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Where Are We With Trends and Research on Hallux Valgus Correction?
Movie sequels are frequently underwhelming at best and often disappointing, with the noted exception of "The Godfather" movies. "The Godfather II" was arguably better than the original, but I consider both cinematic masterpieces. I recently saw a Twitter thread describing the Godfather movies as "boring," which is blasphemy, in my opinion. "The Godfather III" fell far short of the other two films, typical for sequels. Recently, I have been watching "The Offer," a series about the making of "The Godfather." I am not sure how historically accurate the series is, but the original getting made with all the turmoil surrounding production is mind-blowing.
Moving on from the cinematic realm, in foot and ankle surgery, I feel we are entering into a sequel era to the "cheater Akin." In the 1990s, the "cheater Akin" was a much-maligned procedure used to make the hallux look straighter in the context of an undercorrected bunion deformity. When I see social media posts about a Lapidus procedure or minimal incision distal procedures using screw fixation, some (I would like many instead of some because that is what I see) include this same type of Akin osteotomy in the deformity correction. However, the true indication for the Akin osteotomy is a hallux interphalangeus deformity, not visually compensating for an undercorrected bunion deformity.1
The hallux rotates into valgus "as it is tethered at its base to the sesamoids, the deep transverse ligament (via the plantar plate), and the adductor hallucis tendon."2 The sesamoids sublux as much as 72 percent of the time.3 Campbell and colleagues demonstrated a significantly higher pronation angle of the hallux in hallux valgus patients than controls.4 This pronation of the hallux was independent with no correlation to the metatarsal pronation in the hallux valgus cohort.4 These findings make sense because the sesamoid subluxation is independent of the first metatarsal frontal plane rotation. The hallux rotation makes preoperative radiographic evaluation of the actual hallux deformity difficult, including newer measurements like the Delta PP (difference in medial and lateral proximal phalanx wall length), which seem more representative of the deformity.5
If these popular surgical approaches to hallux valgus require an osteotomy distal to the deformity, maybe the new shiny procedures are not the end-all be-all. The way I see it, it was a "cheater Akin" in the 1990s, and it is still a "cheater Akin" today. Unfortunately, I predict this sequel will be like "The Godfather III" instead of "The Godfather II." Despite all the gain in the knowledge base on hallux valgus, the problem remains an under-corrected deformity. So, what is the answer, and why does it feel like I am stuck in a never-ending episode of "The Offer?"
Newer literature continues to shed light on the topic. Conti and associates examined first metatarsal pronation related to patient-reported outcomes (PROMIS) and recurrence rates (defined as a hallux valgus angle greater than 20 degrees) for the Lapidus procedure.6 Patients were divided into two groups based on no postoperative correctionan increase of the preoperative first metatarsal pronation or "any amount" of decrease in the postoperative first metatarsal pronation.6 The recurrence rate of the corrected group was 11.5 percent (shocking, I know), and the uncorrectedworse group was 46.2 percent (yikes!).6 The findings in the uncorrectedworse group were identical to those recently reported by Galli and colleagues, who found the intermetatarsal angle remained corrected. Recurrence occurred due to loss of hallux abductus angle correction.7 Putting the pieces of the puzzle together from these two studies, something is going on distally at the metatarsal head or metatarsal phalangeal joint level in the recurrence cases.
The addition of an Akin osteotomy in the Conti, et al study did not affect recurrence rates, making sense as recurrence is based on the hallux valgus angle, not corrected by an Akin. To slightly modify a quote by Clemenza's character in "The Godfather," "Leave the Akin. Take the cannoli."
