneous prominence. The V-shaped capsular flap medially was sutured onto the bone, using an absorbable suture passed through a small hole created in the distal metatarsal shaft, with the great toe held in neutral plantar flexion-dorsoflexion, slight varus and slight supination. The soft tissues along the plantar and dorsal aspect of the capsular flap were repaired with a careful tension to reduce the sesamoids beneath the metatarsal head. Finally, attention was directed to the first incision where the initial stay suture was tied and soft tissues were repaired to achieve stability to the lateral capsule (Fig. 2). Intraoperative fluoroscopy was helpful to ascertain the correction of the deformity, reduction of the sesamoids and proper osteotomy and screw fixation. Postoperatively a below knee weight bearing cast was applied with the great toe held in corrected position. Weight bearing was allowed on the lateral aspect of the ft and the heel guided by pain. The cast was changed at the time of suture removal and removed 6–8 weeks from surgery. After removal of the cast, a program of active and passive range of motion exercises of the first MTPJ had been started under the supervision of physiotherapist. Patients were instructed to exercise all toes by picking up small objects from the floor and to strengthen sole muscles by controlling a roller or a ball under it. The exercises were done three times a day and lasting ten minutes each time. Athletic activities were commenced three to four months after surgery. The average duration of follow-up was 28.2 months (range, 10–45 months). All patients were asked about improvement of pain, appearance of the ft, problems with wearing shoe, the ability to walk and their satisfaction with the procedure. The passive as well as active arc of motion of the first metatarsophalangeal joint and the amount of pronation of the great toe were measured using the standard goniometer and compared with that taken before operation. Assessment of pronation was made with the patient standing and graded according to Smith et al. [12] as follow: grade 1 (mild); rotation of nail less than 25◦ , grade 2 (moderate); rotation more than 25◦ and grade 3 (severe); rotation more than 45◦ . The transfer lesion “symptomatic callus beneath the second metatarsal head because of inadequate weight-bearing on the first metatarsal” was evaluated at final follow-up. Weight-bearing dorsoplantar radiographs were taken preoperatively and at final follow-up to measure the hallux valgus angle (HVA), first intermetatarsal angle (IMA), the length of first and second metatarsals and the percentage of first metatarsal shortening (Fig. 3). In addition, the position of tibial sesamoid (Fig. 4) and the congruity of the first MTPJ were recorded (Fig. 5). The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal Scale (AOFASS) (Table 2) [13] and the symptomatic score of Broughton and Winson (Table 3) [14] were used for the final assessment of patients. The data of patients was analyzed using the Statistical Package for Social Sciences (SPSS) version 11.5 for windows. Pearson Chi-square test, independent sample T test and one way ANOVA test were used to define relations between clinical and radiological results and the final outcome. Probability values of less than 0.05 were considered significant.
3. Results The distal soft tissue realignment procedure was technically demanding and required careful balancing of soft tissue about medial and lateral aspect of MTPJ. No difficulties were confronted
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Fig. 1. Diagram (a) showing the increased hallux valgus angle and 1st intermetatarsal angle, (b) after excision of medial eminence, proximal osteotomy and countersinking the distal fragment into the proximal base “black arrows”.
with the technique of osteotomy in this study. It was simple and easy with minimal soft tissue dissection, little or minimal bump formation on the medial arch, minimal shortening of the first metatarsal and enough stability to allow early mobilization. We believe that with this type of osteotomy slight proximal displacement ensures a great correction of the deformity distally.
improved from 53.9◦ (range, 38◦ –75◦ ) preoperatively to 70.3◦ (range, 35◦ –84◦ ) postoperatively with an average improvement of 15.6◦ . Pronation of the great toe was moderate to severe in 17 (51.5%) ft preoperatively and improved to mild pronation in only six (18.2%) ft postoperatively. 3.3. Radiological outcome
3.1. Subjective outcome According to the symptomatic score of Broughton and Winson, 22 ft (66.7%) were rated excellent, nine (27.3%) good and two (6.1%) poor. Five of the nine cases with good results were satisfied and happy with the results and four were moderately satisfied and said that given the identical situation they would select the same type of operation. Among the four patients with moderate satisfaction one had recurrent hallux valgus deformity (HVA = 22◦ , IMA = 11◦ ), two had hallux varus (−3◦ and −5◦ ) and one had sensory disturbance along the medial aspect of the great toe. The two patients with poor results were really dissatisfied. One of them had constant pain under the second metatarsal head that caused restriction of daily life activities and the other patient had arthrofibrosis with significant limitation of active movement of MTPJ and restriction of athletic activities. 3.2. Objective outcome The average AOFAS score at the final follow-up was 89.3 (range, 65–100). The high score was significantly obtained in patients with less severe preoperative deformity (p = 0.05). The active arc of movement “dorsoflexion-plantarflexion” of MTPJ was
