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

Eligibility for knee arthroplasty is associated with increased risk of acquired hallux valgus - a Mendelian randomized study

OBJECTIVE

Clinically, it has been found that patients undergoing knee replacement have a high incidence of concomitant hallux valgus. In this study, we analyzed whether patients with osteoarthritis who underwent surgery and those patient who did not have surgery had an increased risk of hallux valgus by Mendelian randomization and performed reverse causal analysis.

DESIGN

Genomewide association study (GWAS) data for osteoarthritis, categorized by knee arthritis with joint replacement, knee arthritis without joint replacement, hip arthritis with joint replacement, and hip arthritis without joint replacement.And acquired hallux valgus were downloaded for Mendelian randomized studies. MR analysis was performed using inverse variance-weighted (IVW), weighted median, and MR-Egger methods. MR-egger regression, MR pleiotropic residuals and outliers (MR-presso), and Cochran's Q statistical methods were used to evaluate heterogeneity and pleiotropy.

RESULTS

The IVW results indicate that, compared to healthy individuals, patients who meet the criteria for knee osteoarthritis joint replacement surgery have a significantly higher risk of acquired hallux valgus. There were no significant causal relationships found for the remaining results. No significant heterogeneity or multiplicity was observed in all the Mr analyses.

CONCLUSION

Our study supports the increased risk of acquired hallux valgus in patients eligible for knee replacement. There is necessary for clinicians to be concerned about the hallux valgus status of patients undergoing knee arthroplasty.

Comparative effects of modified rotary scarf osteotomy and traditional scarf osteotomy in treating moderate to severe hallux valgus: a retrospective cohort study

BACKGROUND

Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of TSO, Modified Rotary Scarf osteotomy (MRSO) was introduced in this study, which aimed to compare the clinical and radiological outcome in the patients treated with MRSO or TSO.

METHODS

Of 175 patients (247 feet) with MSHV, 100 patients (138 feet) treated with MRSO and 75 patients (109 feet) treated with TSO were evaluated according to relevant indicators in twenty-four months follow-up. Pre-surgical and post-surgical HVA, IMA, DMAA, MTP-1 ROM, sesamoid grade and AOFAS (American Orthopaedic Foot and Ankle Society) scores and postsurgical complications were evaluated.

RESULTS

Both groups manifested similar baseline characters. The mean follow-up was of 25.9 (range, 22-37) months. Significantly lower IMA, lower Sesamoid grade and higher DMAA at six months, twelve months and twenty-four months post-surgically had been showed in MRSO group compared to TSO group. There was no significant difference in HVA, MTP-1 ROM and AOFAS data at each follow-up time point post-surgically between the two groups. No major complications occurred in either group.

CONCLUSION

MRSO showed comparable results to TSO, and improved IMA and sesamoid grade to a greater extent, with a lower probability of throughing effect. Although DMAA could be increased by MRSO, MRSO could still be a reproducible, non-dangerous and efficacious alternative procedure for treating HV patients which do not have severe DMAA.

Biomechanical Comparison between Rotational Scarf Osteotomy and Translational Scarf Osteotomy: A Finite Element Analysis

OBJECTIVE

Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis.

METHODS

The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three-point bending test.

RESULTS

Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three-point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm).

CONCLUSION

Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus.

A Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity

Various modifications of distal chevron metatarsal osteotomy (DCMO) have been introduced for correcting moderate hallux valgus deformity; however, the amount of correction may be limited, and complications, such as the recurrence of the deformity and avascular necrosis of the metatarsal head, have been a problem. This study aimed to present a modified 90-degree DCMO technique that overcomes the previously reported shortcomings and to report a successful short-term radiographic outcome. Sixty-eight consecutive patients who underwent the operation with our modified DCMO technique and twenty-two consecutive patients with the conventional DCMO technique (control group) were retrospectively analyzed. The radiographic measurements were evaluated preoperatively, at two months post operation, and at the final follow-up. Both groups showed a significant correction of the hallux valgus angle, first-second intermetatarsal angle, distal metatarsal articular angle, and sesamoid position at the final follow-up, while the amount of correction was significantly greater in the modified DCMO group. In both groups, there were no cases of complications such as avascular necrosis of the metatarsal head, nonunion, and surgical site infection appearing throughout the follow-up period. Therefore, the modified 90-degree DCMO technique is effective and safe, which could serve as a favorable option to treat moderate hallux valgus deformity.

