Hallux Valgus in Men.

Part II: Surgical Treatment

Caio Nery, MD Michael Coughlin, MD Daniel Baumfeld, MD

Disclosure

Caio Nery, M.D. – See Disclosure Information at the AAOS Disclosure Program. There is nothing to disclose related with the subject of this presentation.

Daniel Baumfeld, M.D. – See Disclosure Information at the AAOS Disclosure Program. There is nothing to disclose related with the subject of this presentation

Michael Coughlin, MD . – Elsevier (royalties) / Arthrex, Inc (consultant, royalties). Fore more details, please refer to Disclosure Information at the AAOS Disclosure Program.

Introduction • In the first part of our study we concluded that the Hallux Valgus deformity in men

is hereditary, mainly transmitted by maternal genes, starts precociously and appears more intensely than in women

• The incidence in our study was of 15 women for every man and the Distal Metatarsal Articular Angle (DMAA) proved to be the main intrinsic factor responsible for the expressivity of Hallux Valgus in the male sex.

• In this second part of our study, the goal is to evaluate the response of these patients to the surgical treatment

Variable Characteristic Interpretation

Age Group Balanced incidence in the groups Earlier onset than the deformity in women.

Hereditariness Positive in 68% of the cases (58% maternal and 10% paternal) Reinforces the genetic origin and the juvenile

onset form.

Inadequate footwear There was no correlation Predominance of intrinsic factors

Hallux Valgus Angle, Distal Metatarsal Articular Angle, Tarsal-Metatarsal Angle Significantly higher than in women (especially DMAA) Deformity more intense in

men

Hallux Metatarsal-phalangeal Congruence More frequent among men (2:1)

Reflects the action of the intrinsic agents on the deformity, especially

DMAA.

Bilateralism Bilateral in 71% of the cases The finding is not exclusive to men

Valgus Flatfeet There was no correlation between HV and flatfeet The finding is not exclusive to men

Methods

Deformity HVA IMA Sesam DMAA Techniques

Light 15 ~ 20 10 ~15 G0~G1 <8 Simple Chevron

>8 Biplanar Chevron

Moderate 21 ~ 40 16 ~20 G1~G1 <8 Mitchell / Scarf / Proximal

Osteotomy

>8 Biplanar Mitchell or Scarf /

Proximal Osteotomy combined with a biplanar Chevron

Severe >40 >20 G2~G3 <8 Scarf or Proximal Osteotomy

>8 Biplanar Scarf or Proximal Osteotomy combined with a

biplanar Chevron

• Data from fifty feet of male patients with Hallux Valgus, who were surgically treated by the same surgeon between 1985 and 2005, were retrospectively analyzed • The average follow-up was 10 years (min of 2 and max of 20 years). • All the radiographic measurements were obtained electronically, through the software M2000 (Tesseract, Brazil). This program functioning is based on a series of customized “scripts” that uniforms the methodology of measurements.

Table – Algorithm for the treatment of Hallux Valgus

Results

Table – Pre and Post-Operative Angular Values of patient groups as a whole, without taking into account

the surgical treatment adopted. The significant p values were marked with an asterisk.

Parameter PRE Mean (SD)

POST Mean (SD) p

HVA 29 (9) 17 (8) <0,001*

IMA 11 (3) 7 (3) <0,001*

DMAA 17 (7) 9 (8) <0,001*

ATM 22 (4) 18 (4) <0,001*

IFHV 7 (7) 11 (5) <0,001*

PPAA 3 (4) 6 (5) <0,001*

DPAA 6 (5) 3 (4) <0,001*

MTF-1 Articular

Congruence

Pre-operativ

e

Post-operativ

e

Incongruent N %

21 42%

9 18%

Congruent N %

29 58%

41 82%

Total N %

50 100%

50 100%

Table –Articular congruence of the MTF-1, pre and post-operative. Grouped patients without considering the surgical procedure

adopted

Results

Techniques Number of procedures

Light Deformity

Moderate Deformity

Severe Deformity

Simple Chevron 10 4 6 0

Biplanar Chevron 9 5 4 0

Mitchell Osteotomy

12 0 10 2

Scarf Osteotomy

9 1 5 3

Proximal Osteotomy

10 0 5 5

Total 50 10 30 10

Table – Composition of our sample according to the deformity severity and surgical technique used

Results

Simple Chevron

Biplanar Chevron

Mitchell Osteotomy

Scarf Osteotomy

Proximal Osteotomy

TOTAL Means

N (feet) 10 9 12 9 10 50

HVA 48% 39% 50% 22% 43% 40%

IMA 49% 18% 47% 7% 55% 35%

Sesamoids 69% 32% 84% 0% 60% 49%

DMAA 65% 43% 53% 17% 17% 39%

Pre AOFAS 42 47 33 31 31 37

Post AOFAS 86 90 78 68 81 81

Correction 44 43 45 37 50 44

85 points or + 60% 89% 54% 0% 18% 44%

Table – Comparison of the relative corrective capacity of each surgical technique employed, values of the AOFAS score in the pre and post-operative periods, the score of the correction

achieved and the percentage of patients with 85 points or more in the final assessment.

Complications

Patent with complication of the Basal Osteotomy combined with the distal biplanar osteotomy: a. initial x-ray of the right foot – AP with load; b. X-ray of the right foot in the 3rd PO week; c. X-ray of the right foot in the 6th PO week – the fracture of the synthesis material can be noticed with the deviation and shortening of the metatarsal due to the non healing of the proximal osteotomy site; d. Intra-operative aspect showing the fracture of the plate used to fix the osteotomy; e. X-ray of the right foot with 2 years of evolution of the reoperation with grafting.

Conclusions

The characteristic Hallux Valgus deformities in men were adequately corrected by the techniques employed, thus validating the use of the same treatment algorithm in both genders. We were unable to detect any factor or characteristic that determines a greater difficulty or resistance to the treatment of Hallux Valgus deformities in men. The complication rate observed in this study was of 10% of the cases. Scarf osteotomy presented a lower correction capacity than the other techniques studied. According to our analysis, it should be indicated in cases milder than those recommended in the literature. This observation, nonetheless, is not restricted to male patients. The techniques employed had different DMAA corrective capacity (Scarf and proximal osteotomy alone with 17% of capacity to correct the altered DMAA and the others techniques with at least 43%).

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