All osteotomies healed uneventfully after an average time of 5.4 weeks (range, 4–9 weeks). The average hallux valgus angle improved from 32.5◦ (range, 22◦ –40◦ ) preoperatively to 8◦ (range,−5◦ to 22◦ ) postoperatively with an average correction of 24.5◦ . The average first intermetatarsal angle was 16.5◦ (range, 11◦ –25◦ ) preoperatively and improved to 7.7◦ (range, 2◦ –12◦ ) postoperatively with an average correction of 8.7◦ . The average percentage of first metatarsal shortening after operation was 1.2% (range, 0.75%–2.24%). Patients with preoperative severe hallux valgus deformity were more likely to develop shortening of the first metatarsal (p = 0.04). The tibial sesamoid was lateral in 29 ft (87.9%) preoperatively and in only two ft (6.1%) postoperatively. The medial position of tibial sesamoid was achieved in 78.8% of ft. 3.4. Complications Reflex sympathetic dystrophy was encountered in three ft (9%) in three patients who were reluctant to mobilize early postoperatively and improved dramatically after physiotherapy and weight bearing. One patient had superficial wound infection which was appropriately managed with dressing and oral antibiotics. There were no cases of deep infection, soft tissue irritation related to
M.F. Mostafa, G. El-Adl / The Foot 22 (2012) 186–193
implant, symptomatic arthrosis of the first MTPJ or non union of the osteotomy site. A recurrence of hallux valgus deformity was seen in two patients (two ft). One of them (HVA = 22◦ ) was moderately satisfied and refused to do further surgery while the other patient (HVA = 18◦ ) was satisfied with the results. Recurrent hallux valgus developed
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in patients who had preoperative severe deformity (p = 0.01). Two patients with two ft developed hallux varus deformity after operation that led to some difficulty in wearing shoes in one of them. The two ft with postoperative hallux varus had the lowest mean postoperative first intermetatarsal angle (p = 0.03). The patient who continued to complain of transfer metatarsalgia after
Fig. 2. (a) A 19-year-old girl with severe hallux valgus left ft, splayed forefoot, prominent medial eminence, moderate pronation of great toe and overriding of second toe. (b) Preoperative weight bearing radiograph showing hallux valgus angle 42◦ and 1st intermetatarsal angle 19◦ . (c) The stay suture of the adductor tendon. (d) Elevation of the V-shaped capsular flap to expose the medial eminence. (e) Fixation screw in place after countersinking the lateral edge of the distal fragment into the proximal fragment. (f) Weight bearing radiograph 12 months after surgery. (g) Photograph of the ft at final follow-up.
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Fig. 2. (continued ).
M.F. Mostafa, G. El-Adl / The Foot 22 (2012) 186–193
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Fig. 3. The method of measuring first metatarsal shortening. X is the midpoint of AB. The percentage of first metatarsal shortening is then expressed as: (X1(preoperative)/X2 (preoperative))/(X1 (postoperative)/X2 (postoperative)) × 100.
operation had the highest percentage of first metatarsal shortening (p = 0.002). 4. Discussion Painful hallux valgus is a common clinical problem especially in females willing to wear fashionable shoes. Surgical correction has remained a challenge with at least 130 procedures being described [15]. In agreement with Mann [16] distal soft tissue procedure alone is not enough to correct hallux valgus deformity in patients with increased first intermetatarsal angle. Patients with HVA of 30◦ and IMA of 12◦ or more should have proximal first metatarsal osteotomy in addition to distal soft tissue realignment. Osteotomy is mandatory in patients with HVA more than 40◦ , while optional if IMA is less than 12◦ when judged intraoperatively that metatarsocuniform joint is rigid enough to prevent correction [17]. Distal metatarsal osteotomy is advised to correct mild hallux valgus deformity with distal metatarsal articular angle (DMAA) malalignment [18]. It is not recommended to be done in combination with lateral soft tissue release because of the risk of osteonecrosis of the first metatarsal head as the nutrient artery enter the diaphysis 2.5 cm proximal to the capsule of the first MTPJ [3,11]. On the other hand, basilar metatarsal osteotomy is performed in an area of rich blood supply and consequently has a less chance for avascular necrosis. In the current series, there were no cases of osteonecrosis of the first metatarsal head at the time of final follow-up. The most popular principle types of proximal metatarsal osteotomy are the closed-wedge osteotomy [6] that usually results in metatarsal shortening and transfer metatarsalgia, the openwedge osteotomy [7] can result in early recurrence because of
Fig. 4. To determine the position of the sesamoid, the 1st metatarsal is bisected and the tibial sesamoid is divided into quarters. The position of tibial sesamoid is considered medial if 75% of its width is medial to the central line and lateral if lateral to the central line. Otherwise, the sesamoid is considered to be central.
the metatarsal lengthening and the dome osteotomy [8] which is proposed to avoid the previous problems. In the present study, a countersinking osteotomy was introduced believing that impaction of the distal fragment into the proximal one along the lateral aspect, soft tissue tension along the medial aspect and fixation with lag screw will increase stability and allow early mobilization with less
Fig. 5. Two straight lines are drawn representing effective articular surface of the first metatarsal head and base of proximal phalanx; (a) congruent joint: parallel lines, (b) deviated joint: lines converge outside the joint, (c) subluxated joint: lines intersect within the joint.
