- Email: [email protected]
Triple osteotomy for the correction of severe hallux valgus deformity: Patient reported outcomes and radiological evaluation
Accepted Manuscript Title: Triple osteotomy for the correction of severe hallux valgus deformity: patient reported outcomes and radiological evaluation Authors: Sean Booth MRCSEd Abhijit Bhosale MD FRCS (Tr and Orth) Mustafa Abubakar MRCS Ravi Shenoy MS (Orth), DNB (Orth), MDres MRCSEd, FRCSEd Anand Pillai FRCS (Tr and Orth) PII: DOI: Reference:
S0958-2592(16)30064-5 http://dx.doi.org/doi:10.1016/j.foot.2016.09.009 YFOOT 1440
To appear in:
The Foot
Received date: Revised date: Accepted date:
25-3-2016 29-7-2016 19-9-2016
Please cite this article as: Booth Sean, Bhosale Abhijit, Abubakar Mustafa, Shenoy Ravi, Pillai Anand.Triple osteotomy for the correction of severe hallux valgus deformity: patient reported outcomes and radiological evaluation.The Foot http://dx.doi.org/10.1016/j.foot.2016.09.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Triple osteotomy for the correction of severe hallux valgus deformity: patient reported
outcomes and
radiological evaluation Mr Sean Booth, MRCSEd1 Mr Abhijit Bhosale MD, FRCS (Tr & Orth)1 Mr Abubakar Mustafa, MRCS1 Mr Ravi Shenoy, MS(orth), DNB(orth), MRCSEd, MDres, FRCSEd (Tr & Orth)2 Mr Anand Pillai, FRCS (Tr&Orth)1 1Department
of Orthopaedics, University Hospital South Manchester,
Southmoor Road, Manchester, UK, M23 9LT 2Royal
National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex,
HA7 4LP
Corresponding author: Sean Booth1 Email: [email protected]
1
Highlights
Triple osteotomy without lateral release is a contributing factor to early deformity recurrence
Patients need to be counseled on the risk of future metalwork removal and extended period of post operative swelling
Good radiological and patient reported outcomes are seen with double metatarsal and proximal phalanx osteotomies
Abstract Background Symptomatic Hallux valgus can be treated with metatarsal osteotomy combined with proximal phalangeal osteotomy, however this might not be sufficient to treat severe HV deformities.
Methods Fifteen feet in eleven female patients treated with double first metatarsal and proximal phalanx osteotomies without lateral release were prospectively studied and outcome measures including radiological angles and validated patient reported outcome scores collected.
Results Mean radiological follow up was 15 months and PROMs data 17 months. Mean hallux valgus and intermetatarsal angles were corrected from 45 to 24.7 degrees and 18.7 to 7.4 degrees respectively. There was an eight degree recurrence of hallux valgus angle. There was no wound problems, non-unions or evidence of avascular necrosis.
2
The
EQ-5D
descriptive
index
showed
a
non-statistically
significant
improvement. All three elements of the MOxFQ score showed a statistically significant improvement: Forefoot pain (59 to 26.8), Walking and Stability (49.9 – 29.6) and Social Interaction (56.4 to 33.1)
Conclusion Triple osteotomy, without a lateral soft tissue release, leads to good radiological and functional outcomes in those with severe hallux valgus deformity. Patients need to be warned of the recovery time and potential for future metalwork removal. The risk of early recurrence suggests that a lateral release should be included in order to maintain a long lasting correction.
Keywords Hallux valgus Lateral release Triple osteotomy Outcome study
What is already known Severe hallux valgus deformity is challenging to correct First metatarsal osteotomy combined with proximal phalangeal osteotomy and lateral release is a popular method for correction of these deformities Severe deformities may only be amenable to fusion MTPJ procedures
What this paper adds Triple osteotomy should include a lateral release in order to reduce the risk of early recurrence
3
Patients should be counseled about the longer time to recovery and potential for future metalwork removal with this more invasive procedure The procedure significantly improves the functional outcome of the operated foot
Introduction Hallux valgus (HV) is lateral deviation of the great toe towards the second with subluxation of the first metatarsophalangeal joint and medial deviation of the first metatarsal. An estimated 2% to 4% of the population are affected by HV with its prevalence increasing with age affecting between 12% and 65% of those over 65 years old [1,2]. More than 90% of patients are women, which may be attributable to tight footwear [3,4]. The pathogenesis of hallux valgus is complex. Patients with moderate to severe deformity report higher incidence (almost 70%) of family history and bilateral disease. This coupled with anatomical anomalies predisposed by tight footwear lead to the development of the classical foot deformity. Surgical correction has provided better functional outcome and hence quality of life improvement in these patients as compared to conservative management [5,6]. Radiological examinations of the foot, especially weight bearing views are vital in formulating a surgical plan. Normal radiological markers are Hallux Valgus Angle (HVA) of less then 15 degrees; Inter-metatarsal Angle (IMA) of less than 9 degrees; and Hallux Inter-phalangeus Angle (IPA) of less than 10 degrees. Distal Metatarsal Articular Angle (DMAA) of more than 6 degrees will classify the deformity as incongruent or congruent. Severe HV deformity will typically have HVA more than 40 degrees and IMA more than 18 degrees. Throughout the past century approximately 130 operative procedures have been described for the treatment of HV[7]. Traditionally, for operative correction of mild and moderate deformity the chevron osteotomy is the standard of care, whereas for moderate to severe deformity the scarf
4
osteotomy, opening wedge basal osteotomy or Lapidus procedures are generally used [8]. For moderate deformities, first metatarsal osteotomy combined with a proximal phalangeal osteotomy can provide a good correction. These procedures are commonly done in association with a lateral release in severe deformities, however this may not always result in adequate correction. We present a case series of patients with severe incongruent hallux valgus deformity who were treated with triple osteotomy without a lateral release.
Methods We prospectively included sequential patients with severe hallux valgus deformity with failed conservative management who opted for operative correction. The study period was from August 2012 to April 2014. The data collection included patient demographics, pre and post-operative radiological data and patient reported outcome measures. Patients with inflammatory arthritis and diabetes mellitus were excluded. Metatarsal width was not considered in our patient selection as the procedure included a proximally based osteotomy.
