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The Relationship Between the Sesamoid Complex and the First Metatarsal After Hallux Valgus Surgery Without Lateral Soft-Tissue Release: A Prospective Study
The Journal of Foot & Ankle Surgery xxx (2015) 1–5
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Original Research
The Relationship Between the Sesamoid Complex and the First Metatarsal After Hallux Valgus Surgery Without Lateral Soft-Tissue Release: A Prospective Study Marıa Lamo-Espinosa, MD 1, Borja Flo rez, MD 2, Carlos Villas, MD, PhD 1, Jose 1 M. Bondıa, MD 3, Jesu s Da maso Aquerreta, MD, PhD 4, Juan Pons-Villanueva, MD, PhD , Jose 1 Matias Alfonso, MD, PhD Professor, Department of Orthopedic Surgery and Traumatology, Clınica Universidad de Navarra, Pamplona, Spain n Hospital de Calahorra, Logron ~ o, Spain Professor, Department of Orthopedic Surgery and Traumatology, Fundacio 3 Professor, Department of Radiology, Clınica Universidad de Navarra, Pamplona, Spain 4 Assistant Professor, Department of Radiology, Clınica Universidad de Navarra, Pamplona, Spain 1 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Some investigators have emphasized restoring the relationship between the sesamoid complex and the first metatarsal head to reduce the risk of hallux valgus recurring after surgical reconstruction. In a prospective study, we analyzed whether the first metatarsophalangeal joint could be realigned after scarf-Akin bunionectomy without lateral soft tissue release. A total of 25 feet, in 22 patients, were prospectively enrolled and analyzed using anteroposterior radiographs and coronal computed tomography scans obtained before and 3 months after surgery. The Yildirim sesamoid position decreased from a preoperative of 2 (range 1 to 3) to a postoperative position of 0 (range 0 to 1; p < .001), the mean first intermetatarsal angle decreased from 12.6 2.4 to 5.8 2.1 (p < .001), and the mean distance between the second metatarsal and the tibial sesamoid changed from 25.7 4.6 to 25.9 4.6 (p ¼ .59). Our findings suggest that dislocation of the sesamoid complex is actually caused by displacement of the first metatarsal. In conclusion, the scarf-Akin bunionectomy adequately restores the alignment of the first metatarsophalangeal joint, including restoration of the sesamoid apparatus, without direct plantar–lateral soft tissue release. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: adductor hallucis bunion first metatarsal great toe proximal phalanx tibial sesamoid
Some investigators have emphasized the need to restore the anatomic relationship between the sesamoid complex and the first metatarsal head when surgically correcting the hallux valgus (1–7) to reduce the risk of recurrent deformity (1,8–13). The line of force of the flexor hallucis longus runs between the tibial and fibular sesamoids. In hallux valgus, the sesamoids take an intermediate position between the first and second metatarsal heads, producing a predominantly lateral force on the first metatarsophalangeal joint (MTPJ) that increases abduction of the great toe, increasing the first metatarsophalangeal (abduction) angle (8,13–16). However, the position of the sesamoids relative to the second metatarsal is fixed (9,17,18), indicating that the first metatarsal, not the sesamoid complex, is displaced medially relative to the sesamoids. Thus, we have questioned Financial Disclosure: None reported. Conflict of Interest: None reported. Marıa Lamo-Espinosa, MD, Department of Address correspondence to: Jose Orthopedic Surgery and Traumatology, Clınica Universidad de Navarra, Av. Pio XII, 36, Pamplona 31008, Spain. E-mail address: [email protected] (J.M. Lamo-Espinosa).
the need for lateral soft tissue release, specifically sectioning (and, perhaps, transfer) of the conjoined tendon of adductor hallucis, sectioning of the fibular sesamoidal ligament, and transection of the deep transverse intermetatarsal ligament, in isolation or combed, to restore balance to the first MTPJ–sesamoid complex. To test this hypothesis, we prospectively measured the relationship between the sesamoid complex and the first metatarsal head before and after hallux valgus surgery using scarf-Akin bunionectomy, without any form of plantar–lateral first MTPJ soft tissue release, in a series of patients treated for symptomatic bunion deformity. Patients and Methods Patients aged 18 years were eligible for the study if they had hallux valgus and had undergone scarf-Akin bunionectomy without any adjunct surgical intervention from April 2005 to November 2006. All the patients provided written informed consent for participation in clinical research before enrollment in the study. All the patients were from the practices of 2 of us (M.A., C.V.), who performed all the operations. The surgeons used the same surgical intervention (ie, the scarf first metatarsal osteotomy as described by Zygmunt et al [19] and the Akin osteotomy of the proximal phalanx [20]). After the surgery, each patient underwent the same postoperative protocol, including
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immediate weightbearing using an orthopedic shoe (Super Shoe II; Soroufe Health Care ProductsÒ, Ligonier, IN), combined with surgical bandages for approximately the first 40 days, followed by use of a great toe alignment splint (DARCO TASÔ, Toe Alignment Splint; DARCO International, Huntington, WV) for the first 6 postoperative weeks. All the patients followed the same postoperative protocol with 4 weeks of partial weightbearing. Standard anteroposterior (AP) weightbearing radiographs and coronal computed tomography (CT) scans were obtained before surgery and again approximately 3 months after surgery. We measured 2 standard angles commonly associated with hallux valgus: the first intermetatarsal angle (IMA), the angle between the longitudinal axis of the first and second metatarsals (normal value <10 ) (21), and the hallux valgus angle or first metatarsophalangeal joint (MTPJ) angle, the angle formed between the longitudinal axis of the first metatarsal and the proximal phalanx of the hallux (21). The preoperative metatarsophalangeal angle was categorized as mild (16 to 25 ), moderate (26 to 35 ), or severe (>35 ) (21). CT scans were taken of the sesamoids in the axial plane (Spiral, Mombispi, Somaton Sensation; Siemens, Erlangen, Germany), using the following settings: 1 mm thickness, 1 mm pitch, 30 acquisition kernel, 1 mm reconstruction. On these images, we measured the distance between the second metatarsal to the tibial sesamoid (ie, the distance from the medial side of the tibial sesamoid to the bisector of the second metatarsal) (17) (Fig. 1) and the rotation angle of the sesamoids, defined as the angle between the line that connects the 2 plantar margins of the sesamoids and the horizontal plane (22) (Fig. 1). The position of the sesamoids was designated according to Yildirim et al (23) as viewed on the CT scans in positions € ller according to those described by Smith et al (24) in the tangential Walter-Mu radiographic view (Fig. 2). Yildirim et al (23) defined 4 grades of sesamoid position: grade 0, the medial sesamoid is entirely medial to the intersesamoid ridge; grade 1, less than one half of the width of the medial sesamoid is subluxated laterally; grade 2, more than one half of the width of the medial sesamoid is subluxated laterally; and grade 3, the medial sesamoid is entirely lateral to the intersesamoid ridge. Grades 0 and 1 are considered normal (24), and we excluded patients with a preoperative Yildirim position of grade 0. Statistical Analysis The pre- and postoperative values were compared using Student’s t tests for paired samples of normally distributed data and the Wilcoxon signed ranks test otherwise. The a value was set at 0.05, and all tests were 2-tailed. Data were analyzed using STATA, version 12.0, for Windows (StataCorp, College Station, TX). The analyses were performed by 1 of us (J.P.V.).
