Minimally invasive surgery for severe hallux valgus in 106 feet

Utilisation of the minimally invasive chevron akin (mica) osteotomy for severe hallux valgus: a systematic review

BACKGROUND AND AIM

Hallux valgus is the most common forefoot disease that can cause pain and be disabling for the patient. Many surgical procedures have been described to correct this deformity; over the last years, the minimally invasive Chevron and Akin osteotomies (MICA) technique has become very popular. The aim of this review was to assess if MICA technique is a reliable procedure for treating severe hallux valgus.

METHODS

A systematic review was performed according to the Preferred Reporting Items for systematic Reviews and Meta-Analysis (PRISMA) guidelines. The keywords were searched in PubMed Medline and Cochrane library. To minimise the number of missed studies, no filters were applied to the search strategy. To be considered for this review, the articles needed to comply with the following inclusion criteria: Minimally invasive Chevron and Akin osteotomy (MICA) for severe hallux valgus (HVA > 40°, IMA > 16°), patient age over 18 years and minimum follow-up of 6 months.

RESULTS

Following the PRISMA flow chart 7 studies met the inclusion criteria and were taken into consideration in the review. We reached a population of 582 patients for a total of 676 feet. Males and females were 64 and 518, respectively. The mean age was 54.15 ± 8.25. The mean follow-up was 23.74 ± 9.60 months. All the studies reported an improvement in clinical results, in terms of function and quality of life. Radiological variables, mostly IMA and HVA, assessed pre- and postoperatively showed significant improvement in all studies included.

CONCLUSIONS

Despite the limited number of published studies in the literature, the available evidence reveals good clinical outcomes and high levels of patient satisfaction. Percutaneous surgery for severe hallux valgus can achieve great deformity correction with reasonable rates of residual deformity. Patient satisfaction and quality of life following third-generation MICA surgery is very high.

Revision of Recurrent Hallux Valgus Deformity Using a Percutaneous Distal Transverse Osteotomy: Surgical Considerations and Early Results

Hallux valgus (HV) is a common forefoot deformity that can cause pain and difficulty with walking. There are a range of surgical techniques to treat HV deformity, but there is a risk of recurrence. This article reviews the clinical assessment and management of recurrent HV as well as a detailed description of how percutaneous surgical techniques can be used to treat recurrent HV. Overall, percutaneous surgical techniques using a transverse osteotomy and distal screw fixation can successfully treat a wide range of recurrent deformity severities with significant improvement in clinical and radiographic outcomes.

Does Use of Allograft Affect Union Rates in Minimal Invasive Hallux Valgus Surgery?

BACKGROUND

Hallux valgus (HV) is a common foot deformity that can cause significant discomfort. Surgical correction of hallux with minimally invasive surgery (MIS) has been gaining popularity in recent years among surgeons. The use of allograft in traditional open approaches has been proposed to improve the outcomes of foot and ankle procedures by expediting time to union. We performed a retrospective analysis of patients undergoing MIS HV correction with and without the allograft at the time of surgery. The primary aim of our study was to determine if use of allograft in HV MIS correction led to different time to union as well as rate of unions.

METHODS

A retrospective cohort study was designed to compare the radiographic outcomes of patients who underwent hallux valgus correction with or without allograft. Patients included in the analysis underwent primary HV correction using fourth-generation minimally invasive techniques and had postoperative weightbearing radiographs. Exclusion criteria included revision HV surgery, open surgery for HV correction, and patients lost to follow-up. All surgeries were performed by 3 fellowship-trained foot and ankle orthopaedic surgeons at a single center in Miami, Florida, from September 2019 to December 2022, with only 1 surgeon using allograft. All patients had similar postoperative protocols. The allograft group received 2 mL of a demineralized bone matrix (DBM) gel (Allosync; Arthrex). Radiographs were evaluated by 2 independent orthopaedic surgeons who were anonymized to the patient's group allocation. The primary outcome of this study was time to radiographic union, defined as formation of 2 neocortices on postoperative radiographs, as well as overall rate of union. The secondary outcomes included a comparison of traditional radiographic measurements and the incidence of complications.

