Review Question - QID 3683

A proximal metatarsal osteotomy,(e.g. Ludloff or Scarf osteotomy) combined with a soft tissue release is most appropriate for the HVA and IMA measurements associated with this patient's hallux valgus deformity. A lateral metatarsophalangeal joint soft-tissue release (modified Mcbride) is appropriately combined with the osteotomy because the radiograph demonstrates an incongruent MTP joint.

The term congruity is used to describe the relationship of the metatarsal and phalangeal articular surfaces. When the surfaces are aligned, the joint is said to be congruous. When they are not aligned, the articulation is incongruous (subluxation of the metatarsophalangeal joint). It is important to distinguish a congruous MTP joint from an incongruous one. This will influence the a specific operative approach that is required. An intra-articular realignment (such as a modified McBride procedure or another distal soft-tissue reconstruction) achieves correction by realigning the articular surfaces and improving the hallux valgus angle.

Chiodo et al. performed a Level 4 review of 82 cases of moderate to severe hallux valgus corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. They found that the HVA and IMA measurements postoperatively corrected to an average of 11 degrees and 7 degrees and that 69 patients (98%) were satisfied with the results of surgery.

Trnka et al. report Level 4 evidence of 99 patients that had 111 moderate to severe hallux valgus deformities that underwent a Ludloff and a combined distal soft-tissue procedure. In the 111 osteotomies, the AOFAS score improved significantly from 53 points preoperatively to 88 points at a mean of thirty-four months, and the average intermetatarsal angle decreased from 17° to 8°.

Easley et al. present a Level 5 evidence based analysis of the literature for the operative treatments of hallux valgus.

Figure A is a clinical photograph of a patient with hallux valgus deformity of the left foot. Figure B shows an AP radiograph of bilateral feet with a substantial hallux valgus deformity and an incongruent joint on the left side. Illustration A is a drawing showing the osteotomy sites of the Ludloff and Scarf first metatarsal osteotomies. Illustration B demonstrates hallux valgus cases of a congruent first MTP joint and Illustration C demonstrates some examples of an incongruent (subluxed) first MTP joint.

Incorrect Answers:
Answer 1: Proximal phalanx (Keller) resection arthroplasty has largely been abandoned. It should only be used in patients with extremely low functional demands.
Answer 2: A distal metatarsal osteotomy is indicated in mild disease with an HVA < 25 and IMA < 13.
Answer 4: A first tarsometatarsal arthrodesis (modified Lapidus) is indicated when there is severe deformity (HVA > 41, IMA > 16), radiographic/clinical evidence of first TMT instability, and/or evidence of arthritis at the TMT joint.
Answer 5: Lateral metatarsophalangeal (MP) joint soft-tissue release is indicated only when the HVA < 25 and IMA < 15