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Juvenile hallux valgus (JHV) is a relatively common condition in the female adolescent. The etiology of the condition has been attributed to various deformities in the forefoot, ranging from the first metatarsophalangeal joint, the morphology of the distal metatarsal, and the intermetatarsal angle (IMA). There have been very few studies evaluating the first metarsocuneiform (MTC) joint, and the results available vary. The purpose of this study is to more critically evaluate the MTC joint with novel angular measurements as a contributor to JHV. A cohort of 46 feet from 29 patients (average age 14.2 years) with hallux valgus as defined as IMA of greater than 10 degrees were evaluated. The hallux valgus angle, IMA, base of first metatarsal to articular surface of medial cuneiform angle, first metatarsal to cuneiform (1MCA), second metatarsal to cuneiform (2MCA), intrinsic medial cuneiform obliquity angle (COA), distal metatarsal articular angle, and ratio of first cuneiform to second cuneiform length were measured. The same was done for an age-matched control group of 36 normal feet from 25 patients (average age 13.2 years). The two groups were statistically compared. There were several statistically significant differences between the study and control groups. Naturally, the hallux valgus angle and IMA were statistically greater by definition. In addition, the distal metatarsal articular angle and 1MCA were significantly larger in the study group. The magnitude of the 2MCA was found to positively correlate with the magnitude of the IMA. The COA angle was not found to be statistically different. In conclusion, the role of the MTC joint in JHV has been evaluated earlier with varying results. The objective of this study is to critically evaluate the MTC joint with novel angular measurements to delineate its contribution to JHV. One such novel measurement is the 1MCA. The statistically significant increase in 1MCA suggests that a property intrinsic to the articulation between the medial cuneiform and the first metatarsal may be involved in JHV. Another angle, the 2MCA was found to positively correlated with increased IMA, further implicating the MTC joint as a contributor to increased IMA and thus, JHV. Third, the COA was used to define the intrinsic obliquity of the medial cuneiform articular angle. This angle was not found to be statistically different between the study and control groups, suggesting that the morphology of the cuneiform is not involved in JHV.
Introduction The aetiology of hallux valgus is almost certainly multifactoral. The biomechanics of the first ray is a common factor to most. There is very little literature examining the anatomy of the proximal metatarsal articular surface and its relationship to hallux valgus deformity.
Methods We examined 42 feet from 23 specimens in this anatomical dissection study.
Results This analysis revealed three distinct articular subtypes. Type 1 had one single facet, type 2 had two distinct articular facets, and type 3 had three articular facets one of which was a lateral inferior facet elevated from the first. Type 1 joints occurred exclusively in the hallux valgus specimens, while type 3 joints occurred exclusively in normal specimens. Type 2 joints occurred in both hallux valgus and normal specimens. Another consistent finding in regards to the proximal articular surface of the first metatarsal was the lateral plantar prominence. This prominence possessed its own articular surface in type 3 joints and was significantly flatter in specimens with hallux valgus (p < 0.001) and the angle with the joint was significantly more obtuse (p < 0.001).
Conclusions We believe the size and acute angle of this prominence gives structural mechanical impedance to movement at the tarsometatarsal joint and thus improves the stability.
Does metatarsal pronation exist and, if so, what is its impact?
Hallux valgus is a deformity associating angulation and a rotational component. The present study sought to investigate the nature and origin of the coronal plane displacement.
MATERIALS AND METHODS:
A prospective single-center radiological and anatomic study was conducted on 100 feet operated on for hallux valgus. Baseline X-ray determined the preoperative position of the 1st metatarsal head in the coronal plane. The range of motion (ROM) of the cuneometatarsal joint in pronation-supination was measured peroperatively. An anatomic study investigated possible diaphyseal torsion.
Mean radiologic pronation in hallux valgus was 12.7° (range, 0°-40°). Cuneometatarsal rotational ROM was determined by adding peroperative ROM in pronation (mean, 9.3°; range, 0°-30°) and in supination (mean, 8.7°; range, 0°-20°). Intermetatarsal divergence showed no correlation with radiologic pronation or ROM in pronation. Radiologic pronation showed no correlation with peroperative ROM in pronation. Pronation of the metatarsal head was never observed without associated sesamoid pronation; the latter, however, was in some cases observed without the former. Twenty randomly selected metatarsal cadaver specimens from the anatomy laboratory of the University of Nice (France) showed diaphyseal torsion in 80% of cases, with the metatarsal head in neutral position or in supination with respect to the base.
In hallux valgus, 1st ray pronation appears to be systematic, in contrast to the typical supination found in the general population. Metatarsal rotation is always associated with sesamoid rotation, whereas the converse is not the case: displacement of the sesamoids appears to displace the metatarsal head via the metatarsosesamoid ligaments. This "drive-belt" effect, however, varies in its mechanical properties and the transmission is imperfect and likely subject to progressive ligament stretching, so that head rotation does not exactly follow and may even become independent of the sesamoid displacement. Radiologic and clinical rotation thus do not match any longer. The anatomic study showed that, while diaphyseal torsion cannot be ruled out, the metatarsal pronation mainly derives from cuneometatarsal joint rotational instability, the evolution of which does not parallel lateral instability, no correlation being found between degree of varus and rotational instability.
The present study found metatarsal pronation to be associated with hallux valgus, making a preoperative AP view useful; the underlying mechanism was generally cuneometatarsal instability. Although difficult to specify exactly without correlation between radiological and clinical data, any such pronation raises the question of whether replacing the metatarsal head on its sesamoid supports is sufficient to achieve stability in all planes, or whether on the contrary derotation should be associated to metatarsal valgization osteotomy to restore horizontal support.
Re: The role of the first metarsocuneiform joint in hallux valgus.
Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the Literature
Paul Dayton, DPM, MS, FACFAS, Mindi Feilmeier, DPM, FACFAS, Merrell Kauwe, BS, Jordan Hirschi, BS Journal of Foot and Ankle Surgery; Article in Press
Rotation of the first metatarsal, as a component of hallux abducto valgus, is rarely discussed and is not addressed as a component of most hallux valgus corrective procedures. We believe frontal plane rotation of the first metatarsal to be an integral component of hallux abducto valgus deformity (the “third plane of deformity”) and believe de-rotation is necessary for complete deformity correction. We observed the change in angular measurements commonly used in the evaluation of hallux valgus deformity in patients who underwent a modified lapidus procedure. We measured the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position on weightbearing radiographs of 25 feet in 24 patients who had undergone tarsal metatarsal corrective arthrodesis and lateral capsular release. Specific attention was given to reduction of the frontal plane rotation of the first metatarsal during correction. Our results showed a change in the angular measurements observed by 4 investigators as follows. The mean change in the intermetatarsal angle was 10.1° (p < .0001). The mean change in the hallux abductus angle was 17.8° (p < .0001). The mean change in the proximal articular set angle was 18.7° (p < .0001). The mean change in the tibial sesamoid position was 3.8 (p < .0001). Also, a consistent valgus, or everted position of the first metatarsal, was noted as a component of the hallux abducto valgus deformity in our patient population and was corrected by varus rotation or inversion of the metatarsal. We also reviewed the current literature related to anatomic changes in the first ray in the patient with hallux valgus deformity and reviewed our hypothesis regarding the reduction in the proximal articular set angle, which we believe to be related to frontal plane rotation of the first metatarsal, resulting in a radiographic artifact.