RESULTS

Sixty-eight patients (68 feet) met inclusion criteria: allograft group (n = 26) and a control group (n = 42). Demographics between both groups were similar. In our study, all 68 feet obtained complete union and no malunions or nonunions were observed in either group. The average time to complete union for the allograft group was 5.69 ± 3.16 months (95% CI 4.45-6.93) and the control group was 6.0 ± 3.95 months (95% CI 4.80-7.19); union times between groups did not reach statistical significance (P = .731). Maintenance of surgical correction was observed in all patients.

CONCLUSION

In this study, the use of demineralized bone matrix allograft during MIS HV correction did not result in a statistically significant difference in time to union or overall union rates. Although the allograft group showed a slightly shorter average union time, this difference was not clinically or statistically significant. These findings suggest that the routine use of allograft in MIS HV correction may not provide a meaningful benefit.

A Multi-Dimensional Systematic Review of Minimally Invasive Bunion Surgery (MIBS)

Background/Objectives: Hallux valgus, or a bunion, is a prevalent foot deformity associated with pain, limited mobility, and reduced quality of life. Surgical treatments include minimally invasive and traditional open techniques, but the optimal approach remains debated. This systematic review evaluates long-term outcomes, patient satisfaction, cost-effectiveness, the influence of patient-specific factors, rehabilitation protocols, and complication rates for these methods. Methods: A comprehensive search of PubMed, Medline, EMBASE, and Cochrane databases identified 22 studies published within the last 15 years, each with a minimum follow-up of 2 years. The systematic review adhered to PRISMA-ScR guidelines. Eligible studies reported on at least one of six key outcomes, and data were extracted on radiographic and clinical results, patient satisfaction, costs, rehabilitation timelines, and adverse events. Results: Minimally invasive bunion surgery (MIBS) showed faster recovery, higher patient satisfaction, and improved quality of life compared to open surgery. Radiographic outcomes, including hallux valgus and intermetatarsal angle correction, were durable, though outcomes were less consistent for severe deformities. MIBS was more cost-effective over time, owing to shorter operating times and faster recovery. Rehabilitation was accelerated, and wound complications were fewer with MIBS. However, open techniques remained preferable for severe deformities due to their reliability in complex corrections. Conclusions: MIBS offers substantial advantages for most patients undergoing bunion surgery, including faster recovery and fewer complications. However, open techniques may be better suited for severe deformities. Further research is needed to refine patient selection criteria and evaluate long-term outcomes in diverse populations.

Learning Curve for Minimally Invasive Surgery (MIS) for the Treatment of Hallux Valgus

IntroductionCorrection of hallux valgus through minimally invasive surgery (MIS) has grown in popularity in recent years. Despite the increase in use, there has been limited research into the learning curve associated with the procedure, which has been documented extensively for other MIS procedures. Our study looked to determine the learning curve associated with MIS hallux valgus surgery.MethodsA retrospective review was conducted of patients who underwent MIS hallux valgus surgery, performed by 2 foot and ankle fellowship-trained orthopaedic surgeons, between November 2021 and April 2023. Demographic information, procedure data, and postoperative data were collected for each patient. A multivariable analysis was conducted for each surgeon to determine the relationship between case number and operative duration, patient-reported outcomes, and complications. Findings were significant if P < .05.ResultsCase number was found to have a significant negative relationship with operative duration for both of our surgeons (β = -0.578, -0.736, R2 = 0.637, 0.426, P < .001, .02). There was no significant relationship between case number and patient-reported outcomes (P = .49, .408) or complications (P = .319, .387) for either surgeon.ConclusionWe established the presence of a learning curve for operative duration, but not for patient-reported outcomes or complications. Overall, our results are conflicting regarding the presence of a learning curve for MIS hallux valgus procedures. Further study with other institutions is needed to further elucidate the presence of a learning curve.Level of Evidence:III.

The Learning Curve of Reverdin-Isham and Akin Percutaneous Osteotomies for Hallux Valgus Correction: A Bayesian Approach

