Cost effectiveness of different techniques in hallux valgus surgery

Chevron osteotomy and scarf osteotomy for hallux valgus angle and intermetatarsal angle correction: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis aimed to investigate the differences in hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopedic Foot and Ankle Society (AOFAS) scores, and complication rates between chevron osteotomy and scarf osteotomy for correcting hallux valgus.

METHODS

Two investigators independently searched for randomized controlled trials (RCTs) published from 2007 to 2018 on PubMed, Web of Science, and Cochrane Library databases. Next, chevron and scarf osteotomies were compared for their postoperative outcomes using HVA, IMA, and AOFAS scores and their complication rates. Meta-analysis was performed using Review Manager (version 5.3).

RESULTS

Six RCTs-comprising 507 feet, of which 261 and 246 underwent chevron and scarf osteotomies, respectively-were included. The meta-analysis revealed that chevron osteotomy led to significantly smaller postoperative HVAs than scarf osteotomy (weighted mean difference [WMD] = -1.94, 95% CI = - 2.65 to - 1.29, P < .00001). However, the differences in postoperative IMA (WMD = - 0.44, 95% CI = - 1.10 to 0.22, P = .19), postoperative AOFAS scores (WMD = 0.75; 95% CI = - 5.32 to 6.82; P = .81), and complication rates (risk ratio = 1.22, 95% CI = 0.65-2.27, P = .53) between feet that underwent chevron and scarf osteotomies were nonsignificant.

CONCLUSIONS

Compared with scarf osteotomy, chevron osteotomy had significantly more favorable postoperative outcomes in terms of HVA correction, but not in terms of IMA, AOFAS scores, or complication rates.

LEVEL OF EVIDENCE

Level I, systemic review and meta-analysis.

Outcomes After Chevron Osteotomy with and Without Additional Akin Osteotomy: A Retrospective Comparative Study

Background

Chevron osteotomy is one of the most common approaches to hallux valgus corrective surgery. This procedure is often combined with Akin osteotomy of the proximal phalanx of the hallux. There are no definitive guidelines specifying the indications for a given osteotomy technique nor data on postoperative loss of correction or the effect of the type of first-ray surgery on the development of adjacent-joint arthritis. The aim of this study was to assess radiographic treatment outcomes via chevron osteotomy with and without Akin osteotomy.

Methods

The study evaluated 117 patients treated in the period 2016-2019. Ninety-nine of those patients underwent distal chevron osteotomy alone, and 18 patients underwent a combined chevron-Akin double osteotomy. The analyzed radiograms had been obtained preoperatively, at 6 weeks after surgery, and after a long-term follow-up. The following parameters were assessed: the intermetatarsal angle (IMA), hallux valgus angle (HVA), interphalangeal angle (IPA), postoperative recurrence of valgus deformity, adjacent-joint arthritis, and complications.

Results

Chevron-Akin osteotomy helped maintain lower HVA and IPA values in long-term follow-up in comparison with those in the patients who underwent chevron osteotomy alone. The chevron osteotomy group showed a significant increase in the mean HVA from 18.37° at the first follow-up visit to 20.81° at the last follow-up visit. There were no differences between the groups in terms of the remaining assessed radiographic parameters. Hallux valgus surgery does not increase adjacent-joint arthritis.

Conclusion

The use of combined chevron-Akin osteotomy does not affect HVA or IMA correction. The combination of chevron and Akin osteotomies reduces the risk of increased HVA and IPA in long-term follow-up. The additional Akin osteotomy does not increase the risk of adjacent-joint arthritis. Combining chevron osteotomy with Akin osteotomy is recommended in hallux valgus deformity correction.

