The Journal of Foot & Ankle Surgery 61 (2022) 339−344

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The Syndesmosis Procedure Correction of Hallux Valgus Feet Associated

With the Metatarsus Adductus Deformity
Daniel Yiang Wu, MD1, Eddy Kwok Fai Lam, PhD2
1
Orthopedic Surgeon, Hong Kong Adventist Hospital, Hong Kong, China
2
Associate Professor, Department of Statistics and Actuarial Science, University of Hong Kong, Hong Kong, China

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 3 Metatarsus adductus and hallux valgus are common foot deformities. Corrective surgery of hallux valgus feet with
Keywords: metatarsus adductus deformity can be challenging and experience a high deformity recurrence rate. The purpose of
bunion this study was to demonstrate if the syndesmosis procedure can correct such feet satisfactorily without osteotomies
mechanical function and arthrodesis. 75 hallux valgus feet in 45 patients with a Sgarlato's metatarsal adductus angle ≥15° were studied
metatarsus primus varus after having undergone the syndesmosis procedure for an average of 20.22 months. Their average preoperative
plantar calluses intermetatarsal angle of 12.56° was improved to 6.00° (p < .001) and metatarsophalangeal angle from 35.61° to
recurrence 23.46° (p < .001) significantly. Their average American Orthopedic Foot and Ankle Society's clinical scores improved
significantly from 56.41 to 90.53 points (p < .001). Fifty-five feet (73.33%) had preoperative metatarsal calluses, and
all but 3 had a noticeable reduction in severity. Forty-one patients (91.11%) were able to return to their desired activ-
ities and footwear. All relevant raw data formed this study, including x-ray and photographic images, were submit-
ted as Supplementary Material for online viewing and reference. Despite the possible intrinsic rigidity of metatarsus
adductus forefoot, this study demonstrated that hallux valgus feet with metatarsus adductus deformity could be cor-
rected anatomically and functionally with the soft tissue syndesmosis procedure and without correcting the preex-
isting metatarsus adductus deformity. This study also supports the notion that the MA deformity accentuates hallux
valgus alignment preoperatively and postoperatively, and possibly all feet in general.
© 2021 The Author(s). This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Metatarsus adductus (MA) deformity is a common foot condition at
birth. Its cause is still uncertain but is possibly related to intrauterine mal-
positioning of the foot and not hereditary. It is usually flexible and can
often correct by itself in time. It can also be satisfactorily corrected if
desired by conservative treatment such as manipulation, bracing, and
serial casting (1). The unresolved MA deformity seen in adulthood may be
related to a more severe and rigid variety or residual rigidness of the Lis-
franc joint. Dawoodi and Perera measured 150 feet with 5 common MA
deformity methods, and the prevalence of MA deformity ranged 45% to
70% depending on the angle measuring method (2). There has been no
clinical or mechanical evidence that MA would compromise a person's
athletic ability or daily activities (3). Farsetti followed up 45 feet for an
average of 32.5 years and found patients with and without conservative
treatment all had good results of spontaneous correction and function (4).
Hallux valgus (HV) deformity is also a common foot condition, but it
is usually acquired later in life and progressive compared to the MA
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Daniel Yiang Wu, MD, Hong Kong Adventist Hospital,
#40 Stubbs Rd, Hong Kong, China
E-mail address: dymjwu@gmail.com (D.Y. Wu).
deformity. It can happen to feet with MA deformity as well (5,6). Aiyer
et al. (7) claimed: “patients with a history of MA were about 3.5 times
more likely to develop HV”. About 30% of HV feet undergoing surgery
have been noted to have MA deformity (2,8,9). The HV deformity asso-
ciated with MA deformity has been regarded as a more difficult condi-
tion to treat than feet without it but can still be satisfactorily corrected
with conventional osteotomy procedures (8,10,11). While Shibuya et al
(12) noticed no detectable relationship between the underlying MA
deformity and the final outcome of HV correction, Aiyer et al (13)
reported an increased deformity recurrence rate of about 30% irrespec-
tive of the surgical procedure had been performed. HV correction of
feet associated with MA deformity by soft tissue approach has not been
studied or recommended yet. It is unknown if it was due to concerns
over the possible rigid nature of the metatarsus primus varus (MPV)
deformity and inability to correct it without osteotomy or arthrodesis.
The syndesmosis procedure is a soft tissue approach to the MPV and
HV deformity correction. It has been proven capable of correcting MPV
deformity of most if not possibly all severity (14) by realigning the
varus-displaced first metatarsal effectively with the 1-2 intermetatarsal
cerclage suturing technique (15-18), provided its first metatarsal is
mobile, which is usually the case with all acquired MPV deformity of