Operative procedure All surgeries were carried out in an ultra-clean theatre with laminar flow by a consultant foot and ankle surgeon. The procedure was performed with the patient supine, thigh tourniquet inflated to 300mmHg and with image intensifier guidance. Antibiotic prophylaxis consisted of a single dose of Flucloxicillin 2g or Teicioplanin if allergic and Gentamicin 5mg/kg at induction of anaesthesia. Postoperative analgesia was supplemented by use of a forefoot block utilizing 0.5% Bupivocaine to infiltrate around the branches of the superficial and deep peroneal and saphenous nerves. A single medial incision over the first ray including a distally based ‘V’ capsulotomy flap was used to expose the 1st metatarso-phalangeal joint (MTPJ). The bone from the excised medial eminence was preserved. After identifying the medial cuneiform and base of 1 st metatarsal, an osteotomy site
5
was marked 1cm distal to the 1st tarsometatarsal joint (TMTJ), ensuring no intraarticular placement of metalwork. A small core diameter saw was used to create an osteotomy whilst ensuring no breach of the lateral cortex of the first metatarsal. The osteotomy was opened on the intact lateral periosteal hinge to achieve the desired correction. This osteotomy was stabilized with a DARCO® titanium opening wedge plate (Wright Medical (Figure 1). Next, the head of the first metatarsal was exposed ensuring the plantar vascular supply was preserved. A distal first metatarsal Chevron osteotomy was then performed with the cuts extracapsular to preserve blood supply to the head fragment. The head fragment was then displaced 50-60% laterally until the medial edge of the medial sesamoid was flush or close to the medial edge of the first metatarsal head. The Chevron osteotomy was stabilized with a single Barouk® screw (Zimmer Biomet). Further excess medial cancellous bone was excised and preserved. At this stage all preserved bone was morcelised and inserted as a bone graft inside the open wedge basal osteotomy of the first metatarsal. Lastly, the middle of proximal phalanx was exposed subperiosteally and a medial wedge of bony excised to create an Akin osteotomy.
This was
stabilized with a single Varisation® staple (Zimmer Biomet). Medial capsular repair was undertaken using intraosseous sutures with 2 Vicryl, providing more soft tissue correction. The skin was closed with subcuticular 3-0 monocryl and supported with steristrips. No specific post operative bandaging or splinting was used and no patients were placed in plaster casts. Proprietary dressings included opsite wound dressing and gauze bandaging. Formal lateral release was not required in any patient as initially good bony correction was achieved consistently in each case. All operations were performed as a day case surgery and patients were allowed to immediately heel weight bear using a Darco OrthoWedge™ shoe for six weeks. Patients were advised strict leg elevation and encouraged to perform active range of movement exercises of the ankle and foot. Follow up was at two weeks for wound check and then six weeks with weight bearing AP and lateral radiographs of the operated foot. Our standard practice would be to discharge patients at this point from routine follow up with advice to 6
mobilise in wide, supportive fitting trainer type shoes. Typical postoperative radiographic appearances are shown in figures 2 & 3.
Outcome measures We used radiological angles measured on digital weight bearing AP images of the foot pre and post operatively (figure 4). Drawing two lines along the center axis of the first metatarsal and proximal phalanx measured the HVA. The IMA was calculated by the angle created by two lines drawn along the center axis of the first and second metatarsals. The IPA was derived from two lines drawn along the center axis of the proximal and distal phalanx of the hallux. Validated Patient Reported Outcome Measures (PROMs) were used in the form of the EuroQol (EQ-5D) which has been validated across six countries and eight patient groups with multinational trials to be validated across the globe [9,10]. The Manchester Oxford Foot Questionnaire (MOxFQ) score [11](Isis Innovation Ltd, Oxford, United Kingdom) is a PROM specifically for surgery of the foot and ankle. MOxFQ has been shown throughout the literature to be a valid and reliable outcome score when compared to AOFAS, which does not take into account the functional or therapeutic aspect of a patient’s life nor their cosmetic concerns [12].These were collected pre and post operatively by face to face review and via email.
Patients were given full information about the PROMs and consent was obtained to use this data for service evaluation and research purposes. Web based PROMS 2.0 was used to collect, calculate and assess PROMs data. The study was registered as a service evaluation with the audit department at University Hospital South Manchester. Statistical analysis was performed using Graphpad Prism ® using column statistics to summarize pre and postoperative data as means with 95% confidence intervals. Paired t-tests were used to compare differences between the pre and post operative scores with p<0.05 considered significant.
7
Results Fifteen feet from eleven patients with a median age of 60 (range 44.5-82.9) were included in the study. All patients were female with nine right and six left feet operated upon. All participants had incongruent hallux valgus deformity categorized as severe with laterally subl3uxed sesamoids. There was no wound problems or non-unions. Two patients were listed for removal of the distal staple in the proximal phalax at 20 and 24 months respectively for ongoing pain at that site. Post operative forefoot swelling was persistent, with the majority of patients recalling an ability to wear their desired footwear at 9-12 months post op.
Radiological outcome Mean radiological follow up was 15.3 months (range 1-29).
Angle
measurements from radiographs were available on 15 feet pre operatively and immediately following surgery. Final measurements were available on 14 feet. There was no evidence of first metatarsal head avascular necrosis in any patient. The mean pre operative HVA (figure 5) was 45 degrees (95% CI 41 – 49). This improved to 16.1 degrees (95% CI 11.7 – 20.4) immediately following surgery and 24.7 degrees (95% CI 19.7 – 29.6) at final follow up. The reduction in HVA compared to pre op values was significant immediately following surgery (p<0.001) and at final follow up (p<0.001). The mean pre operative IMA (figure 6) was 18.7 degrees (95% CI 16.5 – 20.9). This improved to 6 degrees (95% CI 4.4 – 7.5) immediately following surgery and was 7.4 degrees (95% CI 5 – 9.8) at final follow up. The reduction in IMA compared to pre op values was significant immediately following surgery (p<0.001) and at final follow up (p<0.001). The mean pre operative IPA was 6.8 degrees (95% CI 3.8 – 9.9). This changed to 8 degrees (95% CI 5.4 – 10.7) immediately post op and 6.9 degrees (95% CI 4.2 – 9.6) at final follow up. The change in IPA was not significantly different either immediately (p<0.53) or at final follow up (p<0.93).
