Metatarsus Adductus with Hallux Valgus: A retrospective review of
surgical outcomes and a new angle for surgical planning
Jeff Holmes DPM*, Jordan Panicco DPM*, Richard Derner DPM, FACFAS**
*Resident INOVA Fairfax Medical Campus, Fairfax VA; **Associated Foot & Ankle Centers of Northern Virginia, ACFAS President
STATEMENT OF PURPOSE
PROCEDURE
RESULTS
The purpose of this study is to retrospectively examine patients that have undergone surgical
intervention for the correction of hallux valgus (HV) with associated metatarsus adductus (MA). Our goal
is to present a quantitative radiographic analysis of the pre-operative and post-operative values. Further;
this analysis will present a new angle that may determine if a fifth metatarsal osteotomy is required for
MA correction.
• The mean pre-op IMA (N=56) was 9.28° and 6.48° post-op.
• Pre-post difference of 2.81°.
• The mean pre-op Engel’s angle (N=56) was 33.6° and 19.3° post-op
• Pre-post difference of 14.4°.
• The mean pre-op corrected IMA (N=56) was 24.1° and 7.79° post-op
• Pre-post difference of 16.3°.
METHODOLOGY & HYPOTHESIS
 All values were highly statistically significant using a paired t test
(p ≤ 0.0001)
Between 2002 and 2015, 51 patients who underwent hallux valgus surgery with concurrent surgery
to correct for metatarsus adductus were retrospectively identified. Of the 51 patients reviewed, 13
patients had bilateral deformity that was corrected, recording a total of 64 feet. 8 patients did not
meet the required follow up time of 10 months and were excluded from the study, leaving a total
value of N=56 feet (43 patients).
We evaluated 56 feet that underwent corrective osteotomies simultaneously to address both
deformities (HV & MA). Using standard weight bearing radiographs parameters including the firstsecond inter-metatarsal angle (IMA), metatarsus adductus angle (MAA), and the corrected intermetatarsal (cIM) angle, pre-operative and post-operative values were recorded.
IM angle: Bisection of 1st metatarsal
and 2nd metatarsal (10.4°)
Fig 1. 3 Dorsal incisions for Lepird and
Lapidus.
Fig 2. Oblique osteotomy of a
central metatarsal with rotation of
the capital fragment .
The procedure was performed through two dorsal longitudinal incisions over the second and fourth
inter-metatarsal space. Each of the lesser metatarsals was identified and sub periosteal dissection
completed, exposing the proximal one-third to one-half of the metatarsal segment (Fig. 1). A single
oblique cut oriented from dorsal distal to plantar proximal was made with care taken to avoid
cutting through the plantar cortex. A 2.7 mm screw was inserted across the osteotomy site (Fig. 2).
The screw was then temporarily removed and the osteotomy completed. The 2.7 mm screw was
immediately reinserted. The distal fragments were then rotated laterally into a corrected position
and the screw was tightened.
If an additional fifth metatarsal osteotomy was deemed necessary, a proximal closing base wedge
osteotomy was performed via the fourth inter-metatarsal space incision and secured in place with a
2.7mm screw (Fig. 3).
5th met-cuboid angle: Bisection of
5th metatarsal and lateral border
of cuboid (5.1°)
Increased 5th met-cuboid
angle (19.8°)
Due to the underlying presence of MA , the true IMA may be underestimated. To overcome this
predicament, our study uses a modification of a formula originally proposed by Yu et al to
demonstrate the inter-relationship between the IMA and MAA (10). Using Engel’s angle to measure
MA, we propose: Corrected IMA = IMA + ((MA-15)-3). Our analysis demonstrates a highly
statistically significant difference of 16° in our pre op and post op corrected IMA using a paired t
test (p < 0.0001).
RESULTS
We hypothesized that the radiographic measurements comparing post-op to pre-op values would be
statistically significant (p ≤ .05). Also hypothesized was that the pre-operative values of those who
had a 5th metatarsal osteotomy compared to those who did not would be statistically significant.
All procedures were performed by the senior author. In order to correct the underlying MA, a
rotational base osteotomy (Lepird) of metatarsals 2-4 was most commonly utilized.
Tarsometatarsal arthrodesis was advocated if arthritis was present. If an additional fifth metatarsal
osteotomy was deemed necessary, a proximal closing base wedge osteotomy was performed.
Engel’s angle: Bisection of 2nd
metatarsal and medial
cuneiform (39.2°)
ANALYSIS & DISCUSSION
Fig 3. Closing base wedge osteotomy
of the 5th metatarsal fixated with 2.7mm
screw.
