Percutaneous hallux valgus surgery: a prospective multicenter study of 189 cases

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.

Role of lateral soft tissues release in percutaneous hallux valgus correction: A medium term retrospective study

BACKGROUND

In the field of minimally invasive surgery (MIS) for the treatment of hallux valgus (HV), different techniques have begun to emerge in the literature concerning the distal osteotomy of the first metatarsal bone, the synthesis or not of the metatarsal head, the possible association with lateral soft tissues release (LSTR) and osteotomy of the base of the first phalanx.

AIM

To evaluate the role of LSTR on percutaneous HV correction, evaluating functional and radiographical results.

METHODS

From January 2012 to May 2016 a total of 396 patients with mild to moderate symptomatic HV treated with the MIS technique were included in this retrospective study. The technique provides no internal fixation (WOS). Patients were divided into the LSTR group and no LSTR group (LSTR N). This surgical procedure (LSTR) was reserved for insufficient HV angle (HVA) correction during fluoroscopic control. Patients were evaluated at each follow-up by two other authors after appropriate training by senior authors (first practitioners). Clinical evaluation was performed before surgery, 6 mo after surgery, and 48 mo follow-up. American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) score was used to evaluate pain and function, and complications were recorded. In addition, the incidence of relapses and the degree of joint range of motion (ROM) with the association with the LSTR (capsule, adductor tendon, phalanx-sesamoid ligament, and the deep transverse metatarsal ligament) were evaluated. Radiological parameters included HVA and intermetatarsal angle (IMA). Patient satisfaction was assessed. Student t-test and Fisher exact test were used to assess statistical analysis.

RESULTS

From our study it is clear that no differences in term of HVA, VAS, IMA correction, rate of complications, and AOFAS score were found between groups, while a significant improvement of the same variables was found in each group between pre and postoperative values. A significant improvement in ROM at 6 mo (P = 0.018) and 48 mo (P = 0.02) of follow-up was found in LSTR N group. Complications were rare in both groups.

CONCLUSION

LSTR procedure on percutaneous HV correction seems to increase postoperative joint stiffness with a comparable incidence of relapse and a low incidence of complications.

Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques-a cadaveric study

BACKGROUND

Distal first metatarsal osteotomy is used to correct mild or moderate hallux valgus (HV). We designed a cadaveric study to compare the resistance to axial load between two percutaneous distal first metatarsal osteotomies: Bösch osteotomy and percutaneous chevron. The first aim of this study was to develop a systematic technique for measuring the sagittal displacement on lateral foot X-rays. Our second objective was to measure the resistance to axial load for both of these osteotomies.

METHODS

Ten pairs of freshly frozen cadaveric feet were randomly assigned to one of the two techniques investigated. Pre- and post-operative lateral X-rays were obtained. After surgery, the feet were placed under progressive axial loads up to 60 kg. Metaphyseo-diaphyseal angle (MDA) and the distance between bone fragments were measured, and the differences between the two techniques were statistically assessed.

RESULTS

The MDA decreased in both surgical techniques. The mean plantar tilt was -6.90 degrees (SD = 10.251) for chevron osteotomy and -5.34 degrees (SD = 16.621) for Bösch osteotomy. There was no significant difference between the techniques (p = 0.41). Regarding the distance between the bone fragments, the Bösch osteotomy produced more plantar displacement than the chevron osteotomy, which was statistically significant for the 10 and 20 kg loads (p = 0.031 and 0.04, respectively). At loads ≥ 30 kg, the bone fragment distance did not differ significantly between the techniques (p = 0.114).

CONCLUSIONS

Although the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head.

LEVEL OF EVIDENCE

Cadaveric study.

LEVEL V

Minimally Invasive Chevron-Akin for Correction of Moderate and Severe Hallux Valgus Deformities: Clinical and Radiologic Outcomes With a Minimum 2-Year Follow-up

BACKGROUND

The minimally invasive chevron-Akin (MICA) technique has already demonstrated efficacy compared with other known surgical treatments for mild to moderate hallux valgus (HV). MICA combines percutaneous osteotomies with the benefits of modern, rigid internal fixation. The aim of study was to evaluate the radiographic parameters, clinical improvement, and potential complications in moderate to severe HV cases, operated using the MICA technique.

METHODS

Retrospective study including 70 feet with HV operated using the MICA technique. The AOFAS hallux MTP-IP score and radiographics for HV evaluation were applied preoperatively, and after 6 months, 1 year, and 2 years of follow-up. The following radiographic parameters were measured: metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), interphalangeal angle (IPA), and intermetatarsal angle (IMA).

RESULTS

The average preoperative VAS pain score was 8.2 ± 1.5, which improved to 1.2 ± 2.2 at 24 months. The mean preoperative IMA was 14.8 ± 3.6 degrees compared with a mean of 7.5 ± 2.1 degrees (P < .01) at 24 months. The preoperative HVA value averaged 30.4 ± 9.8 degrees and at 6 months postoperatively 11.1 ± 6.8 degrees (P < .01), which remained stable until measured at 24 months. The mean preoperative DMAA was 16.3 ± 8.6 degrees and at the 6-month follow-up was 7.8 ± 5.4 degrees (P < .01). The mean preoperative IPA was 7.63 ± 4.4 degrees compared with a mean of 6.28 ± 3.5 degrees (P > .05) at 24 months. Complications included painful hardware (14.28%), neuropathic pain (2.85%), and loss of correction (4.28%).

CONCLUSION

In this retrospective review from a single center, we found the MICA technique to be an effective procedure for correcting moderate to severe HV, with a low rate of recurrence and an acceptable rate of complications. Patients undergoing the surgical procedure in our series showed a significant reduction in radiographic parameters and a significant improvement in clinical scores, maintaining these results over time.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Percutaneous, implantless basal closing wedge osteotomy for hallux valgus: Surgical technique and preliminary results in 114 patients

BACKGROUND

Percutaneous, implantless basal closing wedge osteotomy (PIBCO) is a new technique for hallux valgus (HV) deformity correction that does not need internal fixation. We present this technique and its short-term clinical outcomes for moderate-to-severe HV deformities.

METHODS

A retrospective review of 162 feet in 114 patients who underwent PIBCO of the first metatarsal (MT1) was conducted. Follow-up averaged 18.5 months. Outcomes were assessed using the visual analog scale (VAS), hallux valgus angle (HVA), intermetatarsal angle (IMA), and radiologic union. Complications were also assessed.

RESULTS

Average VAS score improved from 6.2 to 1.0 (P < 0.001). HVA improved from 29.8° to 7.6° (P < 0.001). IMA improved from 14.5° to 6.3° (P < 0.001). A total of 8 major complications were noted (4.9%).

CONCLUSIONS

Satisfactory HV deformity correction was achieved. However, some instances may require internal fixation in order to avoid complications related to instability and noncompliance of postoperative rehabilitation protocols.