8
Patient Reported Outcome Measures Mean PROMs follow up was 17.4 months (range 6-29). Data was available for 14 feet (10 patients) post operatively. The EQ-5D index score of global health status showed a non-significant increase from 0.63 (95% CI 0.47 – 0.79) pre op to 0.71 (95% CI 0.55 – 0.87) post operatively, p=0.18. The VAS showed an increase from 71.2 (95% CI 51.51 – 90.89) to 88.2 (95% CI 79.79 – 96.63), p=0.009 (figure 7). With regards to the three domains of the MOxFQ all showed a statistically significant improvement from pre to post op. Mean score for Pain decreased from 59 (95% CI 37.3 – 80.7) to 26.8 (95% CI 11.4 – 42.2) p=0.002. The mean score for Walking decreased from 49.9 (95% CI 28.6 – 71.2) to 29.6 (95% CI 14.3 – 45) p=0.002. The mean score for Social decreased from 56.4 (95% CI 35.1 to 77.7) to 33.1 (95% CI 13.4 to 52.9), p=0.004.
Discussion Severe hallux valgus deformity can be challenging to treat. In some cases double first metatarsal osteotomy with significant shift and added lateral release can achieve a good correction. All the patients in this group had severe deformities with HVA and IMA of 45 and 18.7 degrees respectively. The triple osteotomy described here corrected these angles initially without need for a lateral release, however at further follow up there was a mean loss of eight degrees (54%) of the HVA correction. A recent case series of 45 patients in whom triple osteotomy with lateral release was performed describes a good HVA correction to seven degrees post operatively with a mean follow up of 45 months [13]. Tight lateral structures have been labeled as a causative factor in the classical deformity and in the case of surgery; many would recommend releasing it routinely as part of hallux valgus correction. Our results show an early recurrence of hallux valgus deformity that is likely multifactorial. The post operative radiographs were performed weight bearing with no splintage used to prevent further lateral deviation of the hallux. The surgical correction of a severe deformity may lead to a large 1st to 2nd toe gap and necessitate surgery to the lesser toes. This likely increases the risk of recurrent deformity. The medial soft tissues tend to be of
9
poor quality due to stretching and after surgery this may allow for recurrence when patients’ feet are once again moulded by everyday footwear. Finally, the lack of lateral release would lead to a compounding effect of the aforementioned thus resulting in some recurrence of deformity. A failure to relocate the sesamoids could also be a contributing factor, however the addition of a lateral release has not been shown to improve sesamoid position [14].
The decision not to perform a formal web space approach lateral release was due to the authors’ concerns on excessive soft tissue stripping of the metatarsal head in the presence of a shaft osteotomy and the preference for avoiding a skin bridge in addition to the extensive medial side incision required. Transarticular lateral releases have been shown to provide equivalent outcomes to that of a formal web space approach thus help to address this concern [15]. Avoiding lateral release has the theoretical benefit of preserving the soft tissues lateral to the first metatarsal head and thus alleviating any concerns about damaging the metatarsal head blood supply. A variable incidence between 0-20% of avascular necrosis of the first metatarsal head has been reported with the classic Chevron osteotomy[1620]. Higher incidence of AVN has been reported with the addition of a lateral release to a distal chevron osteotomy, however with the modern chevron osteotomy this risk is negated. [17,18,20].
The Chevron osteotomy is intrinsically stable against dorsiflexion and does not cause any shortening of the first metatarsal. Excellent clinical results have been reported with little or no transfer metatarsalgia when the procedure has been used within limits of correction of the IMA of four to eight degrees and the HVA of 11 to 18 degrees [16]. This osteotomy has been recommended for the correction of mild to moderate deformity [16,17,19]. The operation is most often used in an incongruent deformity with a normal DMAA. All the patients in our group had incongruent hallux valgus with DMAA within normal limits. Basal osteotomy due to a longer lever arm has a potential of higher corrective power [4]. Hence, it is recommended for moderate to severe deformities [16]. 10
However, if used alone for a congruent deformity, it can actually worsen the problem. With added distal Chevron and Akin osteotomies this provides modularity to the technique and multilevel correction to achieve better overall rectification of the deformity. Coughlin and Carlsson [21] added a distal osteotomy to the proximal basal osteotomy to address the problem of incongruent deformity and reported an 81% success rate with good HVA and IMA corrections of 40 to 10 degrees and 16 to 8 degrees respectively. Chuckpaiwong [22] reported comparable results by using proximal and distal osteotomies, but better correction of the angles with proximal osteotomy. Hallux valgus angle improved from 40 to 11 degrees and IMA 18 to 8 degrees with the proximal osteotomy compared with HVA from 40 to 21 degrees and IMA 18 to 11 degrees with the distal. The distal osteotomy was found to be less invasive, with a low complication rate when compared to the more technically demanding proximal osteotomy. Kumar et al [23] used a similar technique to treat HV deformity with a HVA of 45 degrees and IMA of 17 degrees. They used a proximal basal osteotomy stabilized with a low profile plate and added an Akin osteotomy only if required. The HVA was corrected to 13 degrees and IMA to 9 degrees. Good to satisfactory results were reported in 80% (20 of 25) patients. The follow up radiographs also revealed that the correction held on a long term basis.
The technique demonstrated in this paper showed good radiological correction in the immediate postoperative period. Some recurrence of the HV deformity was noted at longer term radiological follow up, in this series the figure was 8 degrees, however the correction remained a statistically significant and clinical improvement compared to the preoperative deformity. This point should be emphasized to any patient considering surgical correction. Our results suggest that the procedure does not significantly improve one’s assessment of their own global health, but with specific reference to the troublesome foot there is significant gains to be made with regard to pain, ability to mobilize and social interaction. This highlights that in addition to being a pain relieving procedure primarily, additional benefits are achievable. 11
Two particular disadvantages of this procedure, which would require specific patient counseling, are persistent post operative foot swelling and the possibility of the requirement of metalwork removal. Patients reported returning to their preferred footwear from six months post surgery. This is longer than one would expect after standard bunion surgery (three to four months) and may be a reflection of the extended medial incision and soft tissue insult in this procedure or be biased by poor patient recall. Two patients subsequently had the phalangeal staple removed at 20 and 24 months due to localised discomfort and so patients should be warned of this possibility due to the prominence of subcutaneous implant. Limitations of our study include the relatively small sample size and incomplete long term follow up of all patients, however at least 12 months of follow up was achieved in 80% (12 of 15) of PROMs data and in 67% (10 of 15) of radiographs. Further work will include a comparative patient group with inclusion of lateral release, establishing a post operative splintage protocol and investigating the effect of lesser toe drift on deformity recurrence.