Results We enrolled 26 feet in 22 patients during the 19-month enrollment period. The preoperative relationship between the first metatarsal head and the sesamoid complex was Yildirim grade 0 in 1 foot (1 female with 2 involved feet), and that foot was excluded from the present analysis. The mean age of these patients at surgery was 55.1 9.01 (range 32 to 77) years. Nineteen patients (86.3%) were female (22 feet) and 2 were male (3 feet [13.7%]). Of the 25 feet, 11 (44%) were right and 14 (56%) were left feet. The sesamoid positions of
Fig. 1. Measurements of the sesamoid axial plane. (A) The distance between the second metatarsal to the tibial sesamoid, defined as the distance in millimeters from the medial side of the tibial sesamoid to the bisector of the second metatarsal. (B) The rotation angle of the sesamoid complex, defined as the angle between the line that connects the 2 planter margins of the sesamoids and the horizontal plane (24).
the 25 feet were Yildirim grade 1 in 9 feet (36%), grade 2 in 12 (48%), and grade 3 in 4 (16%). All 25 feet were realigned to either grade 0 (19 feet [76%]) or grade 1 (6 feet [24%]) after surgery (Table 1). The values for the preoperative to postoperative first IMA, first MTPJ angle, sesamoid rotation angle, Yildirim sesamoid position, and second metatarsal to tibial sesamoid distance are listed in Table 2. The mean first IMA decreased from 12.6 2.4 (range 7.1 to 19.7 ) preoperatively to 5.8 2.1 (range 2.1 to 10.3 ) postoperatively (p < .001). The mean first metatarsophalangeal angle (hallux valgus angle) decreased from 35.8 9.8 (range 22.3 to 59.4 ) preoperatively to 13.3 6 (range 1.3 to 27.2 ) postoperatively (p < .012). The position of the sesamoids in the axial plane varied significantly, as defined by the mean sesamoid rotation angle, which decreased from 25 10 (range 12.4 to 45.3 ) preoperatively to 14.4 8.6 (range 0.2 to 32.3 ) postoperatively (p < .001). The median Yildirim sesamoid position changed from a preoperative value of 2 (range 1 to 3) to a postoperative median of 0 (range 0 to 1; p < .001). The second metatarsal–tibial sesamoid distance was 25.7 4.6 (range 13.3 to 31) mm preoperatively and 25.9 4.6 (range 12.9 to 33) mm postoperatively (p ¼ .59). Thus, the sesamoids in the axial plane maintained a constant distance relative to the position of the second metatarsal. The postoperative metatarsophalangeal angle significantly decreased in each preoperative severity category. Also, in all cases, even severe cases (a preoperative first metatarsophalangeal angle >35 ) returned to normal alignment postoperatively (Table 2). The 4 cases in which the sesamoids were in Yildirim grade 3 before surgery displayed a final postoperative grade of 0 or 1, and all the measured angles had significantly decreased with a statistically significant difference (Table 3). Discussion The position of the sesamoid complex relative to the first metatarsal has been studied by several investigators (9,13,14,23,25–29). In 1923, Silver (5) emphasized the importance of restoring the relationship between the first metatarsal and the sesamoid complex when correcting hallux valgus surgically. Later, McBride (4) called attention to the lateral intrinsic muscles of the first metatarsal as a major mechanical factor in developing hallux valgus. In 1928, he described the first soft tissue procedure for correcting hallux valgus (4). However, the poor results from the technique he described led many investigators to prefer osteotomy and to consider the release and soft tissue procedure as a part of the surgery (1,30–32). Several surgical techniques and soft tissue procedures have since been described to reposition the sesamoid complex (12,13,15,33–35), including fibular sesamoidectomy (36), extracapsular release, intracapsular release, tendon transposition (13,37,38), and the lateral transarticular release recently described by Choi et al (39). Currently, some surgeons have questioned just how best to determine the position of the sesamoid complex, and some have studied the relationship between the first metatarsal head and the sesamoid complex (21,23,29,40). Talbot and Saltzman (29) reported a discrepancy in the measurements between anteroposterior and tangential simple radiographs in 50% of 60 cases. They recommended taking measurements from tangential radiographs using the Walter€ ller view. Some investigators have agreed with them (22,25); Mu € ller view requires dorsiflexion of the MTPJ however, the Walter-Mu (1,25,29), which moves the sesamoid complex distally and dorsally. Yildirim et al (23) obtained CT scans with the ankle in different degrees of dorsiflexion and reported that MTPJ dorsiflexion moves the first MTPJ sesamoids distally and dorsally, reducing them under the first metatarsal head and thus providing an unreliable sesamoid–first metatarsal relationship. Therefore, we believe that the distance between the sesamoid complex and the head of the first metatarsal is
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Fig. 2. Diagram showing Yildirim grade of the sesamoid complex (SC) in relationship to the first metatarsal head (FMH).
best measured on a tangential CT scan made with the first MTPJ in the neutral position without dorsiflexion. Perhaps most interesting is the question of whether plantar– lateral first MTPJ soft tissue release is required for correction and longterm maintenance of first MTPJ alignment and balance as a result of bunionectomy surgery. Any surgical procedure has potential iatrogenic risks. Some investigators perform a sesamoidectomy because the subluxated position of the sesamoids can interfere with translation of the first metatarsal (36,41). Lipsman and Frankel (41) and Gerbert and Sokoloff (36) perform sesamoidectomy in cases with a position of 4 in the longitudinal axis. However, sesamoidectomy can disturb the gait and increases the incidence of hallux varus (14). David et al (42) reported that the sesamoid bones are important in stabilizing the hallux during walking. We have shown in the present study that in even severe cases (Yildirim grade 3), the first IMA can return to normal, with the relationship between the sesamoids and the first metatarsal head restored (Fig. 3). A lateral soft tissue release is often used in treating hallux valgus. Lee et al (43) and Granberry and Hickey (44) associated soft tissue release with greater postoperative stiffness of the MTPJ (25). They reported that soft tissue release should be contraindicated in cases of preoperative MTPJ limitation, despite the greater angular correction provided by the lateral soft tissue release. Lee et al (43) also reported a high rate of dorsal and plantar digital neuritis in patients undergoing soft tissue release, and this risk increased in cases performed percutaneously (45). Finally, as an open procedure, lateral soft tissue release requires a second incision, which is cosmetically undesirable. The risk of avascular necrosis of the first metatarsal head associated with soft tissue procedures is uncertain (14). Meier and Kenzora (46) found distal necrosis in 20% of cases (12 of 60 feet) treated with a Chevron osteotomy alone and in 40% of cases (4 of 10 feet) treated with a Chevron osteotomy and lateral soft tissue release. Trnka and Zemsch (47) found avascular necrosis in 3 of 94 cases treated with proximal osteotomy and lateral soft tissue release. These data were supported by findings from magnetic resonance imaging studies (27,48). In contrast, other investigators have found no association Table 1 Postoperative changes in Yildirim grade of the sesamoid complex after surgery for hallux valgus in 25 feet (22 patients) Preoperative Yildirim Grade*
0 1 2 3 Total (n)
Feet (n)
Total (n)
Postoperative Yildirim Grade 0
1
2
3
NAy 8 8 3 19
NA 1y 4 1 6
NA 0 0y 0 0
NA 0 0 0y 0
NA 9 12 4 25
Abbreviation: NA, not applicable. * Definitions of the Yildirim grades are shown in Fig. 2 and detailed in the text. y No change in grade; remaining data indicate improvement.
