Salvage of recurrence after failed surgical treatment of ... - Springer Link

Arch Orthop Trauma Surg (2012) 132:477–485 DOI 10.1007/s00402-011-1447-6

ORTHOPAEDIC SURGERY

Salvage of recurrence after failed surgical treatment of hallux valgus Xiaojun Duan • Anish R. Kadakia

Received: 30 April 2011 / Published online: 29 December 2011 Ó Springer-Verlag 2011

Abstract Recurrence of the deformity is unfortunately a common occurrence following surgical treatment of hallux valgus. The underlying reason for recurrence is multifactorial and includes surgeon’s factor, patient’s factor, and deformity components that were not addressed at the index procedure. Salvage of recurrence can be challenging for both the patient and the surgeon. Successful treatment requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring the joint congruity, and balancing soft tissues. We present an algorithmic approach to revision hallux valgus surgery.

following the surgery. The rate of complications in hallux valgus surgery ranges from 10 to 55%. Some of the complications are amenable to corrective treatment [13–15]; Recurrence of the deformity is among the most common [1, 16]. Symptomatic recurrence after a failed operation for hallux valgus can be a challenging problem for both the patient and the surgeon [13, 17]. To date, the literature on the treatment of recurrent hallux valgus is sparse [18–22]. This review focuses on this important issue and provides an algorithmic approach to revision surgery.

Current concepts for primary operative treatment Keywords Hallux valgus Revision Bunion Recurrence

Introduction Surgical correction of hallux valgus deformities is one of the most commonly performed foot and ankle procedures [1, 2]. More than 150 operations for correction of hallux valgus have been described in the literature [3–12]. As with any procedure, there are complications which may arise

X. Duan Center for Joint Surgery, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Street, Chongqing 400038, China e-mail: [email protected] A. R. Kadakia (&) Division of Foot and Ankle Surgery, Department of Orthopedic Surgery, University of Michigan, 2098 South Main Street, Ann Arbor, MI 48103, USA e-mail: [email protected]

In order to successfully revise recurrent hallux valgus one must understand the basic concepts for primary operative treatment [15, 16]. A thorough physical exam is critical. The physical examination of a hallux valgus deformity must be performed with the patient sitting and standing [1, 23, 24]. The foot is examined for a pes planus deformity and for contracture of the Achilles tendon, both of which may affect the choice and success of the operation. The metatarsocuneiform joint should be checked for hypermobility, mobility of more than 9 mm represents hypermobility [25], but the absolute amount of motion that constitutes hypermobility is controversial [26, 27]. An interview with the patient is important not only to evaluate the major symptoms associated with the hallux valgus deformity but also to educate the patient with regard to the problem, the alternatives for treatment, and the risks and complications when an operation is indicated [2, 16]. The severity of the hallux valgus deformity and the magnitude of the first–second intermetatarsal angle should be determined with the standing X-ray view. Assessment for the presence of early hallux rigidus or midfoot arthritis is

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critical in the decision making process. Nonoperative care is always the first option for a patient who has hallux valgus deformity [1, 2]. As a general rule we do not recommend surgery to the patient who does not have pain during ambulation. Simple bunionectomy: In a retrospective review of simple bunionectomy, Kitaoka et al. [28] noted high recurrence and high patient dissatisfaction rates. This cannot be recommended in isolation to treat hallux valgus [15] (Fig. 1). Modified McBride Procedure (distal soft-tissue procedure): few recent orthopedic articles report isolated modified McBride procedures for the correction of hallux valgus deformity. In a retrospective review, Mann et al. [29] noted acceptable patient satisfaction rates and improvement in hallux alignment. Johnson et al. [30] retrospectively compared the modified McBride procedure and distal chevron osteotomy. While postoperative satisfaction rates were not significantly different, the distal chevron group exhibited significantly better correction of alignment. The modified McBride procedure is most commonly utilized in combination with a bony correction in the treatment of hallux valgus and should not be used in isolation [9]. The chosen operative technique must correct all elements of the problem [1, 5, 9]: prominence of the medial eminence, increased valgus angulation of the proximal phalanx, an increased first–second intermetatarsal angle, congruency of the metatarsophalangeal joint, subluxation

Fig. 1 Recurrent deformity predictably occurred following a simple medial eminence resection