Conclusion Hallux valgus is a complex condition to correct and surgical procedures can lead to good functional outcomes in carefully selected patients. Mild to moderate deformity can be corrected by single or double osteotomy correction, but severe deformities require more invasive procedures like the triple osteotomy described in this paper.
Whilst not improving ones
assessment of their own global health, surgery significantly improves the functional outcome of the operated foot. Patients should be appropriately counseled on the expected recovery time and potential for future metalwork removal. Our experience suggests that a lateral release should be included in the procedure and likely helps prevent early recurrence of the deformity.
12
References [1] H.B Menz & S.R Lord, Gait instability in older people with hallux valgus, Foot Ankle Int. 26 (2005) 483-489 [2] M. Myerson, Foot and ankle disorders, hallux valgus. Philadelphia: WB Saunders, 1999, pp. 213-89 [3] M. Coughlin & C. Jones, Hallux valgus: demographics, etiology and radiographic assessment, Foot Ankle Int. 28 (2007) 759-777 [4] H.B Menz & M.E Morris, Footwear characteristics and foot problems in older people, Gerontology. 51 (2005) 346-251 [5] D.B Thordarson, E. Ebramzadeh, M. Moorthy et al, Correlation of hallux valgus surgical outcome with AOFAS forefoot score and radiological parameters, Foot Ankle Int. 26 (2005) 122-127 [6] M. Torkki, A. Malmivaara, S. Seitsalo et al, Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial, JAMA. 285 (2001) 2474-2480 [7] H. Kelikian, Hallux valgus, Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia, PA: WB Saunders, 1965, pp. 1-5 [8] M.J Coughlin & R.A Mann, Hallux valgus, in: M.J Coughlin, R.A Mann, C.L Saltzman (Eds.), Surgery of the Foot and Ankle, Mosby Elsevier, Philadelphia, 2007 pp. 183-362 [9] The EuroQol Group, EuroQol – a new facility for the measurement of health-related quality of life, Health Policy. 16 (1990) 199-208 [10] W. Greiner, T. Weijnen, M. Nieuwenhuizen et al, A single European currency for EQ-5D health states. Results from a six country study, Eur J Health Econ. 4 (2003) 222-231 [11] ISIS Innovations, The Manchester-Oxford Foot Questionnaire (MOxFQ). http://isis-innovation.com/outcome-measures/manchester-oxford-footquestionnaire-moxfq, 2014 (accessed 11.03.16) [12] J. Dawson, I. Boller, H. Doll et al, Responsiveness of the ManchesterOxford Foot Questionnaire (MOxFQ) compared with AOFAS, SF-36 and EQ5D assessments following foot or ankle surgery, J Bone Joint Surg BR. 94 (2012) 215-21
13
[13] S.S Al-Nammari, T. Christofi & C. Clark, Double First Metatarsal and Akin Osteotomy for Severe Hallux Valgus, Foot Ankle Int. 36 (2015) 1215-1222 [14] K. Woo, I.S Yu, K.S Sung et al, Effect of Lateral Soft Tissue Release on Sesamoid Position in Hallux Valgus Surgery, Foot Ankle Int. 36 (2015) 14631468 [15] Y.B Park, K.B Lee, S.K Kim et al, Comparison of distal soft-tissue procedures combined with a distal chevron osteotomy for moderate to severe hallux valgus: first web-space versus transarticular approach, J Bone Joint Surg Am. 95 (2013) e158 [16] A.H Robinson & J.P Limbers, Modern concepts in the treatment of hallux valgus, J Bone Joint Surg Br. 87 (2005) 1038-1045 [17] R.E Donnelly, C.L Saltzman, T.A Kile et al, Modified Chevron osteotomy for hallux valgus, Foot Ankle Int, 15 (1994) 642-645 [18] M.A Green, M.F Dorris, T.P Baessler et al, Avascular necrosis following distal chevron osteotomy, J Foot Ankle Surg. 32 (1993) 617-622 [19] C. Nery, R. Borroco R, C. Ressico, Biplanar Chevron osteotomy, Foot Ankle Int. 23 (2002) 792-798 [20] H.J Trnka, A. Zembsch, H. Weisauer et al, Modified Austin procedure for correction of hallux valgus, Foot Ankle Int. 18 (1997) 119-127 [21] M.J Coughlin & R.E Carlsson, Treatment of hallux valgus with increased distal metatarsal articular angle – evaluation of double and triple first ray osteotomies, Foot Ankle Int. 20 (1999) 762-770 [22] B. Chuckpaiwong, Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus, Int Orthop. 36 (2012) 2275-2278 [23] S. Kumar, S. Konan, M.J Oddy et al, Basal medial open wedge first metatarsal osteotomy stabilized by low profile wedge plate, Acta Orthop Belg. 78 (2012) 362-368
14
Figure 1. Operative technique of first metatarsal triple osteotomy. From top left to bottom right image: Exposure of first metatarsal; Basal osteotomy with plate fixation; Chevron osteotomy; Barouk screw placement; Medial V capsular flap; Akin osteotomy.
