The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus

The Learning Curve in Hallux Valgus Surgery

For any surgical technique, the learning curve is the number of times a particular procedure must be undertaken in order to complete it repeatedly with high accuracy and proficiency. Scientifically, a difficult task to master is represented by a flat learning curve, as the steep portion of the learning curve would correlate with rapid learning. Today, there's more literature on the learning curve of percutaneous HV surgery than on any other procedure in foot and ankle surgery. Due to the lack of conclusive research on traditional HV techniques, no comparison to modern percutaneous techniques is possible. The current literature suggests that it takes between 30-40 cases to gain sufficient proficiency in 3rd generation percutaneous hallux valgus correction.

Sesamoid correction achieved during the learning curve for Scarf-Akin osteotomy without lateral soft-tissue release: a single-centre prospective observational study

INTRODUCTION

Scarf-Akin osteotomy (with or without lateral soft-tissue release (LSTR)) is commonly performed to treat hallux valgus (HV). An insufficient correction of sesamoids can be a risk factor for early recurrence of the condition. We set out to determine 1) the radiographic correction achieved after Scarf-Akin osteotomy performed without LSTR and 2) the degree of correction of sesamoids obtained during the learning curve of the technique.

MATERIALS AND METHODS

In this prospective single-centre study, the first 25 feet (25 patients, mean age 55.2 years, 14 left) undergone Scarf-Akin osteotomy without LSTR by a single foot and ankle orthopaedic consultant in his first year of activity were enrolled and followed-up at 1-year. On weightbearing standard pre-operative and 1-year follow-up radiographs two independent observers (senior residents) assessed and compared the hallux valgus angle (HVA), 1st and 2nd intermetatarsal Angle (IMA), distal metatarsal articular angle (DMAA) and tibial sesamoid position (SP, according to the Hardy and Clapham system). The inter and intraobserver reliability of measurements along with the correlation between the improvement achieved in different parameters and the number of cases performed were tested. Intra and post-operative complications were compared between the early (first 12) and late learning periods.

RESULTS

The inter and intraobserver agreement for the radiographic parameters investigated was excellent in all cases (ICC always > 0.92). A statistically significant improvement in mean HVA (from 36 ± 9.8 to 16.3 ± 2.8 degrees), mean IMA (from 14.5 ± 2.3 to 9.9 ± 1.5 degrees), mean DMAA (from 19.4 ± 4.4 to 11.4 ± 1.9 degrees) and median SP (from 4 (IQR, 3-6) to 2 (IQR, 1-2) points) was demonstrated in the cohort (p < 0.001 in all cases). There was a strong positive significant correlation between the progression of cases over time and the improvement achieved in terms of SP (R = 0.60, p = 0.003). Conversely, no significant correlation was demonstrated when comparing the improvement obtained in HVA, IMA and DMAA with the number of cases performed (p > 0.05 in all cases). One complication occurred during the first 12 cases (1 transfer metatarsalgia) and 1 during the last 13 (1 intra-operative fracture).

CONCLUSION

In this series, a satisfactory correction of HV after Scarf-Akin osteotomy was obtained without releasing lateral soft-tissues. Beginner surgeons should be aware that restoring sesamoid position may be more challenging as compared to correcting other angles during the first cases.

LEVEL OF EVIDENCE

Level IV, prospective case series.

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.

Short-term results of minimally invasive surgery using a 3D-printed guide for the treatment of hallux valgus

INTRODUCTION

Minimally invasive surgery (MIS) is often used to treat hallux valgus deformities, as it is associated with few wound complications and shorter recovery times. Minimally invasive chevron osteotomy and Akin osteotomy (MICA) is a common minimally invasive treatment for HV. However, effective correction of hallux valgus and precise screw placement during MIS are difficult. The aim of this study was to introduce and evaluate the clinical and radiographic effectiveness of a novel MIS technique involving the use of a 3D-printed guide for hallux valgus.

MATERIALS AND METHODS

We retrospectively studied the results of MIS with a 3D-printed guide plate for symptomatic hallux valgus from May 2022 to December 2023. The preoperative and postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal pronation angle (M1PA), tibial sesamoid position (TSP), forefoot width, visual analogue scale (VAS) score, AOFAS Hallux MTP-IP score, and the number of intraoperative fluoroscopy were measured.

