The Journal of Foot & Ankle Surgery 55 (2016) 220–225

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The Journal of Foot & Ankle Surgery

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Original Research

Quantitative Analysis of the Degree of Frontal Rotation Required

to Anatomically Align the First Metatarsal Phalangeal Joint During
Modified Tarsal-Metatarsal Arthrodesis Without Capsular Balancing
Paul Dayton, DPM, MS, FACFAS 1, 2, Merrell Kauwe, DPM 3,
Lawrence DiDomenico, DPM, FACFAS 4, Mindi Feilmeier, DPM, FACFAS 5,
Rachel Reimer, PhD 6
1
Residency Director, UnityPoint Health, Trinity Regional Medical Center, Fort Dodge, IA
2
Assistant Professor, Des Moines University College of Podiatric Medicine and Surgery, Fort Dodge, IA
3
Resident, UnityPoint Health, Trinity Regional Medical Center, Fort Dodge, IA
4
Director, Fellowship Training, Youngstown, OH; and Adjunct Professor, Kent State University College of Podiatric Medicine, Independence, OH
5
Assistant Professor, Des Moines University College of Podiatric Medicine and Surgery, Des Moines, IA
6
Associate Professor, Chairperson, and Program Director, Des Moines University, Des Moines, IA

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 4 The data from 35 consecutive patients with hallux valgus undergoing triplane arthrodesis at the first tarsal
metatarsal joint were studied to determine the amount of first metatarsal frontal plane rotation (supination)
Keywords:
hallux abducto valgus needed to anatomically align the first metatarsal phalangeal joint on an anterior posterior radiograph without
Lapidus arthrodesis soft tissue balancing at the first metatarsal phalangeal joint. Radiographs were measured both pre- and
metatarsus primus adducto valgus postoperatively to assess the 1-2 intermetatarsal angle, hallux abductus angle, and tibial sesamoid position
metatarsal pronation (TSP). The mean amount of varus (supination) rotation performed during correction was 22.1! " 5.2! and the
tibial sesamoid position mean amount of intermetatarsal angle reduction achieved after completion of the procedure was 6.9! " 3.0! .
The TSP changed by a mean of 3.3! " 1.2! . A series of univariate linear regression analyses was performed to
analyze the relationship between the frontal plane rotation of the first metatarsal performed during the
operation and the preoperative intermetatarsal angle, hallux abductus angle, and TSP. Greater preoperative
TSP scores were associated with greater intraoperative varus (supination) rotation required for joint align-
ment. Direct observation of the alignment changes at the first metatarsal phalangeal joint after metatarsal
rotation without distal procedures strengthened the notion that the frontal plane rotational position plays an
important role in the bunion deformity.
! 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.

The inconsistency in clinical outcomes when using popular frontal plane position of the first metatarsal. Scranton and Rutkowski
metatarsal osteotomies with supplementary soft tissue balancing for (3) reported both with a preoperative mean metatarsal pronation
hallux abducto valgus (HAV) correction prompted us to explore the value of 14.5! , and Mortier et al (4) reported a mean metatarsal
role of frontal plane rotation of the first metatarsal as a component of pronation of 12.7!.
operative treatment. Available investigations regarding bunion- Recent reports describing the surgical manipulation of first
affected feet have reported both the first metatarsal and the phalan- metatarsal frontal plane position have reported data using a qualita-
geal components of the first metatarsal phalangeal joint (MTPJ) in a tive or directional description alone (5–9). The purpose of the present
valgus (pronated) position (1–4). Studies reporting the observed investigation was to report our results quantifying the amount of
frontal plane position of the first metatarsal include both qualitative frontal plane rotation (supination) used to align the first MTPJ during
and quantitative descriptions. Grode and McCarthy (1) and Eustace a modified tarsal metatarsal arthrodesis without distal joint capsular
et al (2) commented on the directional description, with the terms work. We also report the associations between common preoperative
eversion and pronation used to, respectively, describe the valgus radiographic HAV measurements and the degree of rotation imparted
surgically in our patients.
Financial Disclosure: None reported.
Conflict of Interest: None reported. Patients and Methods
Address correspondence to: Paul Dayton, DPM, MS, FACFAS, UnityPoint Clinic, 804
Kenyon Road, Suite 310, Fort Dodge, IA 50501. The Des Moines University institutional review board granted exempt status to our
E-mail address: [email protected] (P. Dayton). retrospective review. A medical record review was conducted of 35 consecutive

