Hallux valgus (HV) is a first ray forefoot deformity characterized by varus alignment of the first metatarsal and lateral deviation of the great toe, resulting in a medial prominence of the first metatarsal head. It often causes pain, difficulty with normal shoe wear, and loss of the normal biomechanical integrity of the forefoot in locomotion.14 HV is represented on radiographs by an increased hallux valgus angle (HVA), measured between the longitudinal axes of the first metatarsal and that of the proximal phalanx of the great toe (normal < 15 degrees), and an increased intermetatarsal angle (IMA), measured between the longitudinal axes of the first and second metatarsals (normal < 9 degrees).13,17,18 Based on these measurements on a weight-bearing AP radiograph, a HV deformity may be classified as mild, moderate, or severe. For appropriate operative candidates, the severity of deformity on radiographs often dictates the operative procedure performed. Patients with a moderate to severe HV deformity recalcitrant to nonoperative measures are candidates for a proximal first metatarsal osteotomy and a modified McBride distal soft tissue release to correct the IMA and HVA, respectively. These procedures have favorable outcomes and are widely agreed upon.4,9-11,21,22,24
For postoperative management of these patients, many surgeons have traditionally advocated a compressive circular dressing around the metatarsal region of the foot with a hallux toe spica 573748FAIXXX10.1177/ 1071100715573748 Foot & Ankle InternationalPonzio et al research-article2015 1 Rothman Institute/Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA Corresponding Author: Steven M. Raikin, MD, Rothman Institute/Department of Orthopaedic Surgery, Thomas Jefferson University, 1025 Walnut St, Rm 516 College Building, Philadelphia, PA 19107, USA. Email: email@example.com Radiographic Outcomes of Postoperative Taping Following Hallux Valgus Correction Danielle Y. Ponzio, MD1 , David I. Pedowitz, MD, MS1 , Kushagra Verma, MD, MS1 , Mitchell G. Maltenfort, PhD1 , Brian S. Winters, MD1 , and Steven M. Raikin, MD1 Abstract Background: Traditionally, hallux valgus operative correction has been accompanied by serial spica taping of the great toe during the postoperative period. Methods: We retrospectively reviewed 187 adult patients who underwent proximal first metatarsal osteotomy with a modified McBride procedure in 2008-2009 (n = 83) and 2011-2012 (n = 104). Postoperatively, to maintain the corrected position of the hallux, patients from 2008 through 2009 underwent weekly spica taping, while patients from 2011 through 2012 utilized a toe separator. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured using anteroposterior weight-bearing preoperative, 2-week postoperative non-weight-bearing, and 3-month weight-bearing final follow-up radiographs. A mixed-effects linear regression model identified differences between the treatment groups over time, and a t test compared actual radiographic differences at final follow-up. Results: The mixed-effects model revealed no significant difference in the HVA over time when comparing patients taped to those not taped at the preoperative (33 ± 6 vs 33 ± 6), 2-week postoperative (10 ± 7 vs 9 ± 6), and 3-month follow-up (14 ± 6 vs 11 ± 7) visits (P = .08). At final follow-up, the HVA was lower for the group that was not taped, but the difference (2.5 degrees) was below the minimal clinically important difference (MCID) (P = .015, 95% CI 0.5-4.5). For IMA, there was improved maintenance of correction over time in the patients that were not taped compared to those taped at the preoperative (15 ± 3 vs 15 ± 3), 2-week postoperative (2 ± 2 vs 3 ± 3), and 3-month follow-up (5 ± 4 vs 7 ± 4) visits (P = .002). At final follow-up, the IMA was lower for the group that was not taped, but the difference (1.7 degrees) was below the MCID (P = .004, 95% CI 0.7-2.9). Conclusions: We report no radiographic benefit of postoperative taping after hallux valgus correction.
