Consensus on Surgical Management of Hallux Valgus from China

291 2015 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd CONSENSUS Consensus on Surgical Management of Hallux Valgus from China Foot and Ankle Working Committee, Chinese Association of Orthopaedic Surgeons Orthopaedic Branch, Chinese Association of Orthopaedic Surgeons Hallux valgus deformity is one of the most common diseases in foot and ankle surgery. Satisfactory outcomes tend to be achieved only through operative correction. However, selection of the optimal surgical strategy is always a controversial topic, and the rate of dissatisfied patients postoperativelyis still very high. It is well known that there are various pathological changes in hallux valgus deformity, so it is impossible to use one specific procedure to solve all the problems. It requires a careful preoperative physical examination and radiographic assessment to choose the best operation for each kind of deformity according to each pathalogical change, combined with good postoperative dressing, immobilization and proper rehabilitation and follow up, to improve surgical outcomes and reduce postoperative rate of complication and dissatisfaction. In order to achieve these goals, a Consensus on the Operative Correction of Hallux Valgus has been developed by the Foot and Ankle Working Committee, Orthopaedic Branch, Chinese Association of Orthopaedic Surgeons. Foot and ankle surgeons following this consensus must be fully aware of their patients desires, carefully evaluate different pathological processes and clinical symptoms and be skilled in various procedures. Then these procedures can be easily selected, converted and combined based on preoperative plans and intraoperative conditions. Key words: Consensus; Corrective operation; Hallux valgus Introduction Hallux valgus (HV) deformity is one of the most common diseases in foot and ankle surgery as well as the most frequently occurring problems involving the forefoot of adults 1. Its incidence may up to be one-third in Chinese people who wear shoes 2. Satisfactory outcomes tend to be achieved only through operative correction 3. However, there are more than a hundred different surgical methods to correct this deformity, and the selection of an optimal surgical strategy is controversial. It is estimated that more than 200,000 operations are performed per year to correct HV in the USA 4, but disstisfaction with the operation is as high as 25% 33% 5.By contrast, due to shorter history and less HV surgery, as well as the absence of corresponding multicenter studies and reports with high levels of evidence, this rate is likely to be much higher in China. The Foot and Ankle session of the second Oriental Conference of Orthopaedic Surgeons was hold in Shanghai from July 18 to 20, 2014, at which ideas about treating HV were extensively solicited through live debate among experts and the interactive votes of representatives. The collected opinions were further discussed, improved and made into a Consensus on the Operative Correction of Hallux Valgus in April 2015 by the Foot and Ankle Working Committee, Orthopaedic Branch, Chinese Association of Orthopaedic Surgeons (Fig. 1). The preliminary collected opinions show that, for a first metatarsal osteotomy, 61% of surgeons would choose a distal chevron osteotomy, 17% preferred a scarf shaft osteotomy, 8% selected a Ludloff osteotomy, while 7% advocated a basal osteotomy. This result is based on the premise that there is an optimal surgical method. However, it is well known that there Address for correspondence Xin Ma, MD, Department of Orthopaedics, Huashan Hospital, Fudan University, 12 Middle Wulumuqi Road, Shanghai, China 200040 Tel: 0086-015921981259; Fax: 0086-21-62489191; Email: hsyyyb@huashan.org.cn Disclosure: The authors declare that they have no competing interests. List of consultant specialists: Peng Gao, Jian-chao Gui, Jian-jun Hong, Jin-song Hong, Yong Hu, Bao-guo Jiang, Dan Jin, Xiao-jun Liang, Xin Ma, Xu-dong Miao, Zhong-min Shi, Wei-dong Song, Kang-lai Tang, Xu Wang, Zheng-yi Wang, Yong Wu, Jing-yi Xin, Hai-lin Xu, Xiang-yang Xu, Yun-feng Yang, Guang-rong Yu, Hong-tao Zhang, Hui Zhang, Jian-zhong Zhang Received 28 May 2015; accepted 30 August 2015 2015;7:291 296 DOI: 10.1111/os.12207 bs_bs_banner

292 Fig. 1 Overview of management of hallux valgus (HV). DMAA, distal metatarsal articular angle; HVA, hallus valgus angle; IMA, intermetatarsal angle; MTP, metatarsal-phalangeal; TM, tarsometatarsal. are various pathological changes in HV deformity, so it is impossible to use one specific procedure to solve all problems. It requires a careful preoperative physical examination and radiographic assessment to choose the most suitable operation for each kind of deformity according to each pathological change, combined with good postoperative dressing, immobilization and proper rehabilitation and follow up, to improve surgical outcomes and reduce the postoperative rate of complications and patients dissatisfaction. These features constitute the significance of this consensus.