Background/Objectives: Assessing the learning curve is essential for surgical techniques that require precision and technical adaptation. Although modified Reverdin-Isham and Akin percutaneous osteotomies (RIAOs) are well-established procedures for the treatment of hallux valgus (HV), their percutaneous nature and specific technical demands justify the evaluation of the learning curve. Therefore, this study aimed to assess the learning curve of RIAOs for the HV correction, using for the first time a Bayesian approach. Methods: Modified RIAOs were applied to treat mild-to-moderate HV in patients who were prospectively enrolled. The hallux valgus angle (HVA), inter-metatarsal angle (IMA), distal metatarsal articular angle (DMAA) and tibial sesamoid position were assessed. Clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, Visual Analog Scale (VAS) and Numerical Rating Scale (NRS). Surgery and fluoroscopy times were recorded. To evaluate the learning curve, a Bayesian analysis using a change point model was performed. Results: Analysis of 142 patients revealed three distinct phases in the learning curve, with a plateau reached after 112 procedures. Over time, the mean operation duration decreased from 55 to 27 min, and fluoroscopy time decreased from 60 to 28 s. Conclusions: A flexible change point model was used to model a learning curve, guaranteeing a robust interpretation of the data. The correction of the HV angles showed similar results in the three phases of the curve, demonstrating that the surgeon achieved positive results from the beginning of the surgery.

Comparative biomechanical study of different screw fixation methods for minimally invasive hallux valgus surgery: A finite element analysis

BACKGROUND

There are different screw configurations utilised for minimally invasive hallux valgus (HV) deformity despite limited biomechanical data assessing the stability and strength of each construct. We aimed to compare the strength of various screw configurations for minimally invasive HV surgery using finite element analysis (FEA).

METHODS

A FEA model was developed from a CT of a female with moderate HV deformity. Five screw configurations utilizing one or two bicortical or intramedullary screws were tested. Stress analysis considered osteotomy displacement, maximum and minimum principal stresses, and von Mises stress for both implants and bone for each screw configuration.

RESULTS

Fixation with two screws (one bicortical and one intramedullary) demonstrated the lowest values for osteotomy displacement, minimum and maximum total stress, and equivalent von Mises stress on the bone and screws in both loading conditions.

CONCLUSION

The optimal configuration when performing minimally invasive surgery for moderate HV is one bicortical and one intramedullary screw.

LEVEL OF EVIDENCE

Level III.

Current concepts of fourth-generation minimally invasive and open hallux valgus surgery

Hallux valgus (HV) presents as a common forefoot deformity that causes problems with pain, mobility, footwear, and quality of life. The most common open correction used in the UK is the Scarf and Akin osteotomy, which has good clinical and radiological outcomes and high levels of patient satisfaction when used to treat a varying degrees of deformity. However, there are concerns regarding recurrence rates and long-term outcomes. Minimally invasive or percutaneous surgery (MIS) has gained popularity, offering the potential for similar clinical and radiological outcomes with reduced postoperative pain and smaller scars. Despite this, MIS techniques vary widely, hindering comparison and standardization. This review evaluates the evidence for both open Scarf and Akin osteotomy and newer-generation MIS techniques. Fourth-generation MIS emphasizes multiplanar rotational deformity correction through stable fixation. While MIS techniques show promise, their evidence mainly comprises single-surgeon case series. Comparative studies between open and MIS techniques suggest similar clinical and radiological outcomes, although MIS may offer advantages in scar length and less early postoperative pain. MIS may afford superior correction in severe deformity and lower recurrence rates due to correcting the bony deformity rather than soft-tissue correction. Recurrence remains a challenge in HV surgery, necessitating long-term follow-up and standardized outcome measures for assessment. Any comparison between the techniques requires comparative studies. Surgeons must weigh the advantages and risks of both open and MIS approaches in collaboration with patients to determine the most suitable treatment.

Evaluation of hallux valgus treatment: is classical angular correction approach relevant?

BACKGROUND

Hallux valgus correction is mostly done by metatarsal procedures, and widely accepted strategy is to decide which surgical method should be used is based on radiological severity using intermetatarsal (IMA) and hallux valgus (HVA) angles (classical angular correction approach-CACA). The aim of the study is to compare the postoperative improvement in radiographic parameters and morphologic appearance of the foot between patients operated with and without adhering to CACA strategy based on classical severity classification using angle measurements.