The present study challenges the previous dogma of postoperative spica taping as the protocol is cost and time intensive for the patient and surgeon. Level of Evidence: Level III, comparative series. Keywords: hallux valgus, bunion, hallux valgus angle, intermetatarsal angle, taping, proximal metatarsal osteotomy Downloaded from fai.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on February 28, 2015 2 Foot & Ankle International which involves taping the great toe in a neutral or slightly varus position as described by Henri DuVries and popularized by Roger Mann (Figure 1).6 This is designed to hold the first metatarsal out of varus, and to maintain the corrected position and rotation of the toe as the capsular soft tissues heal and is continued for up to 8 weeks postoperatively.10,11 It has been recommended that the spica be applied at weekly intervals after removal of the initial postoperative dressing. This process is time intensive for both the patient and surgeon while its impact on a patient’s final HV correction remains unproven. To date, no study has assessed the outcomes of serial spica taping with regards to its role in maintaining HV correction in the postoperative rehabilitation period. The purpose of this study was to evaluate the impact of postoperative serial spica taping on radiographic outcomes in patients undergoing operative correction of moderate to severe HV deformity. Our hypothesis was that the serial taping protocol would offer no radiographic benefit compared to the use of a simple foam toe separator.
Methods From a prospectively collected database of operative patients, we retrospectively reviewed radiographs of 187 adult patients who underwent a unilateral proximal first metatarsal osteotomy combined with a modified McBride distal soft tissue release in 2008-2009 (n = 83) and in 2011-2012 (n = 104) for correction of moderate to severe symptomatic HV deformity (Table 1). In this study, an oblique rotational osteotomy was used as described by Ludloff and popularized by Myerson.4,9 The operative technique was standardized and performed by a single senior fellowship-trained foot and ankle orthopaedic surgeon (SMR) at a single institution. The operative indication was a symptomatic moderate to severe HV deformity, as defined by an IMA greater than or equal to 14 degrees in the setting of a noncongruent HV deformity recalcitrant to nonoperative treatment. The contraindications to the procedure were osteoarthritis of the first metatarsophalangeal joint or instability of the first tarsometatarsal joint. Patients with significant neurological disorders, known collagen vascular disease, age less than 18 years, generalized ligamentous laxity, or previous HV surgery were excluded. All remaining cases (n = 187) were performed sequentially, and no cases fitting the inclusion criteria were excluded. The 2 patient groups were differentiated based on their postoperative dressing care regimen. All patients had a dressing placed in the operating room to hold the great toe in a neutral position. The operative dressing was maintained for 2 weeks, at which time all patients were seen for their first postoperative office visit for removal of sutures. From 2008 through 2009, the 83 patients began a traditional serial weekly spica taping protocol starting at the 2-week postoperative visit.
The dressing was applied by the surgeon weekly in the office, utilizing the DuVries/Mann technique described above for 6 additional weeks (Figure 1). In contrast, from 2011 through 2012, the 104 patients in the second group had their Figure 1. A postoperative compressive circular dressing consists of spica taping of the hallux in a neutral or slightly varus position to maintain the corrected position of the toe as the soft tissues heal, up to 8 weeks postoperatively. Table 1. Patient Demographics. Taping Group No Taping Group Patients (n) 83 104 Male 6 6 Female 77 98 Mean age 53.4 52.2 Right foot 46 52 Left foot 37 52 Preoperative HVA 32.8 32.6 Preoperative IMA 15.2 14.6 Downloaded from fai.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on February 28, 2015 Ponzio et al 3 dressings discontinued and a large foam toe separator (PediFix Inc, Brewster, NY) placed between the hallux and the second toe at their 2-week postoperative visit (Figure 2). The toe separator was inserted by the surgeon, and instructions were given for use including application technique, removal during showering, and sock utilization to prevent displacing the separator. They were instructed to wear the spacer to bed. The toe separator was continued for the identical time period as was the spica dressing in the first group, after which all patients in both groups were encouraged to use a toe separator until 4 months after their operative procedure. The cases performed during 2010 were excluded, as this was a transition year between the 2 postoperative protocols. The operative technique, hardware used, and all other postoperative protocols were identical between the 2 groups. All patients were placed in a postoperative hard sole shoe in the operating room and remained non-weightbearing for 2 weeks.