1067-2516/$ - see front matter © 2021 The Author(s). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
https://doi.org/10.1053/j.jfas.2021.09.006
340 D.Y. Wu, E.K.F. Lam / The Journal of Foot & Ankle Surgery 61 (2022) 339−344

HV feet. We were interested in determining if the syndesmosis proce-

dure can also correct MPV deformity satisfactorily of adult feet associ-
ated with the MA deformity, which may belong to the more rigid
variety or have residual rigidness in the Lisfranc joint and thus may be
more difficult and less satisfactory to correct than usual. We hypothe-
sized that if the MPV deformity of HV feet with MA deformity is also
acquired later in life, the same way as other HV feet in general, it should
be correctible with the cerclage suturing technique. We also hypothe-
sized that if patients had asymptomatic MA deformity before their HV
development, their feet function could be satisfactorily restored with-
out correcting the preexisting MA deformity. Our primary aim was to
measure the final radiological result in HV deformity correction, and
our secondary aim was to determine if the foot’s satisfactory function
can also be restored. We undertook a retrospective cohort study of
patients with HV feet and the MA deformity and had undergone the
syndesmosis procedure.

Patients and Methods

The author (D.W.) visually previewed preoperative x-ray images of all his HV surgical
patients for the 4 years from 01/2012 to 12/2015 and could confirm 79 surgical feet in 47
patients had a Sgarlato’s MA angle (MAA) ≥ 15°. Sgarlato’s method (Fig. 1) was chosen
because after studying 5 different measuring techniques, Aryan et al (19) found “The MA
angle measured by Sgarlato’s technique demonstrated the highest inter-and intra-
observer reliability as well as reliably demonstrating a significant positive correlation
between HAV and MA angles.” In the same study of 150 feet, 14° was considered the nor-
mal upper limit for the Sgarlato’s MAA. Only feet with Sgarlato’s MAA ≥ 15° were consid-
ered for the present study. Two patients (4 feet) were excluded from this study for their
less than 6 months of follow-up time, although they all had satisfactory results. The study
of the remaining 45 patients and their 75 feet was based on chart review, computer radio-
graphic images, and clinical photos. Patients were not called back for the study. The
author (D.W.) has a unique HV surgical practice that he offers only the syndesmosis pro-
cedure for all his HV corrections without any exception and tried to follow them up for at
least 2 years. No patients were given or rejected for other techniques.
There was 39 female (86.67%) and 6 male (13.33%) patients (Table 1). Four patients
(8.89%) had bilateral procedures but only unilateral MA deformity. Eleven patients
(24.44%) had a unilateral procedure and MA deformity. The average follow-up time was
20.22 months and ranged from 6 to 60 months. Their average Sgarlato’s MAA was 20.45B
and ranged from 15 to 35.5°.
Patients’ preoperative, 6-month postoperative, and final DP-view x-ray images of
their feet were assessed. All x-ray images were done in the author’s (D.W.) clinic with
patients standing over the same foot markings on the platform of a computerized digital
x-ray machine manufactured specifically for podiatric examination by 20/20 ImagingÒ
(Lake in the Hills, IL). Their HV deformity was determined by the metatarsophalangeal
angle (MPA), and their MPV deformity was determined by the intermetatarsal angle
(IMA). Both angles were measured with Hardy’s mid-axial method (20) by the author (D.
W.’s) assistant (R.T.). The Sgarlato’s MAA of all feet were measured by the author (D.W.).
The clinical result was assessed with the 100-point Hallux Metatarsophalangeal-
Interphalangeal Scale by the American Orthopedic Foot and Ankle Society (AOFAS)
(21,22). But it does not include mid metatarsal callus evaluation, which is believed Fig. 1. Sgarlato’s Metatarsus Adductus Angle measurement method: Line (a) extends
strongly by the author (D.W.) to be a useful physical sign of mechanical function ability of between the most lateral point of the 4th metatarso-cuboid and the calcaneo-cuboid
the first ray of HV feet, hence preoperative and final metatarsal calluses were regularly joints. Line (b) extends between the most medial point of the talo-navicular and the
photographed and thus also included as part of a functional assessment for this study. medial cuneiform-first metatarsal joints. Line (c) extends between midpoints of lines (a)
All patients were informed of this study and no objections were received. and (b). Line (d) represents the longitudinal axis of the second metatarsal bone. Line (e) is
perpendicular to line (c) and represents the longitudinal axis of the lesser tarsus. Sgarla-
to's angle is between the lines (d) and (e) (18).
Supplementary Material (SM)