1067-2516/$ - see front matter ! 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2015.08.018
 P. Dayton et al. / The Journal of Foot & Ankle Surgery 55 (2016) 220–225 221

patients (34 females, 1 male) with symptomatic HAV for whom conservative treatment on a scale of 1 to 7. All analyses were conducted by 1 of us (R.R.) using SPSS, version
had failed. These patients had undergone a tarsal metatarsal arthrodesis modified to 22 (IBM Corp., Armonk, NY). First, a series of paired t tests were conducted to
correct the frontal plane rotational component of the deformity from September 2012 examine the differences in pre- and postoperative angle measurements. Next, a
to July 2014. Patients were excluded if previous first ray surgery had been performed. series of univariate linear regression analyses was conducted to examine the effects
The criteria for inclusion in the study were as follows: (1) intraoperative measurement of the preoperative IMA, HAA, and TSP on the postoperative varus rotation. All beta
of the degree of frontal plane rotational correction and (2) pre- and postoperative (b) values reported are unstandardized. Statistical significance was set at the 5%
anteroposterior radiographs available. level (p # .05).
The surgical technique consisted of a dorsal incision made medial to the extensor
hallucis longus tendon and lateral to the tibialis anterior tendon from the mid-first
metatarsal shaft to the proximal aspect of the medial cuneiform. Direct dissection Results
was carried to the level of the bone, with the periosteal tissue reflected as part of a
full-thickness flap. A custom-designed protractor, used during tarsal metatarsal Of the 35 patients identified, 34 (36 feet), with a mean follow-up
corrective fusion for the past several years by the senior author (P.D.) to guide
period of 5 (range 3 to 12, median 5) months, met our inclusion
correction, was used to perform the rotational measurements. The measurement
device was placed to overlie the first tarsal metatarsal joint, and 3 pins were inserted criteria. One (2.9%) patient did not have the amount of rotation
through the device to capture an arbitrary zero point of rotation. The initial pin imparted recorded in the medical record due to the measurement
placement was reproduced in all patients, because the pins were placed in line device being unavailable at the time of their surgery. Additionally, the
through the device. Two pins were inserted into the cuneiform and one pin into the
HAA value of 1 (2.9%) patient was not included in the statistical
metatarsal shaft. After the pins were inserted, the device was removed, and the joint
was appropriately resected to preserve the metatarsal length and correct the trans-
analysis because a phalangeal osteotomy had also been performed.
verse aspect of the deformity. After transverse correction was complete, the first This did not affect the rotational measurement; therefore, that patient
MTPJ joint was observed under a fluoroscopic anteroposterior view and manipulated was not excluded from our study.
by pushing the metatarsal pin to rotate the first metatarsal in a varus direction (su- Complete descriptive statistics are listed in the Table. The mean
pination) until the MTPJ was aligned both radiographically and clinically. Our
change in the IMA following the procedure was 6.97! (SD ¼ 3.04! ),
observation criteria for joint alignment consisted of an assessment of aspects of the
MTPJ that the published data have suggested are related to rotational position, p < .001; mean change in HAA was 13.61 (SD ¼ 6.46), p < .001; mean
including the distal metatarsal articular angle (10,11), the hallux abductus angle change in TSP was 3.33 (SD ¼ 1.22), p < .001 positions respectively. In
(HAA) (7), the prominence of the medial eminence (1), lateral rounding of the sum, all angles were significantly reduced from pre to post mea-
metatarsal head (12), and the tibial sesamoid position (TSP) (13–15) (Fig. 1). surements. The average degree of rotation imparted to the first
After temporary fixation, the device was turned perpendicular to its initial
position and placed on the pins in the medial cuneiform. These 2 pins served as a
metatarsal to obtain MTPJ and sesamoid alignment was 22.1! " 5.15! .
stable reference point of the original rotational position. The degree of supination We conducted a series of hierarchical linear regression analyses. The
used to reduce the first MTPJ was measured by comparing the position of the effects of the preoperative IMA and HAA on operative varus rotation
metatarsal pin after rotational correction to the scale built into the measurement were not significant (p > .2). The effect of the preoperative TSP on
device, and the data were recorded (Fig. 2). Final fixation was performed in this
varus rotation was statistically significant (b ¼ 1.28, standard
same position.
The pre- and postoperative radiographs were measured by 1 of us (M.K.) to error ¼ 0.61, p ¼ .043). Specifically, greater preoperative TSP scores
assess the 1-2 intermetatarsal angle (IMA), HAA, and TSP. The measurements were were associated with greater intraoperative varus rotation required
consistent with those described by Hardy and Clapham (15), with the TSP measured for joint alignment.