At this time they were allowed to heelweight-bear and were advanced to weight-bearing as tolerated at 6 weeks after surgery, weaning back into comfortable shoes as tolerated. Patients utilizing a toe separator were, however, permitted to wash their foot after the first 2 weeks postoperatively, which was not possible for those in a spica dressing. All patients were evaluated for final follow-up at the 3-month time point coinciding with the senior surgeon’s normal postoperative regimen. Outcomes Assessed The 2 patient groups were compared to determine the postoperative correction of their HV deformity and the degree of correction maintained over time through final follow-up at 3 months following surgery. AP radiographic measurements of the HVA and IMA were recorded from preoperative (weight-bearing), 2-week (non-weight-bearing), and 3-month (weight-bearing) follow-up radiographs (Figure 3). Radiographic measurements of the HVA and IMA were performed as described by Shima et al,17 with the longitudinal axis of the first metatarsal being defined as a line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal. For both the proximal phalanx of the hallux and the second metatarsal, the longitudinal axis was defined as a line connecting the centers of the proximal and distal ends of the diaphysis. From previous studies, the measurement error was considered 1 degree, and the minimal clinically important difference (MCID) was greater than 3 degrees for the HVA and greater than 2 degrees for the IMA.15,17 Statistical Methods A mixed-effects linear regression model was utilized for individual patients to identify a statistical relationship between the angles (IMA or HVA) and the variables of time (preoperative, 2 weeks postoperative, 3 months postoperative) and spica taping, while controlling for variation among the subjects.
A mixed-effects model ascertains the change in the HVA or IMA over time with respect to the variable of spica taping while controlling for multiple repeated measurements from the same patient subject. A t test was applied to compare the absolute HVA and IMA at final follow-up between patient groups. The analyses were performed using the “nlme” package in R 3.0.1 (R Foundation for Statistical Computing, Vienna, Austria). Source of Funding There was no external source of funding for this study. Results Hallux Valgus Angle Overall, all patients demonstrated an improvement of the HVA from an average preoperative angle of 33 degrees to 13 degrees Figure 2. A postoperative foam toe separator prevents valgus deviation of the hallux. Downloaded from fai.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on February 28, 2015 4 Foot & Ankle International on average at 3-month final follow-up (P < .0001). When differentiating between treatment groups, the HVA in the taped group improved from 33 ± 6 to 14 ± 6 degrees at final followup. In the nontaped group, the HVA improved from 33 ± 6 to 11 ± 7 degrees at final follow-up. These improvements were statistically significant for both groups (P < .0001). Comparing the taped versus nontaped groups, the degree of HVA improvement over time was equivocal from the preoperative (33 ± 6.3 vs 32.6 ± 6.1) visit through the 2-week postoperative (10 ± 7 vs 9 ± 6) and 3-month followup (14 ± 6 vs 11 ± 7) visits (P = .08; Figure 4). Of note, in either group, 17% of patients were outside 1 standard deviation of the mean at 3 months and had a mild residual deformity. This was, however, a higher percentage in the taping group. Through the postoperative period, the average difference between groups was approximately 1 degree. At final follow-up, the HVA was lower for patients that were not taped (P = .015, 95% CI 0.5-4.5). Though statistically significant, the magnitude of the difference between the groups was 2.5 degrees, which is below the MCID for the HVA. Intermetatarsal Angle Overall, all patients demonstrated an improvement of the IMA from an average of 15 degrees to 6 degrees on average at 3-month final follow-up (P < .0001).