15
Figure 2. Post operative anteroposterior radiograph showing correction of hallux valgus deformity and placement of metalwork
16
Figure 3. Post operative lateral radiograph showing placement of metalwork
17
Figure 4. Anteroposterior radiograph indicating how the hallux valgus angle (dashed line) and intermetatarsal angle (solid line) were measured
18
Figure 5. Hallux valgus angles pre operative, immediately post operative and at final follow up. Graph shows values and mean +- 95% CI
19
Figure 6. Intermetatarsal angles pre operative, immediately post operative and at final follow up. Graph shows values and mean +- 95% CI
20
Figure 7. Visial analogue scale (VAS) of EQ-5D showing pre and post operative values and mean +- 95% CI
21
S0958-2592(16)30064-5 http://dx.doi.org/doi:10.1016/j.foot.2016.09.009 YFOOT 1440
To appear in:
The Foot
Received date: Revised date: Accepted date:
25-3-2016 29-7-2016 19-9-2016
Please cite this article as: Booth Sean, Bhosale Abhijit, Abubakar Mustafa, Shenoy Ravi, Pillai Anand.Triple osteotomy for the correction of severe hallux valgus deformity: patient reported outcomes and radiological evaluation.The Foot http://dx.doi.org/10.1016/j.foot.2016.09.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Triple osteotomy for the correction of severe hallux valgus deformity: patient reported
outcomes and
radiological evaluation Mr Sean Booth, MRCSEd1 Mr Abhijit Bhosale MD, FRCS (Tr & Orth)1 Mr Abubakar Mustafa, MRCS1 Mr Ravi Shenoy, MS(orth), DNB(orth), MRCSEd, MDres, FRCSEd (Tr & Orth)2 Mr Anand Pillai, FRCS (Tr&Orth)1 1Department
of Orthopaedics, University Hospital South Manchester,
Southmoor Road, Manchester, UK, M23 9LT 2Royal
National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex,
HA7 4LP
Corresponding author: Sean Booth1 Email: [email protected]
1
Highlights
Triple osteotomy without lateral release is a contributing factor to early deformity recurrence
Patients need to be counseled on the risk of future metalwork removal and extended period of post operative swelling
Good radiological and patient reported outcomes are seen with double metatarsal and proximal phalanx osteotomies
Abstract Background Symptomatic Hallux valgus can be treated with metatarsal osteotomy combined with proximal phalangeal osteotomy, however this might not be sufficient to treat severe HV deformities.
Methods Fifteen feet in eleven female patients treated with double first metatarsal and proximal phalanx osteotomies without lateral release were prospectively studied and outcome measures including radiological angles and validated patient reported outcome scores collected.
Results Mean radiological follow up was 15 months and PROMs data 17 months. Mean hallux valgus and intermetatarsal angles were corrected from 45 to 24.7 degrees and 18.7 to 7.4 degrees respectively. There was an eight degree recurrence of hallux valgus angle. There was no wound problems, non-unions or evidence of avascular necrosis.
2
The
EQ-5D
descriptive
index
showed
a
non-statistically
significant
improvement. All three elements of the MOxFQ score showed a statistically significant improvement: Forefoot pain (59 to 26.8), Walking and Stability (49.9 – 29.6) and Social Interaction (56.4 to 33.1)
Conclusion Triple osteotomy, without a lateral soft tissue release, leads to good radiological and functional outcomes in those with severe hallux valgus deformity. Patients need to be warned of the recovery time and potential for future metalwork removal. The risk of early recurrence suggests that a lateral release should be included in order to maintain a long lasting correction.
Keywords Hallux valgus Lateral release Triple osteotomy Outcome study
What is already known Severe hallux valgus deformity is challenging to correct First metatarsal osteotomy combined with proximal phalangeal osteotomy and lateral release is a popular method for correction of these deformities Severe deformities may only be amenable to fusion MTPJ procedures
What this paper adds Triple osteotomy should include a lateral release in order to reduce the risk of early recurrence
3
Patients should be counseled about the longer time to recovery and potential for future metalwork removal with this more invasive procedure The procedure significantly improves the functional outcome of the operated foot
Introduction Hallux valgus (HV) is lateral deviation of the great toe towards the second with subluxation of the first metatarsophalangeal joint and medial deviation of the first metatarsal. An estimated 2% to 4% of the population are affected by HV with its prevalence increasing with age affecting between 12% and 65% of those over 65 years old [1,2]. More than 90% of patients are women, which may be attributable to tight footwear [3,4]. The pathogenesis of hallux valgus is complex. Patients with moderate to severe deformity report higher incidence (almost 70%) of family history and bilateral disease. This coupled with anatomical anomalies predisposed by tight footwear lead to the development of the classical foot deformity. Surgical correction has provided better functional outcome and hence quality of life improvement in these patients as compared to conservative management [5,6]. Radiological examinations of the foot, especially weight bearing views are vital in formulating a surgical plan. Normal radiological markers are Hallux Valgus Angle (HVA) of less then 15 degrees; Inter-metatarsal Angle (IMA) of less than 9 degrees; and Hallux Inter-phalangeus Angle (IPA) of less than 10 degrees. Distal Metatarsal Articular Angle (DMAA) of more than 6 degrees will classify the deformity as incongruent or congruent. Severe HV deformity will typically have HVA more than 40 degrees and IMA more than 18 degrees. Throughout the past century approximately 130 operative procedures have been described for the treatment of HV[7]. Traditionally, for operative correction of mild and moderate deformity the chevron osteotomy is the standard of care, whereas for moderate to severe deformity the scarf
4
osteotomy, opening wedge basal osteotomy or Lapidus procedures are generally used [8]. For moderate deformities, first metatarsal osteotomy combined with a proximal phalangeal osteotomy can provide a good correction. These procedures are commonly done in association with a lateral release in severe deformities, however this may not always result in adequate correction. We present a case series of patients with severe incongruent hallux valgus deformity who were treated with triple osteotomy without a lateral release.
Methods We prospectively included sequential patients with severe hallux valgus deformity with failed conservative management who opted for operative correction. The study period was from August 2012 to April 2014. The data collection included patient demographics, pre and post-operative radiological data and patient reported outcome measures. Patients with inflammatory arthritis and diabetes mellitus were excluded. Metatarsal width was not considered in our patient selection as the procedure included a proximally based osteotomy.
