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Case Report
Revised

Case Report: Postsurgical hallux varus in which metatarsophalangeal joint arthrodesis was useful

[version 2; peer review: 2 approved, 1 approved with reservations]
PUBLISHED 09 Jul 2024
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Abstract

A 74-year-old Japanese woman who underwent Mann’s procedure with fibular sesamoidectomy for left hallux valgus 21 years ago complained of left hallucis pain. She was diagnosed with iatrogenic hallux varus and hammer toe deformities. Metatarsophalangeal joint arthrodesis and shortening oblique osteotomy were performed. After surgery, the hallux valgus angle improved from -28° to 0°, and the intermetatarsal angle between the first and the second metatarsus improved from 0° to 6°. The Japanese Society for Surgery of the Foot RA foot and ankle scale improved from 73 to 81 points. She could walk without pain and sustained no deformity at 4 years after the surgery.

Keywords

Hallux valgus; Metatarsophalangeal joint arthrodesis; Iatrogenic hallux varus; Cup and cone reamer; Shortening oblique osteotomy

Revised Amendments from Version 1

We changed JSSF RA foot and ankle scale of preoperative stage into 73 points in the Abstract. 
In Case report section, we corrected IP joint extension degree into -20°. In additon, we rewrote the detailed procedure for the shortening oblique osteotomy. 
In Discussion section, we deleted the 3rd paragraph and the reference of [7] in the original manuscript. we corrected the 4th through 7th paragraphs more clearly. After that, we re-numbered the reference in the revised manuscript up to [10]. 
In Figure legends, the passive flexion of MTP joint of hallucis was corrected to -30°.

See the authors' detailed response to the review by Jun-Ichi Fukushi
See the authors' detailed response to the review by Inderjeet Singh Rikhraj

Introduction

Hallux varus is a rare foot deformity due to iatrogenic, post-traumatic, idiopathic, inflammatory, spontaneous, or congenital pathologies. In particular, the iatrogenic type is the most common cause of hallux varus.1,2 Multiple studies reported that postsurgical hallux varus was observed in 2%–15.4% of cases.3

Post-surgically observed hallux varus is attributed to overcorrection of the hallux valgus deformity. This includes excessive removal of the medial osteophyte and over-release of adductor halluces tendons, transmetatarsal ligament, and lateral metatarsophalangeal (MTP) joint capsule.1 The incidence of iatrogenic hallux varus after surgery of hallux valgus is not very low, and there is a paucity of reports associated with the treatment strategy.

Herein, we report a novel case of postsurgical hallux varus deformity. We performed revision surgery, i.e., MTP joint arthrodesis for hallucis and shortening oblique osteotomy for the lesser toes. Four years after surgery, the patient was satisfied, functionally good, and experienced no pain upon standing or walking. No postoperative callosity was detected.

Case report

A 74-year-old Japanese woman visited our clinic with complaints of left hallucis pain and concerns about medial deviation. Twenty-one years prior, the patient underwent Mann’s procedure with bunionectomy and with fibular sesamoidectomy, a surgical operation for bilateral hallux valgus. After the operation, the MTP joint surface deviated medially in a hyperextended position (Figure 1AC). In addition, the second and fourth toes demonstrated hammer toe deformities (Figure 1A and C). First, an orthosis was applied; however, medial deviation and pain in her MTP joint worsened six months after the orthosis application. Hence, surgical intervention was decided on. Upon physical examination, the left MTP joint of the patient was swollen, tender, and erythematous. Extensor hallucis longus was very tense, the MTP joint was hyperextended, and the interphalangeal (IP) joint was in a flexed position, resulting in the “cock-up deformity” of hallux varus (Figure 2AD). Lateral instability of the MTP joint of the hallux was not detected.

11cc7ebf-0c71-4235-ba7e-3d17fa2c21df_figure1.gif

Figure 1. Preoperative macroscopic findings of the left foot.

The extensor hallux longus is very tense, with the metatarsophalangeal (MTP) joint hyperextended and the interphalangeal (IP) joint in a flexed position, forming a so-called “cock-up deformity” (A). In the lateral view, a preoperative operation scar is clearly detected (B). In the plantar view, the varus deformity is clearly observed, and no callosity is detected (C).

11cc7ebf-0c71-4235-ba7e-3d17fa2c21df_figure2.gif

Figure 2. Passive motion of metatarsophalangeal (MTP) and interphalangeal (IP) joints of the left hallucis.

The passive extension and flexion of the MTP joint are 90° (A) and -30° (B), respectively.

The passive extension and flexion of the IP joint are -20° (C) and 90° (D), respectively.

