Foot & Ankle International - September 2019 - 1084

1084	

Foot & Ankle International 40(9)

Table 3.  Correlation Matrix of Radiographic Measurements.a
Intermetatarsal
Angle

Hallux Valgus Angle
 
Hindfoot
  Calcaneal pitch angle
  Tibiocalcaneal angle
  Talocalcaneal angle
Midfoot
  Naviculocuboid overlap
  Talonavicular coverage angle
Forefoot
  Lateral talo-first metatarsal angle
  AP talo-first metatarsal angle
  Metatarsus adductus angle
Intermetatarsal angle
Distal metatarsal articular angle
First metatarsal cuneiform angle

P Value

Distal Metatarsal
Articular Angle

r

P Value

r

r

P Value

−0.013
0.048
0.185

.869
.546
.018

−0.247
0.229
0.175

.001
.003
.025

−0.023
0.138
0.205

.768
.078
.009

−0.074
0.147
−0.161

0.347
0.061
0.040

0.047
0.101

.548
.201

0.172
0.266

.028
.001

0.089
0.209

.261
.008

−0.094
−0.002

0.231
0.978

0.207
−0.202
0.268
0.589
0.740
0.335

.008
.010
.001
<.001
<.001
<.001

0.373
0.121
−0.031

<.001
.123
.695

0.254
−0.061
0.123

.001
.438
.119

0.029
−0.313
0.545

<.001
0.006

0.270

<.001

0.714
<.001
<.001
 
 
 

0.488
0.216

r

P Value

First Metatarsal
Cuneiform Angle

Abbreviation: AP, anteroposterior.
a
Pearson correlation coefficient (r) was measured for the correlation analysis.

our results a more accurate depiction of alignment in
patients with idiopathic JHV. In another study, simultaneous operative correction of hindfoot valgus was advised to
prevent recurrence of hallux valgus in a child presenting
with both hallux valgus and flatfoot.12 In cerebral palsy
patients, correction of hallux valgus is rarely performed in
isolation and associated etiologic factors should be
addressed simultaneously to prevent recurrence of deformity.6 But our results do not validate this approach in
patients with JHV, and overall, there is little agreement on
the need for surgery of concurrent flatfoot.1,3,17 This operative strategy should be applied cautiously and only in particular instances of JHV, because hindfoot alignment in this
setting is not associated with development of hallux
valgus.
In patients with neuromuscular disease, such as cerebral
palsy, the relationship between flat foot and hallux valgus
may be different from that in patients with idiopathic hallux
valgus. Hallux valgus is frequently seen in association with
planovalgus foot.6 Previously suggested etiologies were
intrinsic muscle imbalance and abnormal extrinsic loading
due to disruption of forefoot mechanics during the stance
phase.8,27 The latter theory may be valid in the development
of idiopathic hallux valgus. But, all patients with JHV did
not have a flatfoot in our study. In addition, there was an
opinion of some surgeons that flatfoot has clinical relevance
only within the context of neuromuscular deficit.4 We
believe that a pronated midfoot, not valgus of the hindfoot,
may be a primary factor in the development of idiopathic
hallux valgus.

A pronated foot in the setting of JHV may impact the
height of longitudinal arch, without changing hindfoot
alignment. As the foot pronates, the first metatarsal bone
rotates on its longitudinal axis and may reduce the longitudinal arch height, without a valgus heel.11 A diagnosis of
flatfoot in practice is based to a greater extent on clinical
appearance than on radiographic measurements. Pronated
feet in patients with JHV may have the appearance of flatfoot while lacking radiologic support.
The forefeet of our patients with JHV were more
adducted and pronated than those of normal controls. To
define forefoot alignment, we used AP and lateral talo-first
metatarsal angles, and although hindfoot alignment may
exert some influence, others have corroborated the relevance of these angles in forefoot alignment.29 A deformity
of the first metatarsal may have some effect as well, so we
added the metatarsus adductus angle to ensure accuracy in
assessing the forefoot. Consequently, the forefoot profiles
in patients with JHV differed entirely from that of flatfoot,
which previous reports have also shown,3,4 linking JHV
with metatarsus adductus instead.
In the JHV group, DMMA and first metatarsal cuneiform
angle were much greater than in control group. The higher
DMMA indicates the distal valgus deformity of the first
metatarsal and may be a distinctive characteristic of the
JHV.3 The higher first metatarsal cuneiform angle represents the proximal varus deformity of first metatarsal related
to the flexibility of the first metatarsal cuneiform joint.15
Increased first metatarsal cuneiform angle may be also a
unique feature in JHV.
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