Fig. 1. (A and B) Aspects of the first metatarsal phalangeal joint that the published data show to be indicative of the frontal plane rotational position, including the prominence of a
medial eminence, lateral deviation of the tibial sesamoid, lateral shape of the metatarsal head, and proximal articular set angle. These changes can be observed on these pre- and
postoperative anteroposterior radiographs (A and B respectively) after Lapidus arthrodesis with varus rotation (supination) of the metatarsal without capsular balancing. Arrows
indicate the change in the lateral roundness of the first metatarsal head. With metatarsal pronation, the lateral plantar aspect of the metatarsal becomes more prominent; the
rounding is reduced with supination. This sign is both an indicator of rotational position and a predictor of recurrence (12). Note the change in the prominence of the medial
eminence without medial resection and the sesamoid position after rotational correction without capsular balancing. These collective changes to the metatarsal phalangeal joint
can be used to assess the joint position intraoperatively.
222 P. Dayton et al. / The Journal of Foot & Ankle Surgery 55 (2016) 220–225

Fig. 2. (A) View of the device used for operative assessment of rotational correction with its initial placement with 2 pins in the cuneiform and 1 pin in the metatarsal, capturing an
arbitrary zero point for rotational assessment. (B) The device is removed, and the triplanar correction, using osteotomies and rotation, is imparted. After correction and temporary fixation,
the device is rotated 90! and placed back over the 2 cuneiform pins to maintain the arbitrary zero point of rotation initially established. The position is maintained until final fixation has
been implemented. (C) The front of the device captures the value in degrees of the rotational correction. (D) A view that helps one to visualize the magnitude and direction of rotation.
Note that no soft tissue or capsular balancing was performed to correct the deformity.