When differentiating between treatment groups, the IMA in the taped group improved from 15 ± 3 to 7 ± 4 degrees at final follow-up. In the nontaped group, the IMA was corrected from 15 ± 3 to 5 ± 4 degrees at final follow-up. Both patient groups showed statistically significant radiographic improvements from the initial preoperative IMA to final follow-up, achieving the planned operative correction (P < .0001). Comparing the taped versus nontaped groups, there was improved maintenance of the IMA correction over time in patients that were not taped compared to those taped from the preoperative (15 ± 3 vs 15 ± 3) visit through the 2-week postoperative (2 ± 2 vs 3 ± 3) and 3-month follow-up (5 ± 4 vs 7 ± 4) visits (P = .0023; Figure 5). Through the postoperative period, the mean difference in the IMA was 1 degree. At final follow-up, the IMA was lower for patients that were not taped (P = .004, 95% CI 0.7-2.9). Though statistically significant, the magnitude of the difference between the groups was 1.7 degrees, which is below the MCID for the IMA. Discussion For symptomatic moderate to severe HV recalcitrant to nonoperative measures, a proximal first metatarsal osteotomy in combination with a modified McBride distal soft tissue release is frequently indicated to correct the IMA and HVA, respectively. The proximal metatarsal osteotomy was initially popularized by Mann utilizing a crescentic derotational osteotomy, although numerous variations for the proximal osteotomy procedure have been reported with similarly favorable outcomes.2-5,8,10,12,16,19,21-23 Traditionally, a circular compression dressing is applied in the operating room, which is then changed to a spica dressing applied weekly for 2 months to maintain the great toe in its corrected position.10 This technique was described by DuVries in 1965, and further popularized by Mann and has been accepted dogma by many surgeons.6,10,11 This process is time intensive requiring the recovering patient to make 6 additional office visits for dressing changes. This is an inconvenience to the patients, blocks potential patient visit slots for the surgeon, and imparts additional cost to all Figure 3. Radiographic measurements of the HVA and IMA for a representative case are shown on AP preoperative (weightbearing), 2-week postoperative (non-weight-bearing), and 3-month postoperative radiographs (weight-bearing) (left to right).
Downloaded from fai.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on February 28, 2015 Ponzio et al 5 involved. Previously, no study has assessed the value of serial spica taping in the postoperative period. The current study a utilized a validated method of measuring the HVA and IMA, with a measurement error of 1 degree.17 Our results suggest that patients who did not undergo postoperative serial spica taping maintained equivalent deformity correction as compared to patients that underwent spica taping. From the previous work of Saltzman et al, the minimal clinical importance difference (MCID) for HVA was determined to be greater than 3 degrees and greater than 2 degrees for the IMA.15,17 As such, while the statistically significant difference detected in the IMA by the mixed-effects analysis supports a separator as being better than spica taping, the difference was less than the MCID and therefore Pre Post 3 months No Tape 32.6 8.6 11.4 Tape 32.8 9.9 14.0 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 HVA (degrees) Hallux Valgus Angle Figure 4. Hallux valgus angle (HVA). There was no significant difference in the HVA over time at preoperative, 2-week postoperative, and 3-month follow-up assessments for patients taped compared to those not taped (P = .08). Pre Post 3 months No Tape 14.6 2.1 5.0 Tape 15.2 3.0 6.7 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 IMA (degrees) Intermetatarsal Angle Figure 5. Intermetatarsal angle (IMA). There was a statistically significant difference in the IMA over time at preoperative, 2-week postoperative, and 3-month follow-up assessments for patients taped compared to those not taped (P = .0023). Downloaded from fai.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on February 28, 2015 6 Foot & Ankle International not clinically relevant.
Comparing the HVA and IMA outcomes at final follow-up using a t test demonstrated a statistically significant improvement in the maintenance of correction of the HVA (2.5 degrees) and IMA (1.7 degrees) without spica taping. Here again, the magnitude of the differences were small, below the MCID, and not likely clinically significant. However, all analyses did trend in favor of improved radiographic outcomes in the absence of postoperative taping following HV correction. This may be due to the imperceptible stretching of the silk tape used for the spica dressing between dressing changes, while alignment was better maintained with the toe separator. As expected, graphical representations of the HVA (Figure 4) and IMA (Figure 5) demonstrate a significant correction at 2 weeks postoperatively. At 3 months, however, there appears to be a partial recurrence of the HVA and IMA deformities. This difference in measurements could be attributed to the non-weight-bearing nature of the 2-week radiographs as compared to the weight-bearing radiographs obtained at 3 months. The change in foot geometry during non-weight-bearing radiographs, as compared to weightbearing radiographs, have previously been demonstrated to result in a significantly decreased measurement of both HVA and IMA.7,20 As such, we feel that the comparison of the preoperative and 3-month weight-bearing radiographs more closely reflect the true deformity correction, and the apparent “recurrence” between the first postoperative radiograph (non-weight-bearing) and final radiographs (weightbearing) is spurious. In addition, while all weight-bearing radiographs were taken utilizing standardized positioning and technique allowing valid interpretation of angular variations between groups, this is often very challenging at the 2-week visit resulting in nonuniform radiographs, which can alter measurements. Although the present study represents the largest comparative single surgeon cohort to date, a limitation of our study is the duration of follow-up.
