SLR - June 2014 - Hannah Johnk

First Tarsometatarsal Joint Derotational Arthrodesis – A New Operative Technique for Flexible Hallux Valgus without Touching the First Metatarsophalangeal Joint

Reference: Klemola T, Leppilahti J, Kalinainen S, Ohtonen P, Ojala R, Savola O. First Tarsometatarsal Joint Derotational Arthrodesis – A New Operative Technique for Flexible Hallux Valgus without Touching the First Metatarsophalangeal Joint. Journal of Foot and Ankle Surgery, 53(1): 22-28, 2014.

Scientific Literature Review

Reviewed By: Hannah Johnk, DPM
Residency Program: Trinity Regional Medical Center, Fort Dodge, IA

Podiatric Relevance: More than 100 different techniques have been described for surgical correction of hallux valgus, most of them involving some type of intervention at the first metatarsophalangeal joint. The authors suggest that dysfunction of the peroneus longus – the only evertor of the first metatarsal – may lead to the development of hallux valgus. This study introduces a new surgical technique of derotational arthrodesis of the first tarsometatarsal joint and initial postoperative results, and the authors purpose a valgus direction of rotation for correction.

Methods: A retrospective analysis of 84 operated feet in 66 patients with flexible hallux valgus was performed. Exclusion criteria included degenerative joint disease of the first metatarsophalangeal joint. Sixty-two patients were female and four were male with a mean age of 48. Radiographs were taken preoperatively and six weeks postoperatively. Operative technique involved exposure of the tarsometatarsal joint and preparation of the joint surfaces with an osteotome as well as sagittal saw. The first metatarsal was then everted and temporarily fixated axially with a guide wire directed dorsal distal to plantar proximal. Permanent fixation was achieved with a single, headless, fully threaded cannulated compression screw.  Postoperative treatment consisted of a removable soft-cast and non-weightbearing for six weeks.

Results: The mean hallux valgus correction angle between preoperative and postoperative radiographs was 19.8° (p < 0.001).  The mean Meary’s angle was -3.9° preoperatively and 8.1° postoperatively, with a mean change of 12.0° (p < 0.001). The average decrease in the first intermetatarsal angle was 8.9° (p <0.001). The LaPorta classification for tibial sesamoid position was used to measure the rotational correction of the fist metatarsal along its longitudinal axis. The median decrease in the LaPorta classification was 2.5 U (p < 0.001).

Conclusions: The authors concluded that derotational arthrodesis of the first tarsometatarsal joint provides good correction of hallux valgus. They stressed that the deformity should be flexible, without any signs of degenerative joint disease of the first metatarsophalangeal joint. This procedure results in improved function of the windlass mechanism and peroneus longus without touching the first metatarsophalangeal joint, the only published procedure thus far to accomplish that. This study was limited by its short follow-up period and its retrospective nature.  

Although the authors cite Root et al to support their claim of varus rotation (inversion) of the first metatarsal in hallux valgus deformity, previous literature consistently states that the first metatarsal is rotated in a valgus (everted) position and that varus rotation produces correction. Studies published by Scranton and Rutkowski, Mortier, Okuda, D’Amico and Schuster, Dayton, and DiDomenico consistently observe valgus rotation in a bunion deformity. 

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