835520

research-article2019
FAIXXX10.1177/1071100719835520Foot & Ankle InternationalShima et al

Article

Foot & Ankle International®

Operative Treatment for

1­–7
© The Author(s) 2019
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DOI: 10.1177/1071100719835520
https://doi.org/10.1177/1071100719835520

to Severe Metatarsus Adductus journals.sagepub.com/home/fai

Hiroaki Shima, MD, PhD1 , Ryuzo Okuda, MD, PhD2, Toshito Yasuda, MD, PhD1,
Katsunori Mori, MD1, Momoko Kizawa, MD1, Seiya Tsujinaka, MD1,
and Masashi Neo, MD, PhD1

Abstract
Background: Operative treatment is indicated for patients who have symptomatic hallux valgus (HV) with moderate
to severe metatarsus adductus (MA). However, there is limited information available on the operative procedures and
outcomes for the treatment of HV with MA. We aimed to investigate the average 10-year follow-up clinical and radiologic
outcomes.
Methods: Seventeen patients (21 feet, average age: 60.1 years) with symptomatic HV with moderate to severe MA were
operatively treated. Mean postoperative follow-up duration was 114.4 (24-246) months. All feet had metatarsus adductus
angle ≥20 degrees on dorsoplantar weight-bearing radiograph. The procedure included a proximal crescentic osteotomy
of the first metatarsal and abduction osteotomy of the proximal third of the second and third metatarsals.
Results: The mean American Orthopaedic Foot & Ankle Society scale score improved significantly postoperatively (P <
.001). The mean postoperative visual analog scale score (17 feet) was 2.0 (0-6). Preoperative metatarsalgia was severe in 2
feet, moderate in 17, and mild in 2. At the most recent follow-up evaluation, 11 feet had no pain, 9 had mild pain, and 1 had
moderate pain. The mean hallux valgus angle, intermetatarsal angle, and metatarsus adductus angle significantly decreased
postoperatively (P < .001 for all). Recurrence of HV (HV angle ≥ 20 degrees) was observed in 4 feet.
Conclusion: The clinical and radiologic results indicated that our novel operative treatment for HV with moderate to
severe MA can achieve significant correction of HV with MA deformities and significant improvement in pain and function.
Level of Evidence: Level IV, retrospective case series.

Keywords: hallux valgus, metatarsus adductus, abduction osteotomy, operative treatment