Operative procedure All surgeries were carried out in an ultra-clean theatre with laminar flow by a consultant foot and ankle surgeon. The procedure was performed with the patient supine, thigh tourniquet inflated to 300mmHg and with image intensifier guidance. Antibiotic prophylaxis consisted of a single dose of Flucloxicillin 2g or Teicioplanin if allergic and Gentamicin 5mg/kg at induction of anaesthesia. Postoperative analgesia was supplemented by use of a forefoot block utilizing 0.5% Bupivocaine to infiltrate around the branches of the superficial and deep peroneal and saphenous nerves. A single medial incision over the first ray including a distally based ‘V’ capsulotomy flap was used to expose the 1st metatarso-phalangeal joint (MTPJ). The bone from the excised medial eminence was preserved. After identifying the medial cuneiform and base of 1 st metatarsal, an osteotomy site
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was marked 1cm distal to the 1st tarsometatarsal joint (TMTJ), ensuring no intraarticular placement of metalwork. A small core diameter saw was used to create an osteotomy whilst ensuring no breach of the lateral cortex of the first metatarsal. The osteotomy was opened on the intact lateral periosteal hinge to achieve the desired correction. This osteotomy was stabilized with a DARCO® titanium opening wedge plate (Wright Medical (Figure 1). Next, the head of the first metatarsal was exposed ensuring the plantar vascular supply was preserved. A distal first metatarsal Chevron osteotomy was then performed with the cuts extracapsular to preserve blood supply to the head fragment. The head fragment was then displaced 50-60% laterally until the medial edge of the medial sesamoid was flush or close to the medial edge of the first metatarsal head. The Chevron osteotomy was stabilized with a single Barouk® screw (Zimmer Biomet). Further excess medial cancellous bone was excised and preserved. At this stage all preserved bone was morcelised and inserted as a bone graft inside the open wedge basal osteotomy of the first metatarsal. Lastly, the middle of proximal phalanx was exposed subperiosteally and a medial wedge of bony excised to create an Akin osteotomy.
This was
stabilized with a single Varisation® staple (Zimmer Biomet). Medial capsular repair was undertaken using intraosseous sutures with 2 Vicryl, providing more soft tissue correction. The skin was closed with subcuticular 3-0 monocryl and supported with steristrips. No specific post operative bandaging or splinting was used and no patients were placed in plaster casts. Proprietary dressings included opsite wound dressing and gauze bandaging. Formal lateral release was not required in any patient as initially good bony correction was achieved consistently in each case. All operations were performed as a day case surgery and patients were allowed to immediately heel weight bear using a Darco OrthoWedge™ shoe for six weeks. Patients were advised strict leg elevation and encouraged to perform active range of movement exercises of the ankle and foot. Follow up was at two weeks for wound check and then six weeks with weight bearing AP and lateral radiographs of the operated foot. Our standard practice would be to discharge patients at this point from routine follow up with advice to 6
mobilise in wide, supportive fitting trainer type shoes. Typical postoperative radiographic appearances are shown in figures 2 & 3.
Outcome measures We used radiological angles measured on digital weight bearing AP images of the foot pre and post operatively (figure 4). Drawing two lines along the center axis of the first metatarsal and proximal phalanx measured the HVA. The IMA was calculated by the angle created by two lines drawn along the center axis of the first and second metatarsals. The IPA was derived from two lines drawn along the center axis of the proximal and distal phalanx of the hallux. Validated Patient Reported Outcome Measures (PROMs) were used in the form of the EuroQol (EQ-5D) which has been validated across six countries and eight patient groups with multinational trials to be validated across the globe [9,10]. The Manchester Oxford Foot Questionnaire (MOxFQ) score [11](Isis Innovation Ltd, Oxford, United Kingdom) is a PROM specifically for surgery of the foot and ankle. MOxFQ has been shown throughout the literature to be a valid and reliable outcome score when compared to AOFAS, which does not take into account the functional or therapeutic aspect of a patient’s life nor their cosmetic concerns [12].These were collected pre and post operatively by face to face review and via email.
Patients were given full information about the PROMs and consent was obtained to use this data for service evaluation and research purposes. Web based PROMS 2.0 was used to collect, calculate and assess PROMs data. The study was registered as a service evaluation with the audit department at University Hospital South Manchester. Statistical analysis was performed using Graphpad Prism ® using column statistics to summarize pre and postoperative data as means with 95% confidence intervals. Paired t-tests were used to compare differences between the pre and post operative scores with p<0.05 considered significant.
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Results Fifteen feet from eleven patients with a median age of 60 (range 44.5-82.9) were included in the study. All patients were female with nine right and six left feet operated upon. All participants had incongruent hallux valgus deformity categorized as severe with laterally subl3uxed sesamoids. There was no wound problems or non-unions. Two patients were listed for removal of the distal staple in the proximal phalax at 20 and 24 months respectively for ongoing pain at that site. Post operative forefoot swelling was persistent, with the majority of patients recalling an ability to wear their desired footwear at 9-12 months post op.
Radiological outcome Mean radiological follow up was 15.3 months (range 1-29).
Angle
measurements from radiographs were available on 15 feet pre operatively and immediately following surgery. Final measurements were available on 14 feet. There was no evidence of first metatarsal head avascular necrosis in any patient. The mean pre operative HVA (figure 5) was 45 degrees (95% CI 41 – 49). This improved to 16.1 degrees (95% CI 11.7 – 20.4) immediately following surgery and 24.7 degrees (95% CI 19.7 – 29.6) at final follow up. The reduction in HVA compared to pre op values was significant immediately following surgery (p<0.001) and at final follow up (p<0.001). The mean pre operative IMA (figure 6) was 18.7 degrees (95% CI 16.5 – 20.9). This improved to 6 degrees (95% CI 4.4 – 7.5) immediately following surgery and was 7.4 degrees (95% CI 5 – 9.8) at final follow up. The reduction in IMA compared to pre op values was significant immediately following surgery (p<0.001) and at final follow up (p<0.001). The mean pre operative IPA was 6.8 degrees (95% CI 3.8 – 9.9). This changed to 8 degrees (95% CI 5.4 – 10.7) immediately post op and 6.9 degrees (95% CI 4.2 – 9.6) at final follow up. The change in IPA was not significantly different either immediately (p<0.53) or at final follow up (p<0.93).