Medial Reduction in Sesamoid Position after Hallux Valgus Correction Surgery Showed Better Outcome in S.E.R.I. Osteotomy than DCMO

BACKGROUND

The purpose of the present study was to compare the degree of sesamoid reduction after hallux valgus correction between distal chevron metatarsal osteotomy (DCMO) and S.E.R.I. (simple, effective, rapid, and inexpensive) osteotomy, and to analyze the effects on the recurrence of hallux valgus.

METHODS

We retrospectively analyzed the foot radiographs of 60 feet (30 DCMO and 30 SERI) treated for hallux valgus from August 2013 to July 2017. Radiographic assessments were performed preoperatively, at early follow-up (at a mean of 3.1 months) and at the most recent follow-up (at a mean of 16.7 months). The location of the medial sesamoid was classified into seven stages, in accordance with the method described by Hardy and Clapham; stage IV or less was defined as the normal position for the medial sesamoid, and stage V or greater was defined as lateral displacement of the sesamoid. The pre- and post-operative hallux valgus angle, 1-2 intermetatarsal angle, and sesamoid position were compared between the two groups.

RESULTS

The mean follow-up period was 18.4 (12-36) months in the DCMO group and 15.0 (12-36) months in the S.E.R.I. group (p = 0.108). The radiologic results showed that the hallux valgus angles were not significantly different between the two groups preoperatively and at the early follow-up: preoperatively, they were 28.8 ± 7.7 in the DCMO group and 32.6 ± 9.5 in the S.E.R.I. group (p = 0.101), and they were 10.4 ± 4.0 and 8.7 ± 5.0 (p = 0.148) at the early follow-up, respectively. However, at the most recent follow-up, the DCMO group (13.9 ± 5.6) showed significantly higher hallux valgus angles than the S.E.R.I. group (10.4 ± 6.4, p = 0.030), and there were no differences between the recurrence of hallux valgus in the DCMO group (13%)and that in the S.E.R.I. group (10%) (p = 0.553). There were no significant differences in the 1-2 intermetatarsal angles between the two groups at the early follow-up (6.1 ± 2.5 vs. 4.8 ± 3.1, p = 0.082) and at the most recent follow-up (7.3 ± 2.9 vs. 6.6 ± 3.5, p = 0.408). After hallux-valgus-correction surgery, the stage change of the tibia sesamoid position from the preoperative stage to the initial follow-up was significantly larger in the S.E.R.I. group (-4.4 ± 1.4) than in the DCMO group (-3.4 ± 1.1) (p = 0.003); the changes from the preoperative stage to the last follow-up were also significantly larger in the SERI group (-3.3 ± 1.7) than in the DCMO group (-2.4 ± 1.5) (p = 0.028); however, the changes from the initial follow-up to the last follow-up showed no significant differences between the two groups (+1.0 ± 1.1 in the DCMO group vs. +1.1 ± 1.2 in the S.E.R.I. group) (p = 0.822). The medial sesamoid was laterally subluxated in all the preoperative cases in the DCMO and S.E.R.I. groups. The lateral subluxation of the tibia sesamoid was more frequently observed in the DCMO group (four cases, 13%) than in the S.E.R.I. group (0 cases, 0%) (p = 0.038) at the early follow-up.

CONCLUSION

In conclusion, our results demonstrated that the S.E.R.I. procedure is superior to DCMO in decreasing the hallux valgus angle and showed that the early post-operative reduction in the sesamoids can be a risk factor for the recurrence of hallux valgus.

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

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

Effects of Foot-Toe Orthoses on Moment and Range of Motion of Knee Joint in Individuals with Hallux Valgus

Although various types of hallux valgus (HV) orthoses have been used to manage hallux valgus deformity, few previous studies have determined the biomechanical effects of applying a foot-toe orthosis as a therapeutic intervention for HV deformity on the kinetics and kinematics of the knee joint. Biomechanical variables were collected from 24 patients with HV. A three-dimensional motion capture system and force platforms were used to analyze the kinetic and kinematic variables in HV orthosis conditions during gait. To determine the biomechanical effect of each orthosis for HV on knee kinetic and kinematic values, repeated-measures ANOVA was used. The knee adduction moment was significantly decreased under a hard plastic orthosis (HPO) condition compared to that under a without foot-toe orthosis (WTO) condition (p = 0.004). There was a significant decrease in maximal external rotation of the knee joint in HPO than in WTO at the stance phase during gait (p = 0.021). All of the kinetic and kinematic data showed no significant differences between WTO and soft silicone orthosis conditions (p > 0.05). This study indicates that a stronger foot-toe orthosis, such as HPO, to correct HV deformity has a positive effect on the moment and joint motion occurring in the knee joint during walking. In particular, the application of this type of HV orthosis can reduce knee adduction moments associated with the development and progression of knee OA.