between necrosis and wide soft tissue release during hallux valgus surgery (11,49–53). Although Jahss (14), in 1981, stated that releasing the sesamoids is not necessary to reduce the first IMA, most later studies have recommend it for patients with severe hallux valgus or sesamoid complex luxation. However, these studies had several limitations. Most were retrospective, all used AP radiographs, and none included severe cases. Lee et al (43) do not perform lateral soft tissue release in cases of mild-to-moderate hallux valgus. However, they did not evaluate patients with severe hallux valgus. Oloff and Bocko (54) recommended wide release of the soft tissues in patients with a large first IMA; however, they used the chevron osteotomy. When using a distal osteotomy, correcting the angle will be difficult in severe cases. It could explain the recommendation of Oloff and Bocko (54). In contrast, Boberg and Judge (25), in a study similar to ours, did not recommend lateral soft tissue release for patients in whom the sesamoid complex had not luxated. In their series, the mean metatarsophalangeal angle was 23 , and all the angles were <38 . In our study, radiographs and CT scans indicated a mean
Table 2 Correction of first intermetatarsal angle, sesamoid rotation angle, and sesamoid position after surgery for hallux valgus in 25 feet (22 patients) stratified by preoperative metatarsophalangeal angle Variable
Preoperative first MTPJ angle ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) First MTP (hallux abductus) angle ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) Sesamoid rotation angle ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) Sesamoid position ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) Second metatarsal–tibial sesamoid distance (mm) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25)
First Intermetatarsal Angle ( )
p Value
Preoperative
Postoperative
11.1 12.1 2.4 13.2 3.3 12.6 2.4
3.2 5.2 0.5 6.7 2.1 5.8 2.1
<.001* <.001* <.001*
22.3 29.8 2.3 43.0 9.7 35.8 9.8
12.8 10.5 6.2 15.9 4.9 13.3 6
<.001* <.001* <.001*
16.5 19.7 9.5 30.5 8 25.0 10
5.2 9.4 7.9 19.9 6.1 14.4 8.6
<.001* <.001* <.001*
1 1 2 2
0 0 0 0
(0 to 0) (0 to 1) (0 to 1) (0, 1)
<.001y .002y <.001y
27 26.6 0.7 25.1 0 25.9 4.6
.06* .12* .59*
(1 to 1) (1 to 2) (1 to 3) (1, 3)
27 24.5 0.7 25.6. 3.5 25.7 4.6
Abbreviations: MTP, metatarsophalangeal angle; MTPJ, metatarsophalangeal angle joint. * Student’s paired t test. y Wilcoxon signed ranks test.
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Table 3 Effect of hallux valgus surgery on position of sesamoid complex and intermetatarsal angle in patients with sesamoid complex of Yildirim grade 3 preoperatively Patient No.
Preoperative Yildirim Grade
First IMA ( )
Postoperative Yildirim Grade
First IMA ( )
1 2 3 4 Median (range) or mean SD
3 3 3 3 3 (3 to 3)
14.0 13.6 14.5 14.2 14.1 0.3
0 0 1 0 0 (0 to 1)
5.1 6.5 9.2 7.5 7.1 1.72
Abbreviations: IMA, intermetatarsal angle; SD, standard deviation. The difference in the decrease in the first IMA was statistically significant at the 0.05 level in all cases.
metatarsophalangeal angle of 35.3 . The key point for Ramdass and Meyr (17) was the axial rotation angle, which could obstruct the repositioning of the first metatarsal on the sesamoid complex. Ramdass and Meyr (17) performed a lateral soft tissue release in all their patients and noted a change in the axial rotation of the sesamoids (16.3 to 8.6 ). We also observed a reduction in the sesamoid rotation angle in the absence of any soft tissue release. We included all the patients with Yildirim grade 1, although many authorities have accepted a Yildirim grade of 0 or 1 as normal for the sesamoid complex (23,24). These values were reported in the study by Smith et al (24) and were based on the results from standing AP radiographs of only 8 feet, 4 in grade 0 and 4 in grade 1. Yildirim included these results in the definition of normal in his CT classification. The study by Smith et al (24) also evaluated the hallux valgus–sesamoid complex. In 20 patients (34 feet) with hallux valgus, 34% of patients had the sesamoids in grade 1. We consider this proportion to be high and thus believe Yildirim grade 1 is associated with hallux valgus. Additional studies are necessary to resolve this question. All the patients in our study underwent Akin osteotomy. Although this procedure complicates the understanding of the isolated effect of the scarf osteotomy, we do not believe it introduced much bias, because it does not affect the first metatarsal displacement. To create a homogeneous and representative sample, we used the same surgical technique for all patients. We appreciate, however, that over time, the influence of the soft tissues inserting into the hallux will be affected by the position of the hallux established by the Akin osteotomy. One of our patients was a 50-year-old autonomous male worker with bilateral hallux valgus. His left foot had a first IMA of 16.2 and a metatarsophalangeal angle 35.8 . We successfully performed a scarf-Akin procedure on the left foot and considered performing it on the right, although the right foot had a first IMA of 7.14 (mild) and a metatarsophalangeal angle of 36.0 (severe). Some investigators have postulated that the return to work after a scarfAkin procedure is earlier than that after other procedures we
Fig. 3. The left foot of a 59-year-old female with hallux valgus. (A) Preoperatively, the Yildirim grade was 3, with an intermetatarsal angle of 14.1. (B) Postoperatively, the Yildirim grade was 0, with an intermetatarsal angle of 5.3 .
might had performed. However, the scarf osteotomy procedure is inherently stable and allows earlier ambulation and return to work (19,55–58). One limitation of the present study was the short period between the surgery and the postoperative CT scan (3 months). Nevertheless, we evaluated the radiologic outcome of the procedure and not its evolution over time. The CT scan is the reference standard for assessing the relationship between the sesamoid complex and the first metatarsal head. Because the position of the sesamoid complex is fixed (9,17,18), we have concluded that the sesamoids must not be the focus of the surgery; rather, the displacement of the first metatarsal must be addressed. Correcting the relationship between the first metatarsal head and the sesamoid complex will result from correcting the first metatarsal displacement. In conclusion, the scarf-Akin osteotomy is enough to provide a corrective translation of the first metatarsal on the sesamoid complex, even in severe cases of hallux valgus, restoring the normal angles and sesamoid to first metatarsal relationship. Thus, lateral soft tissue release would not be necessary.
References 1. Coughlin MJ. Hallux valgus. J Bone Joint Surg Am 78:932–966, 1991. 2. Helal B. The great toe sesamoid bones: the lus or lost souls of Ushaia. Clin Orthop Relat Res 157:82–87, 1981. 3. Hutton WC, Dhanendran M. The mechanics of normal and hallux valgus feetda quantitative study. Clin Orthop Relat Res 157:7–13, 1981. 4. McBride ED. A conservative operation for bunions. J Bone Joint Surg Am 10:735– 739, 1928. 5. Silver D. The operative treatment of hallux valgus. J Bone Joint Surg 5:225–232, 1923. 6. Perice VA. Patologıa del Antepi e, Toray, Barcelona, Spain, 1975, p. 14. 7. Wilson JD, Baines J, Siddique MS, Fleck R. The effect of sesamoid position on outcome following scarf osteotomy for hallux abducto valgus. Foot Ankle Surg 15:65–68, 2009. 8. Gould JS. Problems of the pediatric foot. In: Operative Foot Surgery, pp. 579–597, edited by JS Gould, WB Saunders, Philadelphia, 1994. 9. Judge MS, LaPointe S, Yu GV, Shook JE, Taylor RP. The effect of hallux abducto valgus surgery on the sesamoid apparatus position. J Am Podiatr Med Assoc 89:551–559, 1999. 10. Kilmartin TE. Revision of failed foot surgery: a critical analysis. J Foot Ankle Surg 41:309–315, 2002. 11. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am 91:1637–1645, 2009. 12. Ruch JA, Merrill TJ, Banks AS. First ray hallux abducto valgus and related deformities. edited by ED McGlamry, Lippincott Williams & Wilkins, Philadelphia, 1987. 13. Wooster M, Davies B, Catanzariti A. Effect of sesamoid position on long-term results of hallux abducto valgus surgery. J Foot Surg 29:543–550, 1990. 14. Jahss MH. Sesamoid of the hallux. Clin Orthop Relat Res 2:1–4, 1981. 15. Kempe SA, Singer RH. The modified McBride bunionectomy utilizing the adductor tendon transfer. J Foot Surg 24:24–29, 1985. 16. Root ML, Orien W, Weed J. Normal and Abnormal Function of the Foot, Clinical Biomechanics Corp, Los Angeles, 1977. 17. Ramdass R, Meyr AJ. The multiplanar effect of first metatarsal osteotomy on sesamoid position. J Foot Ankle Surg 49:63–67, 2010. 18. Saragas NP, Becker PJ. Comparative radiographic analysis of parameters in feet with and without hallux valgus. Foot Ankle Int 16:139–143, 1995. 19. Zygmunt K, Gudas CJ, Laros GS. Z-bunionectomy with internal fixation. J Am Podiatr Med Assoc 79:322–329, 1989. 20. Akin OF. The treatment of hallux valgus: a new operative procedure and its results. Med Sentinel 33:678–679, 1925. 21. Karasick D, Wapner KL. Hallux valgus deformity: preoperative radiologic assessment. AJR Am J Roentgenol 155:119–123, 1990. 22. Kuwano T, Nagamine R, Sakaki K, Urabe K, Iwamoto Y. New radiographic analysis of sesamoid rotation in hallux valgus: comparison with conventional evaluation methods. Foot Ankle Int 23:811–817, 2002. 23. Yildirim Y, Cabukoglu C, Erol B, Esemenli T. Effect of metatarsophalangeal joint position on the reliability of the tangential sesamoid view in determining sesamoid position. Foot Ankle Int 26:247–250, 2005. 24. Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report of research committee of American Orthopaedic Foot and Ankle Society. Foot Ankle 5:92–103, 1984.