All working x-ray images for processing MAA, preoperative, and final IMA and MPA
data were submitted for online review and reference as SM 1 and photos of preoperative
and final metatarsal calluses as SM 2. The 3 working Excel tables for Tables 1 and 2 were
submitted as SM 3, 4, and 5. The raw AOFAS score was submitted as SM 6. Metatarsal cal-
lus severity is classified and analyzed in SM 7.
and the vertical incision was to release the lateral collateral ligament of the metatarsopha-
langeal joint to facilitate hallux realignment. To prevent MPV and HV recurrences, an inter-
metatarsal fibrous bonding formation was induced and facilitated by the 1-2
intermetatarsal void created by the cerclage sutures and anchored to the scarified opposing
metatarsal cortices. All feet had their redundant medial skin and capsuloligamentous tis-
sues over the bunion protuberance excised along with exostectomy of the bunion.

Surgical Principle
Detailed surgical technique of the syndesmosis procedure has been well described in
the past (14-18). It is sufficient to repeat only its surgical essences, which are correction of
the MPV deformity and release of the distal lateral soft tissue contracture (Fig. 2). MPV is
corrected by tying the first and second metatarsals together with two #2 absorbable PDS
and two 2-O nonabsorbable Ethibond double-strand sutures through 2-mm drill holes in
the distal half of the first metatarsal and around the second metatarsal. The distal lateral
soft tissue release was carried out with an inverted “T” incision. The horizontal incision
was for releasing the metatarsosesamoid ligament to facilitate fibula sesamoid realignment,
Postoperative Protocol
Full weightbearing walking was allowed on the first postoperative day but restricted
to an average of 3000 steps a day for 3 months. All patients were also instructed to carry
out their own first metatarsophalangeal joint passive extension movement and active
flexion strengthening exercises in place of physiotherapy from the first postoperative
day. Patients were asked to stay home and wear postsurgical shoes by Darco before fore-
foot casts were applied ten days postoperatively when wounds had mostly healed and
most swellings subsided. The cast was to help minimize stress on the intermetatarsal
 D.Y. Wu, E.K.F. Lam / The Journal of Foot & Ankle Surgery 61 (2022) 339−344 341

Table 1
Cohort demography

Gender

No. of Patients Female Male No. of Feet Age (Yrs) (Range) Follow-Up (Months)

Cohort 45 (100%) 38 (84.44%) 7 (15.56%) 75 (100%) 45.44 (20-75) 20.22 (6-60)

Subgroup “A” (MAA < 20°) 30 (66.67%) 29 (64.44%) 1 (2.22%) 43 (57.33%) 42.13 (20-66) 20.87 20.87
Subgroup “B” (MAA ≥ 20°) 23 (51.11%) 17 (37.78%) 6 (13.33%) 32 (42.67%) 47.09 (22-75) 20.39 (6-60)
Note: The total number of patients of the 2 subgroups is greater than the cohort is because some patients are counted twice for their bilateral procedure feet fall into different subgroups.

Table 2
Results summary (SM 3) (Cohort: N = 75 feet in 45 patients; “A”: N = 43 feet in 30 patients; “B”: N = 32 feet in 23 patients)

IMA Difference (p Value)

MAA Pre-op (X) 6-m Post (Y) Final (Z) Pre-op—6-m Post Pre-op—Final

Cohort 20.45 (15.0-35.5) 12.56 (4.7-23.2) 6.30 (2.0-9.8) 6.00 (1.3-11.8) 6.26 (<.0001) 6.56 (<.0001)
Subgroup “A” MAA < 20° 17.25 (15.0-19.8) 12.40 (7.7-20.3) 6.24 (2.9-9.8) 6.07 (1.5-11.8) 6.16 (<.0001) 6.33 (<.0001)
Subgroup “B” MAA ≥ 20° 24.76 (20.0-35.5) 12.78 (4.7-23.2) 6.39 (2.0-9.5) 5.92 (1.3-9.2) 6.39 (<.0001) 6.86 (<.0001)
MPA Difference (p Value)

