{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T02:22:35Z","timestamp":1791944555138,"version":"4.3.4"},"reference-count":61,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2024,1,16]],"date-time":"2024-01-16T00:00:00Z","timestamp":1705363200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Hallux valgus deformity (HVD) involves subluxation of the first metatarsophalangeal joint. While HVD is primarily considered a forefoot condition, midfoot instability may play a significant role in its development and severity. However, very few studies have placed a heavy emphasis on studying this phenomenon. Therefore, this review had a particular focus on understanding midfoot instability based on weightbearing imaging assessments of the TMT joint. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched five databases for studies on midfoot instability in HVD patients. The severity of HVD was defined by hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA). Data was extracted, and articles were graded using the Methodological Index for Non-Randomized Studies (MINORS). Of 547 initially retrieved articles, 23 met the inclusion criteria. Patients with HVD showed higher HVA and DMAA on weightbearing radiographs (WBRG) and weightbearing computed tomography (WBCT) compared to healthy individuals. Midfoot instability was assessed through intermetatarsal angle (IMA) and tarsometatarsal angle (TMT angle). Patients with HVD exhibited greater IMA and TMT angles on both WBRG and WBCT. This review highlights the importance of weightbearing imaging assessments for midfoot instability in HVD. IMA and TMT angles can differentiate between healthy individuals and HVD patients, emphasizing the significance of midfoot assessment in understanding HVD pathology. These findings validate the limited evidence thus far in the literature pertaining to consistent midfoot instability in HVD patients and are able to provide ample reasoning for physicians to place a larger emphasis on midfoot imaging when assessing HVD in its entirety.<\/jats:p>","DOI":"10.3390\/diagnostics14020193","type":"journal-article","created":{"date-parts":[[2024,1,16]],"date-time":"2024-01-16T04:03:30Z","timestamp":1705377810000},"page":"193","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Weightbearing Imaging Assessment of Midfoot Instability in Patients with Confirmed Hallux Valgus Deformity: A Systematic Review of the Literature"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0018-6410","authenticated-orcid":false,"given":"Grayson M.","family":"Talaski","sequence":"first","affiliation":[{"name":"Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA 52242, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4175-3135","authenticated-orcid":false,"given":"Anthony N.","family":"Baumann","sequence":"additional","affiliation":[{"name":"College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bshara","family":"Sleem","sequence":"additional","affiliation":[{"name":"College of Medicine, American University of Beirut, Beirut 1107-2020, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5817-3826","authenticated-orcid":false,"given":"Albert T.","family":"Anastasio","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Duke University, Durham, NC 27708, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kempland C.","family":"Walley","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48109, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4456-9445","authenticated-orcid":false,"given":"Conor N.","family":"O\u2019Neill","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Duke University, Durham, NC 27708, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samuel B.","family":"Adams","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Duke University, Durham, NC 27708, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,1,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1097\/00003086-198106000-00008","article-title":"Hallux valgus\u2014Etiology, anatomy, treatment and surgical considerations","volume":"157","author":"Mann","year":"1981","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_2","unstructured":"Coughlin, M. (1999). Surgery of the Foot and Ankle, Mosby."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1650","DOI":"10.2106\/JBJS.H.01630","article-title":"The pathogenesis of hallux valgus","volume":"93","author":"Perera","year":"2011","journal-title":"JBJS"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"932","DOI":"10.2106\/00004623-199606000-00018","article-title":"Instructional course lectures, The American academy of orthopaedic surgeons-hallux valgus","volume":"78","author":"Coughlin","year":"1996","journal-title":"JBJS"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1080\/00325481.1984.11698000","article-title":"Hallux valgus: Causes, evaluation, and treatment","volume":"75","author":"Coughlin","year":"1984","journal-title":"Postgrad. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1180","DOI":"10.1016\/S0140-6736(52)91086-6","article-title":"Hallux valgus predisposing anatomical causes","volume":"259","author":"Hardy","year":"1952","journal-title":"Lancet"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1302\/0301-620X.33B3.376","article-title":"Observations on hallux valgus","volume":"33","author":"Hardy","year":"1951","journal-title":"J. Bone Jt. Surg. Br. Vol."},{"key":"ref_8","first-page":"387","article-title":"Correction of hallux valgus by metatarsal osteotomy","volume":"27","author":"Hawkins","year":"1945","journal-title":"JBJS"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1177\/107110070502601110","article-title":"The validity and reliability of the Klaue device","volume":"26","author":"Jones","year":"2005","journal-title":"Foot Ankle Int."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1016\/S0891-8422(23)00813-3","article-title":"Hallux valgus surgery. Morton and Lapidus were right!","volume":"13","author":"Hansen","year":"1996","journal-title":"Clin. Podiatr. Med. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1016\/S0891-8422(23)00819-4","article-title":"The Lapidus procedure","volume":"13","author":"Hofbauer","year":"1996","journal-title":"Clin. Podiatr. Med. Surg."},{"key":"ref_12","first-page":"273","article-title":"Hallux valgus due to cuneiform-metatarsal instability","volume":"3","author":"Johnson","year":"1994","journal-title":"J. South. Orthop. Assoc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1025","DOI":"10.3928\/0147-7447-19900901-15","article-title":"Metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus primus varus","volume":"13","author":"Myerson","year":"1990","journal-title":"Orthopedics"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1007\/s00264-021-05198-9","article-title":"Multiplanar instability of the first tarsometatarsal joint in hallux valgus and hallux rigidus patients: A case\u2013control study","volume":"46","author":"Lee","year":"2022","journal-title":"Int. Orthop."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1177\/107110079401500907","article-title":"The influence of X-ray orientation on the first metatarsocuneiform joint angle","volume":"15","author":"Brage","year":"1994","journal-title":"Foot Ankle Int."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1186\/1757-1146-3-21","article-title":"Prevalence of hallux valgus in the general population: A systematic review and meta-analysis","volume":"3","author":"Nix","year":"2010","journal-title":"J. Foot Ankle Res."},{"key":"ref_17","first-page":"57","article-title":"Hallux rigidus: A review of the literature and a method of treatment","volume":"142","author":"Mann","year":"1979","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1563","DOI":"10.2106\/JBJS.17.00975","article-title":"Unfavorable outcomes following surgical treatment of hallux valgus deformity: A systematic literature review","volume":"100","author":"Barg","year":"2018","journal-title":"J. Bone Jt. Surgery. Am. Vol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"105906","DOI":"10.1016\/j.ijsu.2021.105906","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"88","author":"Page","year":"2021","journal-title":"Int. J. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1186\/s13643-016-0384-4","article-title":"Rayyan\u2014A web and mobile app for systematic reviews","volume":"5","author":"Ouzzani","year":"2016","journal-title":"Syst. Rev."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"712","DOI":"10.1046\/j.1445-2197.2003.02748.x","article-title":"Methodological index for non-randomized studies (MINORS): Development and validation of a new instrument","volume":"73","author":"Slim","year":"2003","journal-title":"ANZ J. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1177\/10711007211046938","article-title":"Association of first metatarsal pronation correction with patient-reported outcomes and recurrence rates in hallux valgus","volume":"43","author":"Conti","year":"2022","journal-title":"Foot Ankle Int."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1177\/1071100719883325","article-title":"Effect of the modified Lapidus procedure on pronation of the first ray in hallux valgus","volume":"41","author":"Conti","year":"2020","journal-title":"Foot Ankle Int."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"759","DOI":"10.3113\/FAI.2007.0759","article-title":"Hallux valgus: Demographics, etiology, and radiographic assessment","volume":"28","author":"Coughlin","year":"2007","journal-title":"Foot Ankle Int."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1177\/107110070102201207","article-title":"Mobility of the first tarsometatarsal joint in hallux valgus patients: A radiographic analysis","volume":"22","author":"Faber","year":"2001","journal-title":"Foot Ankle Int."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"972","DOI":"10.1177\/1071100720924016","article-title":"Radiographic assessment of relative first metatarsal length following modified lapidus procedure","volume":"41","author":"Greeff","year":"2020","journal-title":"Foot Ankle Int."