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Table 2 AOFAS hallux metatarsophalangeal–interphalageal scale [13]. Pain (40 points) Non Mild, occasional Moderate, daily Severe, almost always present
40 30 20 0
Function (45 points) Activity limitation No limitations No limitations of daily activities (employment responsibilities, limitations of recreational activities) Limited daily and recreational activities Severe limitation of daily and recreational activities Ft wear requirements Fashionable, conventional shoes, no insert required Comfort footwear, shoe insert Modified shoes or brace MTP joint motion (dorsiflexion plus planterflexion) Normal or mild restriction (75◦ or more) Moderate rrestriction (30◦ –74◦ ) Severe restriction (less than 30◦ ) IP joint motion (planter flexion) No restriction Severe restriction (less than 10◦ ) MTP – IP stability (all Direction) Stable Definitely unstable or able to dislocate Callus related to hallux MTP – IP No callus or symptomatic callus Callus, symptomatic Alignment (15 points) Good, hallux well aligned Fair, some degree of hallux malallignment observed, no symptoms Poor, obvious symptomatic malalignment
10 7 4 0 10 5 0 10 5 0 5 0 5 0 5 0 15 8 0 100
Total
A score more or equal to 65 points was considered to be of a good clinical result.
Table 3 Symptom score according to Broughton and Winson [14]. Grade 1
Grade 2
Grade 3
Happy
Unhappy
None
Slight reservation Occasional
None
Slight
Function/Activities
No restrictions
Shoe wear
Any
Slight restriction in daily activities Slight restriction
Cosmetic appearance Pain in 1st MTP joint Metatarsalgia
On normal activity After <3 h walking/standing Severe restriction in daily activities Difficulty in finding/only special shoes.
The result was regarded as excellent when the patient achieved G 1 in all categories, good when the patient had no more than two G 2 and no G 3 and poor in any other case.
risk of non-union or mal-union. Furthermore, rotation of the distal fragment at or just medial to the center of the osteotomy effect the principle of half wedge osteotomy correcting greater deformity with minimal displacement and at the same time preserving most of the first metatarsal length. The results of the current study regarding the average correction of HVA and IMA and patient satisfaction with the end results were comparable with the results of other studies using basal metatarsal crescentic osteotomy [8,19] and lateral closing wedge osteotomy [6]. Mann et al. [19] reported a greater rate of infection with use of an oblique Steinmann pins or Kirschner-wire for fixation of the osteotomy that prompted them to use screw for fixation. There were no cases of deep infection associated with screw fixation in the
present study. In agreement with Frey, [20] two crossed Steinmann pins or multiple K-wires should be kept as an alternative way of fixation if screw did not hold the osteotomy. These should be cut off and buried under skin to avoid soft tissue irritation and infection. Inadvertent fixation of the osteotomy in a dorsiflexed position and shortening of the first metatarsal can relief the first metatarsal head from pressure and shift it to the second metatarsal head leading to transfer metatarsalgia. The relation between metatarsal shortening and transfer metatarsalgia is still a matter of debate [19]. In order to avoid this problem, Borton and Stephens [9] suggested the necessity to supinate and plantarflex the first metatarsal at the osteotomy. Barouk [21] stated that first metatarsal osteotomy and Weil lesser ray osteotomy can be combined to obtain a normal relationship of the forefoot and to prevent transfer metatarsalgia. In the present series, four of five cases with transfer metatarsalgia preoperatively were completely relieved of pain after operation while only one patient continued to complain of pain under the head of second metatarsal. In this case, the percentage of first metatarsal shortening was the greatest. We agree with Mann et al. [19] who noted that proper correction of hallux valgus will usually alleviate pain of transfer metatarsalgia and there would be no need for the routine combination with Weil osteotomy of the lesser metatarsals. Recurrence of the valgus deformity was common in patients who had preoperative severe deformity and in whom first metatarsal osteotomy had not been done. This could be explained by inadequate release of lateral soft tissue, incomplete mobilization of sesamoid, inadequate plication of the medial joint capsule and less correction of the IMA angle. In the study of Mann et al. [19] the most common complication was hallux varus deformity. They found that mild degree of varus did not bother the patients or limit wearing shoes. The development of hallux varus was closely related to an over correction of the IMA. In the current study, the two patients with postoperative hallux varus deformity had the lowest mean IMA. Despite the minimal degree of varus deformity, one patient experienced some difficulty in wearing fashionable shoes that could be due to arthrofibrosis and less flexibility of MTPJ. 5. Conclusion In conclusion distal soft tissue realignment combined with first metatarsal basal osteotomy is an effective procedure to correct all components of moderate to severe hallux valgus deformity, restore the normal biomechanics around the first MTPJ, relief pain and improve function. However, correction of severe deformity is more demanding and more likely to be complicated with recurrence of the valgus deformity. Despite the limited number of cases, proximal first metatarsal countersinking osteotomy is proved to be a simple, less invasive and stable enough to allow early mobilization with minimal risk of non-union or mal-union. Conflicts of interest The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed to research fund, foundation, educational institution or other charitable or nonprofit organization with which the authors are affiliated or associated. References [1] Hardy RH, Clapham JCR. Hallux valgus predisposing anatomical causes. Lancet 1952;1:1180–3. [2] Piggott H. The natural history of hallux valgus in adolescent and early adult life. The Journal of Bone and Joint Surgery [British volume] 1960;42-B:749–60.