Correlations of Sesamoid Bone Subluxation with the Radiologic Measures of Hallux Valgus and Its Clinical Implications

Background and Objectives: Hallux valgus is one of the most common chronic foot complaints, with prevalences of over 23% in adults and up to 35.7% in older adults. However, the prevalence is only 3.5% in adolescents. The pathological causes and pathophysiology of hallux valgus are well-known in various studies and reports. A change in the position of the sesamoid bone under the metatarsal bone of the first toe is known to be the cause of the initial pathophysiology. Purpose: The relationships between the changes in the location of the sesamoid bone and each radiologically measured angle and joint congruency in the hallux valgus remain as yet unknown. Therefore, this study investigated the relationships of sesamoid bone subluxation with the hallux valgus angle, intermetatarsal angle, and metatarsophalangeal joint congruency in hallux valgus patients. The goal is to know the hallux valgus angle, the intermetatarsal angle, and metatarsophalangeal joint congruency's correlation with hallux valgus severity and prognosis by revealing the relationship between each measured value and sesamoid bone subluxation. Materials and Methods: We reviewed 205 hallux valgus patients who underwent radiographic evaluation and subsequent hallux valgus correction surgery in our orthopedic clinic between March 2015 and February 2020. Sesamoid subluxation was assessed using a new five-grade scale on foot radiographs, and other radiologic measurements were assessed, such as hallux valgus angle, the intermetatarsal angle, distal metatarsal articular angle, joint congruency, etc. Conclusions: Measurements of the hallux valgus angle, interphalangeal angle, and joint congruency exhibited high interobserver and intraobserver reliabilities in this study. They also showed correlations with sesamoid subluxation grade.

Biomechanical Investigation of Hallux Valgus Deformity Treated with Different Osteotomy Methods and Kirschner Wire Fixation Strategies Using the Finite Element Method

The aim of this study was to propose a finite element method based numerical approach for evaluating various hallux valgus treatment strategies. We developed three-dimensional hallux valgus deformity models, with different metatarsal osteotomy methods and Kirschner wire fixation strategies, under two types of standing postures. Ten Kirschner wire fixations were analyzed and compared. The fixation stability, bone stress, implant stress, and contact pressure on the osteotomy surface were calculated as the biomechanical indexes. The results showed that the biomechanical indexes of the osteotomy and Kirschner wire fixations for hallux valgus deformity could be effectively analyzed and fairly evaluated. The distal metatarsal osteotomy method provided better biomechanical indexes compared to the proximal metatarsal osteotomy method. This study proposed a finite element method based numerical approach for evaluating various osteotomy and Kirschner wire fixations for hallux valgus deformity before surgery.

Hallux Valgus Repair with Chevron Osteotomy Significantly Narrows Forefoot Width

Background: Hallux valgus (HV) is a common adult foot deformity. There is uncertainty concerning the effect of HV surgery on foot width. We examined the effect of chevron first metatarsal osteotomy on forefoot width using calibrated pre and postoperative standing radiographs. Methods: A retrospective cohort of 50 patients underwent chevron osteotomy HV surgery. All had HVA > 30°, IMA > 11°, DMMA > 3°, >6-month follow-up, and calibrated pre and postoperative standing foot radiographs. Bony width (BW) and soft tissue width (STW) were used to measure the surgery’s effect on foot width. Measurements were made preoperatively and 3–6 months following surgery. Results: The study group included 42 women with an average age of 63.4 (±8.3) and a mean BMI of 28.7 (±4.9). Preoperative HVA and IMA were 31.7° (±6.8°) and 13.4° (±2.8°), respectively. Following surgery, HVA and IMA improved significantly, by 15.6° (±5.7°) and 8.7° (±2.3°), respectively. The preoperative average BW was 9.4 cm (±0.6), and the STW was 10.6 cm (±0.7). Following surgery, significant changes in BW and STW were measured, with a mean narrowing of 1.2 cm (±0.4) in BW (p < 0.001) and 0.95 cm (±0.5) in STW (p < 0.001). Paradoxically, an increase in age led to a lower correction of the IMA (p = 0.04, r = 0.57), but higher BW and STW reductions (p = 0.01, r = 0.35 and p = 0.008, r = 0.37, respectively). Conclusions: This study reinforced chevron osteotomy as a valid treatment option that significantly narrows forefoot width; it is thus expected to improve cosmetic outcomes, shoe selection options, and quality of life. This study also found that older age correlates with better forefoot narrowing following hallux valgus repair, possibly due to stiffer soft tissues.