J.M. Lamo-Espinosa et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
25. Boberg JS, Judge MS. Follow-up of the isolated medial approach to hallux abducto valgus correction without interspace release. J Am Podiatr Med Assoc 92:555–562, 2002. 26. Eustace S, O’Byrne J, Stack J, Stephens MM. Radiographic features that enable assessment of first metatarsal rotation: the role of pronation in hallux valgus. Skeletal Radiol 22:153–156, 1993. 27. Neary MT, Jones RO, Sunshein K, Van Manen W, Youngberg R. Avascular necrosis of the first metatarsal head following Austin osteotomy: a follow-up study. J Foot Ankle Surg 32:530–535, 1993. 28. Potter HG, Pavlov H, Abrahams TG. The hallux sesamoids revisited. Skeletal Radiol 21:437–444, 1992. 29. Talbot KD, Saltzman CL. Assessing sesamoid subluxation: how good is the AP radiograph? Foot Ankle Int 19:547–554, 1998. 30. Johnson KA, Spiegl PV. Extensor hallucis longus transfer for hallux varus deformity. J Bone Joint Surg Am 66:681–686, 1984. 31. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy: a long-term follow-up. J Bone Joint Surg Am 74:124–129, 1992. € ne O. Lapidus arthrodesis for management of hallux valgusda retro32. Rink-Bru spective review of 106 cases. J Foot Ankle Surg 43:290–295, 2004. 33. Cralley JC, McGonagle W, Fitch K. The role of adductor hallucis in bunion deformity (part II). J Am Podiatry Assoc 68:473–483, 1978. 34. Goldfarb WL, Melillo TV, Levinson FN, Newman LM, Battey M. The tear-drop capsulectomy and capsulorrhaphy: a new approach in aiding the soft tissue repair of hallux abducto valgus. J Foot Surg 19:199–201, 1980. 35. Levin H. Capsule reconstruction. J Foot Surg 15:149–155, 1976. 36. Gerbert J, Sokoloff T. Textbook of Bunion Surgery, Futura Publishing, Mount Kisco, NY, 1981. 37. Pressman MM, Stano GW, Krantz MK, Novicki D. Correction of hallux valgus with positional increased intermetatarsal angle. J Am Podiatr Med Assoc 76:611–616,1986. 38. Tomasello F. Fibular apparatus release for reduction of hallux valgus. J Foot Surg 14:125, 1975. 39. Choi YR, Lee HS, Jeong JJ, Kim SW, Jeon IH, Lee DH, Lee WC. Hallux valgus correction using transarticular lateral release with distal chevron osteotomy. Foot Ankle Int 33:838–843, 2012. 40. Agrawal Y, Desai A, Mehta J. Lateral sesamoid position in hallux valgus: correlation with the conventional radiological assessment. Foot Ankle Surg 17:308–311, 2011. 41. Lipsman S, Frankel JP. Criteria for fibular sesamoidectomy in hallux abducto valgus correction. J Foot Surg 16:43–48, 1977. 42. David RD, Delagoutte JP, Renard MM. Anatomical study of the sesamoid bones of the first metatarsal. J Am Podiatr Med Assoc 79:536–544, 1989.
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43. Lee HJ, Chung JW, Chu IT, Kim YC. Comparison of distal chevron osteotomy with and without lateral soft tissue release for the treatment of hallux valgus. Foot Ankle Int 31:291–295, 2010. 44. Granberry WM, Hickey CH. Hallux valgus correction with metatarsal osteotomy: effect of a lateral distal soft tissue procedure. Foot Ankle Int 16:132–138, 1995. 45. Lui TH, Ng S, Chan KB. Endoscopic distal soft tissue procedure in hallux valgus surgery. Arthroscopy 21:1403.e1–1403.e7, 2005. 46. Meier PJ, Kenzora JE. The risks and benefits of distal first metatarsal osteotomies. Foot Ankle 6:7–17, 1985. 47. Trnka HJ, Zemsch A. Modified Austin procedure for correction of hallux valgus. Foot Ankle Int 18:119–127, 1997. 48. Wilkinson SV, Jones RO, Sisk LE, Sunshein KF, Van Manen JW. Austin bunionectomy: postoperative MRI evaluation for avascular necrosis. J Foot Surg 31:469– 477, 1992. 49. Easley ME, Kelly IP. Avascular necrosis of the hallux metatarsal head. Foot Ankle Clin 5:591–608, 2000. 50. Green MA, Dorris MF, Baessler TP, Mandel LM, Nachlas MJ. Avascular necrosis following distal Chevron osteotomy of the first metatarsal. J Foot Ankle Surg 32:617–622, 1993. 51. Kuhn MA, Lippert FG III, Phipps MJ, Williams C. Blood flow to the metatarsal head after chevron bunionectomy. Foot Ankle Int 26:526–529, 2005. € m A, Gustafson T. Circulatory disturbance of the first metatarsal 52. Resch S, Stenstro head after Chevron osteotomy as shown by bone scintigraphy. Foot Ankle 13:137– 142, 1992. 53. Peterson DA, Zilberfarb JL, Greene MA, Colgrove RC. Avascular necrosis of the first metatarsal head: incidence in distal osteotomy combined with lateral soft tissue release. Foot Ankle Int 15:59–63, 1994. 54. Oloff LM, Bocko AP. Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities. J Foot Ankle Surg 37:481–489, 1998. 55. Surehs SS. Scarf osteotomydis it the procedure of choice in hallux valgus surgery? A preliminary report. Oman Med J 22:47–50, 2007. 56. Jones S, Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus: a prospective clinical and pedobarographic study. J Bone Joint Surg Br 86:830–836, 2004. 57. Newman AS, Negrine JP, Zecovic M, Stanford P, Walsh WR. A biomechanical comparison of the Z step-cut and basilar cresenteric osteotomies of the first metatarsal. Foot Ankle Int 21:584–587, 2000. 58. Trnka HJ, Parks B, Ivanic G, Chu IT, Easley ME, Schon LC, Myerson MS. Six first metatarsal shaft osteotomies: mechanical and immobilisation comparisons. Clin Orthop 13:256–265, 2000.