M.F. Mostafa, G. El-Adl / The Foot 22 (2012) 186–193 [3] Joseph TN, Mroczek KJ. Decision making in the treatment of hallux valgus. Bulletin of the NYU Hospital for Joint disease 2007;65(1):19–23. [4] McBride ED. Hallux valgus, Bunion deformity. In: Edwards JV, editor. Instructional course lectures, vol. 9. Ann Arbor: The American Academy of Orthopaedic Surgeon; 1952. p. 334–6. [5] Mann RA, Coughlin MJ. Hallux valgus––etiology, anatomy, treatment and surgical considerations. Clinical Orthopaedics 1981;157:31–41. [6] Resch S, Stentrom A, Egund N. Proximal closing wedge osteotomy and adductor tenotomy for treatment of hallux valgus. Foot Ankle 1989;9:272–80. [7] Walson TS, Shurans PS. The proximal opening wedge osteotomy for the correction of hallux valgus deformity. Technique in Foot Ankle Surgery 2008;7(1):17–24. [8] Thordarson DB, Leventen EO. Hallux valgus correction with proximal metatarsal osteotomy two years follow-up. Foot Ankle 1992;13:321–6. [9] Borton DC, Stephens MM. Basal metatarsal osteotomy for hallux valgus. The Journal of Bone and Joint Surgery [British volume] 1994;76-B:204–9. [10] Hattrup SJ, Johnson KA. Chevron osteotomy: analysis of factors in patients dissatisfaction. Foot Ankle 1985;5:327–32. [11] Mann RA. Avascular necrosis (in letter to Editor). Foot Ankle 1982;3:125–9. [12] Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment. Report of the Research Committee of the American Orthopedic Foot and Ankle Society. Foot Ankle 1984;5:92. [13] Kitaoka HB, Alexander IJ, Adelaor RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle––hindfoot, midfoot, hallux and lesser toes. Foot and Ankle International 1994;15(7):349–53.
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[14] Broughton NS, Winson IG. Keller’s arthroplasty and Mitchell osteotomy: a comparison with first metatarsal osteotomy of the long-term results for hallux valgus deformity in the younger female. Foot Ankle 1988;10: 201–5. [15] Robinson AHN, Limbers JP. Aspects of current management: modern concepts in the treatment of hallux valgus. The Journal of Bone and Joint Surgery [British volume] 2005;87-B:1038–45. [16] Mann R. Hallux valgus correction using the distal soft tissue procedure and proximal crescentic osteotomy. In: Myerson M, editor. Current therapy in foot and ankle surgery. St Louis: Mosby–Year Book; 1993. [17] Coughlin MJ, Grimes JS. Proximal metatarsal osteotomy and distal soft tissue reconstruction as treatment for hallux valgus deformity. The Keio Journal of Medicine 2005;54(2):60–5. [18] Bonnel F, Canovas F, Poiree G, Dusserre F, Vergnes C. Evaluation of the Scarf osteotomy in hallux valgus related to distal metatarsal articular angle: a prospective study of 79 operated cases. Revue de Chirurgie Orthopedique 1999;85:381–6. [19] Mann RA, Rudical S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term followup. The Journal of Bone and Joint Surgery [American volume] 1992;74-A: 124–9. [20] Frey C. Basilar metatarsal osteotomy with distal soft-tissue realignment for hallux valgus. Technique in Orthopedics 1993;8(1):7–10. [21] Barouk LS. Weil’s metatarsal osteotomy in the treatment of metatarsalgia. Orthopaedics 1996;25:338–44.
Contents lists available at SciVerse ScienceDirect
The Foot journal homepage: www.elsevier.com/locate/foot
Distal soft tissue realignment and proximal metatarsal countersinking osteotomy for moderate to severe hallux valgus Mohamed F. Mostafa ∗ , Gamal El-Adl Department of Orthopaedic Surgery and Traumatology, Mansoura University Hospital, Mansoura, Egypt
a r t i c l e
i n f o
Article history: Received 2 October 2011 Received in revised form 14 March 2012 Accepted 15 March 2012 Keywords: Hallux valgus Countersinking Osteotomy
a b s t r a c t Background: Hallux valgus is a common condition and surgical correction has remained a challenge. Objective: To evaluate the results of distal soft tissue realignment and proximal 1st metatarsal countersinking osteotomy for the treatment of moderate to severe hallux valgus deformity. Materials and methods: This prospective study included 33 ft in 28 patients. The deformity was moderate in 27 ft (23 patients), severe in six ft (five patients) and bilateral in five patients. All operations were performed as a primary procedure with an average duration of follow-up of 28.2 months (range 10–45 months). Results: The average hallux valgus angle was improved from 32.5◦ to 8◦ and the first intermetatarsal angle from 16.5◦ to 7.7◦ . According to the symptomatic score of Broughton and Winson, 22 ft (18 patients) were rated excellent, nine good and two poor. The average American Orthopedic Foot Ankle Society score at the final follow-up was 89.3 (range 65–100). Recurrence of the valgus deformity was seen in three patients and hallux varus in two patients. Conclusions: The current procedure proved to be effective to correct all components of hallux valgus deformity regardless of its severity. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction The condition of hallux valgus (HV) includes not only the lateral deviation of the great toe, but also a medial deviation of the first metatarsal (metatarsus primus varus), with a close relationship between the degree of the two deformities. However, there is no agreement on which is the primary deformity [1,2]. Occasionally, there is a static deformity due to valgus angulation of the distal articular surface of the first metatarsal or proximal phalangeal articular surface [3]. McBride described the specific role of the adductor conjoined tendon as the “culprit” principally responsible for the valgus contracture and the advantages of transplanting it to an important position as the basic principle for surgical repair [4]. It has been observed that a distal soft tissue procedure alone does not always correct the deformity successfully and that an abnormal intermetatarsal angle persists [5]. Most authors agree that patients with HV and a wide first intermetatarsal angle require some procedure at the proximal first metatarsal bone. Basal osteotomies of
∗ Corresponding author at: Mansoura University Hospital, P.O. Box 35516 Mansoura, Egypt. Tel.: +20 115445384; fax: +20 502214715. E-mail address: [email protected] (M.F. Mostafa). 0958-2592/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.foot.2012.03.007
various kinds have been advocated: closed wedge [6], open wedge [7], crescentic [8] and chevron [9]. Distal metatarsal osteotomy in patients with splayed ft has led to high rates of patient dissatisfaction [10]. Mann [11] has warned that the potential complications of distal osteotomy include avascular necrosis, excessive shortening of the metatarsal, mal-alignment of the metatarsal head and overcorrection. The aim of this study was to evaluate the results of distal soft tissue realignment combined with basal first metatarsal countersinking osteotomy as an effective procedure for management of moderate to severe hallux valgus.