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1177\/10711007231175846","article-title":"The role of first tarsometatarsal joint morphology and instability in the etiology of hallux valgus: A case-control study","volume":"44","author":"Ji","year":"2023","journal-title":"Foot Ankle Int."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1177\/107110070202300606","article-title":"Chevron (Austin) distal metatarsal osteotomy for hallux valgus: Comparison of pre-and post-surgical characteristics","volume":"23","author":"Kernozek","year":"2002","journal-title":"Foot Ankle Int."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1177\/107110070402500410","article-title":"Associated deformities and hypermobility in hallux valgus: An investigation with weightbearing radiographs","volume":"25","author":"King","year":"2004","journal-title":"Foot Ankle Int."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1177\/107110070502601103","article-title":"The modified Lapidus procedure for hallux valgus: A clinical and radiographic analysis","volume":"26","author":"Kopp","year":"2005","journal-title":"Foot Ankle Int."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1041","DOI":"10.1177\/10711007221091810","article-title":"Coronal Plane Rotation of the Medial Column in Hallux Valgus: A Retrospective Case-Control Study","volume":"43","author":"Mansur","year":"2022","journal-title":"Foot Ankle Int."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2473011418813318","DOI":"10.1177\/2473011418813318","article-title":"Medial Cuneiform Opening-Wedge Osteotomy for the Treatment of Hallux Valgus","volume":"4","author":"Ahuero","year":"2019","journal-title":"Foot Ankle Orthop."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1016\/j.fas.2021.04.001","article-title":"Can we correct first metatarsal rotation and sesamoid position with the 3D Lapidus procedure?","volume":"28","author":"Ferreyra","year":"2022","journal-title":"Foot Ankle Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1007\/s43465-020-00110-w","article-title":"Three-dimensional printed anatomical models help in correcting foot alignment in hallux valgus deformities","volume":"54","author":"Ozturk","year":"2020","journal-title":"Indian J. Orthop."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1007\/s00264-021-05173-4","article-title":"Correlation between first tarsometatarsal joint mobility and hallux valgus severity","volume":"46","author":"Manceron","year":"2022","journal-title":"Int. Orthop."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"247","DOI":"10.2106\/JBJS.16.00542","article-title":"Evaluation of first-ray mobility in patients with hallux valgus using weight-bearing CT and a 3-D analysis system: A comparison with normal feet","volume":"99","author":"Kimura","year":"2017","journal-title":"JBJS"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1053\/j.jfas.2019.08.020","article-title":"Comparison of radiographic measurements before and after triplane tarsometatarsal arthrodesis for hallux valgus","volume":"59","author":"Dayton","year":"2020","journal-title":"J. Foot Ankle Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1140","DOI":"10.1053\/j.jfas.2018.05.009","article-title":"Evaluation of the mechanical axis of the first ray before and after first metatarsal-phalangeal joint reconstructive surgery","volume":"57","author":"Naguib","year":"2018","journal-title":"J. Foot Ankle Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1053\/j.jfas.2016.01.006","article-title":"Proximal opening wedge osteotomy provides satisfactory midterm results with a low complication rate","volume":"55","author":"Oravakangas","year":"2016","journal-title":"J. Foot Ankle Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1053\/j.jfas.2020.05.022","article-title":"Frontal plane rotation of the first Ray in hallux valgus using standing computerized tomography (CT)","volume":"60","author":"Randich","year":"2021","journal-title":"J. Foot Ankle Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"707","DOI":"10.1053\/j.jfas.2023.02.012","article-title":"Maintenance of Correction of the Modified Lapidus Procedure with a First Metatarsal to Second Metatarsal Screw with \u201cSpot Weld\u201d Technique: A Retrospective and Radiographic Analysis","volume":"62","author":"Thompson","year":"2023","journal-title":"J. Foot Ankle Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1177\/1457496916683095","article-title":"First Tarsometatarsal Joint Derotational Arthrodesis for Flexible Hallux Valgus: Results from Follow-Up of 3\u20138 Years","volume":"106","author":"Klemola","year":"2017","journal-title":"Scand. J. Surg."},{"key":"ref_43","first-page":"1378","article-title":"Radiological Assessment of Postoperative Changes Following Lapidus Procedure for the Treatment of Hallux Valgus","volume":"11","author":"Almaawi","year":"2021","journal-title":"Ann. Med. Health Sci. Res."