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Original Research
The Relationship Between the Sesamoid Complex and the First Metatarsal After Hallux Valgus Surgery Without Lateral Soft-Tissue Release: A Prospective Study Marıa Lamo-Espinosa, MD 1, Borja Flo rez, MD 2, Carlos Villas, MD, PhD 1, Jose 1 M. Bondıa, MD 3, Jesu s Da maso Aquerreta, MD, PhD 4, Juan Pons-Villanueva, MD, PhD , Jose 1 Matias Alfonso, MD, PhD Professor, Department of Orthopedic Surgery and Traumatology, Clınica Universidad de Navarra, Pamplona, Spain n Hospital de Calahorra, Logron ~ o, Spain Professor, Department of Orthopedic Surgery and Traumatology, Fundacio 3 Professor, Department of Radiology, Clınica Universidad de Navarra, Pamplona, Spain 4 Assistant Professor, Department of Radiology, Clınica Universidad de Navarra, Pamplona, Spain 1 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Some investigators have emphasized restoring the relationship between the sesamoid complex and the first metatarsal head to reduce the risk of hallux valgus recurring after surgical reconstruction. In a prospective study, we analyzed whether the first metatarsophalangeal joint could be realigned after scarf-Akin bunionectomy without lateral soft tissue release. A total of 25 feet, in 22 patients, were prospectively enrolled and analyzed using anteroposterior radiographs and coronal computed tomography scans obtained before and 3 months after surgery. The Yildirim sesamoid position decreased from a preoperative of 2 (range 1 to 3) to a postoperative position of 0 (range 0 to 1; p < .001), the mean first intermetatarsal angle decreased from 12.6 2.4 to 5.8 2.1 (p < .001), and the mean distance between the second metatarsal and the tibial sesamoid changed from 25.7 4.6 to 25.9 4.6 (p ¼ .59). Our findings suggest that dislocation of the sesamoid complex is actually caused by displacement of the first metatarsal. In conclusion, the scarf-Akin bunionectomy adequately restores the alignment of the first metatarsophalangeal joint, including restoration of the sesamoid apparatus, without direct plantar–lateral soft tissue release. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: adductor hallucis bunion first metatarsal great toe proximal phalanx tibial sesamoid
Some investigators have emphasized the need to restore the anatomic relationship between the sesamoid complex and the first metatarsal head when surgically correcting the hallux valgus (1–7) to reduce the risk of recurrent deformity (1,8–13). The line of force of the flexor hallucis longus runs between the tibial and fibular sesamoids. In hallux valgus, the sesamoids take an intermediate position between the first and second metatarsal heads, producing a predominantly lateral force on the first metatarsophalangeal joint (MTPJ) that increases abduction of the great toe, increasing the first metatarsophalangeal (abduction) angle (8,13–16). However, the position of the sesamoids relative to the second metatarsal is fixed (9,17,18), indicating that the first metatarsal, not the sesamoid complex, is displaced medially relative to the sesamoids. Thus, we have questioned Financial Disclosure: None reported. Conflict of Interest: None reported. Marıa Lamo-Espinosa, MD, Department of Address correspondence to: Jose Orthopedic Surgery and Traumatology, Clınica Universidad de Navarra, Av. Pio XII, 36, Pamplona 31008, Spain. E-mail address: [email protected] (J.M. Lamo-Espinosa).
the need for lateral soft tissue release, specifically sectioning (and, perhaps, transfer) of the conjoined tendon of adductor hallucis, sectioning of the fibular sesamoidal ligament, and transection of the deep transverse intermetatarsal ligament, in isolation or combed, to restore balance to the first MTPJ–sesamoid complex. To test this hypothesis, we prospectively measured the relationship between the sesamoid complex and the first metatarsal head before and after hallux valgus surgery using scarf-Akin bunionectomy, without any form of plantar–lateral first MTPJ soft tissue release, in a series of patients treated for symptomatic bunion deformity. Patients and Methods Patients aged 18 years were eligible for the study if they had hallux valgus and had undergone scarf-Akin bunionectomy without any adjunct surgical intervention from April 2005 to November 2006. All the patients provided written informed consent for participation in clinical research before enrollment in the study. All the patients were from the practices of 2 of us (M.A., C.V.), who performed all the operations. The surgeons used the same surgical intervention (ie, the scarf first metatarsal osteotomy as described by Zygmunt et al [19] and the Akin osteotomy of the proximal phalanx [20]). After the surgery, each patient underwent the same postoperative protocol, including
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.07.022
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immediate weightbearing using an orthopedic shoe (Super Shoe II; Soroufe Health Care ProductsÒ, Ligonier, IN), combined with surgical bandages for approximately the first 40 days, followed by use of a great toe alignment splint (DARCO TASÔ, Toe Alignment Splint; DARCO International, Huntington, WV) for the first 6 postoperative weeks. All the patients followed the same postoperative protocol with 4 weeks of partial weightbearing. Standard anteroposterior (AP) weightbearing radiographs and coronal computed tomography (CT) scans were obtained before surgery and again approximately 3 months after surgery. We measured 2 standard angles commonly associated with hallux valgus: the first intermetatarsal angle (IMA), the angle between the longitudinal axis of the first and second metatarsals (normal value <10 ) (21), and the hallux valgus angle or first metatarsophalangeal joint (MTPJ) angle, the angle formed between the longitudinal axis of the first metatarsal and the proximal phalanx of the hallux (21). The preoperative metatarsophalangeal angle was categorized as mild (16 to 25 ), moderate (26 to 35 ), or severe (>35 ) (21). CT scans were taken of the sesamoids in the axial plane (Spiral, Mombispi, Somaton Sensation; Siemens, Erlangen, Germany), using the following settings: 1 mm thickness, 1 mm pitch, 30 acquisition kernel, 1 mm reconstruction. On these images, we measured the distance between the second metatarsal to the tibial sesamoid (ie, the distance from the medial side of the tibial sesamoid to the bisector of the second metatarsal) (17) (Fig. 1) and the rotation angle of the sesamoids, defined as the angle between the line that connects the 2 plantar margins of the sesamoids and the horizontal plane (22) (Fig. 1). The position of the sesamoids was designated according to Yildirim et al (23) as viewed on the CT scans in positions € ller according to those described by Smith et al (24) in the tangential Walter-Mu radiographic view (Fig. 2). Yildirim et al (23) defined 4 grades of sesamoid position: grade 0, the medial sesamoid is entirely medial to the intersesamoid ridge; grade 1, less than one half of the width of the medial sesamoid is subluxated laterally; grade 2, more than one half of the width of the medial sesamoid is subluxated laterally; and grade 3, the medial sesamoid is entirely lateral to the intersesamoid ridge. Grades 0 and 1 are considered normal (24), and we excluded patients with a preoperative Yildirim position of grade 0. Statistical Analysis The pre- and postoperative values were compared using Student’s t tests for paired samples of normally distributed data and the Wilcoxon signed ranks test otherwise. The a value was set at 0.05, and all tests were 2-tailed. Data were analyzed using STATA, version 12.0, for Windows (StataCorp, College Station, TX). The analyses were performed by 1 of us (J.P.V.).
