Clinical effectiveness and safety of Weil's osteotomy and distal metatarsal mini-invasive osteotomy (DMMO) in the treatment of metatarsalgia: A systematic review

Weil's osteotomy versus distal metatarsal metaphyseal osteotomy for the treatment of metatarsalgia. A metaanalysis of outcome and complications

BACKGROUND

Weil's osteotomy (WO) and distal metatarsal metaphyseal osteotomy (DMMO) are considered to be the gold standard of managing metatarsalgia. Stiffness and floating toe are the main disadvantages of the WO, whereas delayed union or malunion and prolonged swelling are the main complications of the DMMO. The purpose of this study is to compare these two methods, in terms of outcome and complications, through a metaanalysis of the literature.

MATERIALS AND METHODS

Pubmed, Google Scholar and Mendeley databases were searched for studies comparing directly the outcome of DMMO and Weil's osteotomy, with a minimum follow up of six months. The random effects model was used for the metaanalysis. The quality of studies was assessed using the MINORS criteria.

RESULTS

Four studies were eligible for the analysis including 211 patients in total. The mean difference of the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and the visual analogue scale (VAS) among the two techniques was - 1,04 (C.I.: -3,50 - 1,43) and - 0,39 (CI: -0,83 - 0,08) respectively. The risk difference regarding postoperative stiffness, swelling and residual metatarsalgia was - 0,09 (95% C.I.: -0,23 - 0,06), - 0,17 (95% C.I.: -0,62 - 0,29) and - 0,06 (95% C.I.: -0,20 - 0,08) respectively.

CONCLUSION

Based on the existing literature, Weil's osteotomy and DMMO are equally safe and effective for the treatment of metatarsalgia. More studies of better quality are required, in order to extract safer and absolute conclusions regarding this topic.

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

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

Radiographic Evidence of Sufficient Transverse Plane Alignment after Weil Osteotomy without Screw Fixation

Weil osteotomy is a proven procedure to restore the harmonic distal parabola of the forefoot. In addition to the proximal displacement of the head in the sagittal plane, a displacement in the transverse plane may be necessary, with the refixation of the displaced metatarsal head historically performed by screw fixation. We aimed to determine the radiological differences among 136 feet of 127 patients with 256 Weil osteotomies retrospectively enrolled and divided into groups with (n = 182) and without (n = 74) screw fixation. Demographic data, radiographic union, pre- and postoperative metatarsal angles, and differences in the dorsoplantar view were evaluated. The mean follow-up period was 3.6 months. The mean preoperative metatarsophalangeal angle was 9.24°, and the mean postoperative angle was 12.99°. The restoration of the transversal alignment plane was equally successful in both groups, with a mean extent of angle correction of 10.58°. No nonunions of the osteotomized metatarsals were observed. The radiographic comparisons revealed no significant difference between the groups (p > 0.05). However, visibility of the joint space of the metatarsophalangeal joint was achieved significantly more often in the group without screw fixation (p < 0.05). In the absence of bony malunion and the satisfactory restoration of a harmonious parabola of the forefoot, apparently there does not appear to be a necessity for regular screw fixation after Weil osteotomy based on the available data from the present study.

Percutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness

BACKGROUND AND HYPOTHESIS

Although percutaneous hallux valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies.

PATIENTS AND METHODS

Twenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to this neurovascular structures, tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified.

RESULTS

The medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3mm (SD 1.4) and 2.4mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet.

CONCLUSIONS

The structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid lesions to neurovascular and tendinous structures.

LEVEL OF EVIDENCE

V, Cadaveric study.

Percutaneus intermetatarsal ligament release and minimally invasive distal metatarsal osteotomy for treatment second intermetatarsal space syndrome

BACKGROUND AND OBJECTIVE

Since the description of the syndrome of the second intermetatarsal space, this is a common diagnosis among foot and ankle surgeons. However, no series have been published that consider this syndrome as its own entity. The objective of this study is to evaluate the clinical and radiological results of the release of the intermetatarsal ligament and minimally invasive distal metatarsal osteotomy in patients diagnosed with second space syndrome.

