Two feet were excluded from the analysis, the first due to the addition of a metatarsophalangeal fusion at the time of the index procedure and the second patient since only the initial intraoperative radiographs were available. This second patient had an early loss of fixation after a fall requiring revision to a Lapidus. Thus, data from the remaining 13 patients (14 feet) who underwent pre- and postoperative radiographic and clinical evaluation are presented in this study. These included 5 left and 9 right feet, all with incongruent MTP joints and moderate to severe hallux valgus preoperatively (Table 1). The average patient age was 56 years old (range 22-75). Seven of 13 (54%) patients underwent additional procedures at the time of hallux valgus correction (Table 1).
Radiographic evaluation included assessment of hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), proximal first metatarsal inclination angle (PFMI), and radiographic union (Figure 3). These measurements were made on digital weightbearing anteroposterior radiographs preoperatively, at the first postoperative visit and at the time of most recent follow-up. Final radiographic and clinical analysis occurred at an average of 7 months (range, 3-19 months) postoperatively. Measurements were made by 2 orthopedic foot and ankle fellows blinded to each other's measurements. Each evaluator's measurements were then averaged with those of the other evaluator . Both hallux valgus angle and 1-2 intermetatarsal angle have shown high intraobserver and interobserver reliability across multiple studies.   PFMI was selected as a measure of first TMT joint obliquity.   PFMI was measured as the angle between a line perpendicular to the axis of the second metatarsal and a line parallel to the proximal articular surface of the first metatarsal, which is easier to visualize than the articular surface of the medial cuneiform (Figure 3C). Clinical evaluation consisted of an assessment of clinical alignment, weight-bearing status, return to shoe wear, and complications. Radiographs were reviewed to evaluate healing of the osteotomy.
Statistical analysis consisted of calculating means and ranges for preoperative, postoperative, and final HVA, IMA, and PFMI. Comparison was made between preoperative and immediate postoperative radiographic values to determine whether satisfactory intraoperative correction of the hallux valgus deformity was obtained. Additionally, comparison was made between immediate postoperative and final follow-up radiographs to determine if the intraoperative correction was maintained during the postoperative period. A Student paired t test was performed to determine if there were statistically significant differences between the means of pre- and postoperative measurements and between the means of postoperative and final measurements (Table 2).
There was no commercial support or other external funding provided for this study.
A medial midsagittal incision was made from the midproximal phalanx to the naviculocuneiform joint. An inverted-L capsulotomy was made at the MTP joint, with care taken to avoid injury to the dorsomedial cutaneous nerve. The medial eminence was resected in line with the long axis of the first metatarsal. A second, 2-cm longitudinal incision was made dorsally in the 1-2 interspace at the level of the hallux MTP joint. The adductor tendon was sharply released from its insertion on the base of the proximal phalanx and the lateral aspect of the fibular sesamoid. The transverse metatarsal ligament was identified and divided followed by capsulotomies of the metatarsosesamoid joint and lateral MTP joint to restore appropriate sesamoid station and MTP joint congruency.
Attention was then turned to the medial cuneiform, where a dorsoplantar periosteal incision was made medially at the level of the second TMT joint. Two small Hohmann retractors were placed plantar and dorsal. Care was taken to avoid releasing the first TMT joint capsule, which could destabilize the joint and lead to failure of the correction. An osteotomy was made parallel to the TMT joint through approximately three-fourths of the width of the bone (Figure 4A). Care was taken to avoid completing the cut through the lateral cortex to prevent overlengthening of the first ray. The osteotomy was then carefully wedged open using a distractor. Once the correct IMA alignment had been obtained and the sesamoids had been reduced, a measuring guide was used to measure the osteotomy gap. A nonlocking osteotomy plate (Arthrex Low Profile Opening Wedge, Naples, FL) is then inserted into the osteotomy and fixated with 2.4-mm bicortical screws in all 4 holes. The osteotomy site was then filled with bone graft or bone graft substitute. A suture anchor was then placed centrally in the metatarsal head and the sutures were placed through the plantar medial capsule and tied in a mattress fashion securing the sesamoids into a reduced position and anchoring the joint capsule to the metatarsal head. A pants-over-vest capsulorrhaphy was then completed, with the hallux MTP joint held in a reduced position. A final fluoroscopic examination was performed confirming reduction of the hallux metatarsophalangeal joint, sesamoid position, and osteotomy fixation (Figure 4B). A sterile dressing and short-leg bivalved fiberglass cast were applied postoperatively.
Patients were seen at 2 weeks postoperatively for suture removal and recasting for an additional 2-4 weeks. At 6 weeks, patients were transitioned to a postoperative shoe and allowed to begin progressive weightbearing for 1 month, using a silicone toe spacer during the day and a bunion splint at night. At 10-12 weeks postoperatively, patients were allowed to return to wide toe box shoes with continued use of a toe spacer and night splint for an additional 3 months.