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Background: It is unknown whether postoperative incomplete reduction of the sesamoids is a risk factor for the recurrence of hallux valgus. The purpose of the present study was to clarify the relationship between the postoperative relative sesamoid position and the recurrence of hallux valgus.
Methods: Dorsoplantar weight-bearing radiographs of sixty normal feet (the control group) and sixty-five feet with hallux valgus (the hallux valgus group) in a study of adult women were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs were assessed preoperatively, at the early follow-up interval (at a mean of 3.1 months), and at the most recent follow-up interval (at a mean of forty-five months). The position of the medial sesamoid was classified with a grading system ranging from I through VII as described by Hardy and Clapham. In the feet with hallux valgus, we defined a grade of IV or less as the normal position of the medial sesamoid (the normal-position group) and grade V or greater as lateral displacement of the sesamoid (the displacement group).
Results: Fifty feet (83%) in the control group were classified as grade IV or less and ten, as grade V. All feet in the hallux valgus group were classified as grade V or greater preoperatively, forty-eight feet (74%) were classified as grade IV or less at the early follow-up evaluation, and forty-two feet (65%) were classified as grade IV or less at the most recent follow-up evaluation. The average hallux valgus angle in the hallux valgus group was 38.3° (range, 25° to 60°) preoperatively, 11.9° (range, 4° to 28°) at the time of the early follow-up, and 13.9° (range, 0° to 33°) at the time of the most recent follow-up. There was no significant difference in the average hallux valgus angle between the early and most recent follow-up evaluations in the feet that were considered to be in the normal-position group at the time of the early follow-up (p = 0.084). In the feet that were considered to be in the displacement group at the time of the early follow-up, the average hallux valgus angle at the time of the most recent follow-up was significantly greater than that at the time of the early follow-up (19.5° ± 8.4° compared with 15.0° ± 5.8°) (p = 0.0082). The feet that were in the displacement group at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus at that time than did those in the normal-position group (odds ratio, 10.0; 95% confidence interval, 2.75 to 36.33).
Conclusions: Postoperative incomplete reduction of the sesamoids can be a risk factor for the recurrence of hallux valgus. The identification of incomplete reduction of the sesamoids intraoperatively may allow modification of surgical procedures and improvement of the surgical results.
Measuring Sesamoid Position in Hallux Valgus
When Is the Sesamoid Axial View Necessary?
Dominic Catanese, DPM FACFAS; Daniel Popowitz, DPM, AACFAS; Aharon Z. Gladstein, MD Foot Ankle Spec July 7, 2014
Measuring tibial sesamoid position is an important component of the preoperative radiographic evaluation of hallux valgus as it helps guide the surgeon in surgical selection. Tibial sesamoid position is typically measured on an anteroposterior (AP) radiograph on a scale from 1 to 7 as described by Hardy and Clapham. Some authors have advocated measuring the position on the sesamoid axial view, noting that the AP and axial views often yield different measurements. There is no consensus as to which view is more helpful in guiding the surgeon’s surgical decision. Weightbearing radiographs of 99 feet in patients with a clinical diagnosis of hallux valgus were retrospectively reviewed. Tibial sesamoid position was measured on the AP view using the 7-point scale of Hardy and Clapham. Tibial sesamoid position was also measured on the axial radiograph. Cohen’s kappa statistic was used to assess agreement of measurements obtained on the 2 views. There was poor agreement of the AP and axial views, with a kappa of 0.31. In our analysis of the data, it was determined that the lack of agreement was due mainly to X-rays showing tibial sesamoid positions of 4 and 5. A subgroup analysis of all X-rays with tibial sesamoids in positions other than 4 or 5 showed excellent agreement, with a kappa of 0.95. Anteroposterior and sesamoid axial views of feet with hallux valgus show excellent agreement in patients with the tibial sesamoid in positions other than 4 or 5. If the tibial sesamoid has a position of 4 or 5 on the AP, an axial view may be warranted to further understand the extent of deformity.
A New Measure of Tibial Sesamoid Position in Hallux Valgus in Relation to the Coronal Rotation of the First Metatarsal in CT Scans
Yejeong De Geer, Jin-su Kim, Ki-won Young, Reza Naraghi, Hunki Cho, Sang-young Lee Foot & Ankle International March 26, 2015
Background: We aimed to find a new radiographic measurement for evaluating first metatarsal pronation and sesamoid position in hallux valgus (HV) deformity.
Methods: Data from a clinical study of 19 control patients (19 feet) with no HV deformity were compared with preoperative data of 138 patients (166 feet) with HV deformities. Using a weightbearing plain radiograph in anteroposterior (AP) view, the intermetatarsal angles (IMAs) and the hallux valgus angles (HVAs) of the control and study groups were measured. Using a semi-weightbearing coronal computed tomography (CT) axial view, the α angle was measured in the control and study groups. In addition, the tibial sesamoid grades in plain radiograph tangential view and the CT axial view were measured. The tibial sesamoid position in an AP view was checked preoperatively. Based on these measurements, 4 types of HV deformities were defined.