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Arch Orthop Trauma Surg (2012) 132:477–485

of the sesamoids, and pronation of the great toe. When operative treatment is planned, association of the main symptom with the physical findings as well as the radiographic information helps the surgeon to select the best procedure for correction of a hallux valgus deformity. Failure to correct any of these components places the foot at substantial risk for recurrent deformity [13, 16]. As a general principle, distal, middle, and proximal metatarsal osteotomies are used to correct metatarsus primus varus [16]. Distal metatarsal osteotomies (the chevron and Mitchell) generally are indicated in patients with a hallux valgus angle less than 40° and the intermetatarsal angle less angle less than 15° [5, 30, 31]. Middle and proximal metatarsal osteotomies (chevron, dome, and wedge types), Scarf, and Ludloff are used for more severe deformity [29, 32–35]. Hallux valgus associated with hypermobility of the first ray can be corrected by arthrodesis of the first tarsometatarsal joint [36]. A first metatarsophalangeal (MTP) joint arthodesis generally is reserved for hallux valgus associated with first MTP joint arthrosis, or severe deformities [1, 18, 37]. A large IMA in combination with an increased DMAA cannot be corrected with a proximal osteotomy alone; reducing the IMA will effectively increase the DMAA [15]. In hallux valgus with a large IMA and increased DMAA, a double osteotomy, with a proximal first metatarsal osteotomy or medial opening wedge osteotomy of the first cuneiform to correct the increased IMA and a distal medial closing wedge osteotomy of the first MT to reduce the DMAA, may be considered (Fig. 2) [2].

Fig. 2 Preoperative radiograph following failed simple bunionectomy with a wide IMA and increased DMAA (a). Surgical correction was performed with a double osteotomy to correct both deformities. Proximal opening wedge osteotomy combined with a distal medial closing wedge osteomy was performed (b)


Lapidus originally described an arthrodesis between the bases of the first and second metatarsals and the first intercuneiform joint to correct metatarsus primus varus in patients with hallux valgus [38]. Currently, the modified Lapidus procedure incorporates an isolated arthrodesis of the first TMT joint with a lateral- and plantar-based closing wedge osteotomy of the medial cuneiform [21]. This procedure has been indicated for the correction of metatarsus primus varus in patients with moderate to severe hallux valgus and hypermobility of the first ray [39]. First ray hypermobility has been recommended to this procedure, but it is controversial [26]. Early reports identified nonunion rates of 10–12% with the modified Lapidus procedure. However, a more recent large clinical series reported a 4% nonunion rate and a 2% revision rate in feet treated with the Lapidus procedure [2, 39, 40]. Keller Resection Arthroplasty is the resection of the first proximal phalanx base to correct hallux valgus deformity [18]. Zembesch et al. [41] in a retrospective, uncontrolled comparative case series demonstrated worse results with the Keller procedure than with proximal metatarsal closing wedge osteotomy. This procedure may cause high rates of transfer metatarsalgia. Most authors have suggested that the Keller procedure be used only in older patients with limited functional expectations who may be at risk if subjected to corrective surgery [18, 22].

Clinical recurrence rate studies Various authors have reported complication rates for specific surgical procedures done to correct hallux valgus deformity [13, 14, 24, 42–44].But only a sparse collection of data has been collected for clinical recurrence rate analysis [21, 22, 24]. To identify complications that necessitated revision surgery after the primary operation, a multicenter retrospective chart review was conducted by Lagaay et al. [31] for 646 patients who received either a modified chevronAustin osteotomy (270 patients), modified Lapidus arthrodesis (342 patients), or closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Revision surgery for complications was calculated and compared. All surgery was performed by one of five staff foot and ankle surgeons at Kaiser Permanente medical centers. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection, and capital fragment dislocation. The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevronAustin osteotomy were similar with no statistical difference between them. The total rate for re-operation was

