Minimum-incision metatarsal osteotomies

[Five myths around hallux valgus]

Hallux valgus, also known as a bunion, is one of the most frequent deformities of the forefoot. The prevalence is 23% in people between the ages of 18 and 65 years and 36% in people over 65 years of age. Hallux valgus deformity normally begins between the ages of 30 and 60 years. Women are overall more frequently affected than men. Hallux valgus is characterized by the valgus deviation of the big toe and the varus deviation of the first metatarsal bone (MT-I), also known as metatarsus primus varus. This deformity can lead to a pressure point on the medial MT‑I head due to shoe conflict and can restrict mobility. Hallux valgus is typically identifiable by a physical examination. Imaging techniques are important to assess the severity of the deformity and to rule out possible differential diagnoses, such as hallux rigidus. Hallux rigidus is a degenerative change of the first metatarsophalangeal joint (MTP‑I joint) and the second most common cause of pain in the MTP‑I joint. A combination of hallux valgus and hallux rigidus is not uncommon. The treatment of hallux valgus initially focuses on nonsurgical approaches such as wider shoes, orthoses and nocturnal splints. If conservative treatment is not effective, surgical treatment provides a proven therapeutic benefit. In recent years minimally invasive techniques have also made progress in foot surgery. In addition to the reduced soft tissue trauma, the extra-articular approach in particular shows a significant advantage. This article provides a current overview of hallux valgus by addressing five widespread myths.

Percutaneous flexor digitorum brevis tenotomy: An anatomical study

INTRODUCTION

A percutaneous selective flexor digitorum brevis (FDB) tenotomy and a proximal interphalangeal (PIP) joint arthrolysis may correct a lesser claw toe deformity keeping flexor digitorum longus (FDL) and active flexion. Our study aimed to verify if the procedure was effective and reliable and if it respects the surrounding soft tissues.

MATERIAL AND METHOD

Twelve cadaveric lateral toes were used. A dissection ensured the integrity of both digital nerves, FDL and flexor pulleys and assessed the section of both FDB slips and PIP arthrolysis.

RESULTS

A complete section of the two FDB slips was observed in 4 cases (33%). Arthrolysis was achieved in all cases. Surrounding soft tissues were found intact in all cases.

CONCLUSION

This procedure is effective regarding PIP arthrolysis, but a technical improvement is required to achieve a reliable section of both FDB slips. In the hands of an experienced surgeon, it has proven to be safe.

Treatment of Adolescent Hallux Valgus With Percutaneous Distal Metatarsal Osteotomy

Background. Hallux valgus is a complex deformity of the first ray of the foot, and a significant number of adolescents develop this deformity. More than 130 surgical procedures have been described to treat hallux valgus, but there is no compelling evidence to prefer one method over another. Minimal invasive techniques have been proposed and reported to be successful and cost-effective. The objective of this study was to describe the clinical course of adolescent patients treated with percutaneous distal metatarsal osteotomy. Methods. A retrospective study included patients who had a percutaneous hallux valgus correction during the years 2008 to 2015. The following measurements were compared before surgery up to last follow-up: AOFAS Hallux-Metatarsophalangeal-Interphalangeal questionnaire and radiological measurements (HVA, IMA, DMAA). Any postoperative complications were extracted from the medical records. Results. The procedure was performed on 32 feet (27 patients). All patients were <18 years of age. There were 10 male patients (12 feet) and 17 female patients (20 feet). Average age at surgery was 15.8 years (range = 13-18 years). Average follow-up time was 43 months (range= 24-94 months). The average AOFAS score before surgery was 66, and after surgery, at last follow-up was 96. This difference was significant (P value <.0001). Most patients were pain free after the procedure and returned to appropriate age functioning. Significant improvement was noted in all radiological criteria. Conclusions. Percutaneous distal metatarsal osteotomy is safe, reliable, and effective for the correction of mild to moderate symptomatic hallux valgus in adolescents.Levels of Evidence: Level IV.

Increased rates of delayed union after percutaneous Akin osteotomy

BACKGROUND

Akin osteotomy is a well-known surgical procedure in forefoot surgery. When performing percutaneously, we have found a lot of delayed unions on follow up X-rays. The objective of this study was to assess the incidence of delayed union when performing a percutaneous Akin osteotomy.

METHODS

We report a series of 26 cases who underwent minimally invasive (percutaneous) Akin osteotomy. The mean follow-up duration was 17.6 (range 12 to 24) months. We analys-24) months. We analyzed the time to fusion using standard weight bearing radiographs. All the procedures were uneventful and we had only two skin burns that healed without sequelae.