293 Definition of Hallux Valgus Hallux Valgus HV is best defined as a kind of angular deformity with an angle of more than 15 between the axis of the first metatarsal and that of the proximal phalangeal, which is usually known as hallux valgus angle (HVA). This increased angle is almost secondary to the medial deviation of the first metatarsal and lateral drifting of the hallux, and the deformity is frequently accompanied by sesamoid subluxation and load dysfunction of the first ray. Corrective Operation A corrective operation not only constitutes restoring normal alignment, but also the reconstruction of the function of the first ray. Both the relationship of the first metatarsal with the hallux and the sesamoid complex must be realigned so as to reconstruct the load mechanism of the first ray. To achieve these, both distal soft tissue procedures and osseous surgeries can be performed. Osseous surgeries are aimed to correct structural deformities, while soft tissue procedures help to restore the balance of the first metatarsal-phalangeal (MTP). Clinical Manifestation of Hallux Valgus Symptoms and Physical Signs The most common complaint of patients with HV is pain from a bunion, but it can also appear as a variety of other clinical symptoms. For example, the loading dysfunction of the first ray in HV feet may lead to a keratosis, callus or even metatarsalgia beneath the second and third metatarsal head. Pressure caused by the lateral drift of the hallux can result in overlapping toes, a hammer toe, dislocation of the lateral metatarsophalangeal joint or corns between the toes; the degeneration of the first metatarsophalangeal joint probably causes a limited range of motion or pain of the joint. Other signs include hallux pronation, first ray instability and so on. Radiographic Changes The main radiographic changes of HV include an HVA of more than 15, the first intermetatarsal angle (IMA) of more than 9 and sesamoids subluxation, as well as an increased distal metatarsal articular angle (DMAA) (less than 10 in healthy feet) and an increased hallux interphalangeal angle (less than 10 in healthy feet) 6. Diagnosis and Preoperative Evaluation of Hallux Valgus The diagnostic criteria of HV are relatively simple. It can be defined as when the HVA is greater than 15 on a dorsoplantar view of the foot with standard weight-bearing. However, its diagnosis, severity and pathology should be determined according to the patient s medical and family history, a physical examination and a radiographic evaluation. Medical History History-taking includes the pain location and duration, its influence on daily activity, management attempted, common shoes commonly worn, activity level, family history and so on. The patient s shoe wearing habit and family history are related to predisposition, while different pain locations reflect different pathological changes. For example, pain beneath lateral heads indicate there is much load or pressure here during the gait cycle; pain with the motion of the first MTP joint usually implies degenerative arthritis. Aggressive intervention should prioritize those who prefer wearing high-heel shoes or have a high activity level, while relatively conservative treatment could be considered for much less active patients. Physical Examination In addition to a routine evaluation, attention should also be paid to the range of the first MTP joint motion, the mobility of the first tarsometatarsal (TM) joint, pronation of the hallux, height of the longitudinal arch, tension of the gastrocnemius soleus (GS) muscle and so on. Limited MTP joint motion might be improved by the appropriate shortening of the first metatarsal; hypermobility of the first TM joint or collapse of the longitudinal arch may indicates arthrodesis. Akin osteotomy is often needed to correct obvious hallux pronation; gastrocnemius release can be used to reduce tension of GS muscle so as to alleviate forefoot load during normal gait. Radiographic Evaluation Radiographic measurement is an important step in preoperative assessment. Besides the measurement of HVA and IMA on weight-bearing DP (dorsal-plantar) radiographs, we should not ignore the DMAA, the hallux interphalangeal angle, degenerative signs and congruency of the first MTP joint and the relative length of each ray. The relationship between the first metatarsal head and two sesamoids can be indirectly assessed on a conventional dorsoplantar view, but some special devices can also be applied to get a weight-bearing sesamoid tangent view or a weight-bearing computed tomography scan, which could help to evaluate the metatarsal-sesamoid joint visually 7,8. In addition, some stress radiography or fluoroscopy is also very valuable. For example, fluoroscopy can help to evaluate reversibility under the manual reposition of the hallux and hallux-sesamoid joint, and to observe the reversibility of IMA when the foot is strapped. Classification There is no universally accepted classification of HV deformities. None is a perfect guide to the decision-making process on how to treat the deformity. The classification in this consensus is mainly based on HVA and IMA to define severity mentioned in surgical strategy. Mild HV is characterized by an HVA less than 20 and an IMA no more than 11 ; moderate HV is characterized by an HVA between 20 and 40, and an IMA no more than 16 ; severe HV is characterized by an HVA of more than 40 and an IMA of up to 16 or more 1. Surgical Strategy for Hallux Valgus Before decision-making, it is essential to understand the needs of the patients. It should be kept in mind that relieving patient s actual symptoms should be more important than