The Japanese Society for Surgery of the Foot (JSSF) Rheumatoid Arthritis (RA) foot and ankle scale4 is often used in Japan as a means to evaluate the function of the ankle and foot. In the present case, we evaluated it for the functional outcome because the surgery was performed in not only hallux but also lesser toes. The patient’s scale was 73 out of 100 points (pain, 30 out of 30; deformity, 17 out of 25; range of motion, 13 out of 15; gait, 10 out of 20; and activity of daily life, 3 out of 10).

Regarding the range of motion, the MTP joint was very stiff and showed extension contracture (-90° in extension and -30° in flexion), but the IP joint remained flexible (-20° in extension and 90° in flexion) (Figure 2AD).

Radiographs showed that the hallux valgus angle (HVA) was -28° (Figure 3A). The intermetatarsal angle between the first and the second metatarsus (M1M2A) was 0° (normal range, 6°–9°), which meant that the first and second metatarsal bones were parallel (Figure 3A). As the tibial sesamoid shifted medially, and the fibular sesamoid was absent, excessive medial eminence resection might have been performed. An oblique view of the foot demonstrated that the proximal phalanx subluxated dorsally (Figure 3B).

11cc7ebf-0c71-4235-ba7e-3d17fa2c21df_figure3.gif

Figure 3. Passive motion of metatarsophalangeal (MTP) and interphalangeal (IP) joints of the left hallucis.

Radiographs show that the hallux valgus angle was -28°.

The intermetatarsal angle, which should be approximately 6°–9°, is 0°. This indicates that the first and second metatarsal bones are parallel.

The tibial sesamoid has shifted medially and the fibular sesamoid is absent. Excessive medial eminence resection might have been performed.

In this case, MTP joint arthrodesis, medial capsular release, and EHL tendon lengthening were performed. For the second and fifth toes, a shortening oblique osteotomy was performed. The intraoperative macroscopic findings revealed that the medial portion or the articular surface was impacted by the severe degenerative change. The degenerative changes were also observed in the capsule (Figure 4).

11cc7ebf-0c71-4235-ba7e-3d17fa2c21df_figure4.gif

Figure 4. Macroscopic operative findings.

The medial portion of the articular surface reveals severe degenerative change.

Degenerative change is also seen in the capsule.

A cup and cone type reamer (Wright Medical, Tokyo, Japan) was used to preserve the length of the hallux as much as possible. The metatarsal articular surface was reamed to a cup-shaped surface, and the proximal phalanx articular surface was recreated with a cone-shape.

The hallux valgus angle was fixed at 0°, and the first proximal phalanx axis was dorsally fixed at 15° to the metatarsal bone axis. Two full-thread Acutrak® screws (Nihon Medical Next Co. Ltd, Tokyo, Japan) were inserted at the fixed position in a crisscross fashion. For the lesser toes, a shortening oblique osteotomy was performed (Figure 5A and B). The postoperative radiographs showed that M1M2A was 6° and HVA was 0° (Figure 5A).

11cc7ebf-0c71-4235-ba7e-3d17fa2c21df_figure5.gif

Figure 5. Radiographs after the operation.

A cup and cone reamer are used to preserve the length of the hallux as much as possible. The hallux valgus angle is fixed at 0°, and the 1st proximal phalanx is dorsally fixed at 15° to the metatarsal bone. M1M2A shows 6°. For the lesser toes, a shortening oblique osteotomy is performed (A, anteroposterior view; B, oblique view).

Dorsal curved skin incisions were applied in between the 2nd and the 3rd metatarsals and between the 4th and 5th metatarsals. Wounds were deepened and extensor digitorum brevis tendons were identified and partially resected. Distal metatarsal regions were subperiosteally released and shortening oblique osteotomy were performed with 45-degrees tilted to the metatarsal longitudinal axis for the 2nd through 5th toes. The osteotomized thickness were 7 mm. Then, distal fragment was flipped dorsally and osteophyte in the metatarsal head was totally removed and rasped.

A Kirschner wire of 1.2 mm in diameter was inserted into the metatarsal, and proximal phalanx, mid phalanx, and distal phalanx for each toe.

Three weeks after the insertion, these wires were removed and weight bearing and gait exercises were performed using arch support.

The screws remained intact and in place, and no valgus or varus deformities were apparent four years after surgery (Figure 6AC).

11cc7ebf-0c71-4235-ba7e-3d17fa2c21df_figure6.gif

Figure 6. Macroscopic findings and radiographs are taken four years after the operation.