MATERIALS AND METHODS

A retrospective comparative study between two groups (conforming and not conforming to proposed algorithm) was performed. Of 122 feet of 119 patients underwent metatarsal procedures for hallux valgus between October 2022 and November 2023, 92 feet of 92 patients were enrolled in the study (age 43.86 ± 16.1 years, 15.2% male). Patients were classified into two groups as conforming and non-conforming to CACA algorithm based on IMA and HVA angles (mild: IMA ≤ 13°, HVA ≤ 30°; moderate: 13° < IMA < 20°, 30° < HVA < 40°; severe: IMA ≥ 20°, HVA ≥ 40°). Algorithm proposed distal osteotomies for mild cases, shaft osteotomies for moderate cases and proximal osteotomies or tarsometatarsal arthrodeses for severe cases. HVA and IMA corrections after surgery, bony foot width, soft tissue foot width, medial eminence bony distance and medial soft tissue distance alterations, American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal Scale (AOFAS-MTP-IP) scores and improvement of foot appearance according to Manchester scale in postoperative first year follow-up were compared between groups.

RESULTS

58 procedures (group 1) conformed CACA, while 34 (group 2) did not. There was no statistically significant difference in terms of IMA (3.81° ± 4.01°, 2.72° ± 2.25°, p = 0.423), HVA (12.78° ± 7.81°, 10.31° ± 5.4°, p = 0.106) bony forefoot width (4.41 ± 6.66 mm, 1.65 ± 6.67 mm, p = 0.059), soft tissue forefoot width (1.21 ± 6.61 mm, 2.41 ± 7.45 mm, p = 0.423), medial eminence width (5.72 ± 3.17 mm, 6.07 ± 3 mm, p = 0.609) alterations and AOFAS-MTP-IP scores (82.17 ± 5.26, 83.06 ± 5.18, p = 0.435) between groups. Medial soft tissue width increased in both groups (2.74 ± 2.53 mm, 1.48 ± 1.67 mm, p = 0.011). Manchester stages were improved in 45 feet in group 1 (77.6%) and 19 feet in group 2 (55.9%) (p = 0.029).

CONCLUSION

The CACA strategy of treating more severe deformities with more proximal procedures and milder deformities with distal osteotomies did not significantly impact postoperative radiologic parameters. Nonetheless, following CACA strategy is likely to improve the morphologic appearance of the foot.

LEVEL OF EVIDENCE

III, comparative study.

Minimally Invasive Forefoot Surgeries Using the Shannon Burr: A Comprehensive Review

Since the early 2000s, minimally invasive forefoot surgery (MIS), particularly hallux valgus correction, has significantly advanced with the introduction of the Shannon burr. However, despite numerous relevant studies being published, no comprehensive review articles have summarized MIS for various forefoot conditions. Therefore, in this comprehensive review, we examined the relevant studies about the application of MIS (excluding arthroscopy and endoscopy) for various forefoot conditions. Additionally, we discuss the essential considerations for achieving favorable surgical outcomes and preventing complications associated with each technique. We analyzed the characteristics of each surgical procedure and identified areas for future focus. Effective surgical treatment not only requires MIS, but also the appropriate selection of patients based on suitable indications and executing procedures within the surgeon's capabilities. We hope that this review will help readers to enhance their expertise in this field.

Changes in Foot Width in Minimally Invasive Bunionectomy

BACKGROUND

Minimally invasive bunionectomy (MISB) has emerged as a popular approach to treat symptomatic hallux valgus deformity. Although previous studies focused on distal foot width changes postsurgery, this research introduces a novel midshaft measurement to evaluate proximal transverse midfoot width, aiming for a comprehensive understanding of foot changes post-MISB.

METHODS

A retrospective review of 44 HV patients from an institutional registry was conducted. Demographic data, surgical details, radiographs, and foot width measurements were collected. Changes in hallux valgus angle (HVA) and intermetatarsal angle (IMA) were also measured.

RESULTS

Intraclass correlation coefficients (ICCs) demonstrated good to excellent interobserver reliability (all ICCs > 0.70) for all measurements. MISB resulted in a consistent reduction in distal foot width (P < .001). These reductions correlated with changes in HVA and IMA, suggesting that the extent of deformity correction influenced distal foot width: distal bone width decreased an average of 8 mm, P < .001). However, midshaft bony width increased an average of 4 mm, P < .001). Changes in midshaft foot width showed no correlation with HVA or IMA alterations.

CONCLUSION

We found in this cohort of 44 patients that MISB for HV leads to an expected decrease in distal bony foot width but, on average, an increase in midshaft foot width.