MATERIALS AND METHODS

An observational, longitudinal, retrospective study was carried out in patients with a clinical diagnosis of second space syndrome operated on using a minimally invasive technique. For the clinical results, the visual analog scale (VAS) for subjective pain, the Manchester-Oxford Foot Questionnaire (MOXFQ) and the scale for minor metatarsals and interphalangeals of the American Orthopedic Foot and Ankle Society (AOFAS-LMTS) were used for clinical-functional assessment. Consolidation or not of osteotomies was recorded and complications were recorded.

RESULTS

Twenty-nine feet in 29 patients were included in the study. After a mean follow-up of 39 months (25-50), clinically and statistically significant improvement was obtained in the scores: pain VAS, scales and subscales of the MOXFQ and the AOFAS-LMTS (p < 0.0001). All osteotomies healed at the end of follow-up and no major complications were recorded.

CONCLUSIONS

Percutaneous or minimally invasive surgery, in patients with second intermetatarsal space syndrome, obtains good clinical, functional and subjective results, with few complications. Therefore, we consider it an effective, safe and recommended technique in the hands of experienced surgeons.

Risks of injury in distal metatarsal minimally invasive osteotomy when comparing standard and modified techniques: A cadaveric study

BACKGROUND

The objectives of the study were to evaluate the structures at risk in distal metatarsal mini-invasive osteotomy (DMMO) and to compare standard and intraosseous approaches.

METHODS

DMMO was performed on the second and fourth metatarsals of 11 fresh-frozen cadaveric specimens. The standard technique was performed in 11 metatarsals. It was then compared to a modified intraosseous technique that entails starting inside the bone in 11 other metatarsals. The cadavers were dissected to identify unintentional injury to soft tissue structures.

RESULTS

In the standard group the most injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group injured the EDL (27%), not the MJC (0%) and the EDB (0%). Distances between osteotomies and the dorsal metatarsal head articular surface (DMHAS) were 6.08 ± 3.99 mm in the standard and 9.92 ± 3.42 mm in the modified (p = 0.02).

CONCLUSION

The DMMO techniques most frequently injured the EDL. Intra-articular positioning of the osteotomy was more observed in the standard. Overall, it appears the modified method could be an alternative to the standard DMMO.

CLINICAL RELEVANCE

The modified minimally invasive DMMO has a comparable rate of potential iatrogenic injuries. This intraosseous procedure may present as an option when planning surgery to the lesser metatarsals.

LEVEL OF EVIDENCE

Level III. Comparative Cadaveric Study.

Midterm Outcomes of Sliding Distal Metatarsal Minimally Invasive Osteotomy to Treat Bunionette Deformity

BACKGROUND

Bunionette deformity is described as a painful bony prominence on the lateral aspect of the fifth metatarsal head. The present study prospectively assessed the clinical, functional, and radiographic outcomes of sliding distal metatarsal minimally invasive osteotomy (S-DMMO) used in a large series of patients with a midterm follow-up period.

METHODS

From December 2015 to December 2018, we evaluated 74 feet (57 patients). Radiologic (4-to-5 intermetatarsal angle, fifth metatarsophalangeal angle, the fifth metatarsal head width, lateral deviation angle, fifth metatarsal length, medial displacement, and elevation), clinician-reported scores (AOFAS score, visual analog scale [VAS]) and patient-reported outcomes measure (Foot and Ankle Ability Measure [FAAM] activities of daily living [ADL], FAAM sports, Manchester-Oxford Foot Questionnaire [MOXFQ], and patient satisfaction survey) were included in the analysis. The time to bone union was also assessed.

