Objectives. Minimally invasive surgery (MIS) has gained popularity for hallux valgus, compared to the traditional scarf osteotomy (OS). Though evidence suggests similar clinical outcomes, there is paucity of randomised controlled studies. This study aimed to assess the feasibility of conducting a randomised controlled trial comparing the patient recorded and clinical outcomes for the surgical management of Hallux Valgus between OS and MIS Chevron Akin (MICA). Methods. Patients suitable for surgical correction were invited to participate. Post-op rehabilitation was standardised for both groups. Patients completed a validated questionnaire (Manchester Oxford Foot questionnaire and EQ-5D-5L) pre-operatively and post-operatively at 6 months and 1 year. Radiological parameters and range of motion were measured pre-and post-operatively. Results. 31 patients were recruited between Dec 2017 and June 2022. 17 patients were randomised to MICA (15 female, mean age 51) and 15 to OS (14 female, mean age 51). Both groups had a significant improvement in all MOXFQ parameters at 6m and 12m, as well as radiological parameters. VAS improved for OS (p=0.048) and for MICA (p=0.059) at 6m. There was no significant improvement in EQ-5D in either group at 12 months and no significant difference in operative time (p=0.53). There was a higher number of complications in the MICA group with 5 removal of metalwork (29.4%) and 2 superficial infections (11.8%) versus none in the OS group. The dorsiflexion significantly improved in the OS group at 6months (p=0.04). Recruitment rate dipped during COVID. No patients were lost at follow up. Conclusion. Both surgical options show similar clinical results, but higher complication rates were seen with MICA. This study illustrates the feasibility to conduct a randomised control trial for the comparison between the two techniques. Challenges to recruitment included surgeon equipoise, patient preference, training requirement and the pandemic which could be mitigated in a larger study

Aims. The first metatarsal pronation deformity of hallux valgus feet is widely recognized. However, its assessment relies mostly on 3D standing CT scans. Two radiological signs, the first metatarsal round head (RH) and inferior tuberosity position (ITP), have been described, but are seldom used to aid in diagnosis. This study was undertaken to determine the reliability and validity of these two signs for a more convenient and affordable preoperative assessment and postoperative comparison. Methods. A total of 200 feet were randomly selected from the radiograph archives of a foot and ankle clinic. An anteroposterior view of both feet was taken while standing on the same x-ray platform. The intermetatarsal angle (IMA), metatarsophalangeal angle (MPA), medial sesamoid position, RH, and ITP signs were assessed for statistical analysis. Results. There were 127 feet with an IMA > 9°. Both RH and ITP severities correlated significantly with IMA severity. RH and ITP were also significantly associated with each other, and the pronation deformities of these feet are probably related to extrinsic factors. There were also feet with discrepancies between their RH and ITP severities, possibly due to intrinsic torsion of the first metatarsal. Conclusion. Both RH and ITP are reliable first metatarsal pronation signs correlating to the metatarsus primus varus deformity of hallux valgus feet. They should be used more for preoperative and postoperative assessment. Cite this article: Bone Jt Open 2024;5(11):1037–1040

The October 2024 Foot & Ankle Roundup³⁶⁰ looks at: Hemiarthroplasty for hallux rigidus; Fixed or mobile-bearing ankle arthroplasty? A meta-analysis; Bone grafting for periprosthetic bone cysts following total ankle arthroplasty; Diabetic foot ulcer after first-ray amputation; Early motion after ankle surgery: the path to faster recovery?; Are podiatrists and orthopaedic surgeons approaching zone 2 fifth metatarsal fractures in the same way?.

Aims

The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years.