Recurrence Rates With Longer-Term Follow-up After Hallux Valgus Surgical Treatment With Distal Metatarsal Osteotomies: A Systematic Review and Meta-analysis

BACKGROUND

Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years.

METHODS

This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years.

RESULTS

We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and "others." The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees.

CONCLUSION

At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

A cross-sectional study on reliability and quality of YouTube® videos related to hallux valgus and evaluation of newly developed hallux valgus-specific survey tool

Objective

Previous studies have reported low quality and reliability on YouTube videos about various medical issues including videos related to hallux valgus (HV) treatment. Therefore, we aimed to evaluate the reliability and quality of YouTube videos on HV and develop a new HV-specific survey tool that physicians, surgeons, and the medical industry can use to create high-quality videos.

Methods

Videos viewed over 10,000 times were included in the study. We used the Journal of the American Medical Association (JAMA) benchmark criteria, global quality score (GQS), DISCERN tool, and new HV-specific survey criteria (HVSSC) developed by us to evaluate the quality, educational utility and reliability of the videos, the popularity of which was assessed using the Video Power Index (VPI) and view ratio (VR).

Results

Fifty-two videos were included in this study. Fifteen videos (28.8%) were posted by medical companies producing surgical implants and orthopedic products, 20 (38.5%) by nonsurgical physicians, and 16 (30.8%) by surgeons. The HVSSC indicated that the quality, educational value, and reliability of only 5 (9.6%) videos were adequate. Videos posted by physicians and surgeons tended to be more popular (p = 0.047 and 0.043). Although no correlation was detected among the DISCERN, JAMA, and GQS scores, or between the VR and VPI, we found correlations of the HVSSC score with the number of views and the VR (p = 0.374 and p = 0.006, respectively). A good correlation was detected among the DISCERN, GQS, and HVSSC classifications (rho = 0.770, 0.853, and 0.831, respectively, p = 0.001).

Conclusions

The reliability of HV-related videos on YouTube is low for professionals and patients. The HVSSC can be used to evaluate the quality, educational value, and reliability of videos.

The percutaneous learning curve of 3rd generation minimally-invasive Chevron and Akin osteotomy (MICA)

BACKGROUND

Minimally-invasive Chevron and Akin osteotomy (MICA) represents the third-generation percutaneous hallux valgus surgery which is characterized by an extra-articular osteotomy, stable internal fixation and a high potential for correction. Compared to other percutaneous techniques of the foot, MICA is generally regarded as an advanced and demanding surgical procedure with a flat learning curve. The aim of this study is to analyze a single-surgeons experience with his first 50 consecutive MICA procedures.

METHODS

Between May 2018 and February 2021, 50 consecutive MICA procedures performed by the author with the "K-wires-First technique" were prospectively analyzed focusing on surgery duration, number of fluoroscopies, correction results and surgery-associated complications. A modification of the original MICA technique as described by its inaugurators Redfern and Vernois allows the use of a standard-sized C-arm and aims to reduce revison rates and conversion to open surgery by placing the guidewires prior to performing the osteotomy.

RESULTS

The average surgery time for all MICA procedures was 46.8 min (SD 12.1, range 31-90 min). The average amount of fluoro shots required to perform MICA was n = 126.6 (SD 40.8, range 65-231). Comparing the preoperative and 6-week postoperative radiographs, the IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°. One case required intraoperative conversion to open hallux correction. There were 4 feet in three patients with secondary screw removal of the Chevron fixation due to prominent proximal screw tips.

CONCLUSIONS

Although the learning curve of 3rd generation MICA is flat and requires specific training and intensive practice, the rate of complications is not elevated compared to other percutaneous hallux valgus techniques. Strict adherence to the principles of 3rd generation MICA with stable fixation and meticulous intraoperative control of each surgical step helps to reduce surgery-associated complications. The learning curve showed a continous improvement in regard to surgery time and use of fluoroscopy. After 40 procedures, the surgery time consistently dropped under 45 min and required less than 100 fluoro-shots. The modified surgical technique may help reduce Chevron screw mal-positioning when using large C-arm fluoroscopy for this procedure.

