Pertinent Insights On Hallux Valgus Surgery

Can minimally invasive techniques significantly improve outcomes? Is the lateral release an outdated concept? Does sesamoid position matter? Panelists at the recent ACFAS Scientific Conference addressed these questions and more during informative sessions on hallux valgus repair.

Is there a gap between surgeon and patient satisfaction when it comes to hallux valgus surgery? Michael H. Theodoulou, DPM, FACFAS notes that in the mid 1990’s 4.4 million Americans sought care for bunion deformities annually. Studies also identify that patients recall about 10 percent of their conversations with providers.¹ He points out that it is important to understand how to connect both patient and surgeon expectations in the treatment of hallux valgus.  

Surgeons may be more satisfied with different aspects of clinical or X-ray findings than what the patient finds important, according to Dr. Theodoulou, Chief of the Division of Podiatric Surgery at Cambridge Health Alliance in Boston. He says pain is the most important indicator for both patients and surgeons. Although range of motion is a particularly valued functional outcome for surgeons, patients do not place a similar emphasis on this finding and accept some stiffness. Patients appreciate the need to wear shoes comfortably and walk without restriction. This disconnect is important as more information is becoming available on patient-reported outcomes, maintains Dr. Theodoulou, who is an Instructor of Surgery at Harvard Medical School.

In a 2001 multicenter study involving 311 patients, most patients agreed they felt and functioned better after hallux valgus surgery.² Interestingly, Dr. Theodoulou points out that patients in this study took, on average, six months to make a full physical recovery but emotional recovery took almost twice as long.

Dr. Theodoulou emphasizes that surgeons should look at each patient individually and recognize that one size does not fit all when it comes to hallux valgus surgery. He reminds surgeons to not just treat or evaluate the radiographic measurements, but to be aware of patient expectations.

Does Sesamoid Position Really Matter In Hallux Valgus Correction? 

Harry P. Schneider, DPM, FACFAS says the literature varies greatly on sesamoid position. In 2016, Chin and colleagues recommended correcting tibial sesamoid position to four (by the Hardy and Clapham classification) or less to improve functional outcomes.^3,4 They noted that recurrence after hallux valgus correction was approximately 50 percent when the postoperative tibial sesamoid position was greater than four and approximately 60 percent when the postoperative tibial sesamoid position was greater than five (using a seven-point scale). In another study, Park and Lee concluded that immediate postoperative sesamoid position greater than four significantly correlated with recurrence as did an immediate post-op hallux valgus angle greater than or equal to eight degrees, a pre-operative metatarsus adductus angle greater than or equal to 23 degrees and a preoperative hallux valgus angle of greater than or equal to 40 degrees.⁵

Dr. Schneider cites a 2002 study, which showed that true sesamoid rotation is not always evident on a standard AP radiographic view and that a sesamoid axial view may give a more accurate depiction.⁶ Kim and colleagues in 2015 proposed a different way of analyzing tibial sesamoid position via measuring “metatarsal pronation.”⁷ These researchers found that nearly 26 percent of those studied had tibial sesamoid positions of five or greater on AP radiographs but metatarsal rotation on axial computed tomography (CT) revealed the sesamoids to indeed be in a normal position. Dayton and Feilmeier in 2017 and Shibuya and team in 2019 also published on the role of metatarsal rotation on sesamoid position with varying opinions.^8,9

Sesamoid position does indeed matter, says Dr. Schneider, who is in private practice in Cambridge, Mass. He recommends assessing an axial X-ray view and considering metatarsal rotation, metatarsus adductus and the hallux valgus angle in order to prevent recurrence.

What Is The Role Of The Lateral Release In Bunion Correction?

Is the lateral release necessary in hallux valgus correction or is it merely an antiquated adjunct procedure? Supporting the latter position, Lawrence DiDomenico, DPM, FACFAS says the success of the procedure all comes down to deformity reduction. The continued performance of the lateral release is partially due to surgeon habits and training, according to Dr. DiDomenico, the Section Chief of the Division of Podiatry within the Department of Surgery at St. Elizabeth Health Center in Youngstown, Ohio. Although the lateral release was once perceived as an effective adjunct, Dr. DiDomenico says, in his experience, it does not result in better patient satisfaction.