RESULTS

A total of 22 feet in 19 patients were included in the study. There were 15 women and 4 men with an average age of 38.0 y (range 16-61). The preoperative HVA, IMA, DMAA and M1PA were 30.3 ± 10.7°, 13.9 ± 2.8°, 8.3 ± 2.9° and 16.3 ± 6.5°, respectively. The postoperative HVA, IMA, DMAA and M1PA were 10.7 ± 4.1°, 5.7 ± 1.8°, 2.3 ± 1.7° and 3.5 ± 2.1°, respectively. The forefoot width decreased from 92.1 ± 5.5 mm to 85.6 ± 5.4 mm on average. The VAS and TSP ranged from 4.4 ± 0.9 and 4.9 ± 0.8 to 0.3 ± 0.6 and 2.0 ± 1.1, respectively. The AOFAS Hallux MTP-IP scores improved from 59.1 ± 10.7 to 94.8 ± 5.7 on average. The average number of fluoroscopy shots during operation were 34 times (range 30 to 38).

CONCLUSIONS

A 3D printed guide technique can be beneficial for precise positioning of the first metatarsal head, enhancing the accuracy of screw placement, and reducing radiation exposure.

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.

Research progress in the etiology and minimally invasive therapy of hallux valgus

Hallux valgus (HV) is the most common foot deformity. It has various pathogenic factors that make its pathogenesis challenging to understand. As the disease progresses, patients experience amplified pain and decreased activities, significantly affecting their quality of life. At present, clinics offer several conservative and surgical treatments that must be selected based on patient condition and disease progression. Surgical treatment is frequently the only method available to patients with HV to delay disease progression and correct the deformity after conservative treatment fails. In recent years, minimally invasive surgical treatments have gained significant attention and developed rapidly due to their well-known advantages, such as safety, efficiency, and quick recovery time. The number of literature that provides a systematic review of the subject must be increased. This review tracks recent advancements, summarizing the etiological mechanism, epidemiology, diagnosis, and treatment of HV. In addition, it emphasizes typical surgical therapies and focuses on the progress of minimally invasive treatment from the first generation to the current fourth generation. This review will serve as a systematic basis for the clinical treatment of HV and provide a reference material for future research.

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.

Third generation versus fourth generation percutaneous hallux valgus correction: A radiographic analysis of outcomes

Percutaneous hallux valgus correction is gaining popularity with foot and ankle surgeons. Various studies have found that the percutaneous approach has increased patient satisfaction and outcomes. The technique of the procedure has some variability with the geometry of the distal osteotomy being the most scrutinized. As of this publication, there has been no comparative studies on the geometry of the distal metatarsal osteotomy. This is a retrospective study of 50 patients who underwent percutaneous correction of a hallux valgus deformity with either a percutaneous transverse or modified chevron osteotomy. The two groups were compared radiographically, preoperatively, and postoperatively using both the intermetatarsal and hallux valgus angles. There is no difference in radiographic outcomes when comparing pre and post-operative IM and HAV angles, and it is the surgeon's comfort levels with a particular geometry of the osteotomy that should determine the approach.

The Unfamiliar Complications of Minimally Invasive Foot Surgery

Over the last 5 years, minimally invasive surgery (MIS) has seen a significant surge, propelled by advancements in surgical equipment, implants, methodologies, and comprehensive education. The introduction of specialized hardware and advanced bone-cutting burrs has contributed to a reduction in complications. Evidence from peer-reviewed studies suggests that the outcomes of MIS are often on par with, and at times surpass, those of traditional surgical methods. In the context of MIS, certain complications are specifically linked to the use of burrs and hardware, the types of deformities being addressed, and the tools utilized. This article aims to discuss these complications associated with MIS.