2. Materials and methods Between December 2005 and September 2009, twenty eight patients (33 ft) with moderate to severe HV deformity were treated by distal soft tissue realignment and proximal first metatarsal countersinking osteotomy. All operations were performed as a primary procedure at the King Saud Hospital, Unaizah, Kingdom of Saudi Arabia. Operations were indicated in patients with painful hallux valgus deformity and functional distabilities including the difficulty with shoe wear and activity restriction. Patients with hallux rigidus, marked arthrosis precluding realignment of the joint and underlying connective tissue disorders or neuromuscular diseases were excluded from this study.
M.F. Mostafa, G. El-Adl / The Foot 22 (2012) 186–193 Table 1 Main complaints of patients. Main complain
Number (%)
Pain Shoe wear problems Activity restriction Cosmetic reasons
18 (54.5%) 9 (27.3%) 3 (9.1%) 3 (9.1%)
There were twenty five females (30 ft) and three males (three ft) with an average age of 25.4 years (range, 17–38 years) at the time of surgery. The deformity was bilateral in five females, moderate in 27 ft (23 patients) and severe in six ft (five patients). Pain was the main complain in 18 patients (54.5%), twelve of them had the pain over the medial eminence of the first metatarsal head, five under the head of the second metatarsal, and one in the MTPJ itself (Table 1). 2.1. Operative procedure All patients were interviewed before operation and an informed consent was obtained. For patients with bilateral deformity, operations were performed in two sessions starting with the more symptomatic side (average interval, 10.8 months). Operations were done under general anaesthesia while the patient was in the supine position. A thigh pneumatic tourniquet was used. The ft were cleansed and draped in the usual fashion. The first incision was made between the first and second metatarsals in the line of the web space. The adductor hallucis tendon was released from its insertion into the base of the proximal phalanx and the fibular sesamoid after a stay suture was placed in the proximal end. With tension applied between the metatarsals using a self retaining retractor, the transverse intermetatarsal ligament was released from its attachment into the fibular sesamoid. Care was taken to avoid injury to the underlying common digital nerve. Then the lateral capsule and fibular sesamoid were freed from the first metatarsal head leaving a cuff of tissue that could be repaired. A second longitudinal incision was centered over the medial eminence. Care was taken to create a full thickness flap and to protect the medial dorsal and plantar sensory nerves while exposing the capsule. A V-shaped capsular flap was created with its broad base at the base of proximal phalanx. This allowed exposure of medial eminence and careful assessment of the sagittal sulcus. The medial eminence was then excised with the saw in line with the medial aspect of the metatarsal shaft. At this time, the flexibility of the metatarsocuneiform joint (MTCJ) was tested especially in patients with moderate deformity. A proximal metatarsal osteotomy was decided if intermetatarsal angle could not be corrected due to rigidity of the MTCJ in moderate deformity. An incision 3–4 cm was made along the dorsal aspect of the proximal part of the first metatarsal medial to extensor hallucis longus tendon and end just proximal to the MTCJ. An elevator was placed subperiosteally along the lateral aspect of the first metatarsal base to control displacement of the osteotomy and to protect the communicating artery in the first intermetatarsal space. The osteotomy was done 1.5–2 cm distal to MTCJ with the saw directed perpendicular to the metatarsal shaft and parallel to the joint. A preliminary glide-hole with a 3.5 mm drill-bit was made 1 cm distal to the planned osteotomy. The hole was directed proximally toward the plantar aspect of the proximal fragment, at a 45◦ angle in relation to the shaft of the metatarsal. After the osteotomy had been completed the metatarsal head was displaced laterally while supporting the proximal part of the distal fragment with an elevator. This allowed the distal fragment to be rotated along a point at the center or about 2 mm lateral to the center of the osteotomy and coutersinking the medial edge of the proximal fragment into