Establishment and Validation of a Predictive Nomogram for Hallux Valgus with Pain Under the Second Metatarsal

Objective

To investigate the risk factors for hallux valgus complicated with pain under the second metatarsal and construct an effective model and method for predicting hallux valgus complicated with pain under the second metatarsal based on risk factors.

Methods

A total of 545 patients with hallux valgus who were admitted to our hospital were divided randomly into a training set and a validation set. The demographic characteristics, imaging indices and gait test indices of the patients were collected. The risk factors were identified by univariate and multivariate logistic regression analyses. A risk prediction model for hallux valgus with pain under the second metatarsal was established, and the area under the curve (AUC) of the receiver operating characteristic and a decision curve analysis were used for verification and identification. The value of the model was tested in the verification group.

Results

Second metatarsal length, second metatarsal peak pressure, hallux valgus angle (HVA), intermetatarsal angle 1–2 (IMA1–2) and weight were the risk factors for hallux valgus complicated with pain under the second metatarsal. Based on the weighting of these seven risk factors, a prediction model was established. The AUC of the prediction model was 0.84 (95% confidence interval [CI]: 0.802~0.898, P < 0.05), and the results of a Hosmer–Lemeshow test showed a good degree of calibration (χ² = 10.62, P > 0.05). The internal validation of the AUC was 0.83 (95% CI: 0.737–0.885, P < 0.05). The model had obvious net benefits when the threshold probability was 10%–70%.

Conclusion

Second metatarsal length, second metatarsal peak pressure, HVA, IMA1–2 and weight were the risk factors for hallux valgus combined with second metatarsal pain. The risk prediction model for hallux valgus complicated with pain under the second metatarsal based on these seven variables was proven effective.

Level of Evidence

Level III, retrospective comparative study.

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.

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.

Comparison of outcomes of different osteotomy sites for hallux valgus: A systematic review and meta-analysis

BACKGROUND

Hallux valgus (HV) is a common foot deformity for which several corrective surgical procedures, with different osteotomy sites, have been reported. The purpose of the present study was to systematically review randomized (RCTs) or controlled (CCTs) clinical trials and perform meta-analysis on outcomes of different osteotomy sites of the first metatarsal.

METHODS

An extensive literature search was conducted in PubMed and the Cochrane Library from January 1983 to July 2020. Studies were identified using the terms "hallux valgus" and "osteotomy". We included RCTs or CCTs comparing different locations of osteotomy for the first metatarsal bone (distal vs. mid-shaft, distal vs. proximal, and mid-shaft vs. proximal). The surgical outcomes included postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, perioperative complications and recurrence of deformity. We enrolled 10 studies with a total of 793 feet in the qualitative synthesis following full-text screening.

RESULTS

A majority of patients included in the enrolled trials showed mild to moderate deformity, with mean HVA <40°. Out of the 10 enrolled studies; six compared distal osteotomies with mid-shaft osteotomies and showed no significant differences in the surgical outcomes between the scarf and chevron groups; three RCTs compared distal osteotomies with proximal osteotomies with conflicting results, one RCT showed the superiority of proximal osteotomy while the other two RCTs showed equivalent outcomes; one study that compared between mid-shaft and proximal osteotomies showed equivalent outcomes between the groups.

CONCLUSION

For the management of mild to moderate HV deformity, we found no significant clinical and radiological differences between patients treated with scarf and chevron osteotomies. Further controlled trials comparing different sites of osteotomies for moderate to severe HV deformity are needed.

The use of intramedullary devices for fixation of metatarsal osteotomies in hallux valgus surgery - A systematic review

BACKGROUND

Hallux valgus is a common foot condition with numerous surgical techniques described. Minimally invasive surgery is becoming more popular, with resultant development of suitable fixation devices. The aim of this systematic review was to evaluate the evidence on the use of intramedullary devices in hallux valgus first metatarsal corrective osteotomies, and describe clinical and radiological outcomes, with an overview of techniques and implants used.

METHODS

We searched PubMed, Medline, Embase and EMCare databases, conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Radiological outcomes including the hallux valgus angle (HVA) and intermetatarsal angle (IMA) were recorded, as well as clinical outcome scores and complications. Methodological quality of included studies was assessed using the MINORS score.

RESULTS

