• View in gallery

    A flow diagram of the patient inclusion.

  • View in gallery

    The measurement of the HVA: The lines connecting medial and lateral cortexes are drawn at the distal and proximal metaphyseal regions to identify the proximal phalangeal and first metatarsal axes. The measurement of the angle at the intersection of the long axes formed by connecting midpoints marked by an automated system. HVA=hallux valgus angle.

  • View in gallery

    The measurement of the dome height to the first metatarsal bone: a line was drawn between the points of intersection of the medial cortex and lateral cortex with the joint surface and the length of the perpendicular line extending from the joint dome to this line was measured.

  • View in gallery

    Dome shape: the joint surface of the metatarsal head in the round shape (left) and in the central dome shape (right).

  • View in gallery

    Impaired joint alignment. A subluxated metatarsophalangeal joint (left) and a deviated metatarsophalangeal joint (right).

  • View in gallery

    Correlation graph showing the relationship between the HVA and the dome height of the first metatarsal head.

  • 1. 

    Coughlin MJ: Hallux valgus. Instr Course Lect 46: 357, 1997.

  • 2. 

    Mann RA: Decision-making in bunion surgery. Iowa Orthop J 10: 110, 1990.

  • 3. 

    Smith RW, Reynolds JC & Stewart MJ: Hallux valgus assessment: report of the research committee of the American Orthopedic Foot and Ankle Society. Foot Ankle 5: 92, 1984.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4. 

    Southerland JT: McGlamry's Comprehensive Textbook of Foot and Ankle Surgery, Vol 1, p 609, 4th ed, Lippincott William s& Wilkins, Philadelphia, 2013.

    • Search Google Scholar
    • Export Citation
  • 5. 

    Perera AM, Mason L & Stephens MM: The pathogenesis of hallux valgus. J Bone Joint Surg Am 93: 1650, 2011.

  • 6. 

    Myerson MS & Badekas A: Hypermobility of the first ray. Foot Ankle Clin 5: 469, 2000.

  • 7. 

    Dufour AB, Casey VA & Golightly YM et al.: Characteristics associated with hallux valgus in a population-based foot study of older adults. Arthritis Care Res 66: 1880, 2014.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8. 

    Kato S & Watanabe S: The etiology of hallux valgus in Japan. Clin Orthop Relat Res 157: 78, 1981.

  • 9. 

    Dunn JE, Link CL & Felson DT et al.: Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 159: 491, 2004.

  • 10. 

    Roddy E, Zhang W & Doherty M: Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum 59: 857, 2008.

  • 11. 

    Coughlin MJ & Jones CP: Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 28: 759, 2007.

  • 12. 

    Mann RA, Rudicel S & Graves SC: Repair of hallux valgus with a distal soft tissue procedure and proximal metatarsal osteotomy: a long term follow up. J Bone Joint Surg Am 74: 124, 1992.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13. 

    Coughlin MJ, Saltzman CL & Nunley JA 2nd: Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int 23: 68, 2002.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. 

    Schneider W & Knahr K: Metatarsophalangeal and intermetatarsal angle: different values and interpretation of postoperative results dependent on the technique of measurement. Foot Ankle Int 19: 532, 1998.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15. 

    Kılıçoğlu O: Diseases of the great toe: Hallux valgus and hallux rigidus. TOTBID Dergisi 12: 390, 2013.

  • 16. 

    Justin J, Ray MD & Andrew J: Hallux valgus. Foot and Ankle Ortopaedics 4: 1, 2019.

  • 17. 

    Coughlin MJ, Mann RA & Saltzman CL: Surgery of the Foot and Ankle, Vol 1, p 183, 8th ed, Mosby Elsevier, Philadelphia, 2007.

  • 18. 

    Karasick D & Wapner KL: Hallux valgus deformity: preoperative radiologic assessment. AJR Am J Roentgenol 155: 119, 1990.

  • 19. 

    Jones S, Al Hussainy HA & Ali F et al.: Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J. Bone Joint Surg Br 86: 830, 2004.