No recurrence of hallux varus and hallux valgus is observed (A). The screws are intact, in place, and no valgus or varus deformities are apparent. Additionally, each osteotomized lesser toe is united (B, anteroposterior view; C, oblique view).

Post-operative evaluation of the JSSF score of hallucis was 81 out of 100 (pain, 30 out of 30; deformity, 23 out of 30; range of motion, 5 out of 15; gait, 20 out of 20; and activity of daily life, 3 out of 10), which showed an eight-point increase. A six-point increase in deformity and a 10-point increase in walking abilities were noted; however, an eight-point decrease in range of motion was observed. No deformities were apparent and pain that worsened during movement was relieved.

Discussion

Hallux varus is a clinical condition characterized by the medial deviation of the great toe at the MTP joint. Iatrogenic hallux varus is caused by an imbalance between the various bone, tendon, and capsule-ligament structures of the first MTP joint, including a progressive medial deviation of the hallux.5

The causes of iatrogenic hallux varus are 1) overstitching of the medial joint capsule, 2) medial deviation of the tibial sesamoid, 3) over-traction by the abductor hallucis muscle due to lateral ligament complex release, 4) postoperative dressing in varus position of the hallux metatarsophalangeal joint, and 5) over-excision of the medial bony protrusion of hallux metatarsus. The patient in our case exhibited the second and fifth causes.6

For procedures of MTP joint preservation, soft tissue release and tendon transfer method using extensor hallucis longus tendon or abductor hallucis longus tendon are used.5

For soft tissue release, medial capsule release or intermetatarsal space release are used.5

For tendon transfers, 2 methods such as a dynamic transfer and a static transfer are known. The dynamic transfer means transfer with muscle body and the static transfer means transfer without muscle body. Both transfers compensate for the incompetent lateral collateral ligament. Extensor hallucis longus tendon transfer is selected for a dynamic transfer with or without interphalangeal joint fusion. Abductor hallucis tendon transfer is also used.5

For static tendon transfer, abductor hallucis tendon or artificial implant (TightRope) is selected.5

When MTP joint is unstable or limited range of motion, MTP joint cannot be preserved, so MTP joint arthrodesis is selected.5,7 The present case demonstrated that MTP joint congruity was not so good because of the joint instability and that MTP joint degeneration was clearly detected (Figure 4). Therefore, MTP joint arthrodesis was performed.

MTP joint arthrodesis for hallux varus also significantly improved both the average 1–2 intermetatarsal angle from 4.8° to 8.4° and HVA from -20.7° to 8.1° in 26 patients (29 feet).8 In our case, M1M2 A improved from 0° to 6° and HVA improved from -28° to 0° postoperatively (Figures 3A and 5A).

Tourne et al. reported 14 cases of hallux varus. Each case showed medial arthrolysis of the MTP joint. Of 14 patients, five were treated with a reconstruction procedure of the lateral ligament accompanied by the medial release. Thereafter, nine patients were treated with MTP joint arthrodesis in case the MTP joint was stiff and arthrosis was present. According to the 100-point scoring system, the results were excellent in 56% and good in 44% of the patients with MTP joint arthrodesis.9

The guidelines for our cases were as follows: 1) V-shaped incision was used for the dorsal MTP joint capsule. Thereafter, the articular surface was sufficiently exposed and medial tightness was thoroughly released. Tibial sesamoid was also released and relocated; subsequently, the V-shaped flap was tightly repaired after the MTP joint fusion. 2) The MTP joint level of hallucis after the primary surgery was much shorter than those of the lesser toes. To correct the imbalance of the MTP joint line between hallucis and lesser toes, and to prevent postsurgical metatarsalgia, we used a cup and cone reamer to minimize bone excision of the hallux metatarsus. Ball and cup reamer and osteosynthesis with pure titanium staples have been reported to yield good results in 54 patients with hallux valgus.10 In addition, we performed shortening oblique osteotomy for lesser toes. 3) EHL elongation was performed because the EHL tendon became shortened due to flexion contracture of hallucis.

In conclusion, MTP joint arthrodesis using a cup and cone reamer minimized the shortening length of the metatarsal bone and proximal phalanx bone of the hallux. Additionally, it enabled stabilization in walking and bearing on the foot, resulting in good functional outcomes for this iatrogenic hallux varus case.

Consent

Written informed consent for the publication of their clinical details and clinical images was obtained from the patient.