Cohort 35.61 (9.7-57.1) 23.98 (12.3-38.9) 23.46 (8.7-42.4) 11.63 (<.0001) 12.15 (<.0001)
Subgroup “A” MAA < 20° 34.40 (16.4-51.6) 22.57 (12.3-37.4) 22.00 (11.4-38.9) 11.83 (<.0001) 12.4 (<.0001)
Subgroup “B” MAA ≥ 20° 37.24 (9.7-57.1) 25.93 (16.9-38.9) 25.38 (8.7-42.4) 11.31 (<.0001) 11.86 (<.0001)
AOFAS Score Difference (p Value)

Cohort 56 (39-69) 90 (67-100) 34 (<.0001)

Subgroup “A” MAA < 20° 56.93 (42-67) 92.79 (67-100) 35.86 (<.0001)
Subgroup “B” MAA ≥ 20° 55.72 (39-69) 87.5 (73-100) 31.78 (<.0001)

sutures in walking. High-heel shoes and running were allowed but only after the sixth
postoperative month. It was based empirically on time given to torn knee ligaments and
tendons after repair.
Statistical Analysis
The data were analyzed by using JMP Pro 15.0.0 (SAS Institute, Cary, North Carolina).
Paired t test was adopted to test for the effectiveness of the syndesmosis procedure in
terms of the average of IMA or MPA differences before and after the surgery. A 2-sample t
test was adopted to compare the mean measurements of 2 severity groups. Pearson cor-
relation coefficient was used to assess the strength of association between 2 measure-
ments. All tests were 2-tailed, and a p value <.05 was considered statistically significant.
Results
The average preoperative IMA was significantly reduced from 12.56°
to 6.0° (p < .001) and average MPA from 35.61° to 23.46° (p < .001).
They were statistically significant, and there was also a significant corre-
lation between IMA and MPA preoperatively (correlation coefficient
r = 0.725, p < .001) and postoperatively (r = 0.550, p < .001). The cohort
was also divided into 2 subgroups of different MAA severity for their
IMA and MPA analysis (Table 2). Subgroup “A” was made up of feet with
milder MA deformity of MAA ˂ 20°, and subgroup “B” was made up of
feet with more severe MA deformity of MAA ≥ 20°. There was compara-
ble IMA correction irrespective of the different MA severities between
the 2 MAA subgroups. However, the postoperative MPAs of “B” with
greater MA deformity were significantly greater than those of “A”
(25.38° vs. 22.00°, p = .044) despite their IMAs and other variables were
comparable. There was also a strong statistical correlation between pre-
operative MPA and MAA (r = 0.725, p < .001) but only a weak correlation
between preoperative IMA and MAA (r = 0.247, p = .033).
Patients’ AOFAS scores improved significantly from preoperative 56.41
(range 39-69) points to final 90.53 (range 67-120) points (p < .001) (SM 6).
Fifty-five feet (73.33%) had moderate or severe metatarsal calluses
preoperatively (Table 3). All (Fig. 3A,B) but 3 (5.45%) had more than 50%
reduction of their preoperative metatarsal calluses. The preoperative
and final postoperative photographs to show metatarsal calluses of the
entire cohort are also presented online (SM 2), and no feet had more
metatarsal callus than before their surgery (SM 7).

Additional Surgery

Three feet (4.0%) (SM 1: Case #1505-R,1702-L,1729-R) had second

MPJ total capsulotomy, collateral ligaments release, and extensor

Table 3
Preoperative and final plantar metatarsal callus analysis (N = 75 feet in 45 patients)

Pre-op

Final Severe Moderate Minimal/None

Minimal/none 21 17 N/A
Much reduced 13 1 N/A
No change 2 1 20
Fig. 2. Schematic illustration of key features of the syndesmosis procedure
342 D.Y. Wu, E.K.F. Lam / The Journal of Foot & Ankle Surgery 61 (2022) 339−344

Fig. 3. (a) Metatarsal callus under the second and third metatarsal heads is common due
to lateral shift of push-off force from the first ray in walking and collapse of the metatarsal
arch of hallux valgus feet. (b) Photograph of the same feet (SM 1: Case 1522) 2 years after
surgery revealed complete subsidence of preoperative metatarsal callus, a reliable clinical
sign of function restoration of the first ray.

tendon lengthening for treatment of their dorsal subluxation and claw

toe deformity. No feet had Akin or bunionette osteotomy, toe fusion,
sesamoidectomy, or any other additional procedures.