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"119","DOI":"10.2214\/ajr.155.1.2112832","article-title":"Hallux valgus deformity: Preoperative radiologic assessment","volume":"155","author":"Karasick","year":"1990","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1177\/107110079902001007","article-title":"Mobility of the first tarsometatarsal joint in relation to hallux valgus deformity: Anatomical and biomechanical aspects","volume":"20","author":"Faber","year":"1999","journal-title":"Foot Ankle Int."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"518","DOI":"10.1016\/j.fas.2022.02.014","article-title":"Comparison between Weightbearing-CT semiautomatic and manual measurements in Hallux Valgus","volume":"28","author":"Walt","year":"2022","journal-title":"Foot Ankle Surg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1177\/1071100720962398","article-title":"The role of weightbearing computed tomography scan in hallux valgus","volume":"42","author":"Mahmoud","year":"2021","journal-title":"Foot Ankle Int."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"665","DOI":"10.1177\/10711007211064609","article-title":"Imaging findings and first metatarsal rotation in hallux valgus","volume":"43","author":"Najefi","year":"2022","journal-title":"Foot Ankle Int."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1177\/107110070102200503","article-title":"The reliability of angular measurements in hallux valgus deformities","volume":"22","author":"Coughlin","year":"2001","journal-title":"Foot Ankle Int."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"944","DOI":"10.1177\/1071100715576994","article-title":"A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans","volume":"36","author":"Kim","year":"2015","journal-title":"Foot Ankle Int."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1053\/j.jfas.2017.08.018","article-title":"Factors associated with early loss of hallux valgus correction","volume":"57","author":"Shibuya","year":"2018","journal-title":"J. Foot Ankle Surg."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Wagner, P., Lescure, N., Siddiqui, N., Fink, J., and Wagner, E. (2021). Validity and reliability of a new radiological method to estimate medial column internal rotation in hallux valgus using foot weight-bearing X-ray. Foot Ankle Spec.","DOI":"10.1177\/19386400211029162"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"2473011419S00050","DOI":"10.1177\/2473011419S00050","article-title":"Three-Dimensional Weightbearing Assessment of the First Ray in Hallux Valgus: A Case-Control Study","volume":"4","author":"Lintz","year":"2019","journal-title":"Foot Ankle Orthop."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"955","DOI":"10.1177\/1071100719847700","article-title":"Multicenter early radiographic outcomes of triplanar tarsometatarsal arthrodesis with early weightbearing","volume":"40","author":"Ray","year":"2019","journal-title":"Foot Ankle Int."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1053\/j.jfas.2014.09.010","article-title":"Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy","volume":"54","author":"Dayton","year":"2015","journal-title":"J. Foot Ankle Surg."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1007\/s00776-009-1345-8","article-title":"Correction of hallux valgus deformity using the center of rotation of angulation method","volume":"14","author":"Mashima","year":"2009","journal-title":"J. Orthop. Sci."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1016\/j.otsr.2012.05.005","article-title":"Axial rotation of the first metatarsal head in a normal population and hallux valgus patients","volume":"98","author":"Mortier","year":"2012","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1016\/S0030-5898(20)31927-1","article-title":"Deformity planning for frontal and sagittal plane corrective osteotomies","volume":"25","author":"Paley","year":"1994","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"205","DOI":"10.2106\/00004623-199502000-00006","article-title":"Radiographic analysis of hallux valgus. A two-dimensional coordinate system","volume":"77","author":"Tanaka","year":"1995","journal-title":"JBJS"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/j.fcl.2018.01.005","article-title":"Using the center of rotation of angulation concept in hallux valgus correction: Why do we choose the proximal oblique sliding closing wedge osteotomy?","volume":"23","author":"Wagner","year":"2018","journal-title":"Foot Ankle Clin."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/j.clinbiomech.2017.01.012","article-title":"Three-dimensional analysis of tarsal bone response to axial loading in patients with hallux valgus and normal feet","volume":"42","author":"Watanabe","year":"2017","journal-title":"Clin. Biomech."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/14\/2\/193\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T13:47:49Z","timestamp":1760104069000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/14\/2\/193"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,1,16]]},"references-count":61,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2024,1]]}},"alternative-id":["diagnostics14020193"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics14020193","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,1,16]]}}}