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Multiplanar instability of the first tarsometatarsal joint in hallux valgus and hallux rigidus patients: a case–control study



Hypermobility of the first ray has been considered associated with various forefoot diseases including hallux valgus (HV) and hallux rigidus (HR). Weightbearing CT scan can be a reliable method for analysis of the first tarsometatarsal (TMT) joint in axial, sagittal, and coronal planes. Our objective was to comparatively investigate signs of instability of the first TMT joint on weightbearing CT between three groups (control, HV, and HR).


In this single-centre, retrospective, case–control study, 27 HV patients (30 feet; mean age 54.2 years), 26 HR patients (30 feet; mean age 56.6 years), and 30 controls (30 feet; mean age; 43 years) were enrolled. Measurements of signs of instability were performed in multiplanes including first TMT angle, dorsal translation of the first metatarsal (M1) at the first TMT joint, plantar distance between the medial cuneiform (C1) and M1 in sagittal plane, hallux valgus angle (HVA), intermetatarsal angle (IMA) in axial plane, rotational profiles of C1 and M1 in coronal plane. Analysis of variance (ANOVA) test and chi-square test were performed to compare each parameter between the three groups. Interobserver reliabilities were assessed using interclass correlation coefficients (ICCs).


The HV group had significantly increased first TMT angle (0.23° in controls, 1.15° in HV, 0.19° in HR, p < 0.001), HVA (7.52°, 33.50°, 11.21°, p < 0.001), IMA (9.46°, 16.98°, 11.87°, p < 0.001), C1-M1 angle (22.44°, 29.46°, 23.74°, p < 0.001), and rotational profile of the distal M1 (7.06°, 17.88°, 9.85°, p < 0.001) compared with the control and HR groups. Dorsal translation of M1 (23% in controls, 63% in HV, 70% in HR, p < 0.001) was frequently found in the HV and HR groups with significantly increased plantar distance (0.37 mm, 1.14 mm, 1.46 mm, p < 0.001) compared with controls.


Multiplanar instability of the first TMT joint was confirmed using weightbearing CT in HV and HR groups compared with controls. HV group demonstrated instability mainly in sagittal and axial planes; HR group had sagittal instability predominantly. Our measurement of rotational instability at the first TMT joint was not able to detect differences between groups. A surgical correction of the instability at the first TMT joint can be an option to address HV and HR.

Clinical relevance

First ray hypermobility at the first TMT joint is an important consideration when addressing HV and HR, a surgical correction of the instability at the first TMT joint should be taken in consideration as an option.

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Data availability

The datasets generated during and/or analyzed during the current study are available in the International Orthopaedics repository,


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Authors and Affiliations



All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Hee Young Lee, MD, Matthieu Lalevee, MD, Nacime Salomao Barbachan Mansur, MD, PhD, Christian A. Vandelune, BA, and Cesar de Cesar Netto, MD, PhD. The first draft of the manuscript was written by Hee Young Lee, MD and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Cesar de Cesar Netto.

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Ethical approval

Ethical approval was waived by the local Ethics Committee of University of Iowa in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

Informed consent

Informed consent was obtained from all individual participants included in the study. Patients signed informed consent regarding publishing their data and photographs.

Conflict of interest

For the past 36 months, Cesar de Cesar Netto, MD, PhD has received royalties or licenses from Paragon 28 and Artelon, consulting fees from CurveBeam, Ossio, Paragon28, Zimmer-Biomet, and Nextremity, Payment or honoraria for lectures, presentations, speakers` bureaus, manuscript writing or educational events from Paragon28, CurveBeam, stock or stock options from CurveBeam. Cesar de Cesar Netto, MD, PhD is a AOFAS Committee Member (YPC, Fellowship), Editor-in-Chief Foot and Ankle Clinics, FAI Media Board Member, WBCT International Society Treasurer. The other authors have no relevant financial or non-financial interests to disclose.

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Level of Evidence: Level III, Retrospective Diagnostic Study

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Lee, H.Y., Lalevee, M., Mansur, N.S.B. et al. Multiplanar instability of the first tarsometatarsal joint in hallux valgus and hallux rigidus patients: a case–control study. International Orthopaedics (SICOT) 46, 255–263 (2022).

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  • First ray hypermobility
  • Multiplanar instability
  • First TMT joint
  • Hallux valgus
  • Hallux rigidus
  • Weightbearing CT
  • WBCT