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5.56% among patients who received chevron-Austin osteotomy, 8.82% among those who had a closing base wedge osteotomy, and 8.19% for patients who received modified Lapidus arthrodesis. Among patients who had the chevronAustin osteotomy procedure, rates of re-operation were 1.85% for recurrent hallux valgus. Among patients who had the modified Lapidus arthrodesis, rates of re-operation were 2.92% for recurrent hallux valgus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94% for recurrent hallux valgus. This study showed that the rate of surgical revision in patients who received a chevron-Austin osteotomy, Lapidus arthrodesis, or closing base wedge osteotomy was similar and did not demonstrate a statistical difference. Incidence of recurrence was similar for both surgical procedures even though patient selection for the Lapidus arthrodesis was based on clinically evident first ray instability. Coughlin et al. reported in a prospective study that recurrence of 6 feet occured in 108 patients (127 feet) who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy), recurrent rates were 4.72% [26]. Wukich et al. [44] reported complications included 11.11% recurrences during correction of metatarsus primus varus with an opening wedge plate. Berg et al. [34] reported that only two patients needed a second operation because of recurrence of hallux valgus; this group included 72 feet which were subjected to a Scarf osteotomy of the first metatarsal, which meant that the recurrence rate was 2.78%.

Reasons for recurrence after surgery Many factors need to be considered when evaluating a recurrent hallux valgus deformity. Recurrence after certain procedures can be caused by surgeon’s reason, patient’s reason and HV components not addressed in general (Fig. 3) [1, 2, 13, 31, 44]. For surgeon’s reason [13, 17–19, 21]: (1) The characteristics of the initial deformity must be considered, as well as whether the correct surgical procedure was selected. (2) Poor surgical technique should be avoided; otherwise recurrence and many other complications of bunion surgery may often occur. (3) Certain underlying conditions should be alerted, because these conditions associated with a hallux valgus deformity may preclude a satisfactory result. For example, rheumatoid arthritis, hypothyroidism, gout, diabetic neuropathy, hereditary neuromuscular disorders, Parkinsonism, and cerebral palsy are associated with recurrence of deformity with joint sparing operations. (4) Postoperative incomplete reduction of the sesamoids can be a risk factor for the recurrence of hallux valgus [45].

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lateral joint contracture or realigning the sesamoids, has an increased recurrence rate when used alone. A frequent cause of recurrent hallux valgus after a chevron procedure is when it is selected to correct a deformity that is of greater magnitude than the procedure was intended for. Failure to appreciate joint congruency and a lateral slope of the distal metatarsal articular surface will prevent full correction with the chevron procedure [1, 15]. The DMAA should be measured before a chevron procedure. If it is greater than 15°, a medial closing wedge chevron or an Akin procedure should be added. Recurrent deformity after a crescentic, lateral closing wedge or chevron-shaped proximal metatarsal osteotomy usually results from inadequate bone correction. This may be caused by failure to rotate the osteotomy site adequately or failure to remove enough bone to correct the metatarsus primus varus. In a retrospective study of 51 failed hallux valgus procedures, Scranton et al. recognized that hypermobility was a cause of recurrence. Six patients had recurrence secondary to hypermobility, and all were treated successfully with the Lapidus procedure [42].

Strategy and indications Fig. 3 Algorithm for evaluation of reasons to a patient with failed surgical treatment of hallux valgus

(5) Failure to discuss appropriate postoperative management with the patient may lead to malunion. For patient’s reason [1, 2, 15, 19]: poor compliance of the patient after surgery, and poor choice of footwear after surgery (such as too narrow a shoe or pointed toe box) also influence outcome. Smoking is associated with a higher nonunion rate and increased rate of wound infection in orthopedic surgery and this will result in a less desirable outcome. Certain procedures have specific shortcomings that may predispose to recurrence. A ‘‘simple bunionectomy’’ fails to release the lateral joint contracture and does not reposition the metatarsal head over the sesamoids, and recurrence is common [28]. For a distal soft-tissue procedure to succeed, adequate release of the distal soft-tissue must be performed. The lateral capsular structures, including the adductor tendon insertion into the sesamoid and proximal phalanx, must be released along with the lateral joint capsule. The medial joint capsule must be adequately plicated. The main reason for failure of a distal soft-tissue procedure is failure to recognize that significant metatarsus primus varus is present. A distal soft-tissue procedure cannot be used to correct a fixed bone deformity. The Akin procedure, which includes bunionectomy and varus osteotomy of the proximal phalanx without addressing the