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

Background. The Manchester-Oxford Foot Questionnaire (MOxFQ) is a condition specific patient reported outcome measure (PROM) for foot and ankle surgery. It consists of 16 items across three subscales measuring distinct, but related traits: walking/standing ability, pain, and social interaction. Although it is the most used foot and ankle PROM in the UK, initial MOxFQ validation involved analysis of only 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual's response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ. Methods. This was a single-centre, prospective cohort study involving 6640 patients (mean age 52, range 10–90 years) presenting with a wide range of foot and ankle pathologies between 2013 and 2021. Firstly, to assess whether the MOxFQ responses vary by anatomical region of foot and ankle disease, we performed multi-group confirmatory factor analysis. Secondly, to assess the structural validity of the subscale items, exploratory and confirmatory factor analyses were performed. Results. Measurement invariance by pathology was confirmed suggesting the same model can be used across all foot and ankle anatomical regions. Exploratory factor analysis demonstrated a 2–3 factor model, and suggested that item 13 (inability to carry out my work/everyday activities) and item 14 (inability to undertake social/recreational activities) loaded more positively onto the walking/standing subscale than their original social interaction subscale. Conclusions. This large-cohort study supports the current widespread use of the MOxFQ across a broad range of foot and ankle pathologies. Items 13 and 14 might be better moved from the “social interaction” to the “walking/standing” subscale and this may have future implications for deriving/analysing subscale scores

Background. The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity. Methods. Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity. Results. Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). Females less than 65 years with HV had a statistically significantly worse quality of life compared with females of the same age group in the general population. Above the age of 65, there was no statistically significant difference in EQ-5D-5L Index score between the two groups. There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores. Conclusion. Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with HRQOL measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMs moderately correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life

Background. Surgical intervention for hallux valgus and hallux rigidus is an option for patients presenting with severe pain and deformity. Literature suggest that patients with high Pain Catastrophisation Scores (PCS) have poorer outcomes in spinal and to a lesser extent in arthroplasty surgery. There is however very little evidence pertaining to foot and ankle surgery. Aim. We aimed to study whether catastrophisation as measured by PCS influenced the outcomes following surgery for Hallux valgus and rigidus. Methodology. Ethical approval for this prospective portfolio study was obtained from NRES Committee South Central and Oxford. Approval was granted from the local R&D department prior to data collection. All patients listed for surgery for hallux pathology to the four senior authors were invited to participate. Recruitment into the study started in September 2017 and is ongoing. Pain catastrophising score (PCS), Manchester Oxford Foot Questionnaire (Mox-FQ), Visual analog scale (VAS) for pain and EQ-5D-3L questionnaires were completed Pre-op (baseline), and at 3, 6 and 12- months post-surgery. Results. 93 patients with minimum follow-up of 6 months were analysed using SPSS software. A P-value of less than 0.05 was considered significant. The mean age of the patients was 58.5 years and 83% were women. 70% of the patients had surgery for hallux valgus and rest for rigidus. Both PROMS and PCS improved significantly following surgical intervention. Patients with higher pre-operative PCS had a worse 6-month PROM score and more pain. Conclusion. This study confirms that pre-operative catastrophisation as demonstrated by a high PCS score has an adverse effect on outcomes following hallux surgery. Risk stratifying patients based on their Pre-op PCS scores may be a useful strategy to identify those at risk of poorer outcomes. We recommend that behavioural change interventions should be considered to try to improve outcomes in patients with pre-op PCS

Background. Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiological outcomes. It remains unknown whether these clinical and radiological outcomes are maintained in the medium to long-term. The aim of this study was to investigate the five-year clinical and radiological outcomes following third-generation MIS hallux valgus surgery. Methods. A retrospective observational single surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous Chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60 month clinical and radiographic follow up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) pre-operatively, 6 months and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, Euroqol-5D Visual Analogue Scale and Visual Analogue Scale for Pain. Results. Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA. The mean follow up was 68.8±7.3 (range 60–88) months. There was a significant improvement in radiographic deformity correction; IMA improved from 13.0±3.0 to 6.0±2.6, (p < 0.001) and HVA improved from 27.5±7.6 to 7.8±5.1. There was a statistically significant but not clinically relevant increase of 1.2±2.6° in the HVA between 6 month and ≥60 month radiographs. There was an increase in IMA of 0.1±1.6º between 6 month and ≥60 month radiographs which was not statistically or clinically significant. MOXFQ Index score at ≥follow up was 10.1±17.0. The radiographic recurrence rate was 2.6% at final follow up. The screw removal rate was 4.0%. Conclusion. Radiological deformity correction following third-generation PECA is maintained at a mean follow up of 68.8 months with a radiographic recurrence rate of 2.6%. Clinical PROMs and patient satisfaction levels are high and comparable to other third-generation studies with shorter duration of follow up