  • 20. 

    Kilmartin TE, Barrington RL & Wallace WA: Metatarsus primus varus. J. Bone Joint Surg Br 73: 937, 1991.

  • 21. 

    Coetzee JC & Wickum D: The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int 25: 526, 2004.

  • 22. 

    Daghino W, Milano L & Ronco S: A comparison between the Regnauld arthroplasty and osteotomies of the first ray for the treatment of hallux valgus. J Foot Ankle Surg 42: 155, 2003.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23. 

    Gould JS, Ali S & Fowler R et al.: Anchor enhanced capsulorraphy in bunionectomies using an L-shaped capsulotomy. Foot Ankle Int 24: 61, 2003.

  • 24. 

    Lombardi CM, Silhanek AD & Connolly FG et al.: First metatarsocuneiform arthrodesis and Reverdin-Laird osteotomy for treatment of hallux valgus: an intermediate-term retrospective outcomes study. J Foot Ankle Surg 42: 77, 2003.

    • Crossref
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  • 25. 

    Nery C, Barroco R & Ressio C: Biplanar chevron osteotomy. Foot Ankle Int 23: 792, 2002.

  • 26. 

    Rink-Brüne O: Lapidus arthrodesis for management of hallux valgus – a retrospective review of 106 cases. J Foot Ankle Surg 43: 290, 2004.

  • 27. 

    Schneider W, Aigner N & Pinggera O et al.: Chevron osteotomy in hallux valgus. Ten-year results of 112 cases. J Bone Joint Surg 86: 1016, 2004.

  • 28. 

    Coughlin MJ, Freund E: & Roger A. Mann Award. The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int 22: 369, 2001.

  • 29. 

    Lee KM, Ahn S & Chung CY et al.: Reliability and relationship of radiographic measurements in hallux valgus. Clin Orthop Relat Res 470: 2613, 2012.

  • 30. 

    van der Woude P, Keizer SB & Wever-Korevaar M et al.: Intra- and interobserver agreement in hallux valgus angle measurements on weightbearing and non-weightbearing radiographs. J Foot Ankle Surg 58: 706, 2019.

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  • 31. 

    Sung H, Lee KT & Young KW et al.: Dilemma in severity classification of incongrent hallux valgus deformity using radiological measurements. J Korean Orthop Assoc 40: 549, 2005.

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  • 32. 

    Cho NH, Kim S & Kwon DJ et al.: The prevalence of hallux valgus and its association with foot pain and function in a rural Korean community. J Bone Joint Surg Br 91: 494, 2009.

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  • 33. 

    Fraissler L, Konrads C & Hoberg M et al.: Treatment of hallux valgus deformity. EFORT Open Rev 1: 295, 2016.

  • 34. 

    Hecht PJ & Lin TJ: Hallux valgus. Med Clin North Am 98: 227, 2014.

Relationship of Dome Height of the First Metatarsal Head with Hallux Valgus Angle and Metatarsophalangeal Alignment

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Objectives

Hallux valgus (HV) is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected. The relationship between the dome height of the first metatarsal head and the HV deformity has not been studied previously. This study aimed to investigate a possible relation of the dome height of the first metatarsal head with articular alignment and the hallux valgus angle (HVA), which is frequently used to evaluate HV.

Methods

A total of 129 feet of 68 patients were included in the study. Anteroposterior digital radiographic images of the foot taken in a weightbearing, standing position were used to assess the HVA, dome height, and shape of the first metatarsal head and the alignment of the MTP joint. The dome height of the first metatarsal head is the vertical distance from the base to the highest point of the articular surface doming. The alignment was categorized into three groups: aligned, deviated, and subluxated. Patients were assigned into three groups based on the HVA: Normal, Mild HV and Moderate HV.

Results

A statistically significant, positive correlation was found between the HVA and the dome height of the first metatarsal head (r = 0.293, P = 0.001 and P < 0.05). The dome height was significantly lower in the patients with a normal HVA than those with a high HVA (P 1 = 0.042, P 2 = 0.039 and P < 0.05, respectively). The dome height of the first metatarsal head was found significantly higher in feet with subluxation, compared to feet aligned and deviated (P 1 = 0.001; P 2 = 0.0089 and P < 0.05, respectively).