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The goal of operative treatment of hallux valgus is to correct all pathological elements and yet maintain a biomechanically functional forefoot [5, 13, 15]. Successful treatment of a recurrence requires a special knowledge of the hallux valgus pathomechanics so that a permanent solution may be achieved. Successful treatment requires correcting bony alignment, restoring joint congruity, and balancing soft tissues. Bony alignment also may require lateral capsule release to correct valgus. If the recurrence of the deformity is asymptomatic, the patient is best advised to simply observe the foot as the likelihood of successful revision is reduced [2, 31]. If symptoms are present that is due to the recurrent deformity, than a revision surgery may be considered. Before performing surgery, it is imperative to determine why the initial surgery was not successful to reduce the risk of a second recurrence. Unique issues that must be considered include the adequacy of the medial soft tissues, the adequacy of the medial eminence resection, and the status of the first MTP joint. Radiographically, the intermetatarsal, hallux valgus angle, and distal metatarsal articular angles must be evaluated. Surgical treatment should be undertaken using the same guidelines for correction of a primary hallux valgus deformity (Fig. 4). When recurrent deformity caused by simple bunionectomy, the revision surgery can be done similar to a primary surgery, such as chevron-Austin osteotomy and distal soft-tissue procedure (Fig. 5). But as


Fig. 4 An algorithmic approach to revision surgery

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and hammer toes should be treated simultaneously if they are symptomatic. Because of the influence of the DMAA in recurrence, it may be necessary to perform either a double metatarsal osteotomy to correct the DMAA or to use an Akin osteotomy of the proximal phalanx to create a more normal appearing foot (Fig. 6). The Akin osteotomy does not realign the tendon orientation around the first MTP joint and should rarely be used alone to correct a recurrent deformity. Sammarco et al. [14] recommended the routine use of a proximal osteotomy even in those patients whose IM angle was \15°. Sangeorzan et al. [39] reported that all of seven patients in whom recurrent hallux valgus had been treated with a modified Lapidus procedure had a decrease in symptoms. This led the authors to recommend the Lapidus procedure for revision of a recurrent deformity. Lapidus procedure [21, 39, 40] Indications: (1) Symptomatic recurrence of metatarsus primus varus and hallux valgus after a previous bunion procedure. (2) Obvious hypermobility of the first ray supported by secondary findings such as second metatarsal overload, second metatarsophalangeal joint synovitis, and a dorsal bunion of the first metatarsal. Contraindications: absolute situations include (1) previous excision arthroplasty of the first metatarsophalangeal joint, (2) degenerative changes of the first metatarsophalangeal joint, (3) open growth plates, (4) more than 2 cm of shortening of the first ray as a result of the initial procedure. Relative situations include (1) insulin-dependent diabetes mellitus and peripheral neuropathy, (2) peripheral vascular disease, (3) pantalar fusion. Arthrodesis of the first metatarsophalangeal joint [18, 20, 37, 46] Indications: (1) Revision surgery for instability of the metatarsophalangeal joint (cock-up deformity, floppy toe). (2) Recurrent valgus deformity with arthritis of the metatarsophalangeal joint or with neurological disease. Contraindications: infection, severe vascular disease.

Operative technique

Fig. 5 Preoperative radiograph of a patient who underwent a prior proximal crescentic osteotomy. Recurrence of the deformity occurred secondary to failure to diagnose clinical hypermobility in addition to failure to treat the increased DMAA (a). Successful surgical correction was performed with a Lapidus in conjunction with a medial distal closing wedge osteotomy of the metatarsal (b)

salvage of recurrence after failed surgical osteotomy or arthrodesis, many authors have recommended either a Lapidus or first metatarsophalangeal joint arthrodesis [13, 18–22, 40, 46]. However, a proximal osteotomy is also an excellent solution if there is no evidence of hypermobility. Associated subluxation of lesser metatarsophalangeal joints

The chevron-Austin osteotomy is performed with a medial incision centered on the metatarsal head. The capsule can be opened with multiple techniques, with the authors preferring a simple longitudinal capsuolotmy. The osteotomy is done at the center of the metatarsal head, approximately 1 cm proximal to the articular surface with an angulation of approximately 60°. Variations with a more vertical dorsal limb and transverse and longer plantar limb have been used with success. Fixation is routinely utilized to minimize the risk of malunion. Methods of fixation vary from simple K-wire fixation to screws, or staples. The authors prefer a 2.4- or 3.0-mm headless screw to maintain stability and minimize hardware profile. Capsulloraphy should be