Results We enrolled 26 feet in 22 patients during the 19-month enrollment period. The preoperative relationship between the first metatarsal head and the sesamoid complex was Yildirim grade 0 in 1 foot (1 female with 2 involved feet), and that foot was excluded from the present analysis. The mean age of these patients at surgery was 55.1 9.01 (range 32 to 77) years. Nineteen patients (86.3%) were female (22 feet) and 2 were male (3 feet [13.7%]). Of the 25 feet, 11 (44%) were right and 14 (56%) were left feet. The sesamoid positions of
Fig. 1. Measurements of the sesamoid axial plane. (A) The distance between the second metatarsal to the tibial sesamoid, defined as the distance in millimeters from the medial side of the tibial sesamoid to the bisector of the second metatarsal. (B) The rotation angle of the sesamoid complex, defined as the angle between the line that connects the 2 planter margins of the sesamoids and the horizontal plane (24).
the 25 feet were Yildirim grade 1 in 9 feet (36%), grade 2 in 12 (48%), and grade 3 in 4 (16%). All 25 feet were realigned to either grade 0 (19 feet [76%]) or grade 1 (6 feet [24%]) after surgery (Table 1). The values for the preoperative to postoperative first IMA, first MTPJ angle, sesamoid rotation angle, Yildirim sesamoid position, and second metatarsal to tibial sesamoid distance are listed in Table 2. The mean first IMA decreased from 12.6 2.4 (range 7.1 to 19.7 ) preoperatively to 5.8 2.1 (range 2.1 to 10.3 ) postoperatively (p < .001). The mean first metatarsophalangeal angle (hallux valgus angle) decreased from 35.8 9.8 (range 22.3 to 59.4 ) preoperatively to 13.3 6 (range 1.3 to 27.2 ) postoperatively (p < .012). The position of the sesamoids in the axial plane varied significantly, as defined by the mean sesamoid rotation angle, which decreased from 25 10 (range 12.4 to 45.3 ) preoperatively to 14.4 8.6 (range 0.2 to 32.3 ) postoperatively (p < .001). The median Yildirim sesamoid position changed from a preoperative value of 2 (range 1 to 3) to a postoperative median of 0 (range 0 to 1; p < .001). The second metatarsal–tibial sesamoid distance was 25.7 4.6 (range 13.3 to 31) mm preoperatively and 25.9 4.6 (range 12.9 to 33) mm postoperatively (p ¼ .59). Thus, the sesamoids in the axial plane maintained a constant distance relative to the position of the second metatarsal. The postoperative metatarsophalangeal angle significantly decreased in each preoperative severity category. Also, in all cases, even severe cases (a preoperative first metatarsophalangeal angle >35 ) returned to normal alignment postoperatively (Table 2). The 4 cases in which the sesamoids were in Yildirim grade 3 before surgery displayed a final postoperative grade of 0 or 1, and all the measured angles had significantly decreased with a statistically significant difference (Table 3). Discussion The position of the sesamoid complex relative to the first metatarsal has been studied by several investigators (9,13,14,23,25–29). In 1923, Silver (5) emphasized the importance of restoring the relationship between the first metatarsal and the sesamoid complex when correcting hallux valgus surgically. Later, McBride (4) called attention to the lateral intrinsic muscles of the first metatarsal as a major mechanical factor in developing hallux valgus. In 1928, he described the first soft tissue procedure for correcting hallux valgus (4). However, the poor results from the technique he described led many investigators to prefer osteotomy and to consider the release and soft tissue procedure as a part of the surgery (1,30–32). Several surgical techniques and soft tissue procedures have since been described to reposition the sesamoid complex (12,13,15,33–35), including fibular sesamoidectomy (36), extracapsular release, intracapsular release, tendon transposition (13,37,38), and the lateral transarticular release recently described by Choi et al (39). Currently, some surgeons have questioned just how best to determine the position of the sesamoid complex, and some have studied the relationship between the first metatarsal head and the sesamoid complex (21,23,29,40). Talbot and Saltzman (29) reported a discrepancy in the measurements between anteroposterior and tangential simple radiographs in 50% of 60 cases. They recommended taking measurements from tangential radiographs using the Walter€ ller view. Some investigators have agreed with them (22,25); Mu € ller view requires dorsiflexion of the MTPJ however, the Walter-Mu (1,25,29), which moves the sesamoid complex distally and dorsally. Yildirim et al (23) obtained CT scans with the ankle in different degrees of dorsiflexion and reported that MTPJ dorsiflexion moves the first MTPJ sesamoids distally and dorsally, reducing them under the first metatarsal head and thus providing an unreliable sesamoid–first metatarsal relationship. Therefore, we believe that the distance between the sesamoid complex and the head of the first metatarsal is
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Fig. 2. Diagram showing Yildirim grade of the sesamoid complex (SC) in relationship to the first metatarsal head (FMH).
best measured on a tangential CT scan made with the first MTPJ in the neutral position without dorsiflexion. Perhaps most interesting is the question of whether plantar– lateral first MTPJ soft tissue release is required for correction and longterm maintenance of first MTPJ alignment and balance as a result of bunionectomy surgery. Any surgical procedure has potential iatrogenic risks. Some investigators perform a sesamoidectomy because the subluxated position of the sesamoids can interfere with translation of the first metatarsal (36,41). Lipsman and Frankel (41) and Gerbert and Sokoloff (36) perform sesamoidectomy in cases with a position of 4 in the longitudinal axis. However, sesamoidectomy can disturb the gait and increases the incidence of hallux varus (14). David et al (42) reported that the sesamoid bones are important in stabilizing the hallux during walking. We have shown in the present study that in even severe cases (Yildirim grade 3), the first IMA can return to normal, with the relationship between the sesamoids and the first metatarsal head restored (Fig. 3). A lateral soft tissue release is often used in treating hallux valgus. Lee et al (43) and Granberry and Hickey (44) associated soft tissue release with greater postoperative stiffness of the MTPJ (25). They reported that soft tissue release should be contraindicated in cases of preoperative MTPJ limitation, despite the greater angular correction provided by the lateral soft tissue release. Lee et al (43) also reported a high rate of dorsal and plantar digital neuritis in patients undergoing soft tissue release, and this risk increased in cases performed percutaneously (45). Finally, as an open procedure, lateral soft tissue release requires a second incision, which is cosmetically undesirable. The risk of avascular necrosis of the first metatarsal head associated with soft tissue procedures is uncertain (14). Meier and Kenzora (46) found distal necrosis in 20% of cases (12 of 60 feet) treated with a Chevron osteotomy alone and in 40% of cases (4 of 10 feet) treated with a Chevron osteotomy and lateral soft tissue release. Trnka and Zemsch (47) found avascular necrosis in 3 of 94 cases treated with proximal osteotomy and lateral soft tissue release. These data were supported by findings from magnetic resonance imaging studies (27,48). In contrast, other investigators have found no association Table 1 Postoperative changes in Yildirim grade of the sesamoid complex after surgery for hallux valgus in 25 feet (22 patients) Preoperative Yildirim Grade*
0 1 2 3 Total (n)
Feet (n)
Total (n)
Postoperative Yildirim Grade 0
1
2
3
NAy 8 8 3 19
NA 1y 4 1 6
NA 0 0y 0 0
NA 0 0 0y 0
NA 9 12 4 25
Abbreviation: NA, not applicable. * Definitions of the Yildirim grades are shown in Fig. 2 and detailed in the text. y No change in grade; remaining data indicate improvement.