RESULTS

The average 4-to-5 intermetatarsal angle improved from 11.1 degrees preoperatively to 4.5 degrees postoperatively (P < .001), whereas the average fifth metatarsophalangeal angle improved from 15.7 degrees preoperatively to 4.8 degrees postoperatively (P < .001). The lateral deviation angle was found to be 2.2 degrees. The fifth metatarsal length decreased from 66.6 to 64.3 mm postoperatively. The average initial medial displacement was 4.67 mm preoperatively and 4.54 mm at final follow-up. The elevation of the fifth metatarsal head was 1.08 mm. The American Orthopaedic Foot & Ankle Society score improved from 54.3 ± 20.86 points preoperatively to 93.4 ± 17.3 (P < .001). VAS score decreased from 7.9 to 0.7 (P < .001). Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (P < .001) between preoperative and postoperative periods. Patients found the procedure excellent in 89.1% of cases, very good in 5.4%, and good in 5.4%. Bone union was obtained at 8.1 weeks.

CONCLUSION

The most important finding of the present study is that S-DMMO showed improvement in function and pain associated with a high satisfaction rate. Also, we found substantial capacity to correct deformities and a low incidence of complications.

LEVEL OF EVIDENCE

Level IV, case series.

Ultrasound-guided distal minimally invasive metatarsal osteotomies (US-DMMO): A cadaveric study about its safety and accuracy

BACKGROUND

Distal minimally invasive metatarsal osteotomies have become increasingly popular. This technique requires fluoroscopic control, but recently, an ultrasound-guided procedure has been described. The aim of this anatomical study was to assess the quality safety of ultrasound-guided minimally invasive metatarsal osteotomies.

METHODS

Ultrasound-guided distal minimally invasive metatarsal osteotomies were performed in 9 cadaveric pieces. The location of the osteotomy, its angulation, and the adjacent anatomical structures injuries was evaluated RESULTS: Thirty-six osteotomies were performed. The osteotomy was metaphyseal in 97.2% of the cases, the average angulation was 47.67° (±4.49, 40-59°) and the average distance to the articular cartilage was 3.22 mm (±1.27, 1-7 mm). One osteotomy (2.8%) was intraarticular and there was one joint capsule lesion (2.8%). The failure, the extreme point distance and angulation values, and the joint capsule injury correspond to a fifth metatarsal.

CONCLUSIONS

The ultrasound-guided technique is safe and allows a correct location and angulation of the osteotomies.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Influence of Foot Type on the Clinical Outcome of Minimally Invasive Surgery for Metatarsalgia. A Prospective Pilot Study

Background and aims: Surgical procedures for central metatarsalgia seek to harmonise the metatarsal parabola with osteotomies that can be performed by minimally invasive techniques. However, the possible relationship of the foot type and the mid-term postoperative outcome is poorly described. The objective of this prospective pilot study was therefore to determine whether the foot type (pronate, neutral, or supinate) conditions the postoperative mid-term functional outcome.

Methods: A series of 28 patients (6 men, 22 women) were treated for primary central metatarsalgia by means of minimally invasive distal metaphyseal osteotomy (DMMO).

Results: Their functional outcomes at 6 and 12 months were assessed by the self-reporting AOFAS scale. Pre-surgery, the patients' scores were 42.82 ± 15.60. Scores improved at 6 months to 86.50 ± 8.6 and to 92.93 ± 8.6 at 12 months (p < 0.001 in both cases). There were no differences either by sex or by foot type in these overall values, although there was only a slight limitation of interphalangeal mobility in the supinated feet (p = 0.03) at 6-month follow-up as compared to other foot types.

Conclusion: Hence, DMMO provides an optimal clinical and functional outcome for the surgical treatment of metatarsalgia, regardless of the patient's foot posture. The occurrence of adverse events was minimal and clinically irrelevant.

Trial registration: The study was authorised by the Research Ethics Committee of the Universidad Católica de Valencia San Vicente Mártir, with the registry UCV/2018-2019/019.

Shortening effect influence of Distal Minimally Invasive Metatarsal Osteotomy in primary metatarsalgia

PURPOSE

In primary metatarsalgia, Distal Minimally invasive Metatarsal Osteotomy (DMMO) achieves a correct load distribution which is a factor in pain relief, but contrary to the elevation of the metatarsal head, shortening the metatarsal length has no influence on plantar-loading parameters, while the increased metatarsal length is a factor in the development of metatarsalgia. Thus, we hypothesized that metatarsalgia could be partly related to a functional imbalance between bone structure and soft tissues and pain relief after DMMO results from soft tissue relaxation.