Outcome comparison of minimally invasive proximal and distal chevron Akin osteotomies in patients with severe hallux valgus deformity: A randomized prospective study

PURPOSE

To date, the surgical treatment of severe hallux valgus deformity remains challenging despite the various methods presented. This study aimed to compare the effectiveness of minimally invasive distal chevron Akin osteotomies (d-MICA) and minimally invasive proximal chevron Akin osteotomies (p-MICA) in correcting severe hallux valgus deformities.

METHODS

This prospective follow-up study included patients randomly assigned to undergo p-MICA or d-MICA for hallux valgus deformities with a preoperative hallux valgus angle (HVA) ≥ 40° and/or a first to second intermetatarsal angle (IMA) ≥ 16°. After a minimum follow-up period of two years, we compared various clinico-radiographic parameters of patients whose HVA exceeded 15° at the final follow-up.

RESULTS

In the p-MICA and d-MICA groups, seven of 40 cases (17.5%) and 16 of 41 cases (39.0%), respectively, exhibited HVA > 15° at the final follow-up (P = 0.048). The preoperative parameters showed no significant differences. However, at the first weight-bearing assessment, the HVA, IMA, and relative second metatarsal length were significantly smaller, and the distal metatarsal articular angle (DMAA) was greater in the p-MICA group (all P < 0.05) compared with the d-MICA group. Postoperatively, both groups exhibited significant decreases in HVA and IMA at the final follow-up (P < 0.001 for all parameters). The p-MICA group showed no significant changes in DMAA and the relative length of the second metatarsal (P = 0.253 and 0.185, respectively). However, the d-MICA group showed a significant decrease in DMAA (P < 0.001) and an increase in the relative length of the second metatarsal at the final follow-up (P = 0.01).

CONCLUSIONS

p-MICA and d-MICA procedures demonstrated effective correction potential for severe hallux valgus deformities; however, the d-MICA procedure exhibited a notably higher incidence of unsatisfactory correction at the final follow-up than p-MICA. Therefore, d-MICA may be less predictable in achieving successful outcomes than p-MICA in treating severe hallux valgus deformities.

A Joy-Stick Assistant Three-Dimensional Modified Technique of Minimally Invasive Surgery for Mild or Moderate Hallux Valgus

BACKGROUND

Minimally invasive surgery (MIS) such as minimally invasive chevron osteotomy and Akin osteotomy (MICA) has become popular in the treatment of hallux valgus. However, how to correct three-dimensional deformities in hallux valgus effectively and simply in MICA is still difficult. Special equipment is required in MICA as has been reported before. It is meaningful and necessary to reduce the reliance on special equipment in MICA.

METHODS

From January 2021 to July 2022, patients with mild or moderate hallux valgus were treated with a joy-stick assistant three-dimensional modified technique (Joy-stick 3D technique) of MIS. VAS, AOFAS Hallux MTP-IP scores, hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured pre- and postoperatively at the last follow-up of at least 6 months. Scores and radiologic angles were compared using paired sample t-test.

RESULTS

A total of 36 cases were included. HVA, IMA, and DMAA were (22.3 ± 6.1)°, (14.0 ± 3.2)°, and (8.9 ± 3.2)° preoperatively, and decreased to (7.0 ± 1.8)°, (3.7 ± 1.0)°, and (3.3 ± 1.1)° postoperatively. VAS decreased from 4.3 ± 1.7 to 0.7 ± 0.7. AOFAS Hallux MTP-IP scores improved from 68.6 ± 7.6 to 92.9 ± 6.1. Comparing mild and moderate cases, though HVA, IMA, and DMAA were significantly different preoperatively, the angles became statistically similar after surgery.

CONCLUSIONS

A joy-stick assistant three-dimensional modified technique is proposed to control the three-dimensional position of the metatarsal head and to reduce dependence on special tools. Mild and moderate hallux valgus deformities are effectively corrected using Joy-stick 3D technique.