294 simply correcting the appearance. The patient s age, occupation, general conditions and daily activity level should be fully considered. Then a careful preoperative evaluation, as mentioned above, as well as classification and pathological types could facilitate the decision-making of individualized surgical strategies. Distal Soft Tissue Procedures The lateral release of the first MTP joint is the basic procedure, no matter which kind of metatarsal osteotomy would be performed. However, how to ensure balance around the joint is always a knotty problem, and which soft tissue should be removed has long been controversial 9 11. At present, the common consensus is that the lateral capsule of the first MTP joint should be released; other tissue that should be released involve the insertion of the adductor hallucis muscle to the base of the proximal phalanx, that is, the plantar plate lateral to the fibular sesamoid (the adductor hallucis muscle part of the conjoint tendon); the plantar plate between the fibular sesamoid and the base of the proximal phalanx (the lateral head of the flexor hallucis brevis muscle part of the conjoint tendon) should not be damaged; it is crucial to cut the fibular (lateral) metatarso-sesamoid suspensory ligament for the reduction of the sesamoids; it is sometimes necessary to release the plantar plate to a certain extent proximally for the complete release of the lateral soft tissue contracture; it is unnecessary to cut the deep transverse metatarsal ligament which connects with the lateral sesamoid, nor the insertion of the adductor hallucis muscle on the lateral sesamoid; plication of the medial joint capsule should also be emphasized after lateral release. Osseous Surgery Although the alignment of the MTP joint and the metatarsosesamoids joint can be restored to certain extent by the distal soft tissue procedure, osseous operations are needed for correcting the first metatarsal adductus (an increased IMA). Preoperative preparation includes an oscillating saw for osteotomy (different sizes of saw blade and a special crescent blade for proximal crescent osteotomy), bone forceps or towel forceps for clamping bone fragments, a small rongeur for the management of the articular surface before arthrodesis, and cannulated concave and convex reamers for MTP fusion. According to different procedures, certain types of internal fixation materials should also be prepared and disinfected. Distal Chevron Osteotomy Among different metatarsal osteotomies, a distal chevron osteotomy can be used to solve most HV deformities, because through rotation and adjustment of the distal fragment, the metatarsal head can be pushed laterally, depressed or even derotated to correct the pronation of the first metatarsal in some HV feet. Biplanar chevron osteotomy can be performed to correct increased DMAA 12. If the reduction of the hallux is still difficult after sufficient release, appropriate shortening could be performed during osteotomy to help reduction. In addition, this procedure involves relatively less trauma and simpler manipulation than other osteotomies. Based upon previous experience, distal chevron osteotomy is usually used to correct mild to moderate HV deformity. When faced with a severe deformity, especially an IMA that is greater than 15, its correction ability is limited. Therefore, shaft or basal osteotomy should be considered for severe HV deformity with an IMA greater than 20. Shaft Osteotomy The scarf osteotomy and Ludloff osteotomy of the metatarsal shaft have a relatively greater ability than distal osteotomies to correct IMA. Due to the larger contact surface of the osteotomy, the healing rate should theoretically be faster than other procedures. But it may be difficult to correct the pronation of the first metatarsal using these two procedures. As for the difficulty of a shaft osteotomy, different surgeons have presented different feedback. Some of them encountered complications during or after the surgery, such as the trench effect, under correction, hallux varus and even avascular necrosis of the metatarsal head, which might be related to the individual surgeon s proficiency and skills when performing shaft osteotomies 13,14. However, without doubt, many skilled foot and ankle experts can carry out scarf or Ludloff osteotomy flexibly or even modify them according to their own needs so as to achieve an ideal correction of most HV deformities 15,16. Controversies in regard to a distal chevron osteotomy and a shaft scarf osteotomy still exist. Some experts believe that the correction ability of the chevron procedure is not lower than that of the scarf. Even for severe deformities, satisfactory correction results may also be obtained by the modification of the osteotomy line and displacement control of the first metatarsal head 13,14. But one should note that the technique of chevron procedure for the correction of severe HV deformities has not been mastered yet by most foot and ankle surgeons. Therefore, selection of correction methods based on corresponding deformity severities are still recommended in most situations. Basal Osteotomy The proximal metatarsal osteotomies are best for correcting a large IMA angle and they are thus commonly indicated for moderate to severe deformities 17. The osteotomy line may be deviated closer to the base of the metatarsal when extensive distal soft tissue release is performed. The pronation of first metatarsal can also be corrected by rotating the distal segment after basal osteotomy. For instance, if the direction of a proximal crescent osteotomy as well as an open osteotomy are well controlled both at the coronal and sagittal planes, threedimensional corrections can then be achieved. The length of first metatarsal will increase to a certain extent after an open proximal osteotomy and therefore, is more suitable for HV deformities with a relatively shortened first metatarsal. Combining it with distal osteotomy procedures is appropriate for patients with a large DMAA but may increase the risk of first metatarsal avascular necrosis. Proximal osteotomies have been increasingly accepted by foot and ankle surgeons due to modifications in surgical instruments and the decreasing incidence of complications. Constant improvements in internal fixation