Distal Metatarsal Osteotomies for Chronic Plantar Diabetic Foot Ulcers

In more than 30 years of scientific literature (1986-2021), the few published studies on the management of CPDFUs by DMOs showed satisfactory clinical and radiographic outcomes. Although these reports were all case series, their data suggest that DMOs, performed at a different level of the distal metatarsal bones, are an effective surgical treatment option for achieving rapid healing of CPDFUs and preventing their recurrence after balancing the pressures in diabetic forefeet. Hence, DMOs can be a valid alternative treatment method also for CPDFUs with chronic infection, ulcers penetrating deep structures, and even ulcers with osteomyelitis at the metatarsophalangeal level.

Effectiveness of hallux valgus surgery on improving health-related quality of life: A follow up study

BACKGROUND

Hallux valgus (HV) negatively impacts health-related quality of life (HRQoL). Patientreported outcome measures (PROMs) are increasingly used in clinical studies of the foot and ankle. We aimed to evaluate the effect of HV surgery on PROMs (i.e., pain scales, general HRQoL, and region-specific scales) and radiological angles. Additionally, we aimed to determine whether the effect on these outcomes depends on the type of surgery (including open and percutaneous techniques) and if it is influenced by potential confounding factors (i.e., age, HVA, 1-2 IMA, body mass index (BMI), and distal metatarsal articular angle (DMAA).

METHODS

This was a longitudinal prospective study. We collected the clinical data of all patients who underwent surgery for symptomatic HV deformity in the orthopedic department of the Virgen de la Luz Hospital of Cuenca (Spain).The clinical outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) Hallux metatarsophalangeal-interphalangeal (HMI) scale, visual analogue scale (VAS), Manchester Oxford foot questionnaire (MOXFQ), short form health survey (SF-12) and European Quality of Life-5 Dimensions (EQ-5D).

RESULTS

A total of 72 patients (70 women, 97.2%) were included in the study 72 (72 feet).The AOFAS pre-post-surgery score changed from 42.16 (SD: 10.11) to 83.31 (SD: 6.23). Considering AOFAS domains, the pre-post change was from 14.17 (SD: 9.15) to 33.19 (SD: 4.69) for pain, from 27.22 (SD: 3.90) to 37.94 (SD: 2.78) for function, and from 0.78 (SD: 2.38) to 12.18 (SD: 3.45) for alignment. For other clinical outcomes was VAS score from 5.01(SD: 1.26) to 1.26 (SD: 0.96) and MOXFQ score from 61.44 (SD: 7.09) to 12.35 (SD: 4.85). SF-12 (physical) changed from 36.26 (SD: 5.32) to 47.06 (SD: 4.82), SF-12 (mental) from 38.23 (SD: 8.04) to 46.49 (SD: 4.16), and EQ5-D from 0.64 (SD: 0.008) to 0.90 (SD: 0.10).

CONCLUSIONS

Our data confirmed the improvements in the clinical and radiological outcomes after HV surgery, and provided some evidence of these improvements not depending on the type of surgery or on some potential confounding factors such as BMI, HVA, 1-2 IMA, and DMAA.

Litigation after hallux valgus surgery in France between 2000 and 2020: A review of the two national legal research databases

BACKGROUND

The objectives of this review were to: 1) describe reasons for lawsuits following primary hallux valgus surgery in France from 2000 to 2020; 2) to compare private and public practice.

METHODS

Civil (private practice) and administrative (public practice) court decisions in France between 2000 and 2020 were collected using the two leading legal data sources (Legifrance, Doctrine).

RESULTS

Seventy-two court decisions related to hallux valgus surgery were included. An appeal was filed in 93% of cases. Finally, 70.8% of the verdicts were in favor of the complainants. The average compensation awarded to a plaintiff was €55,333. The main reasons for complaint after hallux valgus surgery were: a failure to provide preoperative information (47.2%), post-operative pain/stiffness (38.9%), and infection (30.6%). A proven lack of information increased the risk of recognizing the occurrence of post-operative pain and stiffness as faulty from 13.3% to 61.5% (p = 0.01), and the average compensation from €25,330 to €76,716 (p = 0.04). The duration of the procedure was about 1.5 years longer in civil proceedings (p = 0.04). There was no significant difference between private and public activity litigation.

CONCLUSION

Clear and adapted patient information and its traceability could be a way to reduce the number of complaints and their consequences in case of disappointing results.

Gait biomechanics evaluation of the treatment effects for hallux valgus patients: A systematic review and meta-analysis

BACKGROUND

Hallux valgus (HV) is a foot deformity characterized by lateral deviation of the big toe and medial deviation of the first metatarsal.

RESEARCH QUESTION

This study aimed to shed light on the treatment effects of different interventions and surgical procedures for HV deformity to determine the effectiveness of gait biomechanics correction.

METHODS

English-language searches of the electronic databases were conducted in the Cochrane Library, Web of Science, PubMed, Scopus, and Embase. Gait biomechanics evaluation before and after conservative or operative treatments was essential for inclusion in this review. Methodological quality was assessed by the Institute of Health Economics (IHE) quality appraisal tool. All pooled analysis was based on the random-effects model.

RESULTS

Twenty-five articles (1003 participants) were identified in this review. Three studies chose conservative therapies for HV deformity, incorporating foot orthotics and minimalist running intervention, and surgeries were performed in twenty-two studies. For the pressure parameter alteration under the hallux, the effect size (ES) in the conservative treatment subgroup was - 0.95 with 95%CI [- 1.69, - 0.21]. It demonstrated a moderate ES of - 0.44% and 95%CI [- 0.81, - 0.07] in the surgery subgroup. The five operations' peak pressure alteration under the hallux demonstrated a moderate ES of - 0.45% and 95%CI [- 0.54, - 0.36].

SIGNIFICANCE

Both non-operative and operative treatments could achieve the forefoot pressure redistribution, decreasing loading beneath the hallux and first metatarsal regions，However, the treatment effects of surgeries were not very robust. The percutaneous DSTR-Akin technique is recommended as an adequate operative treatment, with a large ES and moderate heterogeneity. The negative gait return effect should be noticed while using Scarf osteotomy, despite positive clinical and radiographic outcomes.

A Retrospective Study Characterizing the Radiographic Progression of Hallux Valgus

Background: Hallux valgus deformity is the lateral deviation of the metatarsophalangeal (MTP) joint and is the most common pathology of the great toe, affecting 2%-4% of the population. It is commonly believed that the condition progresses over time both in the magnitude of deformity and development of arthritic changes. To our knowledge, there are rare studies describing the rate of deformity progression and the development of arthritic changes. Our aim is to quantify the progression of hallux valgus and associated arthritic changes in an adult population using radiographs.

Methods: Patients who are 18 years of age and older (mean age: 61.7 years and range: 18.6-94.2) who presented to our institutions between January 1, 2004, and December 1, 2019, were included. Patients were included in the study if they had hallux valgus on weight-bearing radiographs and two such radiographs at least six months apart. Hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsophalangeal (MTP) arthritis, tarsometatarsal (TMT) osteoarthritis, Hardy-Clapham sesamoid position, and round sign were collected per patient in the initial and final radiographs. Included cases were first studied together in a whole group. Then, cases were separated into three groups based on the time between initial and final radiographs.