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Patient Reported Outcome Measures Mean PROMs follow up was 17.4 months (range 6-29). Data was available for 14 feet (10 patients) post operatively. The EQ-5D index score of global health status showed a non-significant increase from 0.63 (95% CI 0.47 – 0.79) pre op to 0.71 (95% CI 0.55 – 0.87) post operatively, p=0.18. The VAS showed an increase from 71.2 (95% CI 51.51 – 90.89) to 88.2 (95% CI 79.79 – 96.63), p=0.009 (figure 7). With regards to the three domains of the MOxFQ all showed a statistically significant improvement from pre to post op. Mean score for Pain decreased from 59 (95% CI 37.3 – 80.7) to 26.8 (95% CI 11.4 – 42.2) p=0.002. The mean score for Walking decreased from 49.9 (95% CI 28.6 – 71.2) to 29.6 (95% CI 14.3 – 45) p=0.002. The mean score for Social decreased from 56.4 (95% CI 35.1 to 77.7) to 33.1 (95% CI 13.4 to 52.9), p=0.004.
Discussion Severe hallux valgus deformity can be challenging to treat. In some cases double first metatarsal osteotomy with significant shift and added lateral release can achieve a good correction. All the patients in this group had severe deformities with HVA and IMA of 45 and 18.7 degrees respectively. The triple osteotomy described here corrected these angles initially without need for a lateral release, however at further follow up there was a mean loss of eight degrees (54%) of the HVA correction. A recent case series of 45 patients in whom triple osteotomy with lateral release was performed describes a good HVA correction to seven degrees post operatively with a mean follow up of 45 months [13]. Tight lateral structures have been labeled as a causative factor in the classical deformity and in the case of surgery; many would recommend releasing it routinely as part of hallux valgus correction. Our results show an early recurrence of hallux valgus deformity that is likely multifactorial. The post operative radiographs were performed weight bearing with no splintage used to prevent further lateral deviation of the hallux. The surgical correction of a severe deformity may lead to a large 1st to 2nd toe gap and necessitate surgery to the lesser toes. This likely increases the risk of recurrent deformity. The medial soft tissues tend to be of
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poor quality due to stretching and after surgery this may allow for recurrence when patients’ feet are once again moulded by everyday footwear. Finally, the lack of lateral release would lead to a compounding effect of the aforementioned thus resulting in some recurrence of deformity. A failure to relocate the sesamoids could also be a contributing factor, however the addition of a lateral release has not been shown to improve sesamoid position [14].
The decision not to perform a formal web space approach lateral release was due to the authors’ concerns on excessive soft tissue stripping of the metatarsal head in the presence of a shaft osteotomy and the preference for avoiding a skin bridge in addition to the extensive medial side incision required. Transarticular lateral releases have been shown to provide equivalent outcomes to that of a formal web space approach thus help to address this concern [15]. Avoiding lateral release has the theoretical benefit of preserving the soft tissues lateral to the first metatarsal head and thus alleviating any concerns about damaging the metatarsal head blood supply. A variable incidence between 0-20% of avascular necrosis of the first metatarsal head has been reported with the classic Chevron osteotomy[1620]. Higher incidence of AVN has been reported with the addition of a lateral release to a distal chevron osteotomy, however with the modern chevron osteotomy this risk is negated. [17,18,20].
The Chevron osteotomy is intrinsically stable against dorsiflexion and does not cause any shortening of the first metatarsal. Excellent clinical results have been reported with little or no transfer metatarsalgia when the procedure has been used within limits of correction of the IMA of four to eight degrees and the HVA of 11 to 18 degrees [16]. This osteotomy has been recommended for the correction of mild to moderate deformity [16,17,19]. The operation is most often used in an incongruent deformity with a normal DMAA. All the patients in our group had incongruent hallux valgus with DMAA within normal limits. Basal osteotomy due to a longer lever arm has a potential of higher corrective power [4]. Hence, it is recommended for moderate to severe deformities [16]. 10
However, if used alone for a congruent deformity, it can actually worsen the problem. With added distal Chevron and Akin osteotomies this provides modularity to the technique and multilevel correction to achieve better overall rectification of the deformity. Coughlin and Carlsson [21] added a distal osteotomy to the proximal basal osteotomy to address the problem of incongruent deformity and reported an 81% success rate with good HVA and IMA corrections of 40 to 10 degrees and 16 to 8 degrees respectively. Chuckpaiwong [22] reported comparable results by using proximal and distal osteotomies, but better correction of the angles with proximal osteotomy. Hallux valgus angle improved from 40 to 11 degrees and IMA 18 to 8 degrees with the proximal osteotomy compared with HVA from 40 to 21 degrees and IMA 18 to 11 degrees with the distal. The distal osteotomy was found to be less invasive, with a low complication rate when compared to the more technically demanding proximal osteotomy. Kumar et al [23] used a similar technique to treat HV deformity with a HVA of 45 degrees and IMA of 17 degrees. They used a proximal basal osteotomy stabilized with a low profile plate and added an Akin osteotomy only if required. The HVA was corrected to 13 degrees and IMA to 9 degrees. Good to satisfactory results were reported in 80% (20 of 25) patients. The follow up radiographs also revealed that the correction held on a long term basis.
The technique demonstrated in this paper showed good radiological correction in the immediate postoperative period. Some recurrence of the HV deformity was noted at longer term radiological follow up, in this series the figure was 8 degrees, however the correction remained a statistically significant and clinical improvement compared to the preoperative deformity. This point should be emphasized to any patient considering surgical correction. Our results suggest that the procedure does not significantly improve one’s assessment of their own global health, but with specific reference to the troublesome foot there is significant gains to be made with regard to pain, ability to mobilize and social interaction. This highlights that in addition to being a pain relieving procedure primarily, additional benefits are achievable. 11
Two particular disadvantages of this procedure, which would require specific patient counseling, are persistent post operative foot swelling and the possibility of the requirement of metalwork removal. Patients reported returning to their preferred footwear from six months post surgery. This is longer than one would expect after standard bunion surgery (three to four months) and may be a reflection of the extended medial incision and soft tissue insult in this procedure or be biased by poor patient recall. Two patients subsequently had the phalangeal staple removed at 20 and 24 months due to localised discomfort and so patients should be warned of this possibility due to the prominence of subcutaneous implant. Limitations of our study include the relatively small sample size and incomplete long term follow up of all patients, however at least 12 months of follow up was achieved in 80% (12 of 15) of PROMs data and in 67% (10 of 15) of radiographs. Further work will include a comparative patient group with inclusion of lateral release, establishing a post operative splintage protocol and investigating the effect of lesser toe drift on deformity recurrence.