Introduction. Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weightbearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores. Methods. We retrospectively analyzed 16 feet (15 patients) who had a WBCT before and after scarf osteotomy for hallux valgus correction. On both scans, hallux valgus angle (HVA), intermetatarsal angle, and anteroposterior/lateral talus-first metatarsal angle were measured using digitally reconstructed radiographs. Metatarsal pronation (MPA), alpha angle, sesamoid rotation angle and sesamoid position was measured on standardized coronal CT slices. Preoperative and postoperative(12 months) clinical outcome scores(MOxFQ and VAS) were captured. Results. Mean HVA was 28.6±10.1 degrees preoperatively and 12.1±7.7 degrees postoperatively. Mean IMA was 13.7±3.8 degrees preoperatively and 7.5±3.0 degrees postoperatively. Before and after surgery, there were no significant differences in MPA (11.4±7.7 and 11.4±9.9 degrees, respectively; p = 0.75) or alpha angle (10.9±8.0 and 10.7±13.1 degrees, respectively; p = 0.83). There were significant improvements in SRA (26.4±10.2 and 15.7±10.2 degrees, respectively; p = 0.03) and sesamoid position (1.4±1.0 and 0.6±0.6, respectively; p = 0.04) after a scarf osteotomy. There were significant improvements in all outcome scores after surgery. Poorer outcome scores correlated with greater postoperative MPA and alpha angles (r= 0.76 (p = 0.02) and 0.67 (p = 0.03), respectively). Conclusion. A scarf osteotomy does not correct first metatarsal coronal rotation, and worse outcomes are linked to greater metatarsal rotation. Rotation of the metatarsal needs to be measured and considered when planning hallux valgus surgery. Further work is needed to compare postoperative outcomes with rotational osteotomies and modified Lapidus procedures when addressing rotation

Background. There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. Objective. To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures. Methods. This is a prospective single-surgeon case series of 420 consecutive feet undergoing MICA surgery between July 2014 and November 2018. Primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D, and the Visual Analogue Pain Scale. Secondary outcome measures included radiographic parameters, and complication rates. Results. Pre-operative and 2 year post-operative patient reported outcomes were collected for 334 feet (79.5%). At minimum 2 year follow-up, the MOXFQ scores (mean ± standard deviation (SD)) had improved for each domain: pain; pre-operative 43.9±21.0 reduced to 9.1±15.6 post-operatively (p<0.001), walking and standing; pre-operative 38.2±23.6 reduced to 6.5±14.5 post-operatively (p<0.001) and social interaction; pre-operative 47.6±22.1, reduced to 6.5±13.5 post-operatively (p<0.001). At 2 year follow-up, the VAS Pain score (mean ± SD) improved from a pre-operative of 31.3±22.4 to 8.3±16.2 post-operatively (p<0.001). 1–2 intermetatarsal angle (mean ± SD) reduced from 15.4°±3.5° to 5.8°±3.1° (p<0.001) and hallux valgus angle reduced from 33.1°±10.2° to 9.0°±5.0° post-operatively (p<0.001). Conclusion. Third-generation MICA showed significant improvement in clinical outcomes at 2 year follow-up and can be successfully used for correction of a wide range of hallux valgus deformities

Purpose. To explore the relationship in terms of time scale between pre-operative expectations and postoperative outcomes and satisfaction after Hallux valgus surgery. Methods. A patient derived questionnaire was developed and 30 patients aged 19 to 67 were included undergoing primary hallux valgus correction with a first metatarsal osteotomy and distal soft tissue release. Patients were asked pre-operatively to quantify their expected time scale for improvement in pain, ability to walk unaided, ability to drive, routine foot wear and foot feeling normal at 6 weeks, 3 and 6 months following surgery, and to indicate their confidence in achieving this result. Patients recorded postoperative outcomes achieved at number of weeks. Ordinal logistic regression multivariate modelling was used to examine predictors of postoperative satisfaction. Results. 90% of the patients were able to walk unaided and drive before or around the expected time scale at an average of five weeks' time. Persistent pain subsided at an average of two weeks post operatively which led to high satisfaction Although differences between patients' expectation and achievement were minimal at 6 weeks post-operatively, there was some discrepancy at 3 months, with patient expectations far exceeding achievement. The least satisfactory outcome was normal feeling of foot at six months follow up. There were significant correlations between failure to achieve expectations and the importance patients attached to recovery. Conclusions. This study underlines the importance of taking preoperative expectations into account to obtain an informed choice on the basis of the patient's preferences. Patients' pre-operative expectations of surgical outcome exceed their functional achievement but satisfaction remains high if pain control and ability to walk unaided is achieved early after hallux valgus corrective surgery