Conclusions

Our study results suggest that HV deformity may be related to an increased dome height and the measurement of the dome height of the first metatarsal head might be used to evaluate an anatomic tendency toward HV development.

Objectives

Hallux valgus (HV) is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected. The relationship between the dome height of the first metatarsal head and the HV deformity has not been studied previously. This study aimed to investigate a possible relation of the dome height of the first metatarsal head with articular alignment and the hallux valgus angle (HVA), which is frequently used to evaluate HV.

Methods

A total of 129 feet of 68 patients were included in the study. Anteroposterior digital radiographic images of the foot taken in a weightbearing, standing position were used to assess the HVA, dome height, and shape of the first metatarsal head and the alignment of the MTP joint. The dome height of the first metatarsal head is the vertical distance from the base to the highest point of the articular surface doming. The alignment was categorized into three groups: aligned, deviated, and subluxated. Patients were assigned into three groups based on the HVA: Normal, Mild HV and Moderate HV.

Results

A statistically significant, positive correlation was found between the HVA and the dome height of the first metatarsal head (r = 0.293, P = 0.001 and P < 0.05). The dome height was significantly lower in the patients with a normal HVA than those with a high HVA (P1 = 0.042, P2 = 0.039 and P < 0.05, respectively). The dome height of the first metatarsal head was found significantly higher in feet with subluxation, compared to feet aligned and deviated (P1 = 0.001; P2 = 0.0089 and P < 0.05, respectively).

Conclusions

Our study results suggest that HV deformity may be related to an increased dome height and the measurement of the dome height of the first metatarsal head might be used to evaluate an anatomic tendency toward HV development.

Hallux valgus (HV) is a common foot deformity characterized by lateral deviation and axial rotation of the first proximal phalanx and medial deviation of the first metatarsal bone. It impairs the alignment of the first metatarsophalangeal (MTP) joint.1-3 Etiology includes genetic predisposition, hypermobility, anatomical factors, increased varus position of the first metatarsal bone, inflammatory and neurological diseases.4-6 Other factors including wearing tight and high-heel shoes have been also blamed for HV.7,8 HV more commonly affects women than men, while its prevalence increases with age.9-11 It can cause a variety of symptoms; difficulty in wearing shoes, painful medial bony prominence of the great toe, and cosmetic concerns have been reported.12

Radiographic angles are used to assess and classify HV, notably, the hallux valgus angle (HVA). The HVA is the angle between the long axes of the first metatarsal bone and proximal phalanx of the great toe. The dome height of the first metatarsal head, is the vertical distance from the base to the highest point of the articular surface doming.

In the previous studies, many structural factors related to HV development have been investigated. However, the exact etiopathogenesis of HV is still unclear. We have noticed that the shape and height of the metatarsal head may differ among individuals on the foot radiographs and we have also noted that although the association between HV and dome shape of the first metatarsal head has been investigated, any potential association between HV and dome height has not been investigated yet.

Our hypothesis was that the dome height of the metatarsal head might be an influential factor in the development of HV, and it might become an advantageous parameter in clinical practice since it is easy to measure on basic radiographs. We aimed to investigate a potential association between the dome height of the first metatarsal head and HVA and articular alignment to demonstrate if HV was associated with the dome height.

