The role of triple osteotomy in managing complex hallux valgus deformity with pronation

BACKGROUND: First metatarsal pronation deformity is contributed to hallux valgus (HV) and a significant risk factor for recurrence. The efficacy of triple osteotomy in specifically correcting pronation deformity of severe HV remains unreported. This study aimed to evaluate the correction of first metatarsal pronation deformity achieved with triple osteotomy (Reverdin, proximal wedge and Akin) in severe HV. METHODS: We retrospectively analyzed data from 29 patients (40 feet) with severe HV and concomitant first metatarsal pronation who underwent triple osteotomy between January 2022 and December 2023. Preoperative and postoperative assessments included the American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), and the pronation of the first metatarsal angle (PFMA) for clinical, radiological, and pronation-specific evaluation. The lateral edge shape of the first metatarsal head was categorized as type A, I and R. RESULTS: Postoperative outcomes demonstrated significant improvements in the measured parameters including AOFAS score, VAS score, HVA, IMA, DMAA, and PFMA (all p < 0.0001). The prevalence of the Type R lateral edge morphology decreased from 90% (36 feet) preoperatively to 0% postoperatively. Complications included one case of superficial infection and three cases of metatarsophalangeal joint stiffness (4 feet totally). CONCLUSIONS: Triple osteotomy successfully corrects the pronation deformity of the first metatarsal associated with severe HV. This procedure warrants priority consideration for the management of severe HV accompanied by pronounced first metatarsal pronation due to its theoretical potential to reduce the risk of recurrence. LEVEL OF EVIDENCE: Ⅳ.