between necrosis and wide soft tissue release during hallux valgus surgery (11,49–53). Although Jahss (14), in 1981, stated that releasing the sesamoids is not necessary to reduce the first IMA, most later studies have recommend it for patients with severe hallux valgus or sesamoid complex luxation. However, these studies had several limitations. Most were retrospective, all used AP radiographs, and none included severe cases. Lee et al (43) do not perform lateral soft tissue release in cases of mild-to-moderate hallux valgus. However, they did not evaluate patients with severe hallux valgus. Oloff and Bocko (54) recommended wide release of the soft tissues in patients with a large first IMA; however, they used the chevron osteotomy. When using a distal osteotomy, correcting the angle will be difficult in severe cases. It could explain the recommendation of Oloff and Bocko (54). In contrast, Boberg and Judge (25), in a study similar to ours, did not recommend lateral soft tissue release for patients in whom the sesamoid complex had not luxated. In their series, the mean metatarsophalangeal angle was 23 , and all the angles were <38 . In our study, radiographs and CT scans indicated a mean
Table 2 Correction of first intermetatarsal angle, sesamoid rotation angle, and sesamoid position after surgery for hallux valgus in 25 feet (22 patients) stratified by preoperative metatarsophalangeal angle Variable
Preoperative first MTPJ angle ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) First MTP (hallux abductus) angle ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) Sesamoid rotation angle ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) Sesamoid position ( ) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25) Second metatarsal–tibial sesamoid distance (mm) Mild (15 to <25 ) (n ¼ 1) Moderate (25 to <35 ) (n ¼ 12) Severe (35 ) (n ¼ 12) Overall (n ¼ 25)
First Intermetatarsal Angle ( )
p Value
Preoperative
Postoperative
11.1 12.1 2.4 13.2 3.3 12.6 2.4
3.2 5.2 0.5 6.7 2.1 5.8 2.1
<.001* <.001* <.001*
22.3 29.8 2.3 43.0 9.7 35.8 9.8
12.8 10.5 6.2 15.9 4.9 13.3 6
<.001* <.001* <.001*
16.5 19.7 9.5 30.5 8 25.0 10
5.2 9.4 7.9 19.9 6.1 14.4 8.6
<.001* <.001* <.001*
1 1 2 2
0 0 0 0
(0 to 0) (0 to 1) (0 to 1) (0, 1)
<.001y .002y <.001y
27 26.6 0.7 25.1 0 25.9 4.6
.06* .12* .59*
(1 to 1) (1 to 2) (1 to 3) (1, 3)
27 24.5 0.7 25.6. 3.5 25.7 4.6
Abbreviations: MTP, metatarsophalangeal angle; MTPJ, metatarsophalangeal angle joint. * Student’s paired t test. y Wilcoxon signed ranks test.
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Table 3 Effect of hallux valgus surgery on position of sesamoid complex and intermetatarsal angle in patients with sesamoid complex of Yildirim grade 3 preoperatively Patient No.
Preoperative Yildirim Grade
First IMA ( )
Postoperative Yildirim Grade
First IMA ( )
1 2 3 4 Median (range) or mean SD
3 3 3 3 3 (3 to 3)
14.0 13.6 14.5 14.2 14.1 0.3
0 0 1 0 0 (0 to 1)
5.1 6.5 9.2 7.5 7.1 1.72
Abbreviations: IMA, intermetatarsal angle; SD, standard deviation. The difference in the decrease in the first IMA was statistically significant at the 0.05 level in all cases.
metatarsophalangeal angle of 35.3 . The key point for Ramdass and Meyr (17) was the axial rotation angle, which could obstruct the repositioning of the first metatarsal on the sesamoid complex. Ramdass and Meyr (17) performed a lateral soft tissue release in all their patients and noted a change in the axial rotation of the sesamoids (16.3 to 8.6 ). We also observed a reduction in the sesamoid rotation angle in the absence of any soft tissue release. We included all the patients with Yildirim grade 1, although many authorities have accepted a Yildirim grade of 0 or 1 as normal for the sesamoid complex (23,24). These values were reported in the study by Smith et al (24) and were based on the results from standing AP radiographs of only 8 feet, 4 in grade 0 and 4 in grade 1. Yildirim included these results in the definition of normal in his CT classification. The study by Smith et al (24) also evaluated the hallux valgus–sesamoid complex. In 20 patients (34 feet) with hallux valgus, 34% of patients had the sesamoids in grade 1. We consider this proportion to be high and thus believe Yildirim grade 1 is associated with hallux valgus. Additional studies are necessary to resolve this question. All the patients in our study underwent Akin osteotomy. Although this procedure complicates the understanding of the isolated effect of the scarf osteotomy, we do not believe it introduced much bias, because it does not affect the first metatarsal displacement. To create a homogeneous and representative sample, we used the same surgical technique for all patients. We appreciate, however, that over time, the influence of the soft tissues inserting into the hallux will be affected by the position of the hallux established by the Akin osteotomy. One of our patients was a 50-year-old autonomous male worker with bilateral hallux valgus. His left foot had a first IMA of 16.2 and a metatarsophalangeal angle 35.8 . We successfully performed a scarf-Akin procedure on the left foot and considered performing it on the right, although the right foot had a first IMA of 7.14 (mild) and a metatarsophalangeal angle of 36.0 (severe). Some investigators have postulated that the return to work after a scarfAkin procedure is earlier than that after other procedures we
Fig. 3. The left foot of a 59-year-old female with hallux valgus. (A) Preoperatively, the Yildirim grade was 3, with an intermetatarsal angle of 14.1. (B) Postoperatively, the Yildirim grade was 0, with an intermetatarsal angle of 5.3 .
might had performed. However, the scarf osteotomy procedure is inherently stable and allows earlier ambulation and return to work (19,55–58). One limitation of the present study was the short period between the surgery and the postoperative CT scan (3 months). Nevertheless, we evaluated the radiologic outcome of the procedure and not its evolution over time. The CT scan is the reference standard for assessing the relationship between the sesamoid complex and the first metatarsal head. Because the position of the sesamoid complex is fixed (9,17,18), we have concluded that the sesamoids must not be the focus of the surgery; rather, the displacement of the first metatarsal must be addressed. Correcting the relationship between the first metatarsal head and the sesamoid complex will result from correcting the first metatarsal displacement. In conclusion, the scarf-Akin osteotomy is enough to provide a corrective translation of the first metatarsal on the sesamoid complex, even in severe cases of hallux valgus, restoring the normal angles and sesamoid to first metatarsal relationship. Thus, lateral soft tissue release would not be necessary.
References 1. Coughlin MJ. Hallux valgus. J Bone Joint Surg Am 78:932–966, 1991. 2. Helal B. The great toe sesamoid bones: the lus or lost souls of Ushaia. Clin Orthop Relat Res 157:82–87, 1981. 3. Hutton WC, Dhanendran M. The mechanics of normal and hallux valgus feetda quantitative study. Clin Orthop Relat Res 157:7–13, 1981. 4. McBride ED. A conservative operation for bunions. J Bone Joint Surg Am 10:735– 739, 1928. 5. Silver D. The operative treatment of hallux valgus. J Bone Joint Surg 5:225–232, 1923. 6. Perice VA. Patologıa del Antepi e, Toray, Barcelona, Spain, 1975, p. 14. 7. Wilson JD, Baines J, Siddique MS, Fleck R. The effect of sesamoid position on outcome following scarf osteotomy for hallux abducto valgus. Foot Ankle Surg 15:65–68, 2009. 8. Gould JS. Problems of the pediatric foot. In: Operative Foot Surgery, pp. 579–597, edited by JS Gould, WB Saunders, Philadelphia, 1994. 9. Judge MS, LaPointe S, Yu GV, Shook JE, Taylor RP. The effect of hallux abducto valgus surgery on the sesamoid apparatus position. J Am Podiatr Med Assoc 89:551–559, 1999. 10. Kilmartin TE. Revision of failed foot surgery: a critical analysis. J Foot Ankle Surg 41:309–315, 2002. 11. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am 91:1637–1645, 2009. 12. Ruch JA, Merrill TJ, Banks AS. First ray hallux abducto valgus and related deformities. edited by ED McGlamry, Lippincott Williams & Wilkins, Philadelphia, 1987. 13. Wooster M, Davies B, Catanzariti A. Effect of sesamoid position on long-term results of hallux abducto valgus surgery. J Foot Surg 29:543–550, 1990. 14. Jahss MH. Sesamoid of the hallux. Clin Orthop Relat Res 2:1–4, 1981. 15. Kempe SA, Singer RH. The modified McBride bunionectomy utilizing the adductor tendon transfer. J Foot Surg 24:24–29, 1985. 16. Root ML, Orien W, Weed J. Normal and Abnormal Function of the Foot, Clinical Biomechanics Corp, Los Angeles, 1977. 17. Ramdass R, Meyr AJ. The multiplanar effect of first metatarsal osteotomy on sesamoid position. J Foot Ankle Surg 49:63–67, 2010. 18. Saragas NP, Becker PJ. Comparative radiographic analysis of parameters in feet with and without hallux valgus. Foot Ankle Int 16:139–143, 1995. 19. Zygmunt K, Gudas CJ, Laros GS. Z-bunionectomy with internal fixation. J Am Podiatr Med Assoc 79:322–329, 1989. 20. Akin OF. The treatment of hallux valgus: a new operative procedure and its results. Med Sentinel 33:678–679, 1925. 21. Karasick D, Wapner KL. Hallux valgus deformity: preoperative radiologic assessment. AJR Am J Roentgenol 155:119–123, 1990. 22. Kuwano T, Nagamine R, Sakaki K, Urabe K, Iwamoto Y. New radiographic analysis of sesamoid rotation in hallux valgus: comparison with conventional evaluation methods. Foot Ankle Int 23:811–817, 2002. 23. Yildirim Y, Cabukoglu C, Erol B, Esemenli T. Effect of metatarsophalangeal joint position on the reliability of the tangential sesamoid view in determining sesamoid position. Foot Ankle Int 26:247–250, 2005. 24. Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report of research committee of American Orthopaedic Foot and Ankle Society. Foot Ankle 5:92–103, 1984.