Introduction
Metatarsus adductus (MA) is a congenital transverse plane
deformity, in which the metatarsus is in an adducted posi-
tion relative to the longitudinal axis of the lesser tarsus.12
The incidence of MA in patients with hallux valgus (HV)
was reported to be 21.6% to 29.5%,2,7 and a linear correla-
tion between an increasing juvenile hallux valgus angle
(HVA) and an increasing metatarsus adductus angle (MAA)
was reported.3
Operative treatment is indicated for patients who have
symptomatic HV with moderate to severe MA when con-
servative treatment fails. HV with MA is characterized by
an abnormally low 1–2 intermetatarsal angle (IMA) result-
ing from the medial deviation of both first and second
metatarsals.8 It is difficult to operatively treat an HV
deformity with significant MA, because the space between
the first and second metatarsals is too narrow to correct the
metatarsus primus varus with an osteotomy of the first
metatarsal. There is little available information on the
operative procedures and outcomes for the treatment of
HV with MA.19,24 Aiyer et al reported that the recurrence
rate of HV with MA after HV correction alone was higher
than that of HV without MA.1 However, it is unknown
1
Department of Orthopedic Surgery, Osaka Medical College, Takatsuki,
Osaka, Japan
2
Department of Orthopaedic Surgery, Shimizu Hospital, Nishikyo-ku,
Kyoto, Japan
Corresponding Author:
Hiroaki Shima, MD, PhD, Department of Orthopedic Surgery, Osaka
Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan.
Email: ort125@osaka-med.ac.jp
2 Foot & Ankle International 00(0)
whether HV alone should be corrected or if MA as well as
HV should be corrected simultaneously.
Since 1997, we have performed a proximal crescentic
osteotomy combined with a proximal abduction osteotomy
of the second and third metatarsals for HV with moderate to
severe MA. In 2002, one of the authors reported a case
treated with our novel procedure for severe HV with MA.19
The purpose of the present study was to investigate the
average 10-year follow-up clinical and radiologic outcomes
of 17 patients (21 feet) who underwent our operative proce-
dure for symptomatic HV with moderate to severe MA.
Methods
This study was approved by the institutional review board.
Between October 1997 and April 2016, patients who had
symptomatic moderate to severe HV with MA were treated
with our combined procedure. MA was considered if MAA
was ≥20 degrees on a dorsoplantar weight-bearing radio-
graph. All patients were operated by 3 of the authors.
Conservative treatment, including shoe modification, non-
steroidal anti-inflammatory medications, and arch supports,
had failed in all patients. Preoperatively, all patients had
pain on the medial side of the first metatarsophalangeal
(MTP) joint and painful callosities at the second and/or
third metatarsal heads. The inclusion criteria were as fol-
lows: (1) patients who underwent an operation at our hospi-
tal after having undergone unsuccessful conservative
treatment and (2) those with a minimum follow-up of 2
years. The exclusion criteria were as follows: patients with
a history of prior foot surgery, rheumatoid arthritis, or hal-
lux rigidus.
The indications for operative intervention were symp-
tomatic moderate to severe HV deformity (HVA >25
degrees and/or IMA >12 degrees) in addition to MA. The
degree of MA was classified according to the MAA on a
dorsoplantar weight-bearing radiograph.8 The magnitude of
MA was assessed to measure the MAA, which consists of
the bisection of the lesser tarsal bones relative to the long
axis of the second metatarsal bone.9,10,13 Normal MAA is 0
to 15 degrees, mild MA is 16 to 19 degrees, moderate MA
is 20 to 25 degrees, and severe MA is >25 degrees.8
A total of 20 patients (24 feet) who had symptomatic
moderate to severe HV with MA and who were treated with
our combined procedure were included. Three patients (3
feet) were lost to follow-up. The remaining 17 patients (16
women and 1 man, 21 feet) were available for follow-up.
The mean age of the patients was 60.1 (range, 35-77) years.
The mean postoperative follow-up duration was 114.4
(range, 24-246) months.
Three feet had HVA<40 degrees, 8 feet had HVA 40 to
49 degrees, and 10 feet had HVA ≥50 degrees. Twelve feet
had moderate MA (20 degrees ≤ MAA ≤ 25 degrees) and
9 had severe MA (MAA > 25 degrees). Four feet also
underwent open reduction and collateral ligament recon-
struction of a second MTP joint dislocation, and 3 feet
underwent collateral ligament reconstruction of both the
second and third MTP joint dislocations.25
Clinical and Radiologic Assessments
The clinical assessment included the American Orthopaedic
Foot & Ankle Society (AOFAS) hallux-MTP-interphalan-
geal scale, severity of metatarsalgia, and patient satisfaction.
The severity of metatarsalgia was rated as none, mild, mod-
erate, and severe by the patients before the procedure and at
the most recent follow-up. Clinical evaluations were per-
formed using a visual analog pain scale (VAS) and the Self-
Administered Foot Evaluation Questionnaire (SAFE-Q)18 to
assess the quality of life (QOL) of patients with pathologic
conditions related to the foot and ankle. The SAFE-Q con-
sists of 34 questions, and the outcomes are expressed as
scores on the following 5 subscales: pain and pain-related,
physical functioning and daily living, social functioning,
general health and well-being, and shoe-related. Each sub-
scale score ranges from 0 to 100, with higher scores indicat-