RESULTS

All the procedures were uneventful and we had only two skin burns that healed without sequelae. The average time to fusion in our series was 4.69 months (2-11): seventeen of the 26 osteotomies (65.4%) were considered radiographically healed at an average time of 2,94 months (2-5), whereas 9 patients (34.6%) sustained a delayed-union and healed at an average of 8 months (7-11).

CONCLUSIONS

Despite few intraoperative complications and satisfactory clinical and radiological outcomes, our data suggest that a delayed union after Akin osteotomy is very common in the daily practice when performing it through a minimally invasive technique.

Percutaneous Triple and Double Osteotomies for the Treatment of Hallux Valgus

BACKGROUND

Percutaneous surgery to correct deformities of the forefoot presents the advantages of using a minimal incision, which involves less soft tissue damage and less risk of wound complications. For severe deformities, percutaneous techniques have not been proven as effective. We propose a technique for the treatment of severe hallux valgus.

METHODS

In a sample of 52 feet operated on 48 patients, we performed a double percutaneous osteotomy (closure proximal osteotomy and a distal Akin) or triple when a Reverdin-Isham osteotomy was added. We measured preoperatively the American Orthopaedic Foot & Ankle Society (AOFAS) score at the 1-year and 2-year follow-up, as well as the values of hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular ankle (DMAA), and shortening and elevation of the first metatarsal. The presence of metatarsalgia was recorded before and after the surgery.

RESULTS

HVA, IMA, and DMAA improved from 39.3 ± 7.1, 17.0 ± 2.0, and 16 ± 8.7 to 11.2 ± 6.2, 8.4 ± 3.4, and 8.3 ± 6.2, respectively. In 5 cases (10%), there was an elevation of the distal metatarsal bone, but only in 2 cases did a transfer metatarsalgia develop. There were no significant correlations between the amount of shortening and the presence of postoperative metatarsalgia. Scores on the AOFAS scale improved from 47.6 ± 5.6 to 89.7 ± 10.1 points.

CONCLUSION

The results are comparable to those reported with other more established techniques. Transfer metatarsalgia did not correlate with lifting or shortening of the metatarsal. We indicate the percutaneous technique for IMA above 15 degrees and increased DMAA or congruent joints.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Managing Complications of Percutaneous Surgery of the First Metatarsal

The percutaneous osteotomy based on a Hohmanntype first metatarsal subcapital linear osteotomy was introduced into Mainland China in the late 1980s. No internal fixation is used for stabilization of the osteotomy, leading unfortunately to unpredictable results. Despite its high acceptance by patients and enthusiasm by surgeons at present, the clinical outcomes of percutaneous surgery have not been promising. The authors have no experience of performing this osteotomy and report only on their management of the complications of this technique and their recommended treatment algorithm.

Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators

Background

There is increasing global interest and performance of minimally invasive foot surgery (MIS) however, limited evidence is available in relation to complications associated with MIS for digital deformity correction. The aim of this prospective audit is to report the surgical and medical complications following MIS for digital deformity against standardised clinical indicators.

Methods

A prospective clinical audit of 179 patients who underwent MIS to reduce simple and complex digital deformities was conducted between June 2011 and June 2013. All patients were followed up to a minimum of 12 months post operatively. Data was collected according to a modified version of the Australian Council of Healthcare standards (ACHS) clinical indicator program. The audit was conducted in accordance with the National Research Ethics Service (NRES) guidelines on clinical audit.

Results

The surgical complications included 1 superficial infection (0.53%) and 2 under-corrected digits (0.67%), which required revision surgery. Two patients who underwent isolated complex digital corrections had pain due to delayed union (0.7%), which resolved by 6 months post-op. No neurovascular compromise and no medical complications were encountered. The results compare favourably to rates reported in the literature for open reduction of digital deformity.

Conclusion

This audit has illustrated that performing MIS to address simple and complex digital deformity results in low complication rates compared to published standards. MIS procedures were safely performed in a range of clinical settings, on varying degrees of digital deformity and on a wide range of ages and health profiles. Further studies investigating the effectiveness of these techniques are warranted and should evaluate long term patient reported outcome measures, as well as developing treatment algorithms to guide clinical decision making.

Revisiting the tailor's bunion and adductovarus deformity of the fifth digit

Correction of the fifth digit deformity and Tailor's Bunion can be rewarding as well as challenging for a foot and ankle surgeon. Immense care should be taken when performing these reconstructive surgical procedure, especially to avoid and minimize complication rates and mainly to prevent neurovascular damage. Appropriate surgical procedure selection for the fifth digit deformity and Tailor's Bunion is necessary in order to obtain a long term predictable outcome.