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the cancellous bone of the proximal fragment (Fig. 1). Then the proximal hole was made with 2.5 mm drill-bit over a sleeve and the osteotomy was secured with a 4 mm cancellous-bone screw. The head of the screw was countersunken to reduce subcutaneous prominence. The V-shaped capsular flap medially was sutured onto the bone, using an absorbable suture passed through a small hole created in the distal metatarsal shaft, with the great toe held in neutral plantar flexion-dorsoflexion, slight varus and slight supination. The soft tissues along the plantar and dorsal aspect of the capsular flap were repaired with a careful tension to reduce the sesamoids beneath the metatarsal head. Finally, attention was directed to the first incision where the initial stay suture was tied and soft tissues were repaired to achieve stability to the lateral capsule (Fig. 2). Intraoperative fluoroscopy was helpful to ascertain the correction of the deformity, reduction of the sesamoids and proper osteotomy and screw fixation. Postoperatively a below knee weight bearing cast was applied with the great toe held in corrected position. Weight bearing was allowed on the lateral aspect of the ft and the heel guided by pain. The cast was changed at the time of suture removal and removed 6–8 weeks from surgery. After removal of the cast, a program of active and passive range of motion exercises of the first MTPJ had been started under the supervision of physiotherapist. Patients were instructed to exercise all toes by picking up small objects from the floor and to strengthen sole muscles by controlling a roller or a ball under it. The exercises were done three times a day and lasting ten minutes each time. Athletic activities were commenced three to four months after surgery. The average duration of follow-up was 28.2 months (range, 10–45 months). All patients were asked about improvement of pain, appearance of the ft, problems with wearing shoe, the ability to walk and their satisfaction with the procedure. The passive as well as active arc of motion of the first metatarsophalangeal joint and the amount of pronation of the great toe were measured using the standard goniometer and compared with that taken before operation. Assessment of pronation was made with the patient standing and graded according to Smith et al. [12] as follow: grade 1 (mild); rotation of nail less than 25◦ , grade 2 (moderate); rotation more than 25◦ and grade 3 (severe); rotation more than 45◦ . The transfer lesion “symptomatic callus beneath the second metatarsal head because of inadequate weight-bearing on the first metatarsal” was evaluated at final follow-up. Weight-bearing dorsoplantar radiographs were taken preoperatively and at final follow-up to measure the hallux valgus angle (HVA), first intermetatarsal angle (IMA), the length of first and second metatarsals and the percentage of first metatarsal shortening (Fig. 3). In addition, the position of tibial sesamoid (Fig. 4) and the congruity of the first MTPJ were recorded (Fig. 5). The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal Scale (AOFASS) (Table 2) [13] and the symptomatic score of Broughton and Winson (Table 3) [14] were used for the final assessment of patients. The data of patients was analyzed using the Statistical Package for Social Sciences (SPSS) version 11.5 for windows. Pearson Chi-square test, independent sample T test and one way ANOVA test were used to define relations between clinical and radiological results and the final outcome. Probability values of less than 0.05 were considered significant.
3. Results The distal soft tissue realignment procedure was technically demanding and required careful balancing of soft tissue about medial and lateral aspect of MTPJ. No difficulties were confronted
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Fig. 1. Diagram (a) showing the increased hallux valgus angle and 1st intermetatarsal angle, (b) after excision of medial eminence, proximal osteotomy and countersinking the distal fragment into the proximal base “black arrows”.
with the technique of osteotomy in this study. It was simple and easy with minimal soft tissue dissection, little or minimal bump formation on the medial arch, minimal shortening of the first metatarsal and enough stability to allow early mobilization. We believe that with this type of osteotomy slight proximal displacement ensures a great correction of the deformity distally.