J.M. Lamo-Espinosa et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
25. Boberg JS, Judge MS. Follow-up of the isolated medial approach to hallux abducto valgus correction without interspace release. J Am Podiatr Med Assoc 92:555–562, 2002. 26. Eustace S, O’Byrne J, Stack J, Stephens MM. Radiographic features that enable assessment of first metatarsal rotation: the role of pronation in hallux valgus. Skeletal Radiol 22:153–156, 1993. 27. Neary MT, Jones RO, Sunshein K, Van Manen W, Youngberg R. Avascular necrosis of the first metatarsal head following Austin osteotomy: a follow-up study. J Foot Ankle Surg 32:530–535, 1993. 28. Potter HG, Pavlov H, Abrahams TG. The hallux sesamoids revisited. Skeletal Radiol 21:437–444, 1992. 29. Talbot KD, Saltzman CL. Assessing sesamoid subluxation: how good is the AP radiograph? Foot Ankle Int 19:547–554, 1998. 30. Johnson KA, Spiegl PV. Extensor hallucis longus transfer for hallux varus deformity. J Bone Joint Surg Am 66:681–686, 1984. 31. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy: a long-term follow-up. J Bone Joint Surg Am 74:124–129, 1992. € ne O. Lapidus arthrodesis for management of hallux valgusda retro32. Rink-Bru spective review of 106 cases. J Foot Ankle Surg 43:290–295, 2004. 33. Cralley JC, McGonagle W, Fitch K. The role of adductor hallucis in bunion deformity (part II). J Am Podiatry Assoc 68:473–483, 1978. 34. Goldfarb WL, Melillo TV, Levinson FN, Newman LM, Battey M. The tear-drop capsulectomy and capsulorrhaphy: a new approach in aiding the soft tissue repair of hallux abducto valgus. J Foot Surg 19:199–201, 1980. 35. Levin H. Capsule reconstruction. J Foot Surg 15:149–155, 1976. 36. Gerbert J, Sokoloff T. Textbook of Bunion Surgery, Futura Publishing, Mount Kisco, NY, 1981. 37. Pressman MM, Stano GW, Krantz MK, Novicki D. Correction of hallux valgus with positional increased intermetatarsal angle. J Am Podiatr Med Assoc 76:611–616,1986. 38. Tomasello F. Fibular apparatus release for reduction of hallux valgus. J Foot Surg 14:125, 1975. 39. Choi YR, Lee HS, Jeong JJ, Kim SW, Jeon IH, Lee DH, Lee WC. Hallux valgus correction using transarticular lateral release with distal chevron osteotomy. Foot Ankle Int 33:838–843, 2012. 40. Agrawal Y, Desai A, Mehta J. Lateral sesamoid position in hallux valgus: correlation with the conventional radiological assessment. Foot Ankle Surg 17:308–311, 2011. 41. Lipsman S, Frankel JP. Criteria for fibular sesamoidectomy in hallux abducto valgus correction. J Foot Surg 16:43–48, 1977. 42. David RD, Delagoutte JP, Renard MM. Anatomical study of the sesamoid bones of the first metatarsal. J Am Podiatr Med Assoc 79:536–544, 1989.
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43. Lee HJ, Chung JW, Chu IT, Kim YC. Comparison of distal chevron osteotomy with and without lateral soft tissue release for the treatment of hallux valgus. Foot Ankle Int 31:291–295, 2010. 44. Granberry WM, Hickey CH. Hallux valgus correction with metatarsal osteotomy: effect of a lateral distal soft tissue procedure. Foot Ankle Int 16:132–138, 1995. 45. Lui TH, Ng S, Chan KB. Endoscopic distal soft tissue procedure in hallux valgus surgery. Arthroscopy 21:1403.e1–1403.e7, 2005. 46. Meier PJ, Kenzora JE. The risks and benefits of distal first metatarsal osteotomies. Foot Ankle 6:7–17, 1985. 47. Trnka HJ, Zemsch A. Modified Austin procedure for correction of hallux valgus. Foot Ankle Int 18:119–127, 1997. 48. Wilkinson SV, Jones RO, Sisk LE, Sunshein KF, Van Manen JW. Austin bunionectomy: postoperative MRI evaluation for avascular necrosis. J Foot Surg 31:469– 477, 1992. 49. Easley ME, Kelly IP. Avascular necrosis of the hallux metatarsal head. Foot Ankle Clin 5:591–608, 2000. 50. Green MA, Dorris MF, Baessler TP, Mandel LM, Nachlas MJ. Avascular necrosis following distal Chevron osteotomy of the first metatarsal. J Foot Ankle Surg 32:617–622, 1993. 51. Kuhn MA, Lippert FG III, Phipps MJ, Williams C. Blood flow to the metatarsal head after chevron bunionectomy. Foot Ankle Int 26:526–529, 2005. € m A, Gustafson T. Circulatory disturbance of the first metatarsal 52. Resch S, Stenstro head after Chevron osteotomy as shown by bone scintigraphy. Foot Ankle 13:137– 142, 1992. 53. Peterson DA, Zilberfarb JL, Greene MA, Colgrove RC. Avascular necrosis of the first metatarsal head: incidence in distal osteotomy combined with lateral soft tissue release. Foot Ankle Int 15:59–63, 1994. 54. Oloff LM, Bocko AP. Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities. J Foot Ankle Surg 37:481–489, 1998. 55. Surehs SS. Scarf osteotomydis it the procedure of choice in hallux valgus surgery? A preliminary report. Oman Med J 22:47–50, 2007. 56. Jones S, Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus: a prospective clinical and pedobarographic study. J Bone Joint Surg Br 86:830–836, 2004. 57. Newman AS, Negrine JP, Zecovic M, Stanford P, Walsh WR. A biomechanical comparison of the Z step-cut and basilar cresenteric osteotomies of the first metatarsal. Foot Ankle Int 21:584–587, 2000. 58. Trnka HJ, Parks B, Ivanic G, Chu IT, Easley ME, Schon LC, Myerson MS. Six first metatarsal shaft osteotomies: mechanical and immobilisation comparisons. Clin Orthop 13:256–265, 2000.