ing better results. The SAFE-Q appears to be sufficient for
the evaluation of foot-related QOL before and after surgery
in patients with HV.17 In addition, patients were asked
whether they were satisfied, satisfied with reservation, or
dissatisfied with the overall results of the surgery.
Dorsoplantar and lateral weight-bearing radiographs
were taken preoperatively and at the most recent follow-up.
Radiologic assessments included measurement of HVA (the
angle between the longitudinal axes of the first metatarsal
and the proximal phalanx), IMA (the angle between the lon-
gitudinal axes of the first and second metatarsals), and MAA
on the dorsoplantar radiographs. The longitudinal axis of the
first metatarsal was defined as the line connecting the center
of the metatarsal head with the center of the proximal articu-
lation.26 The longitudinal axis of the proximal phalanx was
defined as the line connecting the center of the proximal end
of the diaphysis with the center of the distal end of the diaph-
ysis. The longitudinal axis of the second metatarsal was
defined as a line connecting the center of the proximal end of
the diaphysis with the center of the distal end of the diaphy-
sis. The measurement of the MAA was performed as fol-
lows. First, the medial midpoint between the talonavicular
and first metatarsocuneiform joint and the lateral midpoints
between the calcaneocuboid and fifth metatarsocuboid joint
were connected. Next, the angle between the line perpen-
dicular to that line and the longitudinal axis of the second
metatarsus was measured as MAA (Figure 1). The measure-
ment of MAA was demonstrated to have high inter- and
intraclass coefficients of 0.87 and 0.92, respectively.9,10
The inclination angle of the first metatarsal was mea-
sured on the lateral weight-bearing radiographs. The incli-
nation angle was the angle between the longitudinal axis of
Shima et al
Figure 1. The measurements on a dorsoplantar weight-bearing
radiograph: hallux valgus angle (a); intermetatarsal angle (b);
metatarsus adductus angle (c).
the first metatarsal and the floor. The longitudinal axis of
the first metatarsal was defined as a line connecting the cen-
ter of the proximal articular surface with the center of the
distal end of the diaphysis.21
Operative Technique
A 3-cm curved incision that was dorsally convex was made
on the dorsomedial side of the first MTP joint. The medial
eminence was excised minimally to preserve the distal
articular surface of the first metatarsal head. A 2-cm dorsal
longitudinal skin incision was made between the first and
second metatarsal heads. The adductor hallucis tendon was
dissected from its insertion. The transverse metatarsal liga-
ment was released, and a longitudinal incision was made in
the dorsolateral aspect of the capsule of the first MTP joint.
A 3-cm dorsomedial longitudinal skin incision was made
over the first metatarsal base. Crescentic osteotomy was
performed 1.5 cm distal to the metatarsocuneiform joint.
The osteotomy was curvilinear, and the concavity of the cut
was directed distally (Figure 2).
A 3-cm dorsal longitudinal incision was made between
the base of the second and third metatarsals. Proximal
oblique osteotomies of the second and third metatarsals
were performed at the proximal third with an angle of
approximately 60 degrees to the long axis of the metatarsal
using an oscillating saw. After completion of the osteoto-
mies, the distal fragment of the second metatarsal was
abducted so that MAA approached the normal mean value
(MAA ≤15 degrees). In case of excessive second metatar-
sal projection, the distal fragment was dorsally and proxi-
mally displaced to shorten the second metatarsal length
3
Figure 2. Operative procedures. (A) Proximal oblique
osteotomies of the second and third metatarsals were done
at an angle of approximately 60 degrees to the long axis of
the metatarsal using an oscillating saw. The distal fragment of
the second and third metatarsals were abducted so that the
metatarsus adductus angle became nearly the normal mean value
and were fixed with bone screws. (B) The crescentic osteotomy
of the first metatarsal was performed and the distal fragment of
the first metatarsal was moved laterally. Then, a locking plate
was used to fix the osteotomy site.
simultaneously. After the MAA and metatarsal length were
checked intraoperatively using fluoroscopy, the osteotomy
site was fixed with a bone screw or a bone screw and a 1.0-
mm Kirshner wire. The distal fragment of the third metatar-
sal was moved parallel and with equal projection to that of
the distal fragment of the second metatarsal, and the oste-
otomy site was fixed with a bone screw or a bone screw and
a 1.0-mm Kirshner wire.
The distal fragment of the first metatarsal was moved
laterally, and the proximal fragment was moved medially to
correct the metatarsus primus varus. Two or 3 crossed 1.5-
mm Kirschner wires were used to fix the osteotomy site in
early cases (18 feet). In order to achieve more rigid fixation,
a locking plate was used in late cases (3 feet; Figure 3).
The medial capsule of the first MTP joint and the abduc-
tor hallucis tendon were plicated in the desired corrected
position of the great toe.
Postoperative Management
A short leg cast and non-weight-bearing walking were con-
tinued for 3 weeks. At 4 weeks, partial weight-bearing in a
short leg plaster shell as well as active and passive range of
motion exercises were encouraged. At 7 weeks, patients
4 Foot & Ankle International 00(0)