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Kondo N, Igarashi T, Inukai T and Kawashima H. Case Report: Postsurgical hallux varus in which metatarsophalangeal joint arthrodesis was useful [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:344 (https://doi.org/10.12688/f1000research.131495.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 09 Jul 2024
Revised
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Reviewer Report 08 Apr 2025
Kenichiro Nakajima, Center for Foot and Ankle Surgery, Department of Orthopedic Surgery, Yashio Central General Hospital, Saitama, Japan 
Approved
VIEWS 2
This case report describes a patient who developed iatrogenic hallux varus following hallux valgus surgery and subsequently underwent arthrodesis of the first metatarsophalangeal joint, achieving good outcomes. Overall, this paper is well-written; however, some terminology concerns should be addressed.
... Continue reading
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HOW TO CITE THIS REPORT
Nakajima K. Reviewer Report For: Case Report: Postsurgical hallux varus in which metatarsophalangeal joint arthrodesis was useful [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:344 (https://doi.org/10.5256/f1000research.168017.r372510)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 26 Jul 2024
Inderjeet Singh Rikhraj, Singapore General Hospital, Outram Rd, Singapore 
Approved
VIEWS 11
Introduction

A medial osteophyte is not removed, it is a bunionectomy. - ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Rikhraj IS. Reviewer Report For: Case Report: Postsurgical hallux varus in which metatarsophalangeal joint arthrodesis was useful [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:344 (https://doi.org/10.5256/f1000research.168017.r300623)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 27 Jul 2024
    Naoki Kondo, Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, 951-8510, Japan
    27 Jul 2024
    Author Response
    Dear, reviewer 2, 

    Thank you for your comment.
    I would like to revise Introduction.
    I would like to correct  "medial bunionectomy" from "excessive removal of the medial osteophyte" in ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 27 Jul 2024
    Naoki Kondo, Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, 951-8510, Japan
    27 Jul 2024
    Author Response
    Dear, reviewer 2, 

    Thank you for your comment.
    I would like to revise Introduction.
    I would like to correct  "medial bunionectomy" from "excessive removal of the medial osteophyte" in ... Continue reading
Version 1
VERSION 1
PUBLISHED 28 Mar 2023
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Reviewer Report 14 Jun 2024
Inderjeet Singh Rikhraj, Singapore General Hospital, Outram Rd, Singapore 
Approved with Reservations
VIEWS 10
Well written report on a rare complication. Highlights the problem of an iatrogenic hallux varus due to resection of the fibula sesamoid. The JSSF score have improved. It would be good to highlight the Minimal Clinical Important Difference (MCID) of ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Rikhraj IS. Reviewer Report For: Case Report: Postsurgical hallux varus in which metatarsophalangeal joint arthrodesis was useful [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:344 (https://doi.org/10.5256/f1000research.144343.r192634)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 09 Jul 2024
    Naoki Kondo, Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, 951-8510, Japan
    09 Jul 2024
    Author Response
    I appreciate your precious comment. 
    I reconfirmed the operative record. As you pointed out, fibular sesamoidectomy had been performed.
    I corrected from fibular sesamoid to tibial sesamoid In Discussion ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 09 Jul 2024
    Naoki Kondo, Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, 951-8510, Japan
    09 Jul 2024
    Author Response
    I appreciate your precious comment. 
    I reconfirmed the operative record. As you pointed out, fibular sesamoidectomy had been performed.
    I corrected from fibular sesamoid to tibial sesamoid In Discussion ... Continue reading
Views
16
Cite
Reviewer Report 08 Feb 2024
Jun-Ichi Fukushi, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan 
Approved with Reservations
VIEWS 16
The report describes a case with postsurgical hallux varus, which can be a challenging issue for foot and ankle surgeons. This case report is overall well written, and the reviewer understands the usefulness of MTP joint arthrodesis as a reliable ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Fukushi JI. Reviewer Report For: Case Report: Postsurgical hallux varus in which metatarsophalangeal joint arthrodesis was useful [version 2; peer review: 2 approved, 1 approved with reservations]. F1000Research 2024, 12:344 (https://doi.org/10.5256/f1000research.144343.r236596)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 09 Jul 2024
    Naoki Kondo, Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, 951-8510, Japan
    09 Jul 2024
    Author Response
    Points of reviews.

    Introduction
    1.In the first paragraph, the authors documented the incidence of postsurgical hallux varus as 2%-15.4%, which does not seem like “very low” to the reviewer. ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 09 Jul 2024
    Naoki Kondo, Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, 951-8510, Japan
    09 Jul 2024
    Author Response
    Points of reviews.

    Introduction
    1.In the first paragraph, the authors documented the incidence of postsurgical hallux varus as 2%-15.4%, which does not seem like “very low” to the reviewer. ... Continue reading

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 28 Mar 2023
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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