Clinical guideline on the third generation minimally invasive surgery for hallux valgus

Minimally invasive surgery for hallux valgus correction, has been attracting great interests in the recent decades, due to the potential benefits of less pain, decreased recovery times, smaller scars with better cosmesis, and improved early post-operative range of motion. The most recent developments in minimally invasive surgery have evolved into the third generation with modifications of the chevron-type osteotomy. This evidence-based clinical guideline of the third generation minimally invasive surgery for hallux valgus is initiated and developed collectively by the Foot and Ankle Committee of Orthopedic Branch of Chinese Medical Doctor Association, Foot and Ankle Committee of Sports Medicine Branch of Chinese Medical Doctor Association, and Foot and Ankle Expert Committee of Orthopedic Branch of the Chinese Association of the Integrative Medicine. This clinical guideline provides recommendations for indications, contraindications, operative planning and techniques, post-operative management, management of complications, and prognosis of the third generation minimally invasive surgery for hallux valgus. The Translational Potential of this Article This comprehensive guideline aims to establish standardized recommendations for the indications, contraindications, operative techniques, and post-operative management of the third generation minimally invasive surgery for hallux valgus. By adhering to this guideline, the success rate of the procedure could be maximized. This comprehensive guideline serves as a valuable reference for practitioners interested in or preparing to perform minimally invasive surgery for hallux valgus.

Minimally Invasive Chevron Akin Osteotomy: Preoperative Planning Using the Radiographic First-Ray Squeeze Test

Background

Recognizing preoperative first-ray hypermobility is important to planning hallux valgus (HV) surgery. A recent study showed the minimally invasive chevron Akin (MICA) osteotomy increased varus displacement of the proximal fragment of the first metatarsal osteotomy. The present study aims to evaluate the ability of the radiographic first-ray squeeze test to predict the varus displacement of the proximal fragment of the first metatarsal osteotomy when performing the MICA procedure.

Methods

A prospective case series of patients with moderate to severe HV who underwent MICA was performed. The HV deformity correction was analyzed by comparing the preoperative and 12-week postoperative hallux valgus angle (HVA) and the intermetatarsal angle between the first and second rays (1-2 IMA). The ability of the radiographic first-ray squeeze test to predict the varus displacement of the first metatarsal was done by comparing the preoperative 1-2 IMA measured in the AP radiographic first-ray squeeze test (IMA-ST) with the intermetatarsal angle between the second metatarsal and the axis of the first metatarsal osteotomy proximal fragment (IAPF) taken 12 weeks postoperatively.

Results

Between July 2022 and May 2023, a total of 39 feet in 28 patients underwent MICA. The mean IMA improved from 13.8 (SD = 2.2) to 3.8 degrees (SD = 1.5) (P < .001), and the mean HVA improved from 27.8 (SD = 6.1) to 4.9 degrees (SD = 2.5) (P < .001). A linear regression analysis revealed that IMA-ST is highly associated with the 12 week assessed IAPF (P < .001).

Conclusion

The preoperative radiographic first-ray squeeze test appears to predict with high fidelity the varus displacement of the proximal fragment of the first metatarsal that can occur after the MICA procedure.Level of Evidence: Level III, prospective cohort study.

Learning curve associated with minimally invasive surgery for hallux valgus: A systematic review

BACKGROUND

The purpose of this systematic review is to examine the learning curve associated with minimally invasive surgery (MIS) for the treatment of hallux valgus (HV).

METHODS

A systematic review was performed using PubMed, ScienceDirect, Web of Science, CINAHL and MEDLINE databases from database inception to February 16th, 2023. Inclusion criteria was articles with level of evidence I-III, any outcomes associated with learning curve, minimally invasive surgery, and diagnosis of hallux valgus' in adult patients.

RESULTS

Six articles out of 165 articles meet inclusion criteria. For all six articles, 368 total patients (422 total feet) were included in the study with an average age of 55.69 years. Three studies reported the number of surgeries needed to reach the plateau phase of the learning curve of MIS for HV, with a frequency weighted mean of 35.5 surgeries (range 27 - 40). In the selected articles, significant results were found for increased operating room (OR) time and fluoroscopy shots in the learning phase. There was no significant increase in complications in the learning phase. There was no significant decrease in patient outcomes, or the quality of correction performed during the learning phase.

CONCLUSION

An average of 35.5 surgeries (range 27 - 40) are needed to reach the plateau phase for MIS for HV. The learning phase of the learning curve of MIS for HV has a significant increase in OR time and fluoroscopy usage. However, the learning phase of the learning curve of MIS for HV is not associated with decreased outcomes or higher complication rates based on the small sample size in this study.

LEVEL OF EVIDENCE

Level III, Systematic Review.

Minimally Invasive Transverse Distal Metatarsal Osteotomy (MITO) for Hallux Valgus Correction: Early Outcomes of Mild to Moderate vs Severe Deformities

BACKGROUND

We compared the radiological and clinical outcomes of mild to moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon.