Radiographic Outcomes of Hallux Valgus Deformity Correction With Chevron and Scarf Osteotomies

There is no gold standard in the treatment of hallux valgus deformity. The purpose of our study was to compare various aspects of radiographic assessment following scarf and chevron osteotomies and try to determine which technique helps achieve a more pronounced intermetatarsal angle (IMA) and hallux valgus angle (HVA) correction and produces lower rates of complications, including adjacent-joint arthritis. This study included patients who underwent hallux valgus correction with the scarf (n = 32) or chevron (n = 181) method with a follow-up period of over 3 years. We evaluated the following parameters: HVA, IMA, duration of hospital stay, complications, development of adjacent-joint arthritis. The scarf technique helped achieve a mean HVA and IMA correction of 18.3° and 3.6°, respectively, and the chevron technique helped achieve a mean correction of 13.1° and 3.7°, respectively. The achieved deformity correction in terms of both the HVA and IMA was statistically significant in both patient groups. The loss of correction assessed with the HVA was statistically significant only in the chevron group. Neither group showed a statistically significant loss of IMA correction. The duration of hospital stay, reoperation rates, and fixation instability rates were comparable in the 2 groups. Neither of the evaluated methods caused a significant increase in total arthritis scores in the evaluated joints. Our study showed good outcomes of hallux valgus deformity correction in both evaluated groups; however, scarf osteotomy yielded somewhat better radiographic outcomes in HVA correction and no loss of HVA correction at 3.5 years of follow-up.

First metatarsal single-screw minimally invasive chevron-akin osteotomy: A cost effective and clinically reliable technique

Purpose

The common disease hallux valgus results in foot discomfort and dysfunction. Less soft tissue damage and faster wound healing have made minimally invasive surgery (MIS) more popular. However, little research has compared the fixation results of minimally invasive chevron-akin (MICA) osteotomy thus far. In this study, the clinical and radiographic results of MICA with first metatarsal single- or dual-screw fixation are being examined.

Methods

A total of 107 feet of 103 patients with mild to moderate symptomatic hallux valgus treated MICA from January 2018 to June 2020 were retrospective evaluated, with at least 12-months follow-up. 51 patients underwent single-screw fixation procedures and 52 patients received dual-screw fixation procedures. Patients were assessed preoperatively and at the final follow-up with radiographic measurements [hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA)] and clinical scores (american orthopaedic foot and ankle society (AOFAS) forefoot score, visual analog scale (VAS) and Manchester-Oxford Foot Questionnaire (MOxFQ) scores). The coughlin satisfaction scores were also obtained.

Results

Both groups showed significantly improved HVA, IMA and DMAA at the final follow-up (P < 0.001). Regarding clinical outcomes, the AOFAS, VAS and MOxFQ in two categories also significantly improved postoperatively (P < 0.001). There was no obvious difference in the clinical and radiographic outcomes between the two groups (HVA, P = 0.833; IMA, P = 0.073; DMAA, P = 0.35; AOFAS, P = 0.48; VAS, P = 0.86; MOxFQ, P = 0.87). However, the single-screw fixation group showed significantly lower operation time and less number of intraoperative fluoroscopy (P < 0.001). No serious complications were observed in either group. The single-screw fixation technique saves at least $1,086 compared with the dual-screw group.

Conclusion

At the final follow-up, both the single- and dual-screw fixation groups had comparable good to excellent clinical and radiographic outcomes, as well as a similar incidence of complications. Additionally, the single-screw fixation group reduces overall surgical costs, number of intraoperative fluoroscopy and operational time.

Overview of randomised controlled trials in hallux valgus surgery (2,184 patients)

BACKGROUND

The aim of this study is to provide an overview of randomised controlled trials (RCTs) in hallux valgus correction surgery summarising the available high-quality evidence.

METHODS

Following PRISMA guidelines, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE (1946 to 1 February 2020) and Embase (1980 to 1 February 2020). We excluded non-randomised trials, systematic reviews and case-series. We also excluded trials of MTPJ arthrodesis. Trials that met our inclusion criteria were assessed by two authors using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to intervention groups.

RESULTS

32 RCTs met the inclusion criteria and were included. The total number of patients in those trials was 2,184. Only 4 RCTs (12.5%) reported significant differences between the intervention and the control groups. The remaining trials evaluated scarf or chevron osteotomies in 18 RCTs, and 10 RCTs compared other osteotomies or technical aspects of hallux valgus surgery using functional and radiological outcome measures with none reporting significant differences.