Results: A total of 52 radiographic records for 43 patients were included. HVA and IMA progress with time; however, progression does not follow a direct relationship with the time elapsed between initial and final radiographs (p = 0.92 and p = 0.35, respectively). The progression of TMT osteoarthritis, sesamoid position, and round sign do not show a dependence on the time elapsed (p = 0.20, p = 0.11, and p = 0.42, respectively). An increase of one sesamoid unit position over baseline is associated with a 0.85-degree increase in IMA. A one-unit progression of sesamoid position at baseline raises the odds of MTP osteoarthritis progression at the follow-up visit by 2.14 (OR = 2.14, p = 0.0007, CI = [1.35, 3.83]). A HVA increase of one degree increases the odds of TMT osteoarthritis progression at follow-up by a factor of 1.17 (OR = 1.17, p = 0.0005, CI = [1.07, 1.34]). Patients with MTP arthritis at the initial visit have 3.77 times higher odds of round sign progression on their follow-up visit (OR = 3.77, p = 0.027, CI = [1.16, 13.13]).

Discussion: Hallux valgus progression can be quantified. Upon their first visit, a patient’s hallux valgus parameters can be utilized to demonstrate expected progression. Progression of the deformity and arthritic changes is slow. Nonetheless, the results should be considered by surgeons and patients when developing a treatment plan with patients.

Treatment of hallux valgus in children and adolescents

Juvenile hallux valgus is one of the most common pathologies of the forefoot in children and adolescents. Nevertheless, its treatment is still controversial. This deformity has some distinct anatomical features, particularly a lateral tilt of the articular facet of the head of the first metatarsal and congenital metatarsus adductus, which often occur in combination. Some mediocre surgical treatment results can be explained by the lack of correction of all these factors when we approach the problem as we would in adults. A double osteotomy to correct the DMAA and varus of the first metatarsal is a good solution in most cases with satisfactory functional outcomes. A percutaneous approach seems efficient in the pediatric population, given that the periosteum and growth plates, which are very active in younger children, help the osteotomies to heal and remodel. Guided growth surgery - using this approach is a viable alternative in this age bracket. Finally, minimally invasive surgery for juvenile hallux valgus allows another surgery to be done on minimally or undamaged tissues if needed later on.

Hallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis

INTRODUCTION

Treatment of hallux valgus deformity associated with mild or moderate osteoarthritis (OA) is still a topic of debate. In the literature, there are few studies concerning the management of patients affected by this condition. This study aims to report the experience at mid- to long-term results of an original joint-preserving surgical technique.

MATERIALS AND METHODS

Patients affected by mild to moderate hallux valgus deformity and associated to grade 1-2 OA and treated with modified Simple-Effective-Rapid-Inexpensive (SERI) technique from 2008 to 2018 were selected. Inclusion criteria were mild or moderate hallux valgus angle (HVA) <40° and an intermetatarsal angle (IMA) <20° and associated grade 1-2 OA of the first metatarso-phalangeal joint (MTPJ).

RESULTS

128 feet in 120 consecutive patients, undergone modified SERI procedure, have been retrospectively reviewed at a mean follow-up of 5.1 ± 3.8 years (range 2-11). American Orthopaedics Foot Ankle Society (AOFAS) score that was significantly improved from 44.2 ± 13.2 to 88.2 ± 9.6. Pre-operative average HVA and IMA values decreased respectively from 31.6° ± 3.9° to 9.1° ± 4.4° and from 16.2° ± 3.8° to 7.2° ± 3.1°. The average distal metatarsal articular angle (DMAA) value improved from 28.2° ± 6.5° to 7.1° ± 6°. OA of the first MTPJ highlighted a grade 1 in 46 feet and a grade 2 in 82 feet pre-operatively and a grade 0 in 30 feet, grade 1 in 82 feet, and grade 2 in 16 feet at the final follow-up.

CONCLUSIONS

The modifications to the SERI technique could extend the indications to patients affected by hallux valgus with mild to moderate OA. The wider case series and the longer follow-up of this study make us believe this technique is very useful for improving the quality of life in these patients.

LEVEL OF EVIDENCE

IV.

Clinical and Radiographic Outcomes of Percutaneous Chevron-Akin Osteotomies for the Correction of Hallux Valgus Deformity

BACKGROUND

Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort.

METHODS

All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded.

RESULTS

A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2.

CONCLUSION

MICA is good method to correct hallux valgus deformity with low postoperative narcotic use.

LEVEL OF EVIDENCE

Level III, restrospective cohort study of a single surgeon practice.

Cirurgia minimamente invasiva em chevron e osteotomia percutânea de Bosch no tratamento de hálux valgo. Resultados em médio prazo. Estudo radiológico comparativo*

Objective  The purpose of the present study is to compare the radiological results of angular correction and its maintenance in the medium term between two minimally invasive techniques for the treatment of hallux valgus (minimally invasive chevron surgery vs. Bosch technique).

Methods  A comparative prospective analysis of patients undergoing surgery for symptomatic hallux valgus deformity was performed. We compared two minimally invasive techniques in homogeneous groups of population. Two groups of 62 and 63 feet respectively, were constituted. We compared first ray angular corrections and consolidation as well as the correction power of both osteotomies and their maintenance over time. The postoperative complications and surgical time in both study groups were also evaluated. The minimum follow-up was 2 years.

Results  There were differences between both groups in the intermetatarsal angle at 24 months postsurgery. There were no differences between both groups regarding metatarsophalangeal angle, and distal metatarsal articular angle. There were no intraoperative complications in either group. The surgical time between both groups had statistically significant differences.

Conclusions  Both screw-stabilized, Bosch surgery and minimally invasive chevron (hybrid when associated with percutaneous Akin osteotomy) present adequate correction of moderate hallux valgus. However, patients treated with Bosch percutaneous surgery had a greater correction power of the intermetatarsal angle in the medium term, as well as a shorter surgical time, when compared with those who were treated with chevron osteotomy. Both techniques had a similar evolution over time regarding loss of correction and postoperative complications.

Percutaneous, intra-articular, chevron osteotomy (PeICO) for the treatment of mild-to-moderate hallux valgus: a case series

PURPOSE

Treatment for hallux valgus (HV) remains challenging. Third-generation percutaneous procedures try to reproduce chevron-type osteotomies to replicate their benefits, such as intrinsic stability and reproducibility. We report the first results using a percutaneous, intra-articular, chevron osteotomy (PeICO) technique that mimics the classic intra-articular open chevron procedure, associated with a percutaneous adductor tendon release (PATR) for the treatment of mild-to-moderate HV.

METHODS

From May 2015 to October 2018, a total of consecutive 114 feet (74 patients) were included. Primary outcome measures included radiographic (hallux valgus and intermetatarsal angles) and clinical parameters such as visual analog scale (VAS), FAAM Activities of Daily Living (ADL), and FAAM Sport, AOFAS Score, and MOXFQ, preoperatively and at final follow-up (Minimum 18 months). A patient satisfaction survey was also performed. Pronation and length of the first metatarsal were also assessed. Secondary outcomes included fluoroscopic time, length of surgery, complications, recurrence, and re-operation rates.