Discussion reported a mean pronated position of the first metatarsal in a bunion

deformity of 21.9! , significantly different from that of their normal
The most common corrective surgery for HAV involves %1 meta- control subjects (16). Our results have indicated that a frontal plane
tarsal osteotomies, along with capsular balancing. Using this para- correction of an average of 22.1! of supination of the first metatarsal,
digm, priority has been focused on the transverse plane component of concurrently with transverse plane IMA correction, reduces the
what is becoming better understood to be a multiplanar deformity. In deformity nearly completely at the first MTPJ according to the
our study, the average correction of the IMA was 7!, with a mean observation of sesamoid position and joint congruency. Correction of
postoperative IMA of 6.4! . In contrast, the amount of rotational the first metatarsal in the frontal plane, in addition to the transverse
correction averaged 22.1! (Fig. 3). The mean value of supination and sagittal planes, is a distinct departure from the nearly ubiquitous
correction of the first metatarsal needed to achieve clinical and approach of addressing the transverse and sagittal plane components
radiographic alignment of the first MTPJ without soft tissue balancing of the deviated first metatarsal with osteotomy and relying on
in our series was very close to the mean metatarsal pronation found in capsular balancing to align the hallux and sesamoids by soft tissue
feet with bunions reported in a recent partial weightbearing pull (Fig. 4). Using the proposed triplanar paradigm of metatarsal
computed tomography study (16). That computed tomography study supination will eliminate, in most cases, the need for additional sur-
gical procedures or any form of manipulation at the distal joint.
Dramatic improvements in the HAA, sesamoid position, and distal
Table
Descriptive statistics metatarsal articular angle can be realized with proximal correction
alone, if all 3 planar components are addressed.
Angle Feet (n) Minimum (! ) Maximum (! ) Mean (! ) SD (! )
Radiographic assessment of the metatarsal rotation of feet with
Preoperative IMA 36 6.60 22.20 13.36 3.34 HAV can be difficult. The studies reporting on metatarsal rotation
Preoperative HAA 36 7.70 39.00 22.46 7.95
Preoperative TSP 36 3.00 7.00 5.11 1.36
using axial radiographs have been inconsistent in the positioning of
Postoperative IMA 36 2.50 13.00 6.39 2.43 the foot and the method of measurement used. Scranton and
Postoperative HAA 35 1.10 22.60 9.08 4.68 Rutkowski (3) and Saltzman et al (17) obtained their axial image in
Postoperative TSP 36 1.00 4.00 1.77 0.83 line with the long axis of the foot, and Mortier et al (4) obtained the
IMA change* 36 0.10 13.70 6.97 3.04
radiograph in line with the first metatarsal to avoid any tangential
HAA change* 35 2.30 25.30 13.61 6.46
TSP change* 36 1.00 5.00 3.33 1.22 views skewing the perspective of the crista and the actual rotation
Varus rotation 36 12.00 30.00 22.10 5.15 visualized at the metatarsal head. Also, although they both used the
Abbreviations: HAA, hallux abductus angle; IMA, intermetatarsal angle; SD, standard
long axis of the foot as their guide, Scranton and Rutkowski (3) and
deviation; TSP, tibial sesamoid position. Saltzman et al (17) used different parameters to measure rotation.
* p < .001. Scranton and Rutkowski (3) used the lesser metatarsal heads as
 P. Dayton et al. / The Journal of Foot & Ankle Surgery 55 (2016) 220–225 223