CONCLUSION

Evidence from RCTs of hallux valgus surgery suggest that scarf and chevron osteotomies are the most popular techniques and lead to similar clinical outcomes.

Weightbearing Computed Tomography and 3-Dimensional Analysis of Mobility Changes of the First Ray After Proximal Oblique Osteotomy for Hallux Valgus

BACKGROUND

Hypermobility of the first ray has been evaluated using various methods and has conventionally been considered to be involved in the pathology of hallux valgus. We hypothesized that hypermobility of the first ray in hallux valgus could be decreased by simply correcting foot alignment without arthrodesis. This study sought to evaluate first-ray mobility using weightbearing computed tomography (CT) before and after proximal oblique osteotomy and also in healthy volunteer's feet.

METHODS

Subjects were 11 feet of 11 patients with primary hallux valgus who underwent surgery with a plantarly applied anatomic precontoured locking plate and 22 feet of 11 matched healthy volunteers. We performed nonweightbearing and weightbearing (using a load equivalent to body weight) CT scans using an original loading device preoperatively and 1-1.5 years postoperatively. Three-dimensional displacement of the distal bone relative to the proximal bone was quantified for each joint of the first ray by comparing nonweightbearing and weightbearing CT images.

RESULTS

At baseline, there were significant differences in hallux valgus angle (P < .001) and 1-2 intermetatarsal angle (P < .001) between healthy volunteer's feet and preoperative hallux valgus feet. Hallux valgus angle (P < .001) and 1-2 intermetatarsal angle (P < .001) differed significantly between before and after surgery. All first ray joint displacement under loading decreased postoperatively to within 2° of that in healthy volunteer's feet and showed no significant difference between postoperatively hallux valgus feet and healthy volunteer's feet (P > .05).

CONCLUSIONS

We found that first metatarsal osteotomy even without arthrodesis corrected deformity and decreased mobility of the first ray after hallux valgus surgery.

LEVEL OF EVIDENCE

Level III, case-control study.

Cost-effectiveness of interventions for musculoskeletal foot and ankle conditions: a systematic review

OBJECTIVE

Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise and synthesise the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions.

METHODS

Electronic databases were searched for studies presenting economic evaluations of non-surgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35).

RESULTS

Thirty-six studies were identified reporting non-surgical interventions (n=10), non-surgical versus surgical interventions (n=14) and surgical interventions (n=12). The most common conditions were osteoarthritis, ankle fracture and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the non-surgical alternative.

CONCLUSION

Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle complaints to best inform future clinical practice guidelines.

Cost-Effectiveness of Surgical Techniques in Hallux Valgus

Health care costs are increasing. Funding is not increasing at a commensurate rate. Demonstrable cost-effectiveness is critical when selecting operation and implant type. Clinicians must justify their decision on surgery and implant type, providing patient-reported outcome measures (PROM). Providing such data on cost and PROM forms the basis of future cost-effectiveness analysis (CEA). Such analysis is complex. Future research should analyze cost variables individually. Day case surgery, multimodal analgesia, and simultaneous surgery for bilateral cases show promise in reducing cost. With evidence of increased recurrence, requirement for additional equipment and more expensive implants it is unlikely to demonstrate superior cost-effectiveness.

Need for concomitant Akin osteotomy in patients undergoing Chevron osteotomy can be determined preoperatively: a retrospective comparative study of 859 cases

Background

The Chevron osteotomy is a frequently used surgical method for hallux valgus correction. This method is often combined with an Akin osteotomy. To date, clear guidelines for the implementation of an additional Akin osteotomy are missing. The purpose of this study was to elucidate the impact of concomitant phalangeal correction on the outcome after hallux valgus surgery and to define indication criteria for an additional Akin osteotomy.

Methods

Patients (859 feet) undergoing distal Chevron osteotomy at our department were retrospectively grouped into group C (Chevron, 785 feet) and group AC (Chevron plus Akin, 74 ft). Radiological assessment including the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the proximal to distal phalangeal articular angle (PDPAA) was performed preoperatively, postoperatively, after 6 weeks, and after 3 months. Longer-term follow-up with a mean of 36.4 months was available for 248 cases (29%).