He relates that the complications of a lateral release can include avascular necrosis, joint stiffness, deep peroneal nerve injury, scar tissue formation and a cock-up hallux or hallux varus. Taking this into consideration, Dr. DiDomenico questions why one would intentionally destabilize the structures in this area and change the normal anatomy. Focusing on metatarsal angle reduction, in his opinion, is safer, allows for more function, quicker post-op recovery, limits complications and is more patient-friendly, maintains Dr. DiDomenico, who is in private practice in Youngstown, Ohio.

In choosing not to do a lateral release, Dr. DiDomenico instead recommends pursuing a strong surgical technique focusing on excellent reduction with proper bone surface preparation and rigid internal fixation.

Key Considerations In Open Versus Minimally-Invasive Techniques 

Taking on the controversy of open versus minimally-invasive surgery (MIS) techniques for distal metatarsal osteotomies, Jeffrey E. McAlister DPM, FACFAS acknowledges that disagreement exists. Citing a 2018 study, he shares that open versions of this procedure yield overall moderate patient satisfaction, low complication rates and a moderate rate of recurrence.¹⁰ Specifically, Dr. McAlister notes recurrence rates for various procedures, including the Scarf and Chevron osteotomies, ranging between 25 to 78 percent across multiple studies in the literature.^11-14 Overall patient satisfaction over a 14-year follow-up in one study comparing the Scarf and Chevron osteotomies was 30 percent.¹¹ 

Minimal incision surgeries appear to be favorable in comparison to open techniques for mild hallux valgus deformities, states Dr. McAlister. In a 2020 study evaluating 287 patients over a seven-year period, Yassin and colleagues found similar changes in the intermetatarsal and hallux valgus angles.¹⁵ Researchers in this study also found the MIS technique to be safe if the surgeon was running the burr at low speed and with short pulses. There was also significantly less pain in the percutaneous correction group, according to the study authors. Dr. McAlister notes similar findings in other studies and in his own experience.^16,17 

In his 1989 book, Johnson characterized minimally invasive foot surgery as a crippling procedure, influencing most podiatrists and orthopedic surgeons to abandon the technique.¹⁸ However, in more recent years, one can note a resurgence of MIS procedures in many aspects of foot and ankle surgery, says Dr. McAlister, who is in private practice in Scottsdale, Ariz. He asserts that MIS techniques in forefoot reconstruction are here to stay but challenges do still exist.

Dr. McAlister explains that following proper indications for the procedure, ensuring prudent patient selection and understanding that there is a learning curve will help surgeons avoid mistakes made in the past. Additionally, improved techniques and technology may also contribute to a better MIS experience than in past generations, according to Dr. McAlister.

In his experience, Dr. McAlister employs MIS for mild to moderate hallux valgus cases, Coughlin/Shurnas grade zero to two with no metatarsus adductus and reducible deformities. Alternately, he tends to choose open tarsometatarsal rotational fusion for moderate to severe cases. For patients with significant arthritis, Dr. McAlister favors a first MPJ fusion.

In his experience, Dr. McAlister says MIS techniques cause less stiffness, risk of infection, nerve damage and pain in comparison to open counterparts. But in order to optimize outcomes, he says surgeons should focus on patient selection, proper operating room setup, accurate sesamoid rotation measurement, rotation of the capital fragment and thorough washout of bone debris from the surgical site.

What Role Does Intercuneiform Instability Play In The Lapidus Procedure? 

Matthew E. Williams, DPM, FACFAS says recent improvements in fixation constructs now allow earlier weightbearing and lower non-union rates than surgeons previously saw with the Lapidus procedure. However, recurrence continues to be a concern. Why is this? Dr. Williams lists possibilities such as patient non-adherence, walking too early, trauma, undercorrection or an underlying structural or anatomic issue.