METHODS

Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) >40 degrees or preoperative first-to-second intermetatarsal angle (1-2 IMA) >16 degrees; the mild to moderate group was defined as having an HVA <40 degrees and a 1-2 IMA <16 degrees. Pre- and postoperative measurements of the HVA, 1-2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The visual analog scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 physical component summary were used to assess clinical outcomes.

RESULTS

A total of 116 feet were included in this study and median follow-up period of 29.0 months (range, 24-52 months). Both groups showed significant improvements in all radiologic parameters postoperatively, with the degrees of correction greater in the severe group than in the mild to moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups.

CONCLUSION

This study showed that short-term radiographic results for patients with either mild to moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. In this series, we found MITO with screw fixation to be a satisfactory surgical option for patients with mild to severe HV deformities.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Minimally invasive Chevron Akin (MICA) osteotomy for severe hallux valgus

INTRODUCTION

The minimally invasive Chevron Akin (MICA) osteotomy has been widely used to treat hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure and to evaluate the clinical and radiographic outcomes.

MATERIALS AND METHODS

Retrospective study including 60 consecutive feet (52 patients) undergoing MICA for severe HV. The data were collected pre- and post-operatively at the last follow-up. Patients were clinically evaluated by the visual analog pain scale (VAS) and AOFAS hallux MTP-IP score. Radiographic assessments included measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length, distal metatarsal articular angle (DMAA), and plantar translation of MT head. The complications were recorded during the follow-up.

RESULTS

The mean age was 59.9 years, and the mean follow-up was 20.5 months. The average AOFAS increased from 41.2 to 90.9 points, and the VAS from 8.1 to 1.3 at the last follow-up. The average HVA decreased from 41.2º to 11.6º, the IMA from 17.1º to 6.9º, and the DMAA from 17.9º to 7.8º. The average shortening of the first metatarsal and the plantar translation of the MT head was 5.1 mm and 2.8 mm, respectively. The most observed complication was hardware discomfort, observed in 5 feet (8.3%). There were two cases of recurrence (3.3%).

CONCLUSION

MICA technique was demonstrated in this series of cases to be an effective procedure for severe HV, with a low rate of recurrence and an acceptable rate of complications.

LEVEL OF EVIDENCE

IV; case series.

Temporal Changes in Clinical Outcomes after Minimally Invasive Surgery for Hallux Valgus Correction in Women without Postoperative Complications

Minimally invasive surgery (MIS) is currently used to correct hallux valgus deformities. Most studies reporting on MIS techniques to correct hallux valgus deformities included patients with postoperative complications. These reported complications, with an average rate of 23%, had significant negative effects on the clinical outcomes in this patient population. In the present study, a cohort of 63 women who underwent MIS hallux valgus correction was assessed preoperatively and at a mean follow-up of 1.0, 4.7, and 6.5 years using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the Manchester Oxford Foot Questionnaire (MOXFQ). The main criterion for inclusion in this cohort was a lack of complications during the entire follow-up period. The results showed significant improvements in both AOFAS and MOXFQ scores between the preoperative and 1-year follow-up assessments. By contrast, clinically small and nonsignificant changes were observed among postoperative follow-up values. The number of enrolled patients needs to be increased in future studies, with different surgeons and techniques included. Nevertheless, our study findings will inform patients about the outcomes they can expect over the years if no complications occur.

Perspectives and trends for minimally invasive surgery for hallux valgus deformity in the Asia Pacific region

BACKGROUND

Evolving evidence and improved instrumentation have led to increasing importance of minimally invasive surgery (MIS) surgery in the treatment of hallux valgus deformity. This study aims to investigate the current trends of the practice of MIS hallux valgus surgery in the Asia Pacific region.

METHOD

A survey was sent via email to 30 fellowship-trained foot and ankle surgeons in 11 Asia Pacific countries, all registered with their respective national orthopaedic societies. The survey consisted of 8 questions and was designed to assess surgeon experience with MIS hallux valgus surgery, including common contraindications, satisfaction levels, learning curves and post-operative rehabilitation after MIS hallux valgus surgery.