Results

A significant improvement of all parameters could be found to all points of survey (p < 0.001). Loss of correction was detected for HVA (p < 0.001) and IMA (p < 0.007) with higher levels in group C. Preoperative PDPAA exceeding 8° correlated significantly with loss of HVA correction in group C (p < 0.001).

Conclusion

The combined Chevron and Akin osteotomy allowed for better correction of the hallux valgus deformity with better maintenance of the achieved correction. Recommendation for concomitant Akin osteotomy may be determined by a preoperative PDPAA exceeding 8°.

Trial registration

Retrospectively registered. UN5080.

Level of evidence

Therapeutic, Level III, retrospective comparative series.

Quality Measures in Foot and Ankle Care

BACKGROUND

Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.

METHODS

National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.

RESULTS

Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).

CONCLUSIONS

Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.

LEVEL OF EVIDENCE

Level I.

Cost-Utility Study of the Economics of Bunion Correction Surgery

BACKGROUND:

Bunion correction surgery is a very common procedure to improve patients' pain and physical function attributable to a misaligned first metatarsophalangeal joint. The objective of this study was to apply a health utility framework to estimate the cost utility of bunion correction surgery.

METHODS:

Patients were prospectively recruited from the population of patients seen in a lower-extremity orthopedic clinic and scheduled for isolated bunion surgery. Participants completed EuroQoL's EQ-5D(3L) to measure patients' current general health preoperatively and 6 months postoperatively. Participants' change in quality-adjusted life years (QALYs) were calculated by comparing the difference between postoperative utility values and preoperative utility values. The study had 95 patients representing 53% of eligible patients.

RESULTS:

The mean preoperative utility value was 0.6816 and the mean postoperative value was 0.7451, a statistically significant difference denoting an improvement in self-reported health. The cost per QALY, assuming gains in health accrued for 15 years, was $4911 (the 95% confidence interval ranged from $4736 to $5088). The cost per QALY was highest among the oldest patients. Assuming gains in health accrued for 20 years, the cost per QALY was $3922.

CONCLUSION:

This study demonstrated that bunion correction surgery was inexpensive relative to its gains in health compared with commonly applied thresholds for women and men in all age groups, though the gains were not uniformly distributed across age categories. Future research should examine the impact of recurrence on the robustness of these findings.

LEVEL OF EVIDENCE:

Level III, comparative study.

Assessment of the efficacy of SERI osteotomy for hallux valgus correction

BACKGROUND

SERI (Simple, Effective, Rapid, and Inexpensive) osteotomy is an accepted minimally invasive distal first metatarsal osteotomy performed to correct hallux valgus (HV). In the absence of reports of efficacy of the SERI technique in the Middle East, we studied 1-year outcomes of SERI osteotomy performed at our hospital in Saudi Arabia.

METHODS

We reviewed the medical charts of patients aged 20 to 60 years who underwent SERI osteotomy for HV between August 2013 and September 2016 and identified 29 patients, 2 (6.9%) men and 27 (93.1%) women, who met the criteria for inclusion in the study. Patients' clinical and operative characteristics were examined, their pre- and postoperative (1-year) radiographic measurements were compared, and the occurrence of any postoperative complication/event was noted.

RESULT

Patients' mean age was 34.9 ± 13.6 years. Six patients (20.7%) were treated for severe HV. Mean operation time was 11.1 ± 2.3 min. Four patients (13.8%) reported postoperative pain. No revision surgery was done. Congruency of the hallux metatarsophalangeal joint increased significantly, documented in only 4 patients (13.8%) preoperatively but in 17 (58.6%) at 1 year. The mean hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were significantly decreased at 1 year. The HVA normalized in 20 patients (69.0%), the IMA normalized in 25 patients (86.2%), but the DMAA normalized in only 4 patients (13.8%). The number of patients with sesamoid subluxation decreased from 29 (100%) to 13 (44.8%).