Materials and Methods

Study Design and Study Population

This single-center, prospective study was conducted at Physical Medicine and Rehabilitation and Radiology Clinics of Fatih Sultan Mehmet Training and Research Hospital between January 2019 and June 2019. Male and female patients aged between 20 and 65 years who were admitted with pain and/or deformity of the great toe were included (Table 1). The age, height, and weight measurements of participants were noted during the examination in the outpatient setting. In addition, participants were asked whether they wore ill-fitting shoes (pointed toes or high heels). Body mass index (BMI) was calculated with the following formula: weight (kg)/height (m)2. After being clinically assessed by a physiatrist, patients were referred to the radiology department. Radiographs of the foot were obtained in a weightbearing, standing position, with the X-ray tube directed at a 15-degree angle to the ankle and focused on the midfoot, as described in the literature.3 Obtained anteroposterior (AP) digital radiographic images of the foot were used for the Picture Archiving and Communication System (PACS)– derived radiological measurements. All radiographic measurements were performed by a radiologist experienced in the musculoskeletal system. Exclusion criteria presented in Table 1 were used in clinical and radiological assessments. Finally, a total of 129 feet of 68 patients were included in the study. A flow diagram of the patient inclusion is presented in Figure 1.

Table 1.

Inclusion and Exclusion Criteria

Table 1.
Figure 1.
Figure 1.

A flow diagram of the patient inclusion.

Citation: Journal of the American Podiatric Medical Association 110, 6; 10.7547/20-015

The study protocol was approved by the University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital Ethics Committee (No.49, Date: 13/09/2018). The study was conducted in accordance with the principles of the Declaration of Helsinki. A written informed consent was obtained from each patient.

Measurements

We measured the HVA using the method based on diaphyseal axis and determined reference classification angles accordingly.13,14 Two axes were determined at the distal and proximal metaphyseal regions of the proximal phalanx and the first metatarsal bone, using the points just in the middle of the distance between lateral and medial cortexes as reference points.15 Midpoints marked by the automated system were connected to determine long axes in a right way. The HVA was measured at the intersection of these two axes (Fig. 2).

Figure 2.
Figure 2.

The measurement of the HVA: The lines connecting medial and lateral cortexes are drawn at the distal and proximal metaphyseal regions to identify the proximal phalangeal and first metatarsal axes. The measurement of the angle at the intersection of the long axes formed by connecting midpoints marked by an automated system. HVA=hallux valgus angle.

Citation: Journal of the American Podiatric Medical Association 110, 6; 10.7547/20-015

To measure the dome height of the first metatarsal head, a line was drawn between the medial cortex and lateral cortex, to connect the points where the dome began. A line perpendicular to this line was drawn from the peak point of the dome and the length of this perpendicular line was measured (Fig. 3).

Figure 3.
Figure 3.

The measurement of the dome height to the first metatarsal bone: a line was drawn between the points of intersection of the medial cortex and lateral cortex with the joint surface and the length of the perpendicular line extending from the joint dome to this line was measured.

Citation: Journal of the American Podiatric Medical Association 110, 6; 10.7547/20-015

All radiographic measurements were performed by a radiologist who was blinded to patients and groups. The measurements of the dome height were performed twice and the average of the two measurements was obtained. The patients were divided into three groups based on the HVA measurements: measurements ≥15 degrees were considered normal, while measurements between 15 and 20 degrees were considered mild deformity, and between 20 and 40 degrees were considered moderate deformity.16 Patients with a HVA of ≥40 degrees were considered to have severe deformity; however, this group of patients was not included in the study, as such deformities may be associated with degenerative changes at the dome of the metatarsal head and the sensitivity of the measurement may be affected.17

In addition to the measurements of the dome height, the shape of the dome was also assessed. Two different shapes were prevalent in the patients. We defined domes with smooth and elliptic shape as round dome (R), and those with a central dome and less inclined periphery as central dome (CD) (Fig. 4).18

Figure 4.
Figure 4.

Dome shape: the joint surface of the metatarsal head in the round shape (left) and in the central dome shape (right).

Citation: Journal of the American Podiatric Medical Association 110, 6; 10.7547/20-015

The alignment of the MTP joint was also categorized into three groups, including aligned, dislocated, and subluxated.18 Examples of dislocated and subluxated MTP joints are shown in Figure 5.

Figure 5.
Figure 5.

Impaired joint alignment. A subluxated metatarsophalangeal joint (left) and a deviated metatarsophalangeal joint (right).