RESULTS

The vast majority of surgeons (63%) performed MIS hallux valgus surgery. However, only 18% of surgeons performed MIS surgery in more than half of their hallux valgus cases. A severe deformity was the most common contraindication (81%), followed by the instability of the first tarsometatarsal joint (50%), and abnormal DMAA (Distal Metatarsal Articular Angle) (38%). There was no statistically significant difference between the satisfaction score of MIS versus open surgery (p-value 0.1). The median number of cases the surgeons needed to perform before they considered themselves comfortable performing the surgery was 10 cases (range 1-100). Most surgeons allowed full weight bearing at 4-6 weeks after surgery.

CONCLUSIONS

MIS hallux valgus surgery is gaining popularity in the Asia Pacific region, with the majority of surgeons adopting this practice. The fact that severe deformity is seen as the most frequent contraindication and that MIS surgery is still not the most popular alternative demonstrates that surgeons are still circumspect when it comes to MIS surgery. Surgeons can use the findings of this study to guide their adoption of MIS practices in hallux valgus surgery and gauge well they perform in comparison to their counterparts in the Asia Pacific region.

Fourth-Generation Minimally Invasive Hallux Valgus Surgery With Metaphyseal Extra-Articular Transverse and Akin Osteotomy (META): 12 Month Clinical and Radiologic Results

BACKGROUND

Fourth-generation minimally invasive surgery (MIS) includes the multiplanar rotational deformity correction achieved through manipulation of an extra-articular distal first metatarsal osteotomy that is held with rigid fixation using 2 fully threaded screws, of which one must be bicortical to provide rotational and biomechanical stability. The aim of this study is to report the clinical and radiologic outcomes of an evolved fourth-generation MIS hallux valgus technique.

METHODS

A prospective single-surgeon series of consecutive patients undergoing fourth-generation MIS was performed using a distal transverse osteotomy with a minimum 12-month follow-up. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated clinical patient-reported outcome measure (PROM). Secondary outcomes included radiographic deformity correction, clinical assessment, and EuroQol-5D-5L PROMs.

RESULTS

Between September 2019 and June 2021, 50 feet underwent fourth-generation MIS. The mean age was 55.8±15.3 years with a mean follow-up of 1.4 years. Preoperative and minimum 12-month primary outcome data were available for 100% of feet. There was a significant improvement in all MOXFQ domain scores, with the index domain improving from 53.4 to 13.1 (P < .001). There was a significant improvement (P < .001) in hallux valgus angle (32.7 to 7.9 degrees), intermetatarsal angle (14.0 to 4.2 degrees) and distal metatarsal articular angle (18.5 to 5.6 degrees). There was a significant improvement in general health-related quality of life EQ-5D-5L index and EQ-VAS scores (P < .05).

CONCLUSION

The fourth-generation MIS technique is a safe and effective approach to hallux valgus deformity correction with significant improvement in clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus

BACKGROUND

Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiologic outcomes. It remains unknown whether these clinical and radiologic outcomes are maintained in the medium to long term. The aim of this study was to investigate the minimum 5-year clinical and radiologic outcomes following third-generation MIS hallux valgus surgery in the hands of a high-volume MIS surgeon.

METHODS

A retrospective observational single highly experienced MIS surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60-month clinical and radiographic follow-up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) preoperatively, 6 months, and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, EuroQol-5D visual analog scale and the visual analog scale for pain.

RESULTS

Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA, with complete data available for 78 (61.9%) feet. The median follow-up was 65.0 (IQR 64-69; range 60-88) months. There was a significant improvement in radiographic deformity correction; the median IMA improved from 12.0 degrees (interquartile range [IQR]: 10.8-14.2) to 6.0 degrees (IQR: 4.2-7.3) (P < .001), and the median HVA improved from 27.2 degrees (IQR: 20.6-34.4) to 7.2 degrees (IQR: 3.4-11.6). Median MOXFQ Index score at ≥60-month follow-up was 2.3 (IQR: 0.0-7.8). The radiographic recurrence rate (defined as HVA >15 degrees) was 7.7% at final follow-up. The complication rate was 4.8%.

CONCLUSION

Radiologic deformity correction for the 78 feet we were able to follow that had third-generation PECA performed by a single highly experienced MIS surgeon was found to be maintained at a mean follow-up of average 66.8 months, with a radiographic recurrence rate of 7.7%. Clinical PROMs and patient satisfaction levels were high and comparable to other third-generation studies with shorter duration of follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.