CONCLUSION

Our study data indicate that SERI osteotomy reliably reduces a wide spectrum of HV deformities and it is a safe procedure with very minimal complications.

TRIAL REGISTRATION

This study is registered in ClinicalTrials.gov under the following reference number: NCT03669900 .

[Clinical study of three-dimensional printed navigation template assisted Ludloff osteotomy in treatment of moderate and severe hallux valgus]

Objective

To explore the effectiveness and advantage of three-dimensional (3D) printed navigation templates assisted Ludloff osteotomy in treatment of moderate and severe hallux valgus.

Methods

Between April 2013 and February 2015, 28 patients (28 feet) with moderate and severe hallux valgus who underwent Ludloff osteotomy were randomly divided into 2 groups ( n=14). In group A, the patients were treated with Ludloff osteotomy assissted with a 3D printed navigation template. In group B, the patients were treated with traditional Ludloff osteotomy. There was no significant difference in gender, age, affected side, and clinical classification between 2 groups ( P>0.05). The operation time and intraoperative blood loss were recorded. The ankle function of the foot at preoperation, immediate after operation, and last follow-up were assessed by the American Orthopedic Foot and Ankle Society (AOFAS) score. Besides, the X-ray film were taken to assess the hallux valgus angle (HVA), intermetatarsal angle (IMA), and the first metatarsal length shortening.

Results

All patients were followed up 18-40 months (mean, 26.4 months). The operation time and intraoperative blood loss in group A were significantly less than those in group B ( P<0.05). The HVA, IMA, and AOFAS scores in groups A and B at immediate after operaton and last follow-up were sinificantly improved when compared with preoperative values ( P<0.05); but no significant difference was found between at immediate after operation and at last follow-up ( P>0.05). No significant difference was found in HVA and IMA between group A and group B at difference time points ( P>0.05). There were significant differences in AOFAS score and the first metatarsal length shortening at immediate after operation and at last follow-up between 2 groups ( P<0.05). Except 1 case of metastatic metatarsalgia in group B, there was no other operative complications in both groups.

Conclusion

3D printed navigation template assisted Ludloff osteotomy can provide accurate preoperative planning and intraoperative osteotomy. It is an ideal method for moderate and severe hallux valgus.

Economic Analysis of Anatomic Plating Versus Tubular Plating for the Treatment of Fibula Fractures

Ankle fractures are among the most common injuries requiring operative management. Implant choices include one-third tubular plates and anatomically precontoured plates. Although cadaveric studies have not revealed biomechanical differences between various plate constructs, there are substantial cost differences. This study sought to characterize the economic implications of implant choice. A retrospective review was undertaken of 201 consecutive patients with operatively treated OTA type 44B and 44C ankles. A Nationwide Inpatient Sample query was performed to estimate the incidence of ankle fractures requiring fibular plating, and a Monte Carlo simulation was conducted with the estimated at-risk US population for associated plate-specific costs. The authors estimated an annual incidence of operatively treated ankle fractures in the United States of 59,029. The average cost was $90.86 (95% confidence interval, $90.84-$90.87) for a one-third tubular plate vs $746.97 (95% confidence interval, $746.55-$747.39) for an anatomic plate. Across the United States, use of only one-third tubular plating over anatomic plating would result in statistically significant savings of $38,729,517 (95% confidence interval, $38,704,773-$38,754,261; P<.0001). General use of one-third tubular plating instead of anatomic plating whenever possible for fibula fractures could result in cost savings of up to nearly $40 million annually in the United States. Unless clinically justifiable on a per-case basis, or until the advent of studies showing substantial clinical benefit, there currently is no reason for the increased expense from widespread use of anatomic plating for fractures amenable to one-third tubular plating. [Orthopedics. 2018; 41(2):e252-e256.].

Economic Burden of Inpatient Admission of Ankle Fractures

BACKGROUND

Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures.

METHODS

A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation.

RESULTS

Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures.

CONCLUSION

In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually.

LEVEL OF EVIDENCE

Level III, comparative series.