RESULTS

At 24.09 months on average, the AOFAS score improved from 52.1 points preoperatively to 91.1 (p < 0.001) at the latest follow-up. VAS decreased from 6.3 to 1. Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (p < 0.001) when comparing pre-operative and post-operative periods. Patients found the procedure to be excellent in 82% and very good in 13.5% of cases. Our global complication and re-operation rates were 5.26% and 3.5% (screw removal), respectively.

CONCLUSION

PeICO combined with PATR proved to be a safe, reliable, and effective technique for the correction of mild-to-moderate HV deformity.

Midterm Results Following Minimally Invasive Distal Chevron Osteotomy: Comparison With the Minimally Invasive Reverdin-Isham Osteotomy by Means of Meta-analysis

BACKGROUND/AIM

To date, multiple different surgical techniques have been established for hallux valgus surgery, with each technique having its unique advantages and limitations. The open distal chevron osteotomy is widely accepted, but increasing patient demands have led several minimally invasive (MIS) techniques to be described in recent years. The aim of this study was to compare outcomes after minimally invasive (MIS) distal chevron osteotomy and the minimally invasive Reverdin-Isham method.

PATIENTS AND METHODS

We assessed clinical and radiographic outcomes after MIS chevron osteotomy in 57 feet of 49 consecutive patients with a mean follow-up of 58.9 (range=39.0-85.4) months. Outcomes after MIS Reverdin-Isham osteotomy were analyzed by means of a systematic literature review with a minimum follow-up of 6 months.

RESULTS

Radiographic outcomes were significantly better in the MIS chevron cohort for intermetatarsal angle (p<0.001), hallux valgus angle and distal metacarpal articular angle (p<0.05). Concerning clinical outcomes, both methods provided comparable improvement.

CONCLUSION

MIS distal chevron osteotomy in mild to moderate hallux valgus deformity correction results in superior radiographic outcomes compared to the MIS Reverdin-Isham osteotomy. Sufficient correction of IMA cannot be achieved with the MIS Reverdin-Isham osteotomy.

Percutaneous, MIS and open hallux valgus surgery

There is some confusion in the terminology used when referring to MIS (Minimal invasive surgery) or percutaneous surgery. The correct term to describe these procedures should be percutaneous (made through the skin) and MIS should be reserved for procedures whose extent is between percutaneous and open surgery (e.g. osteosynthesis). Minimal incision surgery may be distinguished in first, second and third generation minimal incision surgery techniques.

First generation MIS hallux valgus surgery is mainly connected with the Isham procedure; an intraarticular oblique and incomplete osteotomy of the head of the first metatarsal without fixation.

The Bösch osteotomy and the SERI are classified as second generation MIS hallux surgery. They are both transverse subcapital osteotomies fixed with a percutaneous medial K-wire inserted into the medullary canal. For all these procedures, intraoperative fluoroscopic control is necessary.

Open hallux valgus surgery can be divided into proximal, diaphyseal and distal osteotomies of the first metatarsal. Reviewing the available literature suggests minimally invasive and percutaneous hallux valgus correction leads to similar clinical and radiological results to those for open chevron or SCARF osteotomies. First generation minimally invasive techniques are primarily recommended for minor deformities. In second generation minimally invasive hallux valgus surgery, up to 61% malunion of the metatarsal head is reported. Once surgeons are past the learning curve, third generation minimally invasive chevron osteotomies can present similar clinical and radiological outcomes to open surgeries. Specific cadaveric training is mandatory for any surgeon considering performing minimally invasive surgical techniques.

Cite this article: EFORT Open Rev 2021;6:432-438. DOI: 10.1302/2058-5241.6.210029

Complications on Percutaneous Hallux Valgus Surgery: A Systematic Review

Lately there has been a growing interest in the use of percutaneous surgery for the correction of hallux valgus (HV). The purpose of the present study was to systematically review the published data about this topic and establish the efficacy and safety, stressing the complication rates found on this percutaneous technique. A systematic review of the literature available in PubMed was performed. The radiological and clinical outcomes were evaluated as well as complication rates. A total of 16 studies were included and 1157 procedures reported for percutaneous HV on 1246 patients. The mean angle correction of HV deformity improved postoperatively. Reported complications vary among the studies. The highest complication rate was joint stiffness in 18.47% of cases, followed by HV recurrence and shortening of M1, both in 15.2%, material intolerance in 10.1%, osteoarthritic changes in 9.1%, infection in 7.6%, and transfer metatarsalgia in 5.4%. There is a lack of randomized control trials and insufficient comparative case control studies to assess whether one technique is more effective than another or if the percutaneous surgery is recommended rather than open surgery with respect to complications.

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.

Functional and Radiographic Outcomes of Minimally Invasive Intramedullary Nail Device (MIIND) for Moderate to Severe Hallux Valgus

BACKGROUND

This study was aimed at assessing clinical and radiographic outcomes of the Minimally Invasive Intramedullary Nail Device (MIIND) to correct moderate to severe hallux valgus (HV) and the long-term persistence of its effects.

METHODS

This case series study involved 100 patients, 84 women and 16 men (mean age, 59 years), who underwent the MIIND procedure with a mean follow-up of 97 months. Assessment was performed preoperatively, postoperatively, at 6 and 12 months, and at last follow-up. Clinical outcomes were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS), and patient satisfaction. Intermetatarsal angle (IMA), metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and tibial sesamoid position were assessed. Statistical analysis was performed.

RESULTS

The mean AOFAS score improved from 57.9 to 90.5 points, VAS scale was 1.5 ± 2.0, and patients' satisfaction was 8.7 ± 1.4. The mean correction of the HVA and IMA showed a significant correction; however, the effect of time was not statistically significant on DMAA. Sex (P = .047), severity (P = .050), associated procedures (P = .000), and preoperative angle (P = .000) showed significant association with HVA correction and its persistence over time. Age was not statistically significant. Complications were 9 cases of superficial wound infection and 6 recurrences.

CONCLUSIONS

The MIIND technique proved a viable procedure to correct moderate to severe HV with a low rate of complications and recurrence, producing significant correction of most radiographic parameters assessed and their persistence, even at long term.

LEVEL OF EVIDENCE

Level IV, case series study.

The effect of hallux valgus open and percutaneous surgery on AOFAS scale: a systematic review and meta-analysis

PURPOSE

To estimate the comparative effect of open and percutaneous hallux valgus (HV) surgery on patients' quality of life (QoL) using the American Orthopedic Foot and Ankle Society (AOFAS) scale including total score and individual domains (pain, function, and alignment).

METHODS

MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched from inception to March 2020 for studies on the effect of HV surgery on patients' QoL using the AOFAS score. A standardized mean difference score was calculated on the total AOFAS score and on each AOFAS domain (pain, function, and alignment) using Cohen's d index.

RESULTS

Considering the 53 published studies included, the pooled effect size (ES) estimates for the AOFAS total score were 3.69 (95% CI 3.37-4.01; I² = 95.5%) for open surgery and 3.40 (95% CI 2.99-3.80, I² = 88.2%) for percutaneous surgery. The total pooled ES estimate was 3.61 (95% CI 3.35-3.87, I² = 94.5%). Considering the pain domain, the pooled ES estimates were 2.21 (95% CI 1.98-2.43, I² = 64%) for open surgery and 2.52 (95% CI 1.83-3.20, I² = 92.6%) for percutaneous surgery. For the function domain, the pooled ES estimates were 1.37 (95% CI 0.93-1.81, I² = 91%) for open surgery and 2.28 (95% CI 1.10-3.47, I² = 96.8%) for percutaneous surgery. Finally, the pooled ES estimates for the alignment domain were 3.99 (95% CI 3.51-4.47, I² = 85.7%) for open surgery and 2.66 (95% CI 2.23-3.09, I² = 78.5%) for percutaneous surgery.