Complications

Forty-eight feet (64.0%) had residual HV deformity of MPA > 20°, but
only one foot (1.33%) had partial MPV deformity recurrence with its
preoperative IMA of 20.3° being corrected down to 9.8° by the sixth
postoperative month examination but then increased to 11.8° at 24
months (SM 1: Case #1740-L). Three feet (4.0%) suffered a stress frac-
ture of their second metatarsal during their fourth and fifth postopera-
tive months and healed uneventfully by resuming their forefoot cast for
4 to 6 weeks (SM 1: Case #1505-R, 1540-L, 1570-R). A stainless mini-
plate was subsequently introduced to help protect the second metatar-
sal from undue compression erosion by the cerclage sutures (Figs. 3B,
4B). There were no wound infection cases, hallux varus, MPJ extension
ROM < 60°, or transfer metatarsalgia.
Discussion
MA deformity is a common congenital condition of the foot. HV defor-
mity is also common but acquired later in life. While MA deformity is
largely static and not usually a functional problem for the foot (4), HV
deformity is progressive and can compromise biomechanics of the foot
(23-27). MA deformity seldom requires surgical treatment, but HV feet
may need to restore their proper mechanical function for walking (28-30).
Correcting HV deformity requires primarily proper correction of its
underlying MPV deformity (31), which involves realigning the varus-
displaced first metatarsal and re-stabilizing it to prevent a recurrence.
This study has demonstrated with statistical significance that the
abnormal IMA of adult HV feet associated with the MA deformity could
be adequately corrected with the intermetatarsal cerclage suturing
technique despite the possible presence of any metatarsal rigidity and
also irrespective of their MA deformity severity (Figs. 4A,B; 5A,B; SM 1:
Case #1720). This mobility suggests that the MPV deformity or the
increased IMA of feet with MA deformity is also acquired, and its first
metatarsal can be realigned as expected like other HV feet in general.
It has long been felt that the MA deformity can influence hallux
alignment by accentuating its valgus inclination (2,6,32,33). Although
Coughlin had found that “The presence of metatarsus adductus did not
affect the preoperative hallux valgus angle or the average surgical cor-
rection of the hallux valgus angle” (11), our present study, however,
supports the other notion that MA deformity can accentuate valgus
angulation of the hallux with a positive statistical correlation. Anatomi-
cally, metatarsals are unique in having no muscle or tendon attached to
Fig. 4. (a) A 53-year old female had mild MA feet of left MAA 17.6° and right 17.3° by
Sgarlato’s method (SM 1: Case 1720). Her MPV deformities were also mild with a left foot
IMA of 10.7° and 10.9° on the right, but rather large MPAs of 32.9° and 37.6° (b): Her 24-
month postoperative standing x-ray revealed IMAs of 5.8° on the left and 5.3° on the right
side, but their respective MPAs of 21.8° and 24.7° were much larger than expected for
their satisfactory IMA corrections and sesamoids realignment. (c) This patient had preop-
erative pedobarographic function study of her feet by F-ScanÓ and revealed the minimal
function of her first rays and big toes but most forces were registered under middle meta-
tarsal heads instead (denoted by red) for push-off in walking. There was also unusually
long peak-force time and loading on her heels to probably minimize forefoot loading dis-
comfort in walking. (d) 24 months postoperatively, the unusually large residual MPAs
and uncorrected MA deformity did not hamper her pedobarographic result. There was a
remarkable medial shift of metatarsal forces and loading, resumption of hallux function,
and heel loading reduction. (e): Her preoperative photograph did not truly reflect the
severity of her HV deformity as revealed by the large MPAs of her standing x-ray (Figure
3a). (f): Despite the large residual MPAs 2 years after surgery, both of her great toes
looked virtually straight. However, if without their underlying MA deformity, the actual
hallux valgus angulation would be more evident on the surface.
them distally to help control their alignment or movement, only pas-
sively by the muscles and tendons attaching to the toes bypassing but
in alignment with the metatarsals. Any excessive varus deviation of
particularly the mechanically dominant first metatarsal due to failure
of its stabilizing ligaments (34) would result in lateral displacement of
the digital flexion and extension tendons and then, in turn, exert abnor-
mal valgus vector force on the hallux in a bowstring fashion. This resul-
tant valgus effect, especially on the hallux, is well displayed in HV feet’