Multiple recent studies support the concept that increased first ray mobility is associated with hallux valgus, according to Dr. Williams.^19-21 But what structures influence first ray motion? In a 2002 study, Roling and colleagues showed that the first metatarsocuneiform joint, the naviculocuneiform joint and the talonavicular joint contribute 41, 50 and nine percent of sagittal first ray motion respectively.²² Additionally, Kimura and colleagues in 2017 found that in comparison with normal feet, feet with hallux valgus had significantly greater range of motion at the intercuneiform 1-2 joint.²³ In a retrospective study assessing 38 tarsometatarsal arthrodesis procedures in 34 patients, Fleming and team found that the use of an intraoperative hook test uncovered intercuneiform instability in 73 percent of the patients studied.²¹ Two studies, one in 2002 and one in 2015, found that stabilizing the intercuneiform 1-2 joint with the first tarsometatarsal joint yielded the most stable first ray postoperatively.^22,24 

So how does one best address intercuneiform instability? Dr. Williams notes that intermetatarsal fixation could lead to increased risk of hardware breakage or failure. Naviculocuneiform fusion requires an additional fixation construct and opens up the risks of non-union, medial column shortening and the possible need for bone grafting, according to Dr. Williams. However, incorporating intercuneiform stabilization into the standard fixation for the Lapidus procedure may lower the risk of hardware failure, will not add more first ray shortening and still allows for early weightbearing, says Dr. Williams, a Past President of the American College of Foot and Ankle Surgeons.

Dr. Williams maintains that intercuneiform instability is not a fallacy and that the evidence backs this up. He says including intercuneiform stabilization in the fixation of a Lapidus procedure will likely reduce recurrence and could improve long-term outcomes. 

When Should A Patient Bear Weight After A First Tarsometatarsal Fusion?

What are the best practices when determining weightbearing status after a Lapidus procedure? Sean T. Grambart, DPM, FACFAS says this question warrants consideration of multiple factors including the definition of “early” weightbearing, the type of fixation and the effect of weightbearing time on non-union risk. 

He shares that he considers “early” weightbearing to be before three weeks postoperatively. In a 2016 multicenter study, Prissel and colleagues concluded that early weightbearing did not increase the risk of non-union, and noted that fixation did not play a role either.²⁵ Dr. Grambart, a co-author on that study, emphasizes that  joint preparation is crucial. In a 2017 study, Barp and colleagues concurred that fixation did not significantly impact outcomes for metatarsocuneiform arthrodesis.²⁶ 

Looking at non-union rates over time for Lapidus procedures, Dr. Grambart relates that the overall incidence of non-union is decreasing over time. A 2018 study by Crowell and colleagues of 443 Lapidus procedures revealed a non-union rate of 3.61 percent with weightbearing allowed at less than or equal to two weeks postoperatively.²⁷ The trend is to allow for earlier weightbearing with Lapidus procedures, according to Dr. Grambart, an Assistant Professor at the Des Moines University College of Podiatric Medicine and Surgery.

Dr. Grambart says early weightbearing fusion rates appear to be equivalent with those of later weightbearing cohorts. Stable fixation constructs with proper joint preparation can improve outcomes and increasing numbers of surgeons are choosing earlier weightbearing for Lapidus procedures, notes Dr. Grambart, a Past President of the American College of Foot and Ankle Surgeons. He cautions that the weightbearing decision is patient-specific and that one must take into consideration patient size, smoking status and adherence issues as well. 