Three months was utilized as an end-point as it coincided with the senior surgeon’s usual postoperative regimen and included the postoperative healing period for which the spica taping protocol was intended. After 3 months, all patients in both groups were permitted to return to regular shoe wear and activity as they chose thus ending the standardized protocols within each group. The subsequent variation in choices of shoe wear and activity is likely to influence deformity recurrence rates and as such, we felt it to be more reliable to exclude these influences in our analysis. Last, spica taping of the great toe was initially intended to stabilize the proximal crecentic osteotomy which has the potential to rotate on the axis of its single screw.10 This is not the case with a Ludloff osteotomy utilized in this study. The Ludloff osteotomy is an oblique osteotomy in the sagittal plane which is fixed with 2 screws minimizing risk of rotational recurrence.1 Although spica taping has been traditionally recommended with the Ludloff osteotomy, the increased stability of the construct may also explain why no difference was seen between the 2 groups. In conclusion, the present study gives the strongest evidence to date against the necessity for the postoperative spica taping protocol following HV correction. From nearly 200 patients treated identically by a single surgeon, we report similar radiographic outcomes at 3 months postoperatively between patients treated with serial spica taping compared to use of a toe separator during the postoperative period.
After completion of this study, all foot and ankle surgeons in our institution have discontinued spica taping after HV correction in favor of less cumbersome and less labor intensive to support the soft tissues in the postoperative period. For the senior author, 300 follow-up office visits per year are now avoided. Our findings have important clinical implications for surgeons managing these deformities while reducing overall cost and maximizing surgeon and patient time. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. Acevedo JI, Sammarco VJ, Boucher HR, Parks BG, Schon LC, Myerson MS. Mechanical comparison of cyclic loading in five different first metatarsal shaft osteotomies. Foot Ankle Int. 2002;23(8):711-716. 2. Adam SP, Choung SC, Gu Y, O’Malley MJ. Outcomes after scarf osteotomy for treatment of adult hallux valgus deformity. Clin Orthop. 2011;469(3):854-859. doi:10.1007/ s11999-010-1510-6. 3. Badekas A, Georgiannos D, Lampridis V, Bisbinas I. Proximal opening wedge metatarsal osteotomy for correction of moderate to severe hallux valgus deformity using a locking plate. Int Orthop. 2013;37(9):1765-1770. doi:10.1007/s00264-013- 2019-x. 4. Chiodo CP, Schon LC, Myerson MS. Clinical results with the Ludloff osteotomy for correction of adult hallux valgus. Foot Ankle Int. 2004;25(8):532-536. 5. Choi WJ, Yoon HK, Yoon HS, Kim BS, Lee JW. Comparison of the proximal chevron and Ludloff osteotomies for the correction of hallux valgus. Foot Ankle Int. 2009;30(12):1154- 1160. doi:10.3113/FAI.2009.1154. 6. DuVries H. Surgery of the Foot. 2nd ed. St. Louis, MO: Mosby; 1965. 7. Fuhrmann RA, Layher F, Wetzel WD. Radiographic changes in forefoot geometry with weightbearing. Foot Ankle Int. 2003;24(4):326-331. 8. Lee KB, Seo CY, Hur CI, Moon ES, Lee JJ. Outcome of proximal chevron osteotomy for hallux valgus with and