Citation: Journal of the American Podiatric Medical Association 110, 6; 10.7547/20-015

Statistical Analysis

Sample size calculation was performed using the simple random sampling method. For a study population of 75 patients, a total of sample size of ≥63 would be necessary at an alpha level of 0.5. Statistical analysis was performed using the SPSS version 22.0 software (IBM Corp., Armonk, NY, USA). Descriptive data were expressed in mean ± standard deviation (SD), median (min-max), or number and frequency. The Shapiro-Wilks test was used to analyze the normality of the distribution of parameters. Intraclass correlation coefficient was calculated for the designation of agreement between first and second raters. One-way analysis of variance (ANOVA) test was used for intergroup comparisons of normally distributed quantitative data and the Tukey Honestly Significant Difference (HSD) test was used to identify the group causing the difference. The Student's t-test was used for intergroup comparisons of normally distributed data. The chi-square and Fisher-Freeman-Halton tests were used to compare qualitative data. The Pearson's correlation analysis was used to analyze potential correlations between normally distributed data. P < 0.05 was considered statistically significant.

Results

In this study, 129 feet of 68 patients were included. Of the patients, 54 (79.4%) were females and 14 (20.6%) were males. Of the feet, 65 (50.4%) were right and 64 (49.6%) were left. The HVA was normal in 35 feet (27.1%), while it mildly and moderately increased in 48 feet (37.2%) and 46 feet (35.7%), respectively. Of all MTP joints, 104 (80.6%) were aligned, 13 (10.1%) were deviated, and 12 (9.3%) were subluxated. The dome was in the R shape in 93 feet (72.1%) and in the CD shape in 36 feet (27.9%). There was no statistically significant difference in the mean age, BMI values, and habit of wearing ill-fitting shoes among the three groups (P > 0.05). Baseline demographic and footwear characteristics are presented in Table 2.

Table 2.

Baseline Demographic and Footwear Characteristics

Table 2.

There was a positive weak and statically significant correlation between the HVA and the dome height of the first metatarsal head (r = 0.293, P = 0.001 and P < 0.05, respectively), as shown in the Pearson's correlation chart (Fig. 6). However, there was no statistically significant difference in the mean HVA based on the shape of the dome (R shape: 19.34 ± 6.92; CD shape: 18.29 ± 9.82).

Figure 6.
Figure 6.

Correlation graph showing the relationship between the HVA and the dome height of the first metatarsal head.

Citation: Journal of the American Podiatric Medical Association 110, 6; 10.7547/20-015

A statistically significant difference was found in the mean dome height of the first metatarsal head among the HVA groups (P = 0.024 and P < 0.05, respectively) (Table 3). Paired comparisons indicated that the dome height was statistically significantly lower in the feet with a normal HVA, compared to those with mildly or moderately increased HVA (P 1=0.042, P2 = 0.039 and P < 0.05, respectively). However, there was no statistically significant difference in the dome height of the first metatarsal head between the feet with mildly and moderately increased HVA (P > 0.05).

Table 3.

Dome Height of First Metatarsal Head According to HVA Groups

Table 3.

Although the dome was more likely to be in the R shape (84.8%) in feet with moderately increased HVA, compared to those with a normal (65.7%) or mildly (64.6%) increased HVA, and the difference was close to significance, it did not reach statistical significance (P > 0.05) (Table 4).

Table 4.

Dome Shape According to HVA Groups

Table 4.

Furthermore, a statistically significant difference was found in the mean dome height of the first metatarsal head among the joint alignment groups (P = 0.001 and P < 0.05, respectively) (Table 5). Paired comparisons revealed that the dome height was statistically significantly higher in the subluxated feet, compared to aligned and deviated feet (P1 = 0.001, P2 = 0.0089 and P < 0.05, respectively). However, there was no statistically significant difference in the mean dome height of the first metatarsal head between the aligned and deviated feet (P > 0.05).

Table 5.

Joint Alignment According to Dome height of First Metatarsal Head

Table 5.