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Fig. 6 Preoperative radiograph of a patient who underwent a prior metatarsal osteotomy with minimal correction of the IMA with recurrent deformity (a). In addition to performing a chevron osteotomy, an Akin osteotomy was performed to create a normal clinical appearance of the foot (b)

performed prior to closure with number 0 absorbable or nonabsorable suture [2, 15, 31]. Coetzee et al. recommend the Lapidus procedure as the salvage procedure of choice (Fig. 7) [21, 40]. The patient is placed supine with a tourniquet around the thigh. A 6-cm incision is made over the dorsum of the foot in line with the extensor hallucis longus tendon [1, 2]. The interval between the extensor hallucis longus and the extensor hallucis brevis is used to expose the first and second tarsometatarsal joints. The entire first tarsometatarsal joint is exposed. The medial aspect of the second metatarsal is exposed and is denuded of soft tissue, and the cortex is also perforated to augment the subsequent fusion. The articular cartilage is removed from the opposing surfaces of the first tarsometatarsal joint with either small osteotomes or a saw. When the first metatarsal is short as a result of the previous procedures, only the cartilage should be removed to limit additional shortening. When the first metatarsal is long, a small laterally based wedge is removed from the medial cuneiform to help reduce the tarsometatarsal joint. A plantar-based wedge is also removed from the tarsometatarsal joint to ensure slight plantar flexion of the metatarsal. Next the adductor hallucis tendon is released through a 2-cm incision in the first web space. The lateral aspect of the first metatarsophalangeal joint capsule is incised longitudinally to allow the sesamoids to reduce. A medial incision is then made over the first metatarsophalangeal joint, the capsule is incised longitudinally, and any residual bunion prominence is removed. The first metatarsal is then reduced parallel to the second, closing the intermetatarsal

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Fig. 7 Preoperative radiograph of a patient who underwent a prior proximal crescentic osteotomy. Recurrence of the deformity occurred secondary to failure to diagnose clinical hypermobility in addition to failure to treat the increased DMAA (a). Successful surgical correction was performed with a Lapidus in conjunction with a medial distal closing wedge osteotomy of the metatarsal (b)

gap. It is very important at this time to confirm that the first metatarsal is slightly plantar flexed and is rotated correctly. Fixation can be performed with two cross screws or a plate and cross screw. An auxillary can be a screw inserted from the medial aspect of the first metatarsal into the base of the second metatarsal to close the intermetatarsal gap securely if there is difficulty in maintaining the reduction. With the intermetatarsal gap reduced, the medial aspect of the capsule is plicated at the first metatarsophalangeal joint. It should not be necessary to overtighten the capsule in order to maintain the alignment of the hallux. If a significant capsular plication is required, the IMA is likely not reduced adequately and attention should be placed to correct the bony alignment to prevent recurrence. Local bone graft is packed into any osseous defects at the bases of the metatarsals. The tourniquet is deflated, and the wounds are closed in layers. Machacek et al. performed the salvage arthrodesis of the first metatarsophalangeal joint with use of regional anesthesia (peripheral nerve block), and a tourniquet was used in fourteen cases in this series [22]. In a lower demand patient, the use of a first MTP arthrodesis is a reliable procedure to correct recurrent deformity regardless of the presence of arthritis. A concomitant metatarsal osteotomy to correct the IMA is not required in the setting of a first MTP fusion (Fig. 8). With an appropriate reduction maneuver with adduction of the first metatarsal, the IMA and HVA are reduced concomitantly (Fig. 9). In the setting of a dorsiflexion malunion of the first metatarsal, a plantar


Fig. 8 Preoperative radiograph of a patient who has severe recurrence of her deformity with degenerative changes and pain within the first MTP joint (a). Salvage was performed with a first MTP fusion (b), that corrected both the HVA and the IMA angle without the need for additional proximal osteotomy

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Fig. 9 Intraoperative photograph of the reduction maneuver to correct both the IMA and the HVA when performing a first MTP fusion. Adduction of the first metatarsal with concomitant abduction of the proximal phalanx is required. The deformity should not recur as the metatarsal cannot deviate once the first MTP is stabilized