1. Thompson FM, Coughlin MJ. The high price of high-fashion footwear. Inst Course Lect. 1995;44:371-377.
2. Thorardson DB, Rudicel SA, Ebramzadeh E, Gill LH. Outcome study of hallux valgus surgery – an AOFAS multi-center study. Foot Ankle Int. 2001;22(12):956-959.
3. Chen JY, Rikhraj K, Gatot C, Lee JYY, Rikhraj IS. Tibial sesamoid position influence on functional outcome and satisfaction after hallux valgus surgery. Foot Ankle Int. 2016;37(11):1178-1182.
4. Shibuya N, Kyprios EM, Panchani PN, Martin LR, Thorud JC, Jupiter DC. Factors associated with early loss of hallux valgus correction. J Foot Ankle Surg. 2018;57(2):236-240.
5. Park CH, Lee W-C. Recurrence of hallux valgus can be predicted from immediate postoperative non-weight-bearing radiographs. J Bone Joint Surg Am. 2017;99(14):1190-1197.
6. 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. 2002;23(9):811-817.
7. Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee SY. A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. Foot Ankle Int. 2015;36(8):944-952.
8. Dayton P, Feilmeier M. Comparison of tibial sesamoid position on anteroposterior and axial radiographs before and after triplane tarsal metatarsal joint arthrodesis. J Foot Ankle Surg. 2017;56(5):1041-1046.
9. Shibuya N, Jasper J, Peterson B, Sessions J, Jupiter D. Relationships between first metatarsal and sesamoid positions and other clinically relevant parameters for hallux valgus surgery. J Foot Ankle Surg. 2019;58(6):1095-1099.
10. Barg A, Harmer JR, Presson AP, Zhang C, Lackey M, Saltzman CL. Unfavorable outcomes following surgical treatment of hallux valgus deformity: a systematic literature review. J Bone Joint Surg Am. 2018;100(18):1563-1573.
11. Jeuken RM, Schotanus MGM, Kort NP, Deenik A, Jong B, Hendrickx RPM. Long-term follow-up of a randomized controlled trial comparing Scarf to Chevron osteotomy in hallux valgus correction. Foot Ankle Int. 2016;37(7):687-695.
12. Bock P, Kluger R, Kristen K-H, Mittlbock M, Schuh R, Trnka H-J. The Scarf osteotomy with minimally invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J Bone Joint Surg Am. 2015;97(15):1238-1245.
13. Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Preoperative radiological factors correlated to long-term recurrence of hallux valgus following distal Chevron osteotomy. Foot Ankle Int. 2014;35(12):1262-1267.
14. Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int. 2003;24(1):29-33. 
15. Yassin M, Bowirat A, Robinson D. Percutaneous surgery of the forefoot compared with open technique – functional results, complications and patient satisfaction. Foot Ankle Surg. 2020;26(2):156-162.
16. Lai MC, Rikhraj IS, Woo YL, Yeo W, Ng YCS, Koo K. Clinical and radiological outcomes comparing percutaneous Chevron-Akin osteotomies vs open Scarf-Akin osteotomies for hallux valgus. Foot Ankle Int. 2018;39(3):311-317.
17. Lee M, Walsh J, Smith MM, Ling J, Wines A, Lam P. Hallux valgus correction comparing percutaneous Chevron/Akin (PECA) and open Scarf/Akin osteotomies. Foot Ankle Int. 2017;38(8):838-846.
18. Johnson KA. Dissatisfaction following hallux valgus surgery. Surgery of the Foot and Ankle. New York: Raven Press;1989.
19. Shibuya N, Roukis TS, Jupiter DC. Mobility of the first ray in patients with or without hallux valgus deformity: systematic review and meta-analysis. J Foot Ankle Surg. 2017;56(5):1070-1075.
20. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abductovalgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013;52(3):348-354.
21. Fleming JJ, Kwadu KY, Brinkley JC, Ozuzu Y. Intraoperative evaluation of medial intercuneiform instability after Lapidus arthrodesis: intercuneiform hook test. J Foot Ankle Surg. 2015;54(3):464-472.
22. Roling BA, Christensen JC, Johnson CH. Biomechanics of the first ray. Part IV: the effect of selected medial column arthrodeses. A three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg. 2002;41(5):278-285.
23. Kimura T, Kubota M, Suzuki N, Hattori A, Marumo K. Comparison of intercuneiform 1-2 joint mobility between hallux valgus and normal feet using weightbearing computed tomography and 3-dimensional analysis. Foot Ankle Int. 2018;39(3):355-360.
24. Galli MM, McAlister JE, Berlet GC, Hyer CF. Enhanced Lapidus arthrodesis: crossed screw technique with middle cuneiform fixation further reduces saggital mobility. J Foot Ankle Surg. 2015;54(3):437-440.
25. Prissel MA, Hyer CF, Grambart ST, et al. A multicenter, retrospective study of early weightbearing for modified Lapidus arthrodesis. J Foot Ankle Surg. 2016;55(2):226-229.
26. Barp EA, Erickson JG, Smith HL, Almeida K, Millonig K. Evaluation of fixation techniques for metatarsocuneiform arthrodesis. J Foot Ankle Surg. 2017;56(3):468-473.
27. Crowell A, Van JC, Meyr AJ. Early weightbearing after arthrodesis of the first metatarsal-medial cuneiform joint: a systematic review of the incidence of non-union. J Foot Ankle Surg. 2018;57(6):1204-1206.