Minimally invasive surgery for diabetic plantar foot ulcerations

Complications of diabetes mellitus constitute the most common indications for hospitalization and non-traumatic amputations in the USA. The most important risk factors for the development of diabetic foot ulcerations include the presence of peripheral neuropathy, vasculopathy, limited joint mobility, and pre-existing foot deformities. In our study, 500 diabetic patients treated for plantar forefoot ulcerations were enrolled in a prospective study from 2000 to 2008 at the Federal University of São Paulo, Brazil. Fifty-two patients in the study met the criteria and underwent surgical treatment consisting of percutaneous Achilles tendon lengthening to treat plantar forefoot ulcerations. The postoperative follow-up demonstrated prevention of recurrent foot ulcerations in 92% of these diabetic patients that maintained an improved foot function. In conclusion, our study supports that identification and treatment of ankle equinus in the diabetic population may potentially lead to decreased patient morbidity, including reduced risk for both reulceration, and potential lower extremity amputation.

Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review

Minimally invasive techniques for hallux valgus correction include arthroscopy, percutaneous and minimum incision surgery. In the last few decades, several techniques have been increasingly used. We performed a comprehensive search of CINAHL, Embase, Medline, HealthSTAR and the Cochrane Central Registry of Controlled Trials, from inception of the database to 4 January 2010, using various combinations of the keywords terms 'Bosch', 'PDO', 'percutaneous distal osteotomy', 'SERI', 'percutaneous', 'minimal incision', 'minimum incision', 'minimally invasive', 'less invasive', 'mini-invasive', 'hallux valgus', 'bunion', 'surgery', 'arthroscopy', 'metatarsal' 'forefoot'. Only articles published in peer reviewed journals were included in this systematic review. Several new techniques are available for minimally invasive correction of the hallux valgus. Minimally invasive correction of the hallux valgus may provide better outcome for patients who would not recover well from traditional open approaches, because of decreasing recovery and rehabilitation times, as surgical exposure and deep tissue dissection are smaller and gentler to the soft tissues. Data are lacking to allow definitive conclusions on the use of these techniques for routine management of patients with hallux valgus. Given the limitations of the current case series, especially the extensive clinical heterogeneity, it is not possible to determine clear recommendations regarding the systematic use of minimally invasive surgery for hallux valgus correction, even though preliminary results are encouraging. Studies of higher levels of evidence, concentrating on large adequately powered randomized trials, should be conducted to help answer these questions.

Minimally invasive hallux valgus correction

The most common complication following minimally invasive surgery (MIS) foot procedures is recurrence of the deformity, likely a direct consequence of incorrect selection of the procedure, incorrect surgical technique, or underestimated healing time of the osteotomy. This article describes our surgical MIS for hallux valgus correction, including the postoperative management, and reviews the literature on MIS for hallux valgus correction. The reports on such techniques are few, and mainly case series are reported. More adequately planned and executed randomized prospective clinical trials are needed. Historical attempts, indications, preferred surgical techniques, and complications are discussed.

Bosch osteotomy and scarf osteotomy for hallux valgus correction

Minimally invasive distal metatarsal osteotomies are becoming broadly accepted for correction of hallux valgus. We compared the duration of surgery, the length of hospital stay, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Foot and Ankle Outcome Score (FAOS) in 36 patients who underwent a minimal incision subcapital osteotomy of the first metatarsal with 36 matched patients who had hallux valgus corrected by a scarf technique. The minimum follow-up was 2.1 years (mean, 2.5 years; range, 2.1-3.2 years). Patients having the osteotomy had similar AOFAS and FAOS scores with less operating time and earlier discharge. Less operative time may benefit the patients, and earlier discharge has financial implications for the hospital.

Percutaneous and minimum incision metatarsal osteotomies: a systematic review

Percutaneous and minimum incision metatarsal osteotomies have received increasing recognition because of the perceived efficacy comparable to traditional open approaches but with purported less cost, fewer complications, and higher patient satisfaction. The use of these treatments has also been proposed for medically compromised patients who are not expected to recover well from traditional open approaches, a patient population that comprises a substantial proportion of the author's practice. Therefore, the author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the use of percutaneous and minimum incision metatarsal osteotomies. Information from peer-reviewed journals, as well as that from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they were prospective, involved consecutively enrolled patients undergoing the same percutaneous or minimum incision surgical treatment, evaluated patients at a mean follow-up of 12 months or longer duration, and included outcome measurements consisting of subjective patient satisfaction, radiographic measurements, and details of complications. Three studies involving percutaneous surgical treatment specific to hallux valgus were identified that met the inclusion criteria, all of which were case series of relatively poor methodological quality. Rather than providing strong evidence for or against the use of percutaneous minimum incision metatarsal osteotomies, the results of this review make clear the need for methodologically sound prospective cohort studies and randomized controlled trials that focus on the use of this form of surgical intervention.

LEVEL OF EVIDENCE

1.

Tenotomy and tendon transfer about the forefoot, midfoot and hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeon's options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.