Conclusion Hallux valgus is a complex condition to correct and surgical procedures can lead to good functional outcomes in carefully selected patients. Mild to moderate deformity can be corrected by single or double osteotomy correction, but severe deformities require more invasive procedures like the triple osteotomy described in this paper.
Whilst not improving ones
assessment of their own global health, surgery significantly improves the functional outcome of the operated foot. Patients should be appropriately counseled on the expected recovery time and potential for future metalwork removal. Our experience suggests that a lateral release should be included in the procedure and likely helps prevent early recurrence of the deformity.
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References [1] H.B Menz & S.R Lord, Gait instability in older people with hallux valgus, Foot Ankle Int. 26 (2005) 483-489 [2] M. Myerson, Foot and ankle disorders, hallux valgus. Philadelphia: WB Saunders, 1999, pp. 213-89 [3] M. Coughlin & C. Jones, Hallux valgus: demographics, etiology and radiographic assessment, Foot Ankle Int. 28 (2007) 759-777 [4] H.B Menz & M.E Morris, Footwear characteristics and foot problems in older people, Gerontology. 51 (2005) 346-251 [5] D.B Thordarson, E. Ebramzadeh, M. Moorthy et al, Correlation of hallux valgus surgical outcome with AOFAS forefoot score and radiological parameters, Foot Ankle Int. 26 (2005) 122-127 [6] M. Torkki, A. Malmivaara, S. Seitsalo et al, Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial, JAMA. 285 (2001) 2474-2480 [7] H. Kelikian, Hallux valgus, Allied Deformities of the Forefoot and Metatarsalgia. Philadelphia, PA: WB Saunders, 1965, pp. 1-5 [8] M.J Coughlin & R.A Mann, Hallux valgus, in: M.J Coughlin, R.A Mann, C.L Saltzman (Eds.), Surgery of the Foot and Ankle, Mosby Elsevier, Philadelphia, 2007 pp. 183-362 [9] The EuroQol Group, EuroQol – a new facility for the measurement of health-related quality of life, Health Policy. 16 (1990) 199-208 [10] W. Greiner, T. Weijnen, M. Nieuwenhuizen et al, A single European currency for EQ-5D health states. Results from a six country study, Eur J Health Econ. 4 (2003) 222-231 [11] ISIS Innovations, The Manchester-Oxford Foot Questionnaire (MOxFQ). http://isis-innovation.com/outcome-measures/manchester-oxford-footquestionnaire-moxfq, 2014 (accessed 11.03.16) [12] J. Dawson, I. Boller, H. Doll et al, Responsiveness of the ManchesterOxford Foot Questionnaire (MOxFQ) compared with AOFAS, SF-36 and EQ5D assessments following foot or ankle surgery, J Bone Joint Surg BR. 94 (2012) 215-21
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[13] S.S Al-Nammari, T. Christofi & C. Clark, Double First Metatarsal and Akin Osteotomy for Severe Hallux Valgus, Foot Ankle Int. 36 (2015) 1215-1222 [14] K. Woo, I.S Yu, K.S Sung et al, Effect of Lateral Soft Tissue Release on Sesamoid Position in Hallux Valgus Surgery, Foot Ankle Int. 36 (2015) 14631468 [15] Y.B Park, K.B Lee, S.K Kim et al, Comparison of distal soft-tissue procedures combined with a distal chevron osteotomy for moderate to severe hallux valgus: first web-space versus transarticular approach, J Bone Joint Surg Am. 95 (2013) e158 [16] A.H Robinson & J.P Limbers, Modern concepts in the treatment of hallux valgus, J Bone Joint Surg Br. 87 (2005) 1038-1045 [17] R.E Donnelly, C.L Saltzman, T.A Kile et al, Modified Chevron osteotomy for hallux valgus, Foot Ankle Int, 15 (1994) 642-645 [18] M.A Green, M.F Dorris, T.P Baessler et al, Avascular necrosis following distal chevron osteotomy, J Foot Ankle Surg. 32 (1993) 617-622 [19] C. Nery, R. Borroco R, C. Ressico, Biplanar Chevron osteotomy, Foot Ankle Int. 23 (2002) 792-798 [20] H.J Trnka, A. Zembsch, H. Weisauer et al, Modified Austin procedure for correction of hallux valgus, Foot Ankle Int. 18 (1997) 119-127 [21] M.J Coughlin & R.E Carlsson, Treatment of hallux valgus with increased distal metatarsal articular angle – evaluation of double and triple first ray osteotomies, Foot Ankle Int. 20 (1999) 762-770 [22] B. Chuckpaiwong, Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus, Int Orthop. 36 (2012) 2275-2278 [23] S. Kumar, S. Konan, M.J Oddy et al, Basal medial open wedge first metatarsal osteotomy stabilized by low profile wedge plate, Acta Orthop Belg. 78 (2012) 362-368
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Figure 1. Operative technique of first metatarsal triple osteotomy. From top left to bottom right image: Exposure of first metatarsal; Basal osteotomy with plate fixation; Chevron osteotomy; Barouk screw placement; Medial V capsular flap; Akin osteotomy.
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Figure 2. Post operative anteroposterior radiograph showing correction of hallux valgus deformity and placement of metalwork
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Figure 3. Post operative lateral radiograph showing placement of metalwork
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Figure 4. Anteroposterior radiograph indicating how the hallux valgus angle (dashed line) and intermetatarsal angle (solid line) were measured
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Figure 5. Hallux valgus angles pre operative, immediately post operative and at final follow up. Graph shows values and mean +- 95% CI
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Figure 6. Intermetatarsal angles pre operative, immediately post operative and at final follow up. Graph shows values and mean +- 95% CI
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Figure 7. Visial analogue scale (VAS) of EQ-5D showing pre and post operative values and mean +- 95% CI
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