improved from 53.9◦ (range, 38◦ –75◦ ) preoperatively to 70.3◦ (range, 35◦ –84◦ ) postoperatively with an average improvement of 15.6◦ . Pronation of the great toe was moderate to severe in 17 (51.5%) ft preoperatively and improved to mild pronation in only six (18.2%) ft postoperatively. 3.3. Radiological outcome
3.1. Subjective outcome According to the symptomatic score of Broughton and Winson, 22 ft (66.7%) were rated excellent, nine (27.3%) good and two (6.1%) poor. Five of the nine cases with good results were satisfied and happy with the results and four were moderately satisfied and said that given the identical situation they would select the same type of operation. Among the four patients with moderate satisfaction one had recurrent hallux valgus deformity (HVA = 22◦ , IMA = 11◦ ), two had hallux varus (−3◦ and −5◦ ) and one had sensory disturbance along the medial aspect of the great toe. The two patients with poor results were really dissatisfied. One of them had constant pain under the second metatarsal head that caused restriction of daily life activities and the other patient had arthrofibrosis with significant limitation of active movement of MTPJ and restriction of athletic activities. 3.2. Objective outcome The average AOFAS score at the final follow-up was 89.3 (range, 65–100). The high score was significantly obtained in patients with less severe preoperative deformity (p = 0.05). The active arc of movement “dorsoflexion-plantarflexion” of MTPJ was
All osteotomies healed uneventfully after an average time of 5.4 weeks (range, 4–9 weeks). The average hallux valgus angle improved from 32.5◦ (range, 22◦ –40◦ ) preoperatively to 8◦ (range,−5◦ to 22◦ ) postoperatively with an average correction of 24.5◦ . The average first intermetatarsal angle was 16.5◦ (range, 11◦ –25◦ ) preoperatively and improved to 7.7◦ (range, 2◦ –12◦ ) postoperatively with an average correction of 8.7◦ . The average percentage of first metatarsal shortening after operation was 1.2% (range, 0.75%–2.24%). Patients with preoperative severe hallux valgus deformity were more likely to develop shortening of the first metatarsal (p = 0.04). The tibial sesamoid was lateral in 29 ft (87.9%) preoperatively and in only two ft (6.1%) postoperatively. The medial position of tibial sesamoid was achieved in 78.8% of ft. 3.4. Complications Reflex sympathetic dystrophy was encountered in three ft (9%) in three patients who were reluctant to mobilize early postoperatively and improved dramatically after physiotherapy and weight bearing. One patient had superficial wound infection which was appropriately managed with dressing and oral antibiotics. There were no cases of deep infection, soft tissue irritation related to
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implant, symptomatic arthrosis of the first MTPJ or non union of the osteotomy site. A recurrence of hallux valgus deformity was seen in two patients (two ft). One of them (HVA = 22◦ ) was moderately satisfied and refused to do further surgery while the other patient (HVA = 18◦ ) was satisfied with the results. Recurrent hallux valgus developed
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in patients who had preoperative severe deformity (p = 0.01). Two patients with two ft developed hallux varus deformity after operation that led to some difficulty in wearing shoes in one of them. The two ft with postoperative hallux varus had the lowest mean postoperative first intermetatarsal angle (p = 0.03). The patient who continued to complain of transfer metatarsalgia after
Fig. 2. (a) A 19-year-old girl with severe hallux valgus left ft, splayed forefoot, prominent medial eminence, moderate pronation of great toe and overriding of second toe. (b) Preoperative weight bearing radiograph showing hallux valgus angle 42◦ and 1st intermetatarsal angle 19◦ . (c) The stay suture of the adductor tendon. (d) Elevation of the V-shaped capsular flap to expose the medial eminence. (e) Fixation screw in place after countersinking the lateral edge of the distal fragment into the proximal fragment. (f) Weight bearing radiograph 12 months after surgery. (g) Photograph of the ft at final follow-up.
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Fig. 2. (continued ).
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Fig. 3. The method of measuring first metatarsal shortening. X is the midpoint of AB. The percentage of first metatarsal shortening is then expressed as: (X1(preoperative)/X2 (preoperative))/(X1 (postoperative)/X2 (postoperative)) × 100.
operation had the highest percentage of first metatarsal shortening (p = 0.002). 4. Discussion Painful hallux valgus is a common clinical problem especially in females willing to wear fashionable shoes. Surgical correction has remained a challenge with at least 130 procedures being described [15]. In agreement with Mann [16] distal soft tissue procedure alone is not enough to correct hallux valgus deformity in patients with increased first intermetatarsal angle. Patients with HVA of 30◦ and IMA of 12◦ or more should have proximal first metatarsal osteotomy in addition to distal soft tissue realignment. Osteotomy is mandatory in patients with HVA more than 40◦ , while optional if IMA is less than 12◦ when judged intraoperatively that metatarsocuniform joint is rigid enough to prevent correction [17]. Distal metatarsal osteotomy is advised to correct mild hallux valgus deformity with distal metatarsal articular angle (DMAA) malalignment [18]. It is not recommended to be done in combination with lateral soft tissue release because of the risk of osteonecrosis of the first metatarsal head as the nutrient artery enter the diaphysis 2.5 cm proximal to the capsule of the first MTPJ [3,11]. On the other hand, basilar metatarsal osteotomy is performed in an area of rich blood supply and consequently has a less chance for avascular necrosis. In the current series, there were no cases of osteonecrosis of the first metatarsal head at the time of final follow-up. The most popular principle types of proximal metatarsal osteotomy are the closed-wedge osteotomy [6] that usually results in metatarsal shortening and transfer metatarsalgia, the openwedge osteotomy [7] can result in early recurrence because of
Fig. 4. To determine the position of the sesamoid, the 1st metatarsal is bisected and the tibial sesamoid is divided into quarters. The position of tibial sesamoid is considered medial if 75% of its width is medial to the central line and lateral if lateral to the central line. Otherwise, the sesamoid is considered to be central.
the metatarsal lengthening and the dome osteotomy [8] which is proposed to avoid the previous problems. In the present study, a countersinking osteotomy was introduced believing that impaction of the distal fragment into the proximal one along the lateral aspect, soft tissue tension along the medial aspect and fixation with lag screw will increase stability and allow early mobilization with less
Fig. 5. Two straight lines are drawn representing effective articular surface of the first metatarsal head and base of proximal phalanx; (a) congruent joint: parallel lines, (b) deviated joint: lines converge outside the joint, (c) subluxated joint: lines intersect within the joint.