will create an opposing eversion or pronation positional change to

the metatarsal. Careful analysis of the radiographs in their study
showed changes to the first metatarsal phalangeal joint that are not
consistent with their conclusion, which was that inversion or supi-
nation rotation of the hallux will lead to eversion or pronation of the
metatarsal (Fig. 1). Their application of the reported normal range of
motion to define the osseous position in a foot with HAV, rather than
relying on published data regarding the metatarsal position in a foot
with HAV, shows that confusion regarding the anatomy of a bunion
deformity still exists. In 2014, Dayton et al (19) dedicated a report to
the description of the position and associated terminology of the
bunion deformity to clarify both the position and the descriptors of
the position.
Okuda et al (6) reported on a study of metatarsal rotational
correction, showing that lateral roundness of the metatarsal head is a
sign of pronation or eversion that will be corrected with varus or
supination rotation. This lateral roundness becomes evident as the
lateral and plantar aspects of the metatarsal head become prominent
with first metatarsal pronation. They also hypothesized that the
sesamoid position might be related to the amount of rotation (18).
Dayton et al (13,14), in a series of cadaveric studies, showed that
lateral roundness of the metatarsal head and sesamoid position are a
product of metatarsal eversion or pronation. In addition, Dayton et al
(13,14) showed that the hallux could be a driver of this positional
change in the metatarsal. DiDomenico et al (8) described using this
ligamentotaxis to directionally drive the metatarsal in the same di-
rection as the rotating hallux to correct the rotational component of a
bunion when performing Lapidus arthrodesis.
Fig. 3. Graphic representation of the mean amount of correction in degrees obtained in
our case series. A mean of 22.1! of varus rotation (supination) was required for deformity We have shown a consistent pronated position of the metatarsal
correction and was measured with the custom protractor shown in Fig. 2. A mean of 6.9! in patients with bunion deformities in the present series. However,
in the transverse plane was required for deformity correction measured by the 1-2 our study did not show a significant linear relationship between
intermetatarsal angle (IMA).
the preoperative value of the IMA and HAA and the amount of varus
rotation required for alignment of the MTPJ. Although rotational
their reference, and Saltzman et al (17) used the weightbearing correction was required to align the MTPJ, the degree of rotational
surface of the foot. It is unclear which position and measurement correction required did not linearly increase as the IMA or HAA
would be the most accurate when assessing the deformity. Eustace increased. Thus, we do not recommend use of the IMA and HAA as
et al (2) used anteroposterior radiographs to assess the amount of indicators of the preoperative, intraoperative, or postoperative
rotation and determined that a linear relationship is present be- assessment of rotation. This result is consistent with the work by
tween the IMA and metatarsal pronation. The study by Eustace et al Mortier et al (4) and Saltzman et al (17), which used an open
(2) did not use an open continuous scale and thus would be of little continuous scale to observe the rotation on axial radiographs and
benefit when surgically planning the magnitude of rotational found metatarsal pronation does not have a linear relationship to
correction. Because of the difficulty in quantifying the exact amount the IMA. We have seen cases in which very little metatarsal pro-
of rotation that exists preoperatively, it was not considered in our nation is present in patients with a high IMA. However, we have yet
treatment paradigm. We simply acknowledged that pronation of to identify any patient with an HAV deformity with a supinated
the metatarsal would influence the first MTPJ alignment. Therefore, metatarsal.
we reduced the joint with the degree of supination required to Our study has shown a significant relationship between the pre-
appropriately align the sesamoids and decrease the lateral round operative sesamoid position and the degree of varus rotation required
sign of the first metatarsal head, the distal metatarsal articular to align the MTPJ. This result is consistent with the studies by Inman
angle, and the HAA. (20), Talbot and Saltzman (21), and Dayton et al (13,14), which
The position of the metatarsal in the frontal plane in feet with showed a pronated metatarsal will increase the sesamoid position on
HAV is not easily appreciated in a clinical setting. The assessment will anteroposterior radiographs. In conjunction with the work by Okuda
be more difficult if the reported normal mechanics of the first ray are et al (6,12,18) and Grode and McCarthy (1), we advance the idea that
applied and one assumes that the first ray is dorsiflexed and inverted the sesamoid position, lateral rounding of the metatarsal head, and
in a bunion deformity. This would lead to the inaccurate conclusion the appearance of a medial eminence are effective indicators of the
that in feet with HAV, the hallux is in a frontal plane valgus position rotational position in the assessment, correction, and follow-up of
and the metatarsal is in a frontal plane varus position. It is improper patients with bunion deformities. Reduction of the lateral round sign
to apply the asserted normal mechanics to the position of the first ray of the metatarsal head and sesamoid position improvement, which
in a bunion deformity, because the valgus (pronated) rotational po- are indicators of rotational position, have been shown to decrease the
sition has been clearly delineated in the published data (1–8). incidence of deformity recurrence (6,12,18). Thus, rotational correc-
Misunderstanding the position can lead to inaccuracies. Klemola et al tion reduces the likelihood of recurrence.
(9), reporting on their derotational tarsometatarsal arthrodesis, The number of patients and feet involved limited the direct con-
repeatedly applied the commonly accepted mechanical axis of the clusions of the present retrospective observation. Additional limita-
first ray to describe the rational for the procedure they were per- tions included that our investigation did not report on outcomes.
forming. They purported that inversion or supination of the hallux Rather, we reported solely on the quantification of the intraoperative
224 P. Dayton et al. / The Journal of Foot & Ankle Surgery 55 (2016) 220–225

Fig. 4. (A) Two views of a patient’s foot before operative correction of hallux abducto valgus and metatarsus primus adducto valgus. Note the sesamoid subluxation viewed on the
anteroposterior radiographs does not match the position observed in the axial image owing to the pronated or valgus position of the metatarsal. (B) View of the same patient 5 months
after operative intervention with no first metatarsal phalangeal joint soft tissue balancing performed. Note the alteration of sesamoid position, lateral rounding of the metatarsal head,
appearance of the medial eminence, and proximal articular set angle observed on the anteroposterior radiographs. Also, the pronated position of the metatarsal has been reduced as
observed on the axial radiograph.

rotation to align the MTPJ. Also, no preoperative assessment of rota- rotational exists in patients with HAV, the surgeon can fully consider
tion was performed to guide our operative planning. Future studies this previously underreported anatomic component in the operative
should assess which axial position and measurement techniques planning and surgical technique.
correlate most closely with the measured operative values to give the
surgeon better preoperative guides. In addition, long-term outcome
studies should be performed to assess the incidence of recurrence and References
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