A newly proposed 5th metatarsal-cuboid (5th met-cuboid) angle was also evaluated. Pre-op and
post- op values were obtained in order to necessitate the need of a fifth metatarsal osteotomy. 37 of
the 56 feet underwent a fifth metatarsal corrective osteotomy due to an increased 5th met-cuboid
angle.
PROCEDURE
RADIOLOGICICAL ASSESSMENT
Pre-op: Clinical and AP radiograph left foot. HV
complicated by MA.
Post-op: Correction of MA utilizing Lepird with adjunct CBWO 5th
Met. HV correction utilizing Lapidus and Akin.
37 patients who underwent a fifth metatarsal osteotomy (Yes Group = Osteotomy).
• The mean pre-op 5th metatarsal-cuboid angle was 14.4° and 6.19° post op
• Pre-post difference of 8.21°
19 patients did not undergo a fifth metatarsal osteotomy (No Group = No Osteotomy).
• The mean pre-op 5th metatarsal-cuboid angle was 5.15°
LITERATURE REVIEW
Metatarsus Adductus (MA) is a congenital deformity in which there is adduction of all of the metatarsals relative to
the lesser tarsus, supination of the subtalar joint and plantarflexion of the first ray (1). It is one of the most
common congenital deformities occurring in 1-2 per 1000 births (2). MA has been postulated to be caused by
high intrauterine pressure during the developmental period; however the exact etiology is unclear (3,4).
By and large, MA is thought to precede the development of hallux valgus (HV) and has long been implicated as a
risk factor, increasing the risk by up to 3.5 times (5). The prevalence of MA with HV has been investigated in the
literature and reported to be between 29% and 35% (4,5,6).
A various array of methods have been advocated to radiographically assess MA. Recent studies have
demonstrated high inter and intra-observatory reliability values with multiple methods including the method used
in this study (5,7). Historically, the normal range for the traditional MAA is between 10° and 21° (7). Engel et al
postulated the angle between the longitudinal axis of the middle cuneiform and the second metatarsal to
appropriately asses for MA. This simplified angle was demonstrated it to be 3° greater than the traditional
method, suggesting that an angle greater than or equal to 24° as abnormal (8).
Comparing the two groups:
• Yes Group = Mean pre op: 14.4° (95% CI 12.8-16.0)
• No Group = Mean pre op: 5.15° (95% CI 3.71-6.59)
• The mean pre-op difference was 9.26° (95% CI 7.15-11.4).
Highly statistically significant using a paired t test (p ≤ 0.0001)
Our study critically investigated a new angle, called the 5th metatarsal-cuboid angle which is
defined by the longitudinal axis of the 5th metatarsal and a tangential line along the lateral distal
aspect of the cuboid to the most proximal lateral aspect. The rationale behind developing this angle
is to determine if a fifth metatarsal osteotomy is essential to assist in correction of MA.
Of the original 56 feet, we retrospectively compared the 5th met-cuboid angle in patients that
underwent a 5th metatarsal osteotomy (N=37) to those who did not (N=19). Our data demonstrated
a highly statistically significant difference (p<0.0001) pre operatively. Post op values for patients
that underwent a 5th met osteotomy versus the pre-op values for patients that did not, was
comparable. In this cohort, the data may suggest that a 5th met-cuboid angle greater than ≥13°
necessitates the need for a 5th metatarsal corrective osteotomy.
Furthermore, a value ≤
7°obviates the need for an additional osteotomy.
We believe this is the largest study to quantify radiograhic analysis of pre op and post op corrected
IMA in patients undergoing simultaneous surgical reconstruction of both HV and MA. To the
authors’ knowledge, this study represents the only series available in current literature that
evaluates MA influence on the 5th met-cuboid angle.
• The mean post-op difference was 1.04° (95% CI -1.11-3.19)
P-Value 0.33 (Not statistically significant)
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Ancillary procedures that were utilized to correct the hallux valgus deformity included an oblique
closing base wedge osteotomy of the 1st metatarsal, a base wedge in conjunction with a distal
metaphyseal osteotomy (Logriscino), and most commonly a 1st metatarsal-cuneiform arthrodesis
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The importance of identifying underlying MA has been advocated in previous studies. MA can often complicate
the operative correction of the HV deformity, reports have highlighted the difficulty of transposition of the first
metatarsal head due to a reduction in space between the first and second metatarsal (9,10). Correction of the HV
deformity alone will most likely result in reoccurrence in moderate to severe cases (3,4,11). Aiyer et al quantified
the rate of radiographic recurrence HV and reported 29.6% in patients with MA compared to 15.2% in patients
without MA (12). Furthermore, they demonstrated that patients with moderate MAA (MAA < 31°) were found to
have a recurrence rate of 80% (12).
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