Figure 3. A 67-year-old woman with a severe hallux valgus deformity and significant metatarsus adductus. (A, B) A preoperative
anteroposterior weight-bearing radiograph demonstrating a hallux valgus angle of 52 degrees, an intermetatarsal angle of 14 degrees,
a metatarsus adductus angle of 32 degrees, and an inclination angle of 20 degrees. (C, D) At the 54-month follow-up evaluation, an
anteroposterior weight-bearing radiograph demonstrating a hallux valgus angle of 15 degrees, an intermetatarsal angle of 2 degrees, a
metatarsus adductus angle of 11 degrees, and an inclination angle of 16 degrees.

were instructed to wear shoes with arch supports, and full Table 1. The AOFAS Score.a
weight-bearing walking was allowed. Patients were encour-
Most Recent
aged to return to activities of daily living as tolerated. Preoperative Follow-up P Value
Pain (40) 19.0 (0-30) 35.2 (20-40) <.001
Statistical Analysis
Function (45) 28.8 (9-42) 41.0 (35-45) <.001
Preoperative and postoperative clinical and radiologic data Alignment (15) 0.76 (0-8) 13.6 (0-15) <.001
were compared using the Wilcoxon signed-rank test. Total (100) 48.6 (27-65) 89.9 (57-100) <.001
Differences with P <.05 were considered significant. a
The American Orthopaedic Foot & Ankle Society hallux-
metatarsophalangeal-interphalangeal score. Values are presented as the
mean with range.
Results
Clinical Outcome patients (5 feet) were satisfied with reservation, and 1 patient
The mean AOFAS score improved significantly from an aver- (1 foot, 5%) was dissatisfied with the overall results of the sur-
age of 48.6 (range, 27-65) points preoperatively to 89.9 (range, gery at the most recent follow-up.
57-100) points at the most recent follow-up (P < .001). The At the final follow-up, 14 patients (17 feet) were evalu-
mean pain, function, and alignment scores improved signifi- ated using the VAS and SAFE-Q, and overall patient satis-
cantly from 19.0 (range, 0-30), 28.8 (range, 9-42), and 0.76 faction was also assessed with questionnaire. The mean
(range, 0-8) points preoperatively to 35.2 (range, 20-40), 41.0 postoperative VAS score was 2.0 (range, 0-6.1). The aver-
(range, 35-45), and 13.6 (range, 0-15) points at the most recent age score was 77.7 (range, 33.2-100) for pain and pain-
follow-up, respectively (Table 1). Preoperative metatarsalgia related, 75.3 (range, 18.2-100) for physical functioning and
was severe in 2 feet, moderate in 17, and mild in 2. At the most daily living, 81.9 (range, 0-100) for social functioning, 83.5
recent follow-up, 11 feet had no pain, 9 had mild pain, and 1 (range, 45.0-100) for general health and well-being, and
had moderate pain. Eleven patients (15 feet) were satisfied, 5 60.8 (range, 8.3-100) for shoe-related (Table 2).
Shima et al 5

