Hallux Valgus in Men

Part I: Demographics, Etiology and Comparative Radiology

Caio Nery, MD Michael Coughlin, MD Daniel Baumfeld, MD

Disclosure

Caio Nery, M.D. – See Disclosure Information at the AAOS Disclosure Program. There is nothing to disclose related with the subject of this presentation.

Daniel Baumfeld, M.D. – See Disclosure Information at the AAOS Disclosure Program. There is nothing to disclose related with the subject of this presentation

Michael Coughlin, MD . – Elsevier (royalties) / Arthrex, Inc (consultant, royalties). Fore more details, please refer to Disclosure Information at the AAOS Disclosure Program.

Introduction

• The high frequency of Hallux Valgus in females is a well-known fact and has been widely mentioned in the literature. This finding tends to obscure the importance and the characteristic details of Hallux Valgus in men.

• The severity of the deformity, its precocity and hereditary feature seem to be greater in men, but there are no reports in literature to prove these impressions.

• To clarify details and present the results of the retrospective clinical and radiological analysis in a series of patients of the male gender with Hallux Valgus is the main objective of this study.

Methods

• The records and plain radiographs of 31 men (53 feet) with the diagnosis of Hallux Valgus were analyzed from 1985 to 2005. During that period, the senior author (CN) performed 812 procedures for the correction of Hallux Valgus in women. • In order to find out gender-related differences in this deformity, 31 women’s charts – paired by age and affected side – were randomly selected and both clinical and radiological data were statistically compared. • All the radiographic measurements were obtained electronically, through the program M2000 (Tesseract, Brazil). This program functioning is based on a series of customized “scripts” that uniforms the methodology of measurements.

Radiological and Goniometric Methods

Measurements in WB AP views: • HVA - Hallux Valgus Angle • AIM 1- 2 - Inter-metatarsal Angle 1-2 • SES - Dislocation of the Hallux Sesamoids • DMAA - Distal Metatarsal Articular Angle • PPAA - Proximal Phalangeal Articular Angle • DPAA - Distal Phalangeal Articular Angle • AHVA - Inter-phalangeal Hallux Valgus Angle • TMA - Tarsal Metatarsal Angle of the First Ray • AC - Articular Congruency of the First Metatarsal-Phalanx

Measurements in WB Lateral views: • CIA - Calcaneus Inclination Angle (Calcaneus Pitch) • TIA - Talus Inclination Angle (Talus Pitch) • Meary - Talus First Metatarsal Angle

All measurements were made electronically, based on the scanning of the radiographic images through the software M2000.

Results

Table – Distribution of patients into age groups.

Male Female Total

Negative Inheritance 10 – 32,3% 20 – 64,5% 30 – 48,4%

Maternal Inheritance 18 – 58,1% 9 – 29,0% 27 – 43,5%

Paternal Inheritance 3 - 9,7% 2 - 6,5 % 5 - 8,1%

Total 31 31 62

Age Group Number of Patients %

Under 19 5 16

Between 20 and 29 4 13

Between 30 and 39 5 16

Between 40 and 49 7 23

Between 50 and 59 4 13

Over 60 6 19

Table – Deformity inheritance in both groups

Male Female Total

Adequate 25 – 80,6% 7 – 22,6% 32 – 51,6%

Inadequate 6 – 19,4% 24 – 77,4% 30 – 48,4%

Total 31 31 62

Table – Relation of the deformity with the use of “inadequate” footwear

Results

M F M F M F M F M F M F M F

HVA HVA DMAA DMAA AIM1 -2

AIM1 - 2

TMA TMA

IHVA IHVA PPA

A PPAA DPAA DPAA

Mean 28,6 25,2 16,1 12,1 11,2 11.0 21,9 19,7 7,9 11,8 3,3 2,9 5,7 6,8

SD 9,03 8,57 6,76 5,58 3,61 2,62 4,25 3,49 6,77 7,36 3,91 5,04 4,64 5,42

Min 11 12 2 1 4 5 14 12 -6 -6 -4 -7 -3 -3

Max 51 50 38 28 23 16 36 26 27 33 11 16 17 21

P 0,044 S 0,001 S 0,990 NS 0,004 S 0,006 S 0,715 NS 0,666 NS

Table – Mean, maximum, minimum and SD values of the angular parameters used in the Hallux Valgus study and their statistic significance .

AIM 1-2 DMAA HIVA TMA

HVA 0,447 p=0,001

-0,540 p=0,001

0,461 p=0,001

AIM 1 - 2 0,296 p=0,031

-0,417 p=0,002

0,482 p=0,001

HIVA -0,406 p=0,003

Table - Statistically significant correlations between the parameters studied in the male gender.

Results

MTP Congruency Male Female Total

Incongruent MTP 23 – 43,4% 37 – 69,8% 60 – 56,6%

Congruent MTP 30 – 56,6% 16 – 30,2% 46 – 43,4%

Sesamoids

0 Degree 2 - 3,8% 6 – 11,3% 8 – 7,5%

1 Degree 13 – 24,5% 16 – 30,2% 29 – 27,4%

2 Degrees 25 – 47,2% 22 – 41,5% 47 – 44,3%

3 Degrees 13 – 24,5% 9 – 17,0% 22 – 20,8%

Table – Sesamoid deviation and articular incongruence according to the gender.