MPV deformity. Their correlation is well recognized, so as the more
varus first metatarsal becomes (greater IMA), the more valgus hallux
(greater MPA) becomes.
 D.Y. Wu, E.K.F. Lam / The Journal of Foot & Ankle Surgery 61 (2022) 339−344
Fig. 5. (a) This 67-year old lady had severe MA deformity of feet of left MAA being 25.9°
and right 34.3°; IMA of 20.8° and 9.9° and MPA of 47.8° and 36.9° respectively (SM 1: Case
#1619). (b) Her 24-month postoperative standing x-ray revealed large residual MPAs of
29.6 and 23.1° despite satisfactory IMA results of 8.2 and 3.6°, respectively, and good sesa-
moid realignment. It is also interesting to note how the syndesmosis procedure changed
the metatarsocuneiform joint congruence. (c) This patient also had preoperative pedobaro-
graphic function study by F-ScanÓ, and she used mostly lateral aspect of her left forefoot
and mid metatarsal area of her right forefoot (denoted by red) for push-off in walking. (d)
Her 24-month postoperative pedobarographic study revealed a more normal pattern of
mostly medial loading of her forefeet for push-off in walking. (e) The photographic appear-
ance of this patient’s hallux valgus deformities were again not as true as MPAs by her feet
x-ray. (f): Despite the large residual MPA of 23.1°, her right hallux looked virtually straight.
Her left hallux also appeared quite satisfactorily for its underlying MPA of 29.6°. This is an
illusion caused by the underlying left MAA of 25.9° and right 34.3°. If they were only 15°,
her great toes would look probably 10.9 and 19.3° more valgus, respectively.
For the same reason that if there is any additional varus/adduction
effect on the first metatarsal from the MA deformity, then correspond-
ingly, more valgus/abduction effect on the hallux can be expected.
Therefore, hallux alignment and its MPA is a function of both IMA and
MAA, and their combined impact on the hallux may not necessarily be
exactly equal to their sum but should be greater than either one alone.
This additional HV effect by MA deformity should be true for HV feet
preoperatively and postoperatively (Fig. 4A,B; SM 1: Case #1720)
(Fig. 5A,B; SM 1: Case #1619). This phenomenon can also be revealed
by comparing our current HV feet with MA deformity to the past syn-
desmosis procedure studies of HV feet in general (Table 4). These other
studies did not provide MAA information on their feet, but they would
be understandably less because they were not studying MA feet.
Remarkably, the preoperative and postoperative MPAs of the current
study with greater MAAs were consistently greater than that of the
343
Table 4
Result comparison between the current study of hallux valgus feet with metatarsus
adductus deformity and other general syndesmosis procedure studies (N = 4 prior
publications)
IMA MPA°
# of Feet Ave. F-U In Month Preop Final Preop Final
Current study 75 20.5 12.6 6.0 35.6 23.5
Irwin (15) 62 68 18.9 7.9 31.7 10
Wu (16) 110 23 14 7.0 31 18
Wu (17) 63 25 14.6 6.8 32.5 18.4
Wu (18) 55 63 14.5 6.9 32 18.4
past syndesmosis procedures studies (14-18) of HV feet with less MAA.
Also, our cohort’s average IMA was smaller and expected to have
smaller rather than greater MPA than those other studies. Statistically,
this study has not only confirmed past knowledge of the positive corre-
lation between HV deformity (MPA) and MPV deformity (IMA) but also
between HV deformity (MPA) and MA deformity (MAA). It is probable
that the frequently reported larger-than-usual residual MPA after dif-
ferent HV surgical techniques of feet with MA deformity (13) may not
necessarily be all due to surgical failure or HV recurrence but at least
partly by the normal effect of their underlying MA deformity. Future
randomized comparative studies and meta-analyses can be conducted
to better understand MA deformity's impact on HV alignment.
Irwin et al (15) (Table 4) reported the greatest MPA reduction from
preoperative of 31.7° to 10°. The likely reason is that they consistently
release the hallucis adductus tendon and remove the lateral fibula sesa-
moid. But the current and other past syndesmosis procedure studies
did neither lest to risk the hallux varus complication and compromise
the windlass mechanism for normal hallux function in walking. Despite
the large postoperative residual MPA of the current study, our MPA
data between the sixth postoperative month and final x-ray examina-
tion revealed no significant MPA worsening (Table 2). This stabilization
means that the 2 main influencers, namely MPV and MA deformities,
on the HV deformity were stable and not affecting the MPA any longer.
Although Akin osteotomy is popular to help reduce residual MPA, we