Background. Iatrogenic hallux varus is a rare complication after hallux valgus surgery. Operative treatment comprises a wide variety of techniques, of which the reversed transfer of the abductor hallucis tendon is the most recent described technique. Methods. This paper will present the long-term clinical results of the reversed transfer of the abductor hallucis longus. Therefore, we performed a prospective clinical observational study on 16 female patients. Our hypothesis is that the tendon transfer will persist in a good alignment and patient satisfaction on long term. There is a 100% follow-up rate with a range from 10 to 101 months. Patients were subjected to a clinical examination, three questionnaires and their general satisfaction. Results. Out of 16 patients, at time of follow-up, we found a positive correlation between the subjective outcome score and alignment (r = 0.59), and between the general satisfaction and alignment (r = 0.77). Based on the general satisfaction we achieved a success satisfaction rate of 69% (11 patients). The other 31% (5 patients) patient group was only satisfied with major reservations or not satisfied at all. The two most invalidating complications were a coronal or sagittal malalignment or the combination of both. Conclusion. Our results suggest that the reverse abductor hallucis tendon transfer is a good technique to treat a supple iatrogenic hallux varus with an observed success satisfaction rate of 69% at a mean follow-up time of 48 (range 10–101) months. However, patients should be informed that on the long-term loss of correction is possible

The April 2024 Foot & Ankle Roundup. 360. looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery

Aims. The Manchester-Oxford Foot Questionnaire (MOxFQ) is an anatomically specific patient-reported outcome measure (PROM) currently used to assess a wide variety of foot and ankle pathology. It consists of 16 items across three subscales measuring distinct but related traits: walking/standing ability, pain, and social interaction. It is the most used foot and ankle PROM in the UK. Initial MOxFQ validation involved analysis of 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual’s response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ. Methods. This was a single-centre, prospective cohort study involving 6,637 patients (mean age 52 years (SD 17.79)) presenting with a wide range of foot and ankle pathologies between January 2013 and December 2021. To assess whether the MOxFQ responses vary by anatomical region of foot and ankle disease, we performed multigroup confirmatory factor analysis. To assess the structural validity of the subscale items, exploratory and confirmatory factor analyses were performed. Results. Measurement invariance by pathology was confirmed, suggesting the same model can be used across all foot and ankle anatomical regions. Exploratory factor analysis demonstrated a two- to three-factor model, and suggested that item 13 (inability to carry out work/everyday activities) and item 14 (inability to undertake social/recreational activities) loaded more positively onto the “walking/standing” subscale than their original “social interaction” subscale. Conclusion. This large cohort study supports the current widespread use of the MOxFQ across a broad range of foot and ankle pathologies. Our analyses found indications that could support alterations to the original factor structure (items 13 and 14 might be moved from the “social interaction” to the “walking/standing” subscale). However, this requires further work to confirm. Cite this article: Bone Joint J 2024;106-B(3):256–261

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

Aims

The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS).

The December 2023 Foot & Ankle Roundup. 360. looks at: Subchondral bone cysts remodel after correction of varus deformity in ankle arthritis; 3D-printed modular endoprosthesis reconstruction following total calcanectomy; Percutaneous partial bone excision in the management of diabetic toe osteomyelitis; Hemiepiphysiodesis is a viable surgical option for Juvenile hallux valgus; Ankle arthroplasty vs arthrodesis: which comes out on top?; Patient-related risk factors for poorer outcome following total ankle arthroplasty; The Outcomes in Ankle Replacement Study

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control