METHODS

Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension. To test our hypothesis, we measured intra-operatively the MTPJ pressure of 19 patients suffering from primary metatarsalgia, before and after DMMO. This pressure is being analyzed as a reflection of joint decompression and forefoot soft tissue release. Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension.

RESULTS

Lower metatarsals presenting metatarsalgia show a significantly lower MTPJ pressure compared to asymptomatic rays, and DMMO induces a significant increase of MTPJ pressure.

CONCLUSION

Those variations reflect the functional imbalance between bone structure and soft tissue in primary metatarsalgia. The biomechanical rationale of the shortening effect of DMMO could therefore be explained by the release of forefoot soft tissue, which could take part in the pain relief by restoring this balance.

The metatarsaus adductus effect by the syndesmosis procedure for hallux valgus correction

Aims

The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

Methods

We reviewed clinical records of a single surgical practice from its entire 2014 calendar year. In total, 71 patients (121 surgical feet) qualified for the study with a mean follow-up of 20.3 months (SD 6.2). We measured their metatarsus adductus angle with the Sgarlato’s method (SMAA), and the intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA) with Hardy’s mid axial method. We also assessed their American Orthopaedic Foot & Ankle Society (AOFAS) clinical scale score, and photographic and pedobarographic images for clinical function results.

Results

SMAA increased from preoperative 15.9° (SD 4.9°) to 17.2° (5.0°) (p < 0.001). IMA and MPA corrected from 14.6° (SD 3.3°) and 31.9° (SD 8.0°) to 7.2° (SD 2.2°) and 18.8° (SD 6.4°) (p < 0.001), respectively. AOFAS score improved from 66.8 (SD 12.0) to 96.1 (SD 8.0) points (p < 0.001). Overall, 98% (119/121) of feet with preoperative plantar calluses had them disappeared or noticeably subsided, and 93% (113/121) of feet demonstrated pedobarographic medialization of forefoot force in walking. We reported all complications.

Conclusion

This study, for the first time, reported the previously unknown metatarsus adductus side-effect of the syndesmosis procedure. However, it did not compromise function restoration of the forefoot by evidence of our patients' plantar callus and pedobarographic findings.

Level of Clinical Evidence: III

Cite this article: Bone Jt Open 2021;2(3):174–180.

Lateralising DMMO (MIS) for simultaneous correction of a pes adductus during surgical treatment of a hallux valgus

The surgical correction of a hallux valgus deformity presenting with a pes adductus has long proven to be a difficult undertaking. The medial shift of the metatarsal bones limits the scope for surgical correction and leads to inherently high reoccurrence rates. Current invasive treatments often give rise to profound soft tissue trauma and prolonged swelling, while requiring strict relief from weight-bearing in the affected foot. In this paper, it is aimed to introduce an easy and useful modification of the Distal Metatarsal Minimal-invasive Osteotomy (DMMO) to perform the effective, simultaneous correction of a pes adductus during surgical treatment of a hallux valgus. We followed-up 143 patients with a hallux valgus and simultaneous pes adductus deformity who underwent one of three additional interventions contemporaneous to the lateralising DMMO: The assessment of radiological and clinical outcomes after a follow-up period of 12-25 months showed a sustained and effective correction of the pes adductus with a well-aligned hallux. The surgery was characterised by a low incidence of postoperative complications and high patient satisfaction while allowing for pain-adapted, post-operative weight-bearing. Level of Clinical Evidence: 3.

The Role of Lesser Metatarsophalangeal Joint Arthrodesis for Revision Surgery

Revision hammertoe surgery can be extremely challenging for the foot and ankle surgeon given the scar tissue and available osseous and soft tissue. Although not a common procedure, lesser metatarsophalangeal joint arthrodesis is an option for the patient especially in lieu of an amputation. This article describes the current literature and the surgical technique for a lesser metatarsophalangeal joint arthrodesis.