The authors also demonstrated what several other authors have found, lower PROMIS scores in the no correctionincreased post-operative first metatarsal pronation angle cohort (which also had a significantly higher recurrence rate).6,8,9
The area where I think we are gaining ground on the elusive answer in the surgical correction of hallux valgus is weight-bearing CT scans (WBCT). In addition, Lavelée and team's recent research on the distal metatarsal articular angle (DMAA) in hallux valgus deformity provides additional clues.10 The authors examined the DMMA in hallux valgus patients and controls on weight-bearing radiographs (XR-DMAA), 2D weight-bearing CT scans without planar correction, and 3D weight-bearing CT scans with sagittal and coronal plane correction.10 The DMAA values (with or without planar correction) were higher in the hallux valgus group.10 The methodology allowed the authors "to comparatively quantify the confounding effects of plane positions on DMAA values in HV and to observe that DMAA is not only a radiographic consequence of pronation." The findings were like other studies.11-13
Lavelée and colleagues point out that procedures to correct the DMAA have fallen out of favor in the current frontal plane correction focus age.10 Although XR-DMAA and 2D WBCT overstate the degree of deformity, 3D WBCT findings confirm deformity of the metatarsal head.10 The computerized deformity correction was fully corrected in all planes, not representative of the actual results in the operating room in most cases. Therefore, the DMAA should often be corrected as it is one of two possibilities for recurrence, with the other being soft tissue balancing.
The original description of the SERI procedure used a pin for fixation.14 The medial pin pulls the toe into a slight varus, stretching the lateral soft tissues and producing an indirect release. I see similar findings with the SERI procedure. Therefore, in my opinion, the use of screws, driven by industry, not evidence-based medicine, routinely requires an Akin. These anecdotal findings demonstrate some form of lateral soft tissue contracture.
"The Offer" series reflects our journey to surgically correct hallux valgus deformities in a reproducible manner and is full of twists and turns with interesting characters trying to control the narrative. Hopefully, science, diligence, and honest evaluation of each step along the journey will produce masterpieces like "The Godfather" and "The Godfather II." To quote Michael Corleone, "I respect those who tell me the truth no matter how hard it is."
Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery. Dr. DeHeer is a Partner with Upperline Health and the Medical Director of Upperline Health Indiana. Dr. DeHeer discloses that he is a speaker for Paragon 28.
References
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2. Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg. 2011;93(17):1650-1661.
3. Kim Y, et al. 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.
4. Campbell B, et al. Pilot study of a 3-dimensional method for analysis of pronation of the first metatarsal of hallux valgus patients. Foot Ankle Int. 2018;39(12):1449-1456.
5. Nebhani N, et al. Hallux valgus interphalangeus measurement: Comparison of the 2 radiographic methods. Foot Ankle Spec. (2022):19386400221078677.
6. Conti MS, et al. Association of first metatarsal pronation correction with patient-reported outcomes and recurrence rates in hallux valgus. Foot Ankle Int. (2021):10711007211046938.
7. Galli SH, et al. Patient reported outcomes and recurrence following 127 primary Lapidus surgeries for hallux valgus. Foot Ankle Orthop. 2020;5(4):2473011420S00222.
8. Chong, A., et al. "Surgery for the correction of hallux valgus: minimum five-year results with a validated patient-reported outcome tool and regression analysis. Bone Joint J. 2015;97(2):208-214.
9. Chen JY, et al. Tibial sesamoid position influence on functional outcome and satisfaction after hallux valgus surgery. Foot Ankle Int. 2016;37(11):1178-1182.
10. Lalevée M, et al. Distal metatarsal articular angle in hallux valgus deformity. Fact or fiction? A 3-Dimensional weightbearing CT assessment. Foot Ankle Int. 2021; 10711007211051642.
11. Dayton P, et al. Comparison of radiographic measurements before and after triplane tarsometatarsal arthrodesis for hallux valgus. J Foot Ankle Surg. 2020;59(2):291-297.
12. Dayton P, et al. Observed changes in radiographic measurements of the first ray after frontal plane rotation of the first metatarsal in a cadaveric foot model. J Foot Ankle Surg. 2014;53(3):274-278.
13. Steadman J, Barg A, Saltzman CL. First metatarsal rotation in hallux valgus deformity. Foot Ankle Int. 2021;42(4):510-522.
14. Giannini S, et al. A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI). Int Orthop. 2013;37(9):1805-1813.