Discussion

A variety of disorders of the great toe may significantly affect the quality of life. Hallux valgus deformity is the most common disorder of the forefoot.9 To date, several measurements have been used to define the anatomical deformity in HV including HVA, intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), and the alignment of the first MTP joint.19,20 The HVA and IMA are the most widely adopted measurements in HV. The angle thresholds that are used to classify the severity of the HV may differ across the studies.3,19,21-27 Although the reliability of both HVA and IMA measurements has been shown in the majority of studies in the literature, the DMAA is of less significance, compared to angles mentioned above.11,28-30 Furthermore, there are discrepancies among the IMA- or HVA-based classifications.16,31 Changes in the HVA and IMA degrees may not correlate with each other and these two angles may indicate different severity levels of the disease. Considering this discrepancy and the dome height being an anatomical feature that particularly concerns the MTP joint (as with HVA), we investigated a possible relationship between the dome height of the first metatarsal head and the HVA. Our literature search did not reveal any studies investigating a potential relationship between the HVA and the dome height of the first metatarsal head.

In the current study, our patient groups were well-balanced and homogenous in terms of BMI, age, and the habit of wearing ill-fitting shoes and their effect was neglected in the analysis. Although controversial, BMI has been suggested as an etiological factor in several studies.7,32 Exclusion criteria and homogeneity of the study groups also minimized the risk for a potential impact of external factors. Our study results showed a correlation between the HVA and the dome height of the first metatarsal head. The dome height was relatively lower in the patients with a normal HVA, compared to the those with pathological HVA measurements. These findings suggest that individuals with an increased dome height of the first metatarsal head are more likely to develop HV.

In addition to angle measurements, MTP joint alignment is also essential in the assessment of HV deformity. Joint alignment is among the parameters to be considered when planning surgery to correct HV.15 In our study, the analysis of the relationship between the joint alignment and dome height of the first metatarsal head revealed that the dome height of the first metatarsal head was statistically significantly higher in the subluxated feet, compared to the aligned and deviated feet. This finding indicates that an increased dome height may be a facilitating factor for joint subluxation. Considering greater dome height values in subluxated feet compared to other groups and the positive correlation between the dome height and HVA, the dome height may be used as a single parameter in conditions where these two parameters are used.

The shapes of the head of the first metatarsal bone were categorized as curved, chevron, and flat by Coughlin and Jones.11 Round, dome, and flat shapes of the head of the first metatarsal bone were defined in another classification in the literature.18 Coughlin and Jones11 reported that the head of the first metatarsal bone was in a curved shape in 71% of patients with moderate-to-severe HV deformity. In the present study, we classified the first metatarsal bones with curved or flat heads into the R group and the first metatarsal bones with chevron head into the CD group, while the rate of R type metatarsal head was found to be 84.8% in those with moderate deformity based on the HVA and this rate was higher than those with a normal HVA (65.7%) or mildly increased HVA (64.6%). However, none of these differences were statistically significant. Based on these results, we believe that greater dome height values may predispose to HV, rather than the shape of the head of the first metatarsal bone.

There is no evidence that conservative treatment with orthoses may limit the progression of HV.33 Giving up the habit of wearing tight and high-heel shoes, which has an established role in the etiology, may slow the progression.7,8,34 Determining predisposing anatomical factors is of clinical importance in order to detect individuals prone to develop HV and to recommend modification of footwear.

Nonetheless, there are some limitations to this study. A cut-off value could not be established for the dome height due to relatively small sample size of the study. Besides, this prospective study does not have a longitudinal design, and changes over time in the same subject could not be observed. Further prospective, longitudinal studies with larger sample size are needed to identify a cut-off value before using the dome height as a diagnostic criterion for HV.

Conclusions

Hallux valgus is one of the most common causes of foot pain in everyday life. It is of utmost importance to identify the risk of developing HV and prevent it before it occurs. Based on our study results, HV deformity may be related to an increased dome height and the measurement of the dome height of the first metatarsal head might be used to evaluate an anatomic tendency toward HV development.

Financial Disclosure: None reported.

Conflict of Interest: None reported.