Percutaneous calcaneal sliding osteotomy with the rising sun technique

BACKGROUND

Calcaneal slide osteotomies represent a well-established component in the surgical treatment of joint-preserving hind foot corrections. The percutaneous technique aims to minimize the surgical morbidity and maximize surgical efficiency. There is a consensus that percutaneous calcaneal sliding osteotomy (PCSO), using a low-speed and hightorque burr, is generally performed in four steps corresponding to the four quadrants of the cross-section of the calcaneal tuber. We present a technique that allows a more efficient osteotomy by cutting the far cortex in one step using standard percutaneous equipment. The aim of this study is to present preliminary results and the surgical technique of a modification for percutaneous calcaneal sliding osteotomy.

MATERIALS AND METHODS

Between June 2016 and March 2023, a total of 101 percutaneous calcaneal slide osteotomies were performed using the Rising Sun Technique. Prospective clinical and radiologic evaluation was completed for 70/101 cases (69.3%). Complications were classified according to the modified Clavien-Dindo-Sink Classification (CDS I-III). For the last 25 cases, additional information on surgery duration and use of fluoroscopy was available. The results of two surgeons (S1, S2) with different MIS experiences were compared to determine surgical proficiency.

RESULTS

The mean follow-up was 36 months (range 12-73 months). In 46 cases the underlying deformity was a planovalgus and in 24 a cavovarus deformity. In total, there were 5/70 (7.1%) surgery-related complications, three cases needed revision surgery: 2 patients required superficial surgical wound revision for disturbed wound healing, 1 patient requested screw removal due to discomfort related to the hardware after 15 months. The mean surgery duration for both surgeons combined was 19.6 min, and the average number of fluoroscopies was 20.2.

CONCLUSIONS

Compared to traditional open calcaneal slide osteotomies, PCSO helps to reduce softtissue morbidity and may result in fewer surgery-related complications. The Rising Sun procedure of PCSO represents a safe and easy-to-perform alternative to the traditional 4-quadrants technique in the percutaneous correction of hindfoot malalignment. Our prospective case series showed a low rate of complications and reproducible surgery time and use of fluoroscopy.

Evaluating the learning curve of Minimally Invasive Chevron and Akin Osteotomy for correction of hallux valgus deformity: a systematic review

BACKGROUND

One procedure that has gained popularity in the surgical management of hallux valgus is the minimally invasive Chevron and Akin osteotomy (MICA). The purpose of this systematic review was to evaluate the learning curve associated with this technically demanding procedure.

METHODS

A search of the EMBASE and PubMed databases was performed to identify all clinical studies that assessed the learning curve associated with the MICA procedure. Studies where patients were not diagnosed with hallux valgus, did not undergo MICA, or did not report data on operation time, fluoroscopy exposure, or complications were excluded. A risk of bias assessment was conducted to assess the validity of the studies.

RESULTS

The initial literature search yielded 287 studies, and seven studies were included in the final analysis. A quantitative comparative analysis could not be performed as the included studies used different statistical methods to quantify the learning curve. Lewis et al. determined that after 38 operations, there was a decrease in operation time and fluoroscopy exposure (p < .001). Merc et al. found that it took 29 and 30 operations to reach a plateau for operation time and fluoroscopy exposure, respectively (p < .001). Palmanovich et al. found that it took 20 and 26 operations to reach a plateau for operation time and fluoroscopy exposure, respectively (p < .001). Toepfer and Strässle found there was a significant decrease in operation time and fluoroscopy exposure after the first 19 procedures in their series (p < .001). With respect to complications, one study found a significant difference after the 42nd operation (p = .007). However, the remaining studies found that complication rates did not significantly change with increased technical proficiency. All seven studies were deemed to have a moderate risk of bias.

CONCLUSIONS

Surgeons can expect a learning curve of 20 to 40 operations before reaching technical proficiency with the MICA procedure. After the learning curve is achieved, surgeons can expect to see a significant decrease in both operation times and fluoroscopy exposure. No consistent significant difference was found in complications as one becomes more technically proficient with the procedure.

A Novel Simulation Model and Training Program for Minimally Invasive Surgery of Hallux Valgus

BACKGROUND

Minimally invasive surgery (MIS) for hallux valgus (HV) has gained popularity. However, adopting this technique faces the challenges of a pronounced learning curve. This study aimed to address these challenges by developing and validating an innovative simulation model and training program, targeting enhanced proficiency in HV MIS.