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Table 2 AOFAS hallux metatarsophalangeal–interphalageal scale [13]. Pain (40 points) Non Mild, occasional Moderate, daily Severe, almost always present
40 30 20 0
Function (45 points) Activity limitation No limitations No limitations of daily activities (employment responsibilities, limitations of recreational activities) Limited daily and recreational activities Severe limitation of daily and recreational activities Ft wear requirements Fashionable, conventional shoes, no insert required Comfort footwear, shoe insert Modified shoes or brace MTP joint motion (dorsiflexion plus planterflexion) Normal or mild restriction (75◦ or more) Moderate rrestriction (30◦ –74◦ ) Severe restriction (less than 30◦ ) IP joint motion (planter flexion) No restriction Severe restriction (less than 10◦ ) MTP – IP stability (all Direction) Stable Definitely unstable or able to dislocate Callus related to hallux MTP – IP No callus or symptomatic callus Callus, symptomatic Alignment (15 points) Good, hallux well aligned Fair, some degree of hallux malallignment observed, no symptoms Poor, obvious symptomatic malalignment
10 7 4 0 10 5 0 10 5 0 5 0 5 0 5 0 15 8 0 100
Total
A score more or equal to 65 points was considered to be of a good clinical result.
Table 3 Symptom score according to Broughton and Winson [14]. Grade 1
Grade 2
Grade 3
Happy
Unhappy
None
Slight reservation Occasional
None
Slight
Function/Activities
No restrictions
Shoe wear
Any
Slight restriction in daily activities Slight restriction
Cosmetic appearance Pain in 1st MTP joint Metatarsalgia
On normal activity After <3 h walking/standing Severe restriction in daily activities Difficulty in finding/only special shoes.
The result was regarded as excellent when the patient achieved G 1 in all categories, good when the patient had no more than two G 2 and no G 3 and poor in any other case.
risk of non-union or mal-union. Furthermore, rotation of the distal fragment at or just medial to the center of the osteotomy effect the principle of half wedge osteotomy correcting greater deformity with minimal displacement and at the same time preserving most of the first metatarsal length. The results of the current study regarding the average correction of HVA and IMA and patient satisfaction with the end results were comparable with the results of other studies using basal metatarsal crescentic osteotomy [8,19] and lateral closing wedge osteotomy [6]. Mann et al. [19] reported a greater rate of infection with use of an oblique Steinmann pins or Kirschner-wire for fixation of the osteotomy that prompted them to use screw for fixation. There were no cases of deep infection associated with screw fixation in the
present study. In agreement with Frey, [20] two crossed Steinmann pins or multiple K-wires should be kept as an alternative way of fixation if screw did not hold the osteotomy. These should be cut off and buried under skin to avoid soft tissue irritation and infection. Inadvertent fixation of the osteotomy in a dorsiflexed position and shortening of the first metatarsal can relief the first metatarsal head from pressure and shift it to the second metatarsal head leading to transfer metatarsalgia. The relation between metatarsal shortening and transfer metatarsalgia is still a matter of debate [19]. In order to avoid this problem, Borton and Stephens [9] suggested the necessity to supinate and plantarflex the first metatarsal at the osteotomy. Barouk [21] stated that first metatarsal osteotomy and Weil lesser ray osteotomy can be combined to obtain a normal relationship of the forefoot and to prevent transfer metatarsalgia. In the present series, four of five cases with transfer metatarsalgia preoperatively were completely relieved of pain after operation while only one patient continued to complain of pain under the head of second metatarsal. In this case, the percentage of first metatarsal shortening was the greatest. We agree with Mann et al. [19] who noted that proper correction of hallux valgus will usually alleviate pain of transfer metatarsalgia and there would be no need for the routine combination with Weil osteotomy of the lesser metatarsals. Recurrence of the valgus deformity was common in patients who had preoperative severe deformity and in whom first metatarsal osteotomy had not been done. This could be explained by inadequate release of lateral soft tissue, incomplete mobilization of sesamoid, inadequate plication of the medial joint capsule and less correction of the IMA angle. In the study of Mann et al. [19] the most common complication was hallux varus deformity. They found that mild degree of varus did not bother the patients or limit wearing shoes. The development of hallux varus was closely related to an over correction of the IMA. In the current study, the two patients with postoperative hallux varus deformity had the lowest mean IMA. Despite the minimal degree of varus deformity, one patient experienced some difficulty in wearing fashionable shoes that could be due to arthrofibrosis and less flexibility of MTPJ. 5. Conclusion In conclusion distal soft tissue realignment combined with first metatarsal basal osteotomy is an effective procedure to correct all components of moderate to severe hallux valgus deformity, restore the normal biomechanics around the first MTPJ, relief pain and improve function. However, correction of severe deformity is more demanding and more likely to be complicated with recurrence of the valgus deformity. Despite the limited number of cases, proximal first metatarsal countersinking osteotomy is proved to be a simple, less invasive and stable enough to allow early mobilization with minimal risk of non-union or mal-union. Conflicts of interest The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed to research fund, foundation, educational institution or other charitable or nonprofit organization with which the authors are affiliated or associated. References [1] Hardy RH, Clapham JCR. Hallux valgus predisposing anatomical causes. Lancet 1952;1:1180–3. [2] Piggott H. The natural history of hallux valgus in adolescent and early adult life. The Journal of Bone and Joint Surgery [British volume] 1960;42-B:749–60.
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