feel it is mainly a cosmetic endeavor and has not been proven necessary
or beneficial to the foot's function.
This study’s low MPV recurrence rate corresponded to a 5-year
study of the syndesmosis procedure (18), which demonstrated the first
metatarsal could be re-stabilized with no significant MPV deformity
recurrence after the first 6 postoperative months, thus neither any fur-
ther change in MPA. It can be said that such syndesmosis re-stabiliza-
tion concept of the first metatarsal is predictable and reproducible
within a consistent time frame also for HV feet with MA deformity.
Shima et al (35) recommended proximal osteotomy of all medial 3
metatarsals to correct both the MPV and MA deformities at the same
time. Loh et al (8) found that “MA did not predispose the patient to
poorer functional outcome after scarf osteotomy.” Our results supported
the belief that correcting underlying MA deformity is unnecessary to
restore the foot’s pre-HV symptom-free functional state. Our significant
AOFAS score improvement was evident, especially the consistent post-
operative subsidence of metatarsal calluses (SM 2) after patients
returned to unrestricted activities and footwear. The markedly reduced
metatarsal calluses is an objective physical sign that the plantar push-
off force in walking had shifted medially away from mid metatarsals
and back to its normal physiological location under the first ray (Fig. 4C,
D; SM 1: Case #1720) (Fig. 5C,D; SM 1: Case #1619). The uncorrected
underlying MA deformity and its associated larger-than-usual residual
HV malalignment did not hamper the foot’s function results, and our
study hypothesis was verified. The slight AOFAS result difference
between subgroups A and B (Table 2) was due mostly to the greater
MPA of subgroup B feet and their poorer radiological alignment scores.
344 D.Y. Wu, E.K.F. Lam / The Journal of Foot & Ankle Surgery 61 (2022) 339−344
The larger-than-usual preoperative and postoperative MPA in this
study often appeared much less an HV deformity on the surface than their
radiological measurements would suggest (Fig. 4E,F; SM 1: Case #1720)
(Fig. 5E,F; SM 1: Case #1619). The reason for such a straighter looking hal-
lux or less MPA than real is an illusion that is accentuated by its underly-
ing metatarsal adduction deformity. In other words, the appearance of the
increased valgus deformity of the hallux is compensated by the increased
varus alignment of the forefoot due to its MA deformity. If MPA is not
increased to accommodate the MA deformity, then the hallux would
assume a more varus alignment like an in-toeing foot. Such increased HV
adjustment of MA feet is probably not mainly to improve the cosmetic
appearance but functional results. For hallux, with or without MA defor-
mity, to be in line with the body axis is probably more effective mechani-
cally for the forward direction in walking. Future studies in this regard are
still needed to help better understand this phenomenon.
This study’s main weaknesses are its single-surgeon authorship, and
its data were based on chart review. The other is it not being a compar-
ative study due to the author's (D.W.) exclusive single technique prac-
tice, but without any selection of patients and technique, all possible
methodology bias was maximally minimized. All relevant raw data and
images that this study was based on were submitted for online elec-
tronic viewing and the readers’ reference to facilitate greater transpar-
ency and accountability. Due to the author’s (D.W.) extensive
experience in the syndesmosis procedure, his results may not be readily
reproducible by other surgeons. This study’s strength is its highly
reproducible x-ray imaging protocol with the same podiatric digital x-
ray equipment, technique, and technician throughout the entire study
period for a highly consistent inter-and intrapatient comparison.
In conclusion, this study demonstrated that HV feet the MA defor-
mity can be satisfactorily corrected anatomically and functionally with
the syndesmosis procedure by consistently delivering a satisfactory
MPV correction. Its larger-than-usual residual HV alignment is probably
a normal phenomenon of MA feet without compromising foot function
was also discussed.
Hospital Board Approval
The letter of approval by the ethical committee of the Hong Kong
Adventist Hospital was obtained.
Acknowledgments
We would like to thank Ms. Rachel Tam for her diligent radiological
technique and measurement and Peggie Wong for data retrieving and
processing.
Supplementary Materials
Supplementary material associated with this article can be found in
the online version at https://doi.org/10.1053/j.jfas.2021.09.006.
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