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Geng X, Teng Z, Chen L, Zhang C, Huang J, Wang X, Ma X. A Joy-Stick Assistant Three-Dimensional Modified Technique of Minimally Invasive Surgery for Mild or Moderate Hallux Valgus. Orthop Surg 2024. [PMID: 38616159 DOI: 10.1111/os.14056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/16/2024] Open
Abstract
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.
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Affiliation(s)
- Xiang Geng
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Zhaolin Teng
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Li Chen
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Chao Zhang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Jiazhang Huang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Xu Wang
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
| | - Xin Ma
- Department of Orthopedic Surgery, Huashan Hospital, Fudan University, No. 12 Wulumuqi Middle Road, Shanghai, 200040, China
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Marciano G, Ashinsky BG, Mysore N, Vulcano E. Fracturing the Lateral Hinge Improves Radiographic Alignment and Does Not Affect Clinical Outcomes of the Minimally Invasive Akin Osteotomy. Foot Ankle Int 2024; 45:52-59. [PMID: 38047491 DOI: 10.1177/10711007231209765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
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.
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Affiliation(s)
- Gerard Marciano
- Columbia University Medical Center/New York-Presbyterian Hospital, Department of Orthopedic Surgery, New York, NY, USA
| | - Beth G Ashinsky
- Columbia University Medical Center/New York-Presbyterian Hospital, Department of Orthopedic Surgery, New York, NY, USA
| | - Nishad Mysore
- Nova Southeastern University, College of Medicine, Fort Lauderdale, FL, USA
| | - Ettore Vulcano
- Mount Sinai Medical Center/Columbia University, Miami, FL, USA
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Baumann AN, Walley KC, Anastasio AT, Gong DC, Talusan PG. Learning curve associated with minimally invasive surgery for hallux valgus: A systematic review. Foot Ankle Surg 2023; 29:560-565. [PMID: 37524619 DOI: 10.1016/j.fas.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
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.
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Affiliation(s)
- Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kempland C Walley
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI, USA.
| | | | - Davin C Gong
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul G Talusan
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI, USA
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Liu JP, Yao XC, Xu ZY, Du XR, Zhao H. Learning curve of tibial cortex transverse transport: a cumulative sum analysis. J Orthop Surg Res 2023; 18:650. [PMID: 37658426 PMCID: PMC10474655 DOI: 10.1186/s13018-023-04149-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023] Open
Abstract
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.
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Affiliation(s)
- Jun-Peng Liu
- Department of Orthopaedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xing-Chen Yao
- Department of Orthopaedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Zi-Yu Xu
- Department of Orthopaedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xin-Ru Du
- Department of Orthopaedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Hui Zhao
- Department of Orthopaedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
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Alimy AR, Polzer H, Ocokoljic A, Ray R, Lewis TL, Rolvien T, Waizy H. 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. Clin Orthop Relat Res 2023; 481:1143-1155. [PMID: 36332131 PMCID: PMC10194698 DOI: 10.1097/corr.0000000000002471] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Assil-Ramin Alimy
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, University Hospital, LMU Munich, Germany
| | - Ana Ocokoljic
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robbie Ray
- King’s Foot and Ankle Unit, King’s College Hospital National Health Service Foundation Trust, London, UK
| | - Thomas L. Lewis
- King’s Foot and Ankle Unit, King’s College Hospital National Health Service Foundation Trust, London, UK
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Tan CY, Thevendran G. Perspectives and trends for minimally invasive surgery for hallux valgus deformity in the Asia Pacific region. J Orthop Surg (Hong Kong) 2023; 31:10225536231180332. [PMID: 37458528 DOI: 10.1177/10225536231180332] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
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.
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