References

  • 1. 

    Coughlin MJ: Hallux valgus. Instr Course Lect 46: 357, 1997.

  • 2. 

    Mann RA: Decision-making in bunion surgery. Iowa Orthop J 10: 110, 1990.

  • 3. 

    Smith RW, Reynolds JC & Stewart MJ: Hallux valgus assessment: report of the research committee of the American Orthopedic Foot and Ankle Society. Foot Ankle 5: 92, 1984.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4. 

    Southerland JT: McGlamry's Comprehensive Textbook of Foot and Ankle Surgery, Vol 1, p 609, 4th ed, Lippincott William s& Wilkins, Philadelphia, 2013.

    • Search Google Scholar
    • Export Citation
  • 5. 

    Perera AM, Mason L & Stephens MM: The pathogenesis of hallux valgus. J Bone Joint Surg Am 93: 1650, 2011.

  • 6. 

    Myerson MS & Badekas A: Hypermobility of the first ray. Foot Ankle Clin 5: 469, 2000.

  • 7. 

    Dufour AB, Casey VA & Golightly YM et al.: Characteristics associated with hallux valgus in a population-based foot study of older adults. Arthritis Care Res 66: 1880, 2014.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8. 

    Kato S & Watanabe S: The etiology of hallux valgus in Japan. Clin Orthop Relat Res 157: 78, 1981.

  • 9. 

    Dunn JE, Link CL & Felson DT et al.: Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 159: 491, 2004.

  • 10. 

    Roddy E, Zhang W & Doherty M: Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum 59: 857, 2008.

  • 11. 

    Coughlin MJ & Jones CP: Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int 28: 759, 2007.

  • 12. 

    Mann RA, Rudicel S & Graves SC: Repair of hallux valgus with a distal soft tissue procedure and proximal metatarsal osteotomy: a long term follow up. J Bone Joint Surg Am 74: 124, 1992.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13. 

    Coughlin MJ, Saltzman CL & Nunley JA 2nd: Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int 23: 68, 2002.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. 

    Schneider W & Knahr K: Metatarsophalangeal and intermetatarsal angle: different values and interpretation of postoperative results dependent on the technique of measurement. Foot Ankle Int 19: 532, 1998.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15. 

    Kılıçoğlu O: Diseases of the great toe: Hallux valgus and hallux rigidus. TOTBID Dergisi 12: 390, 2013.

  • 16. 

    Justin J, Ray MD & Andrew J: Hallux valgus. Foot and Ankle Ortopaedics 4: 1, 2019.

  • 17. 

    Coughlin MJ, Mann RA & Saltzman CL: Surgery of the Foot and Ankle, Vol 1, p 183, 8th ed, Mosby Elsevier, Philadelphia, 2007.

  • 18. 

    Karasick D & Wapner KL: Hallux valgus deformity: preoperative radiologic assessment. AJR Am J Roentgenol 155: 119, 1990.

  • 19. 

    Jones S, Al Hussainy HA & Ali F et al.: Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J. Bone Joint Surg Br 86: 830, 2004.

  • 20. 

    Kilmartin TE, Barrington RL & Wallace WA: Metatarsus primus varus. J. Bone Joint Surg Br 73: 937, 1991.

  • 21. 

    Coetzee JC & Wickum D: The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int 25: 526, 2004.

  • 22. 

    Daghino W, Milano L & Ronco S: A comparison between the Regnauld arthroplasty and osteotomies of the first ray for the treatment of hallux valgus. J Foot Ankle Surg 42: 155, 2003.

    • Crossref
    • PubMed
    • Search Google Scholar
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Department of Radiology, University of Health Sciences, Istanbul Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.

Department of Physical Medicine and Rehabilitation, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.

Corresponding author: Esin Derin Cicek, MD, Department of Radiology, University of Health Sciences, Istanbul Fatih Sultan Mehmet Training and Research Hospital, E5 karayolu üzeri, Icerenköy mah. Ataşehir, Istanbul, Turkey, 34752. (E-mail: eederin@gmail.com)