CONCLUSION

Our data support that HV surgery increases the total AOFAS score as well as the AOFAS scores by domain (pain, function, and alignment). Furthermore, our data show that HV surgery increases patients' QoL, after both open and percutaneous surgery, without differences between them.

The Endolog technique for moderate to severe hallux valgus treatment: Clinical and radiographic analysis of 194 patients

BACKGROUND

Endolog is an intra-medullary titanium device used for a minimally-invasive hallux valgus correction. The aim of this study was to evaluate clinical and radiographic outcomes of this device.

METHODS

A retrospective study with a prospective data collection was conducted. Patients underwent to Endolog procedures from September 2009 to April 2017 were enrolled. Mild HV deformity (HVA ≤ 19° and IMA ≤ 13°) or associated procedure to Endolog technique were excluded. The radiological (HVA, IMA and PASA) and clinical (AOFAS score) pre and post-operative data were compared through Wilcoxon Signed-Rank test.

RESULTS

194 feet (144 moderate and 50 severe HV) underwent HV correction respecting study's criteria. AOFAS scores significantly improved from 31.0 ± 12.7 points preoperatively to 88.5 ± 8.0 at 24 months. Even all radiographic measurements significantly improved during 2 years' follow-up. Only 6 patients experienced complications: 4 cases of HV recurrence and 2 cases of intolerance device-related pain.

CONCLUSIONS

Endolog technique proved to be a valid option in the moderate-to-severe hallux valgus treatment, comparable to other surgical techniques described in literature.

Percutaneous Lateral Release in Hallux Valgus: Anatomic Basis and Indications

In the last decade, minimally invasive or percutaneous surgery has evolved rapidly through the development of novel techniques. Treatment of hallux valgus deformity is one of the indications for percutaneous surgery, both for bony and soft tissue correction. The release of the structures on the lateral part of the first metatarsophalangeal joint (lateral release) is one of the best indications for percutaneous surgery in the forefoot. In this article, a detailed description of the anatomy of the metatarsophalangeal joint is provided, along with the indications and tips to perform a safe percutaneous lateral release.

Complications of Minimally Invasive Surgery for Hallux Valgus and How to Deal with Them

This article discusses the possible complications in minimally invasive surgery (MIS) for hallux valgus. The rate of complications and the outcomes are at least comparable with open techniques. A percutaneous technique provides the best conditions for undisturbed healing. Some possible complications exist in MIS that do not exist in open surgery, such as lesion of soft tissue structures that are not under direct visible control or skin burns. These complications usually result from technical mistakes in performing the operation. It is therefore crucial to get proper education from cadaver training and visiting experienced colleagues, as is done in open surgery.

Minimally Invasive Hallux Valgus Surgery-A Systematic Review and Assessment of State of the Art

Minimally invasive techniques in the treatment of hallux valgus deformity have seen growing popularity since the 1990s. The purpose of this article is to assess the existing body of literature as to the safety and efficacy of minimally invasive techniques and identify areas for further development. The appeal of minimizing soft tissue damage, reducing surgical time, and faster recovery is currently offset by the initial learning curve and a lack of high-quality studies regarding minimally invasive techniques. There is currently insufficient evidence to recommend one minimally invasive technique over another and further high-level evidence studies are warranted.

Anatomical Study of Minimally Invasive Lateral Release Techniques for Hallux Valgus Treatment

BACKGROUND

Lateral release (LR) for the treatment of hallux valgus is a routinely performed technique, either by means of open or minimally invasive (MI) surgery. Despite this, there is no available evidence of the efficacy and safety of MI lateral release. Our aim was to study 2 popular techniques for MI LR in cadavers by subsequently dissecting the released anatomical structures.

METHODS

Twenty-two cadaveric feet were included in the study and allocated into 2 groups, 1 for each procedure: 1 group underwent a MI adductor tendon release (AR), and in the other group, an extensive percutaneous lateral release (EPLR) (adductor tendon, suspensory ligament, phalanx-sesamoid ligament, lateral head of flexor hallucis brevis, and deep transverse metatarsal ligament) was performed. Anatomical dissection was performed to identify neurovascular injuries and to verify the released structures.

RESULTS

Both techniques demonstrated to be effective in reproducing a MI LR. A satisfactory release of the adductor tendon was achieved equally in both techniques (P = .85), being partial in most EPLR cases and full in the majority of AR cases. The EPLR was successful in releasing the intended additional structures (P < .05). One case of inadvertent complete section of the flexor hallucis longus was identified in the percutaneous adductor tendon release group. No cases of dorsolateral nerve injury were seen with either of the techniques.

CONCLUSION

Percutaneous lateral release was a reliable and accurate technique in this cadaveric model. The MI AR proved to be more effective in fully releasing the adductor tendon while the ER was intended and able to release a number of other structures.

CLINICAL RELEVANCE

MI LR is a safe procedure that could obviate the need for open surgery to achieve the same surgical goal. It can be associated to either open or MI osteotomies in the correction of hallux valgus.

Mini Invasive Floating Metatarsal Osteotomy for Diabetic Foot Ulcers Under the First Metatarsal Head: A Case Series

Diabetic foot ulcers under the first metatarsal head are difficult to treat and prevent recurrence. The aim of this study is to summarize the results of a distal first metatarsal minimally invasive floating osteotomy for ulcers under the first metatarsal head in patients with diabetic neuropathy. We reviewed files of patients with diabetic neuropathy undergoing a floating first metatarsal osteotomy. Demographic and clinical data were collected and analyzed to determine success and complications. We found records for 21 patients (mean age 64) with University of Texas 1A ulcers. The ulcer's mean age was 11.2 months. Following surgery, the ulcer completely resolved after a mean of 3.7 (2 to 11) weeks in 19 patients. During the first year, there were 4 complications related to the surgery (including 3 infections). At latest follow-up, 17/21 (81%) patients had healed with satisfactory results. Minimal invasive floating distal osteotomy of the first metatarsal can cure and prevent recurrence of diabetic foot ulcers under the first metatarsal head in 80% of the patients, but the ability to provide close follow-up and prompt response are prerequisites.

Functional outcomes of percutaneous correction of hallux valgus in not symptomatic flatfoot: a case series study

Hallux valgus (HV) and Pes Planus (PP) are two common conditions characterized by aesthetic dissatisfaction with or without pain. The aim of the study was to assess clinical and functional outcomes at two years follow-up of percutaneous surgery in patients with HV and concomitant not-symptomatic PP. From January 2014 to May 2015 a total of 12 females and 2 males (14 feet) were enrolled in the study (mean age 41.9±13.28). The inclusion criteria were patients with HV surgically treated with the percutaneous approach, mild or moderate not symptomatic PP at 24 months follow-up. Percutaneous distal metatarsal osteotomy and exostectomy is performed for all patients and followed by a weekly bandage. American Orthopaedic Foot and Ankle Society (AOFAS) score for HV (AOFAS-HV), patient satisfaction, and preoperative and postoperative X-ray at 6 weeks follow-up were evaluated. Numerical data are reported as the mean± SD and 95% confidence intervals. The pre-operative hallux valgus angle (HVA) was 30.14°±11.26°, the post-operative HVA was 18.36°±10.13 with a mean correction of 11.79°±2.67° with p<0.0001. Mean AOFAS-HV increased from 42.07±10.82 pre-operatively to 83±8.96 post-operatively with p<0.0001. One out of 14 patients had recurrence of HV without needing revision surgery at the last follow-up. All patients were satisfied with the clinical outcomes. Our results suggested that percutaneous osteotomy with the mini-burr is an effective treatment for patients with HV despite PP presence, even if the mean functional score was slightly worse when compared with the literature.

Does the minimally invasive complete plantar fasciotomy result in deformity of the Plantar arch? A prospective study

BACKGROUND

Complete plantar fasciotomy has been associated with changes in foot loading, leading to medial longitudinal arch collapse. The purpose of this study is to analyse our clinical experience with percutaneous complete plantar fasciotomy and quantify the possible changes in foot loading measured by the calcaneal pitch angle.

METHODS

A prospective case series study with patients operated between 2005-2012 was conducted, where AOFAS, Maryland Foot Score (MFS), VAS and radiological calcaneal pitch (CP) were recorded. Postoperative data were collected, where the surgeon evaluated the presence of complications, and an independent investigator performed radiological and scale evaluations follow-up: AOFAS, MFS, VAS and Benton-Weil questionnaire.

RESULTS

A total of 60 patients, 62 feet, with a mean follow-up of 57 months (range 13-107) were studied. The MFS increased a mean of 21 points (p=.001), the AOFAS score a mean of 25 points (p=.001), and the VAS decreased a mean of 8.89 points (p=.001). A total of fifty-seven feet (91.9%) were pain-free at the end of follow-up. The mean CP dropped from 20.2° (range 11-34) preoperatively to 19.3° (range 11-34) at the end of follow-up (p=.05). In 25 feet (40.3%) there were no changes in the calcaneus pitch angle, in 21 feet dropped 1° (33.9%), in 11 dropped 2° (17.8%), 3 feet 3° (4.8%) and 2 feet (3.2%) 4°. Postoperative complications were noted in 4 feet (6.4%), with lateral column pain. The surgery meets the expectations of all patients.

CONCLUSIONS

Percutaneous total fascia release is safe and does not produce a significant drop in arch height based on the radiological finding. Lack of success after surgery may be explained by other pathologies that might appear like plantar fasciitis. Further studies with gait analysis after total plantar fascia release in patients are needed.

Evolution of Minimally Invasive Surgery in Hallux Valgus

Minimally invasive (MIS) or percutaneous surgery has evolved rapidly through the development of novel techniques with precise description, correct indications, and the incorporation of modifications of safe and effective techniques described in open surgery. The correct term to describe these procedures should be percutaneous and MIS should be reserved for procedures between percutaneous and open surgery (eg, osteosynthesis). According to results, third-generation techniques are useful, effective, and easier than open procedures. It seems that MIS surgery has an extensive learning curve, and therefore it may be difficult to duplicate the results shown on already-published data.

Percutaneous surgery of the forefoot compared with open technique - Functional results, complications and patient satisfaction

BACKGROUND

The use of percutaneous surgery is currently very common in foot and ankle surgery. The following prospective open-label patient-preference based study compares the traditional open technique versus the percutaneous surgery technique.

METHODS

The current study describes the results of 287 patients operated due to forefoot deformities either by open surgery or percutaneously. 96 of them underwent hallux valgus corrective surgery. The rest had lesser toe deformities. They were followed for a period of up to 24 months, to assess the surgery related pain, complications, and patient satisfaction. 112 patients were operated using a conventional open technique were compared to 175 patients treated using a percutaneous technique. Technique choice was left to the patient preference, though older patients with disturbed blood flow, were advised to undergo percutaneous surgery.

RESULTS

There is less pain using the percutaneous techniques relative to the open technique during the first 6 post-operative weeks. The 6, and 24 months FAOS score is similar in both groups. Complications are rare in any of the groups, with a significantly higher ASEPSIS score in the open surgery group.

CONDCLUSIONS

Percutaneous forefoot surgery appears safe and efficacious, demonstrating equal radiographic (in a 96 strong cohort of hallux valgus patients) and clinical results at six and 24 months. Due to less post-operative pain, and less infection risk it appears that percutaneous techniques are superior to open technique in some respects of treatment and indeed the PGIC of patients was significantly higher in this group.

Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes

BACKGROUND

Many procedures and different osteotomies have been described for percutaneous hallux valgus correction. Percutaneous techniques may lead to reduced morbidity, surgery, and recovery time. The aim of this study is to evaluate the clinical and radiographic outcome of a new percutaneous procedure (PBS-Percutaneous Bianchi System).

METHODS

Fifty-eight cases were treated with Percutaneous Bianchi System procedure for correction of mild, moderate or severe hallux valgus deformity. All patients were clinically assessed preoperatively and then followed up by weight-bearing x-rays, AOFAS (American Orthopedic Foot and Ankle Score), VAS (Visual Analog Scale) pain score, and patient satisfaction.

RESULTS

AOFAS scores improved from 28.6 at the preoperative assessment to 91.7 at the latest follow-up. The VAS pain score improved from 6.7 before surgery to 0.6 at the latest follow-up. The mean Hallux valgus angle (HVA), Intermetatarsal angle (IMA) and Distal metatarsal articular angle (DMAA) significatively decreased from the preoperative assessment to the latest follow-up.

CONCLUSIONS

The PBS technique is a safe, reliable, and effective procedure for the correction of symptomatic mild-to-severe hallux valgus.

Minimally invasive distal first metatarsal osteotomy can be an option for recurrent hallux valgus

BACKGROUND

Recurrence rate of surgical treatment of hallux valgus ranges in the literature from 2.7% to 16%, regardless of used procedure. In this study, long-term results of a minimally invasive distal osteotomy of the first metatarsal bone for treatment of recurrent hallux valgus are described.

METHODS

32 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 26 patients for treatment of recurrent hallux valgus. Primary surgery had been soft tissue procedures in 8 cases (25%), first metatarsal or phalangeal osteotomies in 19 cases (59.4%) and Keller procedures in 5 cases (15.6%).

RESULTS

Patients were assessed with a mean follow-up of 9.8±4.3 years. All patients reported the disappearance or reduction of the pain. The mean overall AOFAS score improved from 46.9±17.8 points to 85.2±14.9 at final follow-up. The mean hallux valgus angle decreased from 26.1±9.1 to 9.7±5.4°, the intermetatarsal angle decreased from 11.5±4.5 to 6.7±4.0°. No major complications were recorded with a re-recurrence rate of 3.1% (1 case).

CONCLUSIONS

Percutaneous distal osteotomy of the first metatarsal can be a reliable and safe surgical option in the recurrent hallux valgus with low complication rate and the advantages of a minimally invasive surgery.

LEVELS OF EVIDENCE

IV, Retrospective Case Series.

Percutaneous, Intra-articular, Chevron Osteotomy (PeICO) for the Treatment of Hallux Valgus: A Cadaveric Study

BACKGROUND

Percutaneous surgery is experiencing sustained growth based on third-generation techniques. This cadaveric study was designed with the main goal of exploring the risk of iatrogenic tendon and neurovascular lesions and defining the safe zones in a percutaneous, intra-articular, chevron osteotomy (PeICO) procedure, as well as assessing the accuracy of the osteotomy itself.

METHODS

Eight feet from below-knee fresh-frozen specimens were selected. After the procedure, the specimens were dissected, and structures were inspected for damage.

RESULTS

The results of the safety measurements were as follows: (1) distance between portal 1 (P1) and the lateral border of the extensor hallucis longus (EHL) tendon: average 17.6 mm (range 12.7-21.3); (2) distance between P1 and the dorsomedial digital nerve (DMDN): average 7.2 mm (range 1.6-10.4); (3) distance between P1 and the metatarsophalangeal joint: average 15.7 mm (range 9.4-20.5); distance between portal 2 (P2), or the osteosynthesis portal, and the metatarsophalangeal joint: average 25.5 mm (range 22-30.4); distance between P2 and the lateral border of the EHL tendon: average 12.7 mm (range 8-16.7); and distance between P2 and the DMDN: average 4.1 mm (range 1.7-8.2). There were no iatrogenic injuries. The osteotomy angulation in the sagittal plane (reproducibility) average was 85.6 degrees.

CONCLUSION

There were no iatrogenic injuries on this cadaveric study of PeICO.

CLINICAL RELEVANCE

This study will help orthopedic surgeons understand the risks of performing percutaneous surgery by mimicking an accepted open technique (chevron).

Stiffness and Range of Motion After Minimally Invasive Chevron-Akin and Open Scarf-Akin Procedures

BACKGROUND

Stiffness after open hallux valgus surgery affects 7% to 38% of patients. Minimally invasive surgery (MIS) is thought to decrease this rate by reducing soft tissue trauma. MIS, now in its third generation, is advertised as delivering results superior to open surgery. However, no studies have reported stiffness or range of motion (ROM).

METHODS

Between January 2014 and December 2015, a total of 50 patients received open scarf-Akin surgery and 48 received minimally invasive Chevron Akin (MICA) surgery. The endpoints were American Orthopaedic Foot & Ankle Society (AOFAS) score, range of motion, visual analog scale for pain, scar length, and subjective foot value. The minimal follow-up time was 2 years.

RESULTS

Moderate stiffness occurred in 3 cases in both groups. In MICA, extension increased by 10 degrees while it remained unchanged in scarf. Both groups showed similar improvements in AOFAS score, pain, and subjective foot value. Radiographic evidence of correction was comparable, except for an increased shortening of the first metatarsal by 3 mm in MICA. The scars were smaller in MICA (1.2 cm) than in scarf (5 cm). Wound problems included delayed healing in 10% in scarf and wound infections in 4% in MICA. The rate of recurrence and other complications were comparable, except for reoperations, which were higher in MICA (27% mainly for protruding screws) than in scarf (8% mainly for stiffness). In MICA, 14% were intraoperatively converted to open surgery.

CONCLUSION

MICA showed no advantages over scarf other than a shorter scar. The observed gain in extension could be related to the increased shortening of the first metatarsal because of the size of the burr.

LEVEL OF EVIDENCE

Level II, prospective cohort (nonrandomized, comparative) study.

Two year outcomes of minimally invasive hallux valgus surgery

BACKGROUND

We report our experience with the Minimally Invasive Chevron Akin (MICA) technique for correcting hallux valgus, and evaluate its effectiveness and associated complications.

METHODS

Case series of 13 feet with mild to moderate symptomatic hallux valgus treated surgically from July 2013 to December 2014, with at least 48-months follow-up. Patients were assessed pre-operatively and post-operatively with radiographical measurements (Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA)) and clinical scores (American Orthopaedic Foot and Ankle Society (AOFAS), 36-Item Short Form Health Survery (SF-36), Visual Analog Scale (VAS)).

RESULTS

Mean HVA and IMA decreased from 30.4° and 13.9°-10.9° and 10.2° respectively (p<0.05). The mean AOFAS score improved from an average of 59.0-93.7 (p<0.05). All patients reported a VAS score of 0 post-operatively, and the 4 SF-36 domains improved significantly (p<0.05).

CONCLUSIONS

The MICA technique is a safe and effective method in the surgical correction of mild to moderate hallux valgus deformity, and continued use is justified.

Use of a percutaneous osteotomy with plate fixation in hallux valgus correction

BACKGROUND

With hundreds of operative methods described for correction of hallux valgus we can state that the ideal surgical treatment is still controversial. The Bösch technique has been used as a percutaneous way of correcting hallux valgus deformities with the use of a pin fixation. The aim of this study is to evaluate a new method of fixation by using a percutaneous locking plate.

METHODS

Between June 2013 and January 2015, 24 consecutive percutaneous subcapital osteotomies of the first metatarsal bone were performed for the treatment of painful hallux valgus deformities in 24 patients. Additional surgical procedures included DMMO's (Distal Metatarsal Minimally-Invasive Osteotomies) in 12 of the operated feet (44.44%); minor digits were corrected in 7 cases (25.9%). An Akin procedure was performed in 81% of cases and all cases underwent an adductor hallucis tenotomy. All patients were clinically assessed using the AOFAS score. Radiographic measures included the preoperative and postoperative values of the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), and the Distal Metatarsal Articular Angle (DMAA).

RESULTS

The mean correction achieved improved for AHV from 36.57±7.1 to 12.22±8.69°, for IMA from 13.8±1.59 to 7.08±2.72 and for DMAA from 13.98±7.38 to 6.07±4.99. Clinically, scores on the AOFAS scale improved from a 45.8±9.6 to 91.29±9.8. Although healing of the osteotomies was observed radiographically within 6 to 12 weeks, two cases (8.3%) exhibited delayed healing. There were no cases of nonunion. There were no superficial or deep infections or wound healing problems. Plate had to be removed in 3 cases (12.5%).

CONCLUSION

This technique modification is an acceptable procedure to correct hallux valgus in patients with a moderate level of deformity.

LEVEL 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.

Reverdin-Isham procedure for mild or moderate hallux valgus: clinical and radiographic outcomes

BACKGROUND

In the last decade, interests in minimal incision surgery have been growing. Theoretically, this kind of procedure could decrease time to recovery and rehabilitation, with a reduction in morbidity. The present study assessed clinical and radiological outcomes and complications of percutaneous surgery for mild-to-moderate hallux valgus using Reverdin-Isham and Akin osteotomies without fixation after 60 months of follow-up.

METHODS

A series of 48 patients (57 cases) with medium-to-moderate hallux valgus underwent the same percutaneous surgery, between 2003 and 2011. Data collection involved preoperative dorsal flexion, plantar flexion, M1P1, M1M2, DMAA angles, AOFAS scale score, and subjective satisfaction.

RESULTS

AOFAS scale score rose from a preoperative median of 55.9-89.2/100 postoperatively (p < 0.001); 51 surgical procedures (89.5%) were considered as satisfactory or very satisfactory by patients at the end of follow-up. Hallux valgus and distal metatarsal articular angle (DMAA) were significantly reduced (29.3° and 14.1°-15.4° and 7.7°, p < 0.001, respectively). There was a significant increase in MTPJ 1 stiffness (p < 0.001).

DISCUSSION

Percutaneous correction by Reverdin-Isham and Akin osteotomies seems to be effective in isolated medium-to-moderate hallux valgus. Stiffness observed is comparable to other percutaneous and open procedures but needs to be compared in a randomized controlled clinical trial to extra-articular percutaneous procedures without capsule detachment in association with an internal fixation which allows an early mobilization.

LEVEL OF CLINICAL EVIDENCE

IV.

Percutaneous Osteotomies in Hallux Valgus: A Systematic Review

Percutaneous and minimally invasive surgery is one of the greatest advances in the operating field of orthopedic since the late 1990s. The potential advantages include a shorter operative time, quicker recovery, and reduced hospital stay compared with traditional open surgery. However, scientific validation of the safety and efficacy of hallux valgus (HV) percutaneous surgery remains inconclusive. The objective of the present study was to systematically review the published data and clinical evidence for percutaneous HV surgery, evaluate the scientific method of the reports, and clarify the indications, safety, efficacy, and potential risks of these surgical techniques. Two reviewers independently identified the studies using a PubMed search, with the keywords "hallux valgus," "osteotomy," "minimally invasive," and "percutaneous." Quality assessment was performed using the Coleman methodology scale, and each study was assigned a level of evidence and grade of recommendation. Eighteen studies were included and reported a total of 1534 procedures for percutaneous HV surgery on 1397 patients. Of the 18 studies, 14 (77.8%) were level IV, 2 (11.1%) were level III, and 2 (11.1%) were level II. Overall, the average angle correction of the HV deformity improved postoperatively. Regarding the complications, although some investigators revealed no major complications, others described deformity recurrence in 7.8%, stiffness of the first metatarsophalangeal joint in 9.8%, malunion in 4% to 8.7%, and infection rates ranging from 1.9% to 14.3%. The main indication for percutaneous HV surgery is the correction of mild deformities. The complication rate was elevated even in experienced surgeons. In conclusion, future research in percutaneous techniques should include adequately sized randomized control trials, standardization of treatment protocols, and the use of validated tools for the measurement of clinical outcomes.

Percutaneous treatment of hallux valgus: What's the evidence? A systematic review

Hallux and first MTP joint have a fundamental role in the transfer of the weight-bearing load during the normal ambulation. The aim of this paper is to review and analyze the available literature about the percutaneous surgical management of the hallux valgus to highlight its strengths and weakness, also comparing with other minimal invasive techniques. A systematic search of PubMed and Google Scholar databases has been performed, covering the period between 1981 and 2016. Various combinations of the keyword terms "PDO," "hallux valgus," "bunion," "percutaneous," "surgery," "non-invasive," "minimal invasive," "burr," "osteotomy," "distal," "linear," "saw" have been used.Four papers, published from 2005 to 2015, fulfilled the inclusion criteria. A total of 464 hallux valgus has been treated with a properly percutaneous distal first metatarsal osteotomy. Mean AOFAS score, retrieved from the 4 studies included in our review, has been recorded. There are different aspects that the foot and ankle non-experienced surgeon has to consider about percutaneous surgery: limitation of the tools, radioexposure, lack of direct visual control of the osteotomy and higher costs and patient risk due to surgical time.

Minimally invasive and percutaneous surgery of the forefoot current techniques in 2018

Minimally invasive and percutaneous techniques used to repair deformities of the forefoot have considerably developed recently. Like standard osteotomies, these techniques must take advantage of the mechanical advances made in the restoration of the foot's architecture. Instead of an endpoint, these techniques represent an additional tool implemented towards a rapid functional, post-operative recovery. This review describes the power of this surgery, details its techniques and lists its indications. We also report our own experience and review the recent literature.

Increasing the safety of minimally invasive hallux surgery-An anatomical study introducing the clock method

BACKGROUND

The purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures.

METHODS

Ten fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section RESULTS: The DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5-45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5-40).

CONCLUSIONS

Using the clock method the DMDN and DLDN were found consistently between 10 o'clock and 2 o'clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery.

Percutaneous Hallux Valgus Surgery Without Distal Metatarsal Articular Angle Correction

BACKGROUND

Many factors are considered predictors of recurrence after hallux valgus (HV) surgery, including preoperative distal metatarsal articular angle (DMAA). The restoration of the bone and joint alignment would be more important than realigning the cartilaginous surface of the metatarsal head. Therefore, is DMAA correction essential for a good clinical and radiological results after HV surgery? This study aims to illustrate the results of percutaneous forefoot surgery (PFS) for correction of HV deformity without DMAA correction.

MATERIAL AND METHODS

A prospective single-center study of 74 patients (89 feet), with mild-to-moderate hallux valgus deformity, who underwent PFS. The mean latest follow-up was 57.3 months.

RESULTS

Preoperative median visual analog scale was 7 points and AOFAS scores were 52 points. At the mean latest follow up both scores improved to 0 points and 90 points, respectively. Median HV angle and intermetatarsal angle changed from 30° and 12° preoperatively, to 21° and 11° at mean latest follow-up. Overall, 80% of the patients were satisfied or very satisfied. Recurrence of medial first metatarsal head pain occurred in 12 cases (13.5%).

CONCLUSIONS

PFS, without DMAA correction, is a valid procedure for surgical correction in patients with HV, despite the slightly worse radiographic results in our study.

LEVELS OF EVIDENCE

Level II: Prospective study.

Percutaneous forefoot surgery for treatment of hallux valgus deformity: an intermediate prospective study

BACKGROUND

This study aims to illustrate the results of percutaneous forefoot surgery (PFS) for correction of hallux valgus.

MATERIALS AND METHODS

A prospective study of 108 patients, with hallux valgus deformity, who underwent PFS was conducted. The minimum clinical and radiological follow-up was two years (mean 57.3 months, range 22-112).

RESULTS

Preoperative mean visual analog scale was 6.3 ± 1.5 points, and AOFAS scores were 50.6 ± 11 points. At the last follow-up, both scores improved to 1.9 ± 2.4 points and 85.9 ± 1.83 points, respectively. Mean hallux valgus angle changed from 34.3° ± 9.3° preoperatively to 22.5° ± 11.1° at follow-up. At follow-up, 76.5% of the subjects were satisfied or very satisfied. Recurrence of medial 1st MT head pain happened in 22 cases (16.7%).

CONCLUSIONS

PFS, in our study, does not improve the radiological and patient satisfaction rate results compared with conventional procedures. The main advantage is a low postoperative pain level, but with an insufficient HVA correction.

LEVEL OF EVIDENCE

II, prospective study.