Table 2. VAS and SAFE-Q Scores at the Most Recent Follow-up. severe recurrence of HV with metatarsalgia. One year after
revision surgery, there were no symptoms and the HVA and
Median
Subscale Mean (Range) (Quartiles) IMA were corrected to 5 and 2 degrees, respectively. None
of the feet had hallux varus deformity, defined as HVA <0
VAS 2.0 (0-6) 1.6 (0-4) degrees, at the most recent follow-up. Postoperative trans-
Pain and pain-related 77.7 (33-100) 90.3 (62-96) fer lesion developed in 1 foot beneath the fourth metatarsal
Physical functioning and daily 75.3 (18-100) 84.1 (61-97) head. Metatarsalgia of this patient improved using insole.
living
None of the patients had nerve injury, infection, or delayed
Social functioning 81.9 (0-100) 91.7 (88-96)
wound healing.
General health and well-being 83.5 (45-100) 90.0 (75-95)
Shoe-related 60.8 (8-100) 66.7 (38-79)
Discussion
Abbreviations: SAFE-Q, Self-Administered Foot Evaluation
Questionnaire; VAS, visual analog scale. In the present study, we described operative treatment con-
sisting of a proximal crescentic osteotomy combined with a
Table 3. Radiographic Measurements.a distal soft-tissue procedure and a proximal abduction oste-
otomy of the second and third metatarsals for correction of
Preoperative Most Recent Follow-up P Value
HV with MA and retrospectively reviewed the average
HVA (degrees) 47.2 (26-62) 14.4 (0-37) <.001 10-year follow-up results of 17 patients (21 feet) who
IMA (degrees) 14.9 (10-21) 4.8 (–6 to 11) <.001 underwent this procedure. Our clinical and radiologic
MAA (degrees) 24.6 (20-37) 14.4 (7-22) <.001 results indicated significant improvement in pain and func-
IA (degrees) 16.2 (13-20) 13.5 (6-20) .001 tion and significant correction of HV and MA deformities.
Abbreviations: HVA, hallux valgus angle; IMA, intermetatarsal angle;
To our knowledge, this is the first case-series study to report
MAA, metatarsus adductus angle; IA, inclination angle. the operative outcomes of patients with severe HV associ-
a
The values are presented as the mean with range. ated with MA. In addition, there are no reports about the
intermediate and long-term follow-up results, such as a
median of 10 years, of such cases.
Radiologic Outcomes MA is a congenital deformity with an incidence of 0.1%
Successful union was observed at the osteotomy sites in all in the general population, and its etiology is not clear.
patients. There was no delayed union in any patients. The Although several investigators have reported on the rela-
mean HVA, IMA, and MAA significantly decreased, from tionship between HV and MA in adults,11,14 it is unknown
47.2 degrees (range, 26.0-62.0), 14.9 degrees (range, 10.0- whether they have a positive or negative relationship. HV
21.0), and 24.6 degrees (range, 20.0-37.0) preoperatively to associated with significant MA is difficult to treat opera-
14.4 degrees (range, 0-37.0), 4.8 degrees (range, –6.0 to tively, because the space between the first and second meta-
11.0), and 14.4 degrees (range, 7.0-22.0) postoperatively, tarsals is too narrow to correct the metatarsus primus varus
respectively (P < .001 for all) (Table 3). The mean inclina- with osteotomy of the first metatarsal alone. Consequently,
tion angle of the first metatarsal decreased significantly osteotomy of the first metatarsal alone may lead to incom-
from 16.2 degrees (range, 13.0-20.0) preoperatively to 13.5 plete correction of the metatarsus primus varus, even if the
degrees (range, 6.0-20.0) postoperatively (P = .001) (Table first and second IMA were properly corrected. Correction
3). Of 18 feet fixed with Kirschner wires, 5 feet (28%) had osteotomies of the lesser metatarsals may be required to
a decrease of ≥5 degrees in the inclination angle between correct the metatarsus primus varus deformity in HV with
the preoperative and final follow-up. All 3 feet fixed with a significant MA. Therefore, we devised a novel operative
locking X-plate had a decrease of ≤4 degrees. treatment consisting of a proximal crescentic osteotomy
with a distal soft-tissue procedure and a proximal abduction
osteotomy of the second and third metatarsals.
Complications In the present study, the mean AOFAS score improved
The recurrence of HV deformity, defined as HVA ≥20 significantly from 49 points preoperatively to 89 points
degrees, was observed in 4 feet (19.0%; HVA: 24, 24, 28, with a patient satisfaction rate of 95% at the final follow-up,
and 37 degrees) at the most recent follow-up. All 4 feet had and the average HVA decreased from 47 to 14 degrees.
severe HV deformity, with preoperative HVA ≥50 degrees. Markbreiter et al15 reported the results of 25 crescentic oste-
One of these patients did not have pain, joint stiffness, or otomies after a mean follow-up of 62 months and found that
difficulty wearing shoes. Two feet had mild pain but no the mean AOFAS score improved significantly from 47 to
joint stiffness and no difficulty wearing shoes. The remain- 93 points with a patient satisfaction rate of 96%, and the
ing 1 foot required revision surgery with a Lapidus proce- average HVA decreased from 38 to 12 degrees. Veri et al27
dure at 24 months after the primary surgery because of reviewed the results of 31 crescentic osteotomies after a
6 Foot & Ankle International 00(0)
mean follow-up of 12 years and found that the mean AOFAS
score improved significantly from 37 points to 92 points
with a patient satisfaction rate of 94%, and the average HVA
decreased from 37 to 13 degrees. Coughlin et al6 presented
the results of 122 crescentic osteotomies after a mean fol-
low-up of 27 months and found that the mean AOFAS score
improved significantly from 57 points to 91 points with a