Male Female Total

Normal foot 25 – 52,1% 26 – 54,2% 51 – 53,1%

Flat foot 23 – 47,9% 22 – 45,8% 45 – 46,9%

Table – The occurrence of Normal Feet and Flat Feet associated with Hallux Valgus according to the gender

Conclusion

Based on our findings, we can conclude that:

Hallux Valgus in men is a hereditary deformity predominantly transmitted by maternal genes, with an early onset with a more aggressive behavior in men than in women. Its incidence is within a proportion of 6,5%, or 15 women to every man. Most of the time, it affects both feet and is not directly related to the use of inadequate footwear in males. The uniform method of angular measurement can improve the reliability of angular analisys. The deformities are more intense in men, and this greater intensity may be credited to intrinsic, constitutional factors, especially to the Distal Metatarsal Articular Angle (DMAA). This finding will certainly impact the preoperative planning of hallux valgus correction in men.

Bibliography

1. Coughlin, MJ: Hallux valgus. Causes, evaluation, and treatment. Postgrad Med. 75: 174-178, 183, 186-177. 2. Coughlin, MJ: Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 16: 682-697. 3. Coughlin, MJ: Hallux valgus. J Bone Joint Surg Am. 78: 932-966. 4. Coughlin, MJ: Hallux valgus in men: effect of the distal metatarsal articular angle on hallux valgus correction. Foot Ankle Int. 18: 463-470. 5. Coughlin, MJ; Carlson, RE: Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies. Foot Ankle

Int. 20: 762-770. 6. Coughlin, MJ; Freund, E: Roger A. Mann Award . The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int. 22: 369-379. 7. Coughlin, MJ; Jones, CP: Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 28: 759-777. 959647 [pii]10.3113/FAI.2007.0759 8. Coughlin, MJ; Shurnas, PS: Hallux valgus in men. Part II: First ray mobility after bunionectomy and factors associated with hallux valgus deformity. Foot Ankle Int. 24:

73-78. 9. Coughlin, MJ; Thompson, FM: The high price of high-fashion footwear. Instr Course Lect. 44: 371-377. 10. Hardy, RH; Clapham, JC: Observations on hallux valgus; based on a controlled series. J Bone Joint Surg Br. 33-B: 376-391. 11. Inman, VT: Hallux valgus: a review of etiologic factors. Orthop Clin North Am. 5: 59-66. 12. Johnston, O; Davis, RW: On the inheritance of hand and foot anomalies in six families. Am J Hum Genet. 5: 356-372. 13. Kilmartin, TE; Wallace, WA: The significance of pes planus in juvenile hallux valgus. Foot Ankle. 53-56. 14. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynec and Obstet. 58: 183-91, 1934. 15. Mann, RA; Coughlin, MJ: Hallux valgus--etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res. 31-41. 16. Mann, RA; Coughlin, MJ: Adult hallux valgus. In Mann, RA; Coughlin, MJ (eds): Surgery of the foot and ankle, 7th edition, C.V. Mosby, St. Louis, pp 159 – 269, 1999. 17 . Morton, D: The human foot. Its evolution, physiology, and functional disorders. Columbia University Press, New York, 1935. 18. Netto AA, Nery CAS, Benevento M, Réssio CR. Avaliação Radiográfica do Hálux Valgo: Estudo Populacional de Novos Parâmetros Angulares. Acta Ortop Bras 9(2): 41-

48, 2001. 19. Palladino, SJ; Towfigh, A: Intra-evaluator variability in the measurement of proximal articular set angle. J Foot Surg. 31: 120-123. 20. Piggott, H: The natural history of hallux valgus in adolescence and early adult life. J. Bone Joint Surg. 42-B:749 – 760, 1960. 21.. Richardson, EG; Graves, SC; McClure, JT; Boone, RT: First metatarsal head-shaft angle: a method of determination. Foot Ankle 14:181 – 185, 1993. 22. Sarrafian SK, Anatomy of the Foot and Ankle: Descriptive, Topographic and Functional, 2nd ed. Lippincott Company, Philadelphia, 1993. 23. Smith, RW; Reynolds, JC; Stewart, MJ: Hallux valgus assessment: report of research committee of American Orthopaedic Foot and Ankle Society. Foot Ankle. 5: 92-103. 24. Srivastava, S; Chockalingam, N; El Fakhri, T: Radiographic angles in hallux valgus: comparison between manual and computer-assisted measurements. J Foot Ankle

Surg. 49: 523-528. S1067-2516(10)00287-5 [pii]10.1053/j.jfas.2010.07.012 25. Truslow, W: Metatarsus primus varus or hallux valgus. J. Bone Joint Surg. 7:98 – 108, 1925.