295 materials have greatly resolved problems in terms of the loss of corrections or delayed unions which contribute the most to the failures of fixations. First Tarsometatarsal Joint Arthrodesis The relationship between the mobility of the first TM joint and HV deformities is still uncertain. A first TM joint arthrodesis (Lapidus procedure) has been widely used in recent decades, since the hypermobility of first TM joint has long been regarded as the cause and accelerating factor in HV deformities 18. Nonetheless, more recent studies have demonstrated that the first TM joint is more unstable with the development of HV deformities. Such findings result from the impaired stabilizing functions of the plantar aponeurosis to the first ray after the presence of an abnormal alignment of the plantar aponeurosis during HV deformities. The instability may only be the consequence of the deformity formation instead of its cause 19. Large amounts of clinical and biomechanical evidence demonstrate there is obvious recovery of the first TM joint stability after extraarticular osteotomies rather than joint arthrodesis 20 22. Therefore, the common point of view nowadays is that arthrodesis is not necessary for the correction of first TM joint instabilities. Moreover, the Lapidus procedure is associated with a relatively high rate of non-union and is technically more complicated than osteotomies. It is more often indicated at present, for severe HV deformities, in particular for those patients with obvious laxity of the first TM joint and the pes planus. The First MTP Joint Arthrodesis The first MTP joint arthrodesis is suitable for the treatment of severe HV deformities (HVA > 50 ), rheumatoid arthritisrelated HV deformities, HV with obvious degenerations of first MTP joint and deformities originating from nervous system diseases 23,24. It can be also selected as a revision procedure after the failure of initial HV surgeries. Some experts suggest proper expansion of the indications for first MTP joint fusion due to its satisfactory results for deformity correction and pain relief. The preoperative evaluation on the difficulty of joint fusion should be noted. Application of compression screws along with dorsal plate fixations can generally obtain the best biomechanical strength and as a consequence, the highest union rate. Delayed postoperative weight bearing should be introduced in patients with rheumatoid arthritis. Other Procedures Besides the above frequently used procedures, several others also serve as important supplements. For example, a distal Reverdin osteotomy is used to reduce increased DMAA; Akin procedures can be used to correct hallux pronation or interphalangeal valgus; Weil osteotomy should be used to treat calluses or even metatarsalgia beneath the lateral metatarsal head, as well as the dislocation of lateral MTP joints. Postoperative Management Postoperative dressings after the correction of HV are of equal importance. Compression dressing should be applied in the first week. The wound dressing is routinely changed twice a week and all sutures are removed at 2 weeks. Postoperative dressing should follow the fashion that the bandage wraps the right foot in a counter-clockwise direction and wraps the left foot in a clockwise direction. Such dressing techniques or utilizing a toe-separation pad can be helpful to hold the great toe in anatomic alignment and should be maintained until 6 weeks. Either the below knee plaster should be used for fixation or a forefoot decompression shoe for weight-bearing avoidance at the forefoot. An anteroposterior radiograph should be obtained at 6 weeks after surgery to confirm the alignment of first MTP joint. If the pain can be endured, active and passive motion exercises of the MTP joint should then be started to prevent joint stiffness. Walking with wide shoes can be permitted when the bone union is achieved. Activity levels should be gradually increased until complete recovery to normal daily life. Summary With better understanding of the pathological processes of HV deformity, corrective procedures are continuously invented, selected, abandoned, or popularized. The methods referred in this consensus are those most accepted at present and have been recommended by a great many foot and ankle surgeons after decades of clinical practice. They have their own pros and cons which may compensate for each other and are indicated for different pathological types of HV deformities. As foot and ankle surgeons, it is necessary to be fully aware of patients desires, to carefully evaluate different pathological processes and clinical symptoms and to become skilled in various procedures. Then these procedures can be easily selected, converted and combined, based on preoperative plans and intraoperative conditions, together with proper rehabilitation programs, in order to achieve satisfactory outcomes through individualized treatments. References 1. Hecht PJ, Lin TJ. Hallux valgus. Med Clin North Am, 2014, 98: 227 232. 2. Sim-fook L, Hodgson AR. A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J Bone Joint Surg Am, 1958, 40: 1058 1062. 3. Torkki M, Malmivaara A, Seitsalo S, Hoikka V, Laippala P, Paavolainen P. 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