patient satisfaction rate of 93%, and the average HVA
decreased from 30 to 10 degrees. Our clinical and radio-
logic findings suggested that the outcomes after a mean
follow-up of 10 years were compatible with those reported
for the crescentic osteotomy, although 18 feet (86%) had a
preoperative HVA of ≥40 degrees in the present study.
Postoperative HV recurrence is a common complication
in HV surgery. Several authors have reported an HV recur-
rence rate of (HVA ≥ 20 degrees) ranging from 4% to 30%
following a proximal or shaft osteotomy of the first meta-
tarsal, and these HV recurrence rates were observed in
those with moderate to severe HV with a mean preopera-
tive HVA ranging from 31 to 39 degrees.4,5,16,21,23 To our
knowledge, there have been no reports of postoperative
recurrence rates in those with a severe HV deformity (HVA
≥40 degrees). A preoperative HVA of ≥40 degrees is sig-
nificantly associated with postoperative recurrence of
HV.22,23 Two studies reported on the mean preoperative
HVAs in patients with and without postoperative recur-
rence (HVA ≥20 degrees) following a proximal metatarsal
osteotomy. The mean preoperative HVA in patients with
recurrence and no recurrence was 45.5 ± 7.1 degrees and
36.0 ± 7.7 degrees in one study,20 and 43.3 ± 9.5 degrees
and 33.7 ± 6.9 degrees in the other, respectively.23 These
results suggest that the postoperative recurrence rate in
those with severe HV is likely to be higher than that in
those with mild to moderate HV. In addition, preoperative
moderate to severe MA is significantly associated with
postoperative recurrence of HV.1,23 Aiyer et al1 reported on
the HV recurrence rate (HVA ≥ 20 degrees) in patients
with moderate to severe MA who underwent HV correction
alone using a distal or proximal first metatarsal osteotomy
or a Lapidus procedure, and found that the HV recurrence
rate was 29% and was close to 2 times higher than that of
HV without MA. In their study, the mean preoperative
HVA in patients with MA was 33.6 degrees, which might
explain how most patients had mild to moderate HV preop-
eratively. In the present study, the mean preoperative HVA
was 47.2 degrees, and 18 (85.6%) of the 21 feet had severe
HV preoperatively. Although the mean preoperative HVA
in the present study was higher than that in the previous
studies4,5,16,21,23 and the mean preoperative MAA (24.6
degrees) in the present study was higher than that reported
by Park et al,23 the recurrence rate of 19.0% in the present
study falls within the range in the previous reports.4,5,16,21,23
In addition, all 4 feet with recurrence had preoperative
HVA of ≥50 degrees. In severe hallux valgus, a large
amount of correction of the metatarsus primus varus is
needed. We believe that the large displacement of the distal
metatarsal fragment at the osteotomy site leads to the great
instability at this site, and postoperative loss of correction
at the osteotomy site may be a cause of postoperative recur-
rence. Therefore, we now use a locking plate for a more
rigid fixation as opposed to K-wire fixation in patients with
severe hallux valgus.
The SAFE-Q is a reliable and valid measurement tool to
evaluate foot-related QOL before and after HV surgery.17
To our knowledge, no studies have used the SAFE-Q to
evaluate the outcomes of HV surgery in patients without
rheumatoid arthritis. In the present study, the SAFE-Q was
only used in 14 patients (17 feet) at the final follow-up
because this measurement tool was devised in 2013.
Statistical assessment for the efficacy of our operative treat-
ment was limited by the SAFE-Q, although all subscale
indices except the shoe-related index were relatively good.
We believe that the postoperative SAFE-Q score in the
present study can be used as a reference for evaluating clini-
cal outcomes in patients who underwent HV surgery.
In the present study, the inclination angle was signifi-
cantly decreased postoperatively, which indicated dorsiflex-
ion deformity at the osteotomy site of the first metatarsal.
Five feet (28%) fixed with Kirschner wires had a decrease of
≥5 degrees in the inclination angle. We support the notion
that Kirschner-wire fixation is inadequate to prevent postop-
erative dorsiflexion deformity, and more rigid fixation
might help prevent postoperative dorsiflexion deformity.28
Since 2012, we have performed fixation of the osteotomy
site with a locking plate. Further investigations of the fixa-
tion stability of a locking plate are needed.
There are several limitations in this study. First, the num-
ber of patients was relatively small. However, the operative
treatment of MA associated with HV is relatively rare and a
challenging intervention because of the lack of available
information. Therefore, the outcomes of our study may be
useful for future investigations. Second, the psychometric
properties of the AOFAS scoring system, including validity
and reliability, have never been examined. However, there
is still value in the comparison of our results with those of
other published studies.
In conclusion, the present study demonstrated that our
novel operative procedure, consisting of a proximal cres-
centic osteotomy combined with a proximal abduction oste-
otomy of the second and third metatarsals, achieved
significant correction of HV and MA deformities and sig-
nificant improvement in pain and function for severe HV
with moderate to severe MA.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article. ICMJE forms for all authors are available online.
Shima et al
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Hiroaki Shima, MD, PhD, https://orcid.org/0000-0003-4930
-0007
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