Results: The mean values of the α angle in the control and HV deformity groups (control group µ = 13.8 degrees, study group µ = 21.9 degrees) was significantly different. Among 166 HV feet, 145 feet (87.3%) had an α angle of more than 15.8 degrees, which is the upper value of the 95% confidence interval of the control group, indicating the existence of abnormal first metatarsal pronation in HV deformity. Four types of HV deformities were defined based on their α angles and tibial sesamoid grades in CT axial view (CT 4 position). Among 25.9% (43/166) of the study group, abnormal first metatarsal pronation with an absence of sesamoid deviation from its articular facet was observed. The prominent characteristic of this group was that they had high grades in the AP 7 position (≥5); however, in the CT 4 position, their grade was 0. This group was defined as the “pseudo-sesamoid subluxation” group.
Conclusions: Patients with HV deformities had a more pronated first metatarsal than the control group, with a greater α angle. Pseudo-subluxation of the sesamoids existed in 25.9% of our study group. From our results, we suggest that the use of the CT axial view in assessments of HV deformity may benefit surgeons when they make operative choices to correct these deformities. With regard to the pseudo-sesamoid subluxation group, the use of the distal soft tissue procedure is not surgically recommended.
The Relationship Between the Sesamoid Complex and the First Metatarsal After Hallux Valgus Surgery Without Lateral Soft-Tissue Release: A Prospective Study
Jos? Mar?a Lamo-Espinosa, MDcorrespondenceemail, Borja Fl?rez, MD, Carlos Villas, MD, PhD, Juan Pons-Villanueva, MD, PhD, Jos? M. Bond?a, MD, Jes?s D?maso Aquerreta, MD, PhD, Matias Alfonso, MD, PhD JFAS; Article in Press
Some investigators have emphasized restoring the relationship between the sesamoid complex and the first metatarsal head to reduce the risk of hallux valgus recurring after surgical reconstruction. In a prospective study, we analyzed whether the first metatarsophalangeal joint could be realigned after scarf-Akin bunionectomy without lateral soft tissue release. A total of 25 feet, in 22 patients, were prospectively enrolled and analyzed using anteroposterior radiographs and coronal computed tomography scans obtained before and 3 months after surgery. The Yildirim sesamoid position decreased from a preoperative of 2 (range 1 to 3) to a postoperative position of 0 (range 0 to 1; p < .001), the mean first intermetatarsal angle decreased from 12.6? ? 2.4? to 5.8? ? 2.1? (p < .001), and the mean distance between the second metatarsal and the tibial sesamoid changed from 25.7 ? 4.6 to 25.9 ? 4.6 (p = .59). Our findings suggest that dislocation of the sesamoid complex is actually caused by displacement of the first metatarsal. In conclusion, the scarf-Akin bunionectomy adequately restores the alignment of the first metatarsophalangeal joint, including restoration of the sesamoid apparatus, without direct plantar–lateral soft tissue release.
Inter and Intra-Observer Reliability in Assessment of the Position of the Lateral Sesamoid in Determining the Severity of Hallux Valgus
Sunil Panchani, Jonathan Reading, Jaysheel Mehta The Foot; Article in Press
•The position of the lateral sesamoid correlates well in previous studies with the severity of Hallux Valgus.
•We performed an intra and inter observer reliability study on this classification system.
•Kappa Values were high amongst Consultant and Registrar observers.
•The Lateral Sesamoid Classification System shows good Intra and Inter Observer Reliability.
The position of the lateral sesamoid on standard dorso-plantar weight bearing radiographs, with respect to the lateral cortex of the first metatarsal, has been shown to correlate well with the degree of the hallux valgus angle. We aimed to assess the inter- and intra-observer error of this new classification system.
Five orthopaedic consultants and five trainee orthopaedic surgeons were recruited to assess and document the degree of displacement of the lateral sesamoid on 144 weight -bearing dorso-plantar radiographs on two separate occasions. The severity of Hallux Valgus was defined as normal (0%), mild (≤ 50%), moderate (51% - ≤99%) or severe (≥ 100%) depending on the percentage displacement of the lateral sesamoid body from the lateral cortical border of the first metatarsal.
Consultant intra-observer variability showed good agreement between repeated assessment of the radiographs (mean Kappa = 0.75). Intra-observer variability for trainee orthopaedic surgeons also showed good agreement with a mean Kappa = 0.73. Intraclass correlations for consultants and trainee surgeons was also high.
The new classification system of assessing the severity of Hallux Valgus shows high inter- and intra-observer variability with good agreement and reproducibility between surgeons of consultant and trainee grades.