flexion osteotomy is required in addition to first MTP fusion (Fig. 10). If this is not performed, the phalanx will be left in a dorsally translated position, which will impede shoewear. Fixation can be performed with cross screws or a dorsal plate and a cross screw. The use of a dorsal plate and a cross screw has shown the highest biomechanical stability and should be considered in the setting of osteopenia. Postoperative care A gauze-and-tape compression dressing is applied in the operating room and is changed weekly. The patient should remain nonweightbearing for the first 2 weeks while wearing a wooden-soled postoperative shoe. And then the sutures are removed. Postoperative bandaging maintained the hallux in a rectus position. The accessory fixation and convalescence may be different, depending on the particular procedure, the intraoperative stability of the internal fixation and the anticipated compliance by the patient [1, 2, 31]. After chevron osteotomy, weightbearing is allowed on the heel while the patient is wearing a wooden-soled postoperative shoe and the Kirschner wire is removed at 4 weeks. Passive range-of-motion exercises are initiated at 6 weeks. If the site of the osteotomy is unstable, a belowthe-knee weightbearing cast is applied for 3 weeks or until adequate bone healing has been documented radiographically [5, 30].

Fig. 10 Preoperative lateral radiograph of a patient with a dorsiflexion malunion of a proximal metatarsal osteotomy with concomitant pain and stiffness of the first MTP joint (a). Postoperative lateral radiograph demonstrating successful correction with a combined plantar flexion osteotomy of the proximal metatarsal and first MTP fusion (b). Failure to correct the dorsiflexion malunion would have resulted in an elevated phalanx that would impede shoe wear. Additionally, an isolated first MTP fusion in excess plantar flexion to compensate will result in increased stress on the IP joint and a persistently prominent first metatarsal head and should be avoided. All components of the deformity must be corrected for a successful result

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After arthrodesis of the first metatarsophalangeal joint, the patients either wear a stiff-soled shoe and are allowed weightbearing to tolerance on the heel only for an average of 7 weeks or have a below-the-knee walking cast for an average of 6 weeks, after which they wear a postoperative shoe for another 4 weeks. The first ray is protected until adequate union is demonstrated radiographically, usually at 8–12 weeks postoperatively [1, 20]. After Lapidus procedure, the patient should remain nonweightbearing for 6–8 weeks [39, 40]. If the radiographs demonstrate satisfactory progression of the fusion, weightbearing is initiated in a removal of walking boot or wooden-soled shoe, which can be discontinued 12 weeks from the date of surgery. Patients are advised not to return to any vigorous physical activity for at least 3 months, although they may begin swimming and bicycling at 8 weeks.


risk for degenerative changes after first MTP joint arthrodesis. But only one patient in their study reported symptomatic changes in the interphalangeal joint, and no patient reported symptoms at the metatarsocuneiform joint at an average followup of 8 years [47].

Summary The successful treatment of recurrent hallux valgus deformity requires a thorough understanding of the multiple sites of deformity. No single procedure can be recommended given the complexity of the deformity. The most appropriate surgical strategy can be devised by performing a detailed physical examination and radiographic analysis. Surgical strategy based solely upon radiography carries a risk of failure as a rigid deformity, instability, or pain within the MTP cannot be identified and will lead to persistent pain or recurrence if not addressed.

Function and outcomes To date, there are limited reports about the results of reoperation for recurrent hallux valgus. Coetzee et al. had done the intermediate-term study of 26 feet showed a significant improvement in pain scores and other outcome measures following the Lapidus procedure for the treatment of recurrent hallux valgus deformity, and the patients reported satisfaction after 81% of the procedures [21]. At 24 months, the mean score according to the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal- interphalangeal Scale had increased from 47.6 to 87.9 points, the mean score according to the visual analog pain scale had improved from 6.2 to 1.4, the mean hallux valgus angle had improved from 37.1° to 17.1°, and the mean intermetatarsal angle had improved from 18° to 8.6°. Thompson et al. [13] thought the tarsometatarsal and first and second metatarsal fusions eliminate any rotation or translation of the first ray. When the space between the first and second intermetatarsal is reduced adequately, it is almost impossible for the hallux valgus or metatarsus primus varus deformity to recur. Machacek et al. [22] evaluated arthrodesis of the first metatarsophalangeal joint as a salvage technique following a failed Keller procedure including recurrent valgus deformity and cock-up deformity. Satisfaction was excellent or good in 23 cases (total 28 patients), and the postoperative score according to the modified hallux metatarsal-interphalangeal scale averaged 76 points (maximum, 90 points). So they recommend arthrodesis for salvage following a failed Keller procedure since it may be associated with a higher rate of patient satisfaction and better clinical results. Grimes JS found that the first interphalangeal and the first metatarsocuneiform joints are at

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