METHODS

A training program and a high-fidelity simulation model for HV MIS were designed based on experts' recommendations. Four foot and ankle surgeons without experience in MIS formed the novice group and took the program that encompassed six-session instructional lessons, hands-on practice on simulated models, and immediate feedback. The program concluded with a cadaveric surgery. Four foot and ankle experienced MIS surgeons formed the expert group and underwent the same procedure with one simulated model. Participants underwent blind assessment, including Objective Structured Assessment of Technical Skills (OSATS), surgical time, and radiograph usage.

RESULTS

Expert evaluation of the simulation model indicated high satisfaction with anatomical representation, handling properties, and utility as a training tool. The expert group consistently outperformed novices at the initial assessment across all outcomes, demonstrating OSATS scores of 24 points (range, 23 to 25) versus 15.5 (range, 12 to 17), median surgical time of 22.75 minutes (range, 12 to 27) versus 48.75 minutes (range, 38 to 60), and median radiograph usage of 70 (range, 53 to 102) versus 232.5 (range, 112 to 280).

DISCUSSION

Novices exhibited a significant improvement in OSATS scores from the fifth session onward (P = 0.01), reaching the desired performance of 20 points. Performance at the final training with the simulated model did not differ from cadaveric surgery outcomes for all parameters.

CONCLUSION

This study validated a simulation model and training program, allowing nonexperienced HV MIS foot and ankle surgeons to enhance their surgical proficiency and effectively complete a substantial portion of the learning curve at the fifth session, and this performance was successfully transferred to a cadaver model.

LEVEL OF EVIDENCE

III.

The surgical learning curve for percutaneous Zadek osteotomy for treatment of insertional achilles tendinopathy

INTRODUCTION

The Zadek Osteotomy has been described as an effective technique for the treatment of insertional Achilles tendinopathy. Recently, this strategy has been modified using minimally invasive techniques. A learning curve has been observed in many minimally invasive procedures in foot and ankle surgery. This retrospective study first intended to evaluate if there is a learning curve associated with the percutaneous Zadek Osteotomy. Further, if a learning curve was observed, we planned to assess the data for associated changes in complications and postoperative outcomes.

METHODS

A retrospective analysis of 98 patients who underwent percutaneous Zadek Osteotomy was performed. Patient charts were reviewed for operative times, complications, union rates, and Foot Function Index (FFI) and Visual Analogue Scale (VAS) scores. Analysis of variance was utilized to assess for differences between groups of cases.

RESULTS

Patients included 61 females and 37 males. Mean age was 51.28 ± 11.12 (range 28-81) years. Mean follow-up time was 42.07 ± 12.99 (range 24-65) months. Significant increases in operative times were observed in cases 1-14 when compared to cases 15-98 (p < 0.001). Improvements in FFI and VAS scores were observed at final follow-up within each case group (p < 0.001); there were no differences detected in FFI or VAS scores between groups of cases. There was no difference detected in number of complications between intervals of cases.

CONCLUSION

A learning curve was observed for the percutaneous Zadek Osteotomy, which was overcome around case 14. This learning curve was only observed in terms of procedure length. A surgeon's level of inexperience with the technique does not appear to affect functional outcomes, nonunion, or need for revision.

LEVEL OF EVIDENCE IV

Data will not be deposited in a repository.

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.

Fracturing the Lateral Hinge Improves Radiographic Alignment and Does Not Affect Clinical Outcomes of the Minimally Invasive Akin Osteotomy

BACKGROUND

Intraoperative fracture of the lateral cortex is common during Akin osteotomy. In a recent study, lateral cortex fracture did not impede healing or result in loss of correction in a combined cohort of open and percutaneous osteotomies stabilized by K-wire fixation. We hypothesize that undesired lateral cortex fracture will not affect radiographic correction and patient-reported outcomes in a percutaneous cohort stabilized by permanent, rigid screw fixation.

METHODS

Consecutive patients with hallux valgus who underwent first metatarsal osteotomy and percutaneous Akin osteotomy stabilized by permanent, rigid screw fixation between May 2020 and January 2022 were retrospectively reviewed. Patients were stratified based on fractured lateral cortex (FC) or its absence (nonfractured cortex [NFC]). Visual analog scale (VAS) and Foot Function Index (FFI) were used to assess pain and patient-reported outcomes at 1-year follow-up. Patients were polled for satisfaction at 1-year follow-up by yes/no survey.

RESULTS

Ninety-eight patients (89% female) were reviewed (98 feet; 43 NFC, 55 FC). Mean age was 48.3 years (range, 18-83 years). Mean preoperative VAS score was 7.5 and 7.7 in NFC and FC groups, which significantly decreased to 0.6 (P < .01) and 0.6 (P < .01), respectively. Mean total FFI was 53.9 and 54.2 and decreased to 17.9 (P < .01) and 17.2 (P < .01) in the NFC group and FC group, respectively. Overall, 97.8% of the NFC group and 96.4% of the FC group reported satisfaction.Mean HVA improved from 27.2 (16-42) degrees to 10.7 degrees (4-12) postoperatively in the NFC group. And in the FC group, HVA improved from 29.3 (19-39) degrees to 7.1 (4-12) degrees postoperatively. Postoperative HVA was significantly lower in the FC group (P < .05).

CONCLUSION

In an exclusively percutaneous surgical cohort with correction maintained by rigid screw fixation, fracture of the lateral cortex is associated with improved postoperative radiologic alignment without detriment to patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, retrospective 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.

Learning curve of tibial cortex transverse transport: a cumulative sum analysis

OBJECTIVE

This study aimed to describe the learning curve of surgeons performing tibial cortex transverse transport (TTT) and explore its safety and effectiveness during the initial stages of surgeon's learning.

METHODS

The clinical data of patients with diabetic foot ulcers classified as Wagner grade ≥ 2, who underwent TTT at our hospital from January 2020 to July 2021, were included in this retrospective analysis. The same physician performed all procedures. Patients were numbered according to the chronological order of their surgery dates. The cumulative sum and piecewise linear regression were used to evaluate the surgeon's learning curve, identify the cut-off point, and divide the patients into learning and mastery groups. A minimum follow-up period of 3 months was ensured for all patients. Baseline data, perioperative parameters, complications, and efficacy evaluation indicators were recorded and compared between the two groups.

RESULTS

Sixty patients were included in this study based on the inclusion and exclusion criteria. After completing 20 TTT surgeries, the surgeon reached the cut-off point of the learning curve. Compared to the learning group, the mastery group demonstrated a significant reduction in the average duration of the surgical procedure (34.88 min vs. 54.20 min, P < 0.05) along with a notable decrease in intraoperative fluoroscopy (9.75 times vs. 16.9 times, P < 0.05) frequency, while no significant difference was found regarding intraoperative blood loss (P = 0.318). Of the patients, seven (11.7%) experienced complications, with three (15%) and four cases (10%) occurring during the learning phase and the mastery phase, respectively. The postoperative ulcer area was significantly reduced, and the overall healing rate was 94.8%. Significant improvements were observed in postoperative VAS, ABI, and WIFI classification (P < 0.05). There were no significant differences in the occurrence of complications or efficacy indicators between the learning and mastery groups (P > 0.05).

CONCLUSION

Surgeons can master TTT after completing approximately 20 procedures. TTT is easy, secure, and highly efficient for treating foot ulcers. Furthermore, TTT's application by surgeons can achieve almost consistent clinical outcomes in the initial implementation stages, comparable to the mastery phase.

Does Minimally Invasive Surgery Provide Better Clinical or Radiographic Outcomes Than Open Surgery in the Treatment of Hallux Valgus Deformity? A Systematic Review and Meta-analysis

BACKGROUND

Hallux valgus is the most common foot deformity and affects 23% to 35% of the general population. More than 150 different techniques have been described for surgical correction. Recently, there has been increasing interest in the use of minimally invasive surgery to correct hallux valgus deformities. A variety of studies have been published with differing outcomes regarding minimally invasive surgery. However, most studies lack sufficient power and are small, making it difficult to draw adequate conclusions. A meta-analysis can therefore be helpful to evaluate and compare minimally invasive and open surgery.

QUESTIONS/PURPOSES

We performed a systematic review and meta-analysis of randomized controlled trials and prospective controlled studies to answer the following question: Compared with open surgery, does minimally invasive surgery for hallux valgus result in (1) improved American Orthopaedic Foot and Ankle Society (AOFAS) scores and VAS scores for pain, (2) improved radiologic outcomes, (3) fewer complications, or (4) a shorter duration of surgery?

METHODS

The systematic review and meta-analysis was conducted according to the guidelines of the Cochrane Handbook for Systematic Reviews of Intervention and the Preferred Reporting Items for Systematic Reviews and Meta-analyses. A search was performed in the PubMed, Embase, Scopus, CINAHL, and CENTRAL databases on May 3, 2022. Studies were eligible if they were randomized controlled or prospective controlled studies that compared minimally invasive surgery and open surgery to treat patients with hallux valgus. We defined minimally invasive surgery as surgery performed through the smallest incision required to perform the procedure accurately, with an incision length of approximately 2 cm at maximum. Open surgery, on the other hand, involves a larger incision and direct visualization of deeper structures. Seven studies (395 feet), consisting of six randomized controlled studies and one prospective comparative study, were included in the qualitative and quantitative data synthesis. There were no differences between the minimally invasive and open surgery groups regarding age, gender, or severity of hallux valgus deformity. Each included study was assessed for the risk of bias using the second version of the Cochrane tool for assessing the risk of bias in randomized trials or by using the Newcastle-Ottawa Scale for comparative studies. Most of the included studies had intermediate quality regarding the risk of bias. We excluded one study from our analysis because of its high risk of bias to avoid serious distortions in the meta-analysis. We performed a sensitivity analysis to confirm that our meta-analysis was robust by including only studies with a low risk of bias. The analyzed endpoints included the AOFAS score (range 0 to 100), where higher scores represent less pain and better function; the minimum clinically important difference on this scale was 29 points. In addition, the VAS score was analyzed, which is based on a pain rating scale (range 0 to 10), with higher scores representing greater pain. Radiologic outcomes included the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle. Complications were qualitatively assessed and evaluated for differences. A random-effects model was used if substantial heterogeneity (I 2 > 50%) was found; otherwise, a fixed-effects model was used.

RESULTS

We found no clinically important difference between minimally invasive and open surgery in terms of the AOFAS score (88 ± 7 versus 85 ± 8, respectively; mean difference 4 points [95% CI 1 to 6]; p < 0.01). There were no differences between the minimally invasive and open surgery groups in terms of VAS scores (0 ± 0 versus 0 ± 1, respectively; standardized mean difference 0 points [95% CI -1 to 0]; p = 0.08). There were no differences between the minimally invasive and open surgery groups in terms of the hallux valgus angle (12° ± 4° versus 12° ± 4°; mean difference 0 points [95% CI -2 to 2]; p = 0.76). Radiographic measurements of the intermetatarsal angle did not differ between the minimally invasive and open surgery groups (7° ± 2° versus 7° ± 2°; mean difference 0 points [95% CI -1 to 1]; p = 0.69). In addition, there were no differences between the minimally invasive and open surgery groups in terms of the distal metatarsal articular angle (7° ± 4° versus 8° ± 4°; mean difference -1 point [95% CI -4 to 2]; p = 0.28). The qualitative analysis revealed no difference in the frequency or severity of complications between the minimally invasive and the open surgery groups. The minimally invasive and open surgery groups did not differ in terms of the duration of surgery (28 ± 8 minutes versus 40 ± 10 minutes; mean difference -12 minutes [95% CI -25 to 1]; p = 0.06).

CONCLUSION

This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery. Methodologic shortcomings of the source studies in this meta-analysis likely inflated the apparent benefits of minimally invasive surgery, such that in reality it may be inferior to the traditional approach. Given the associated learning curves-during which patients may be harmed by surgeons who are gaining familiarity with a new technique-we are unable to recommend the minimally invasive approach over traditional approaches, in light of the absence of any clinically important benefits identified in this meta-analysis. Future research should ensure studies are methodologically robust using validated clinical and radiologic parameters, as well as patient-reported outcome measures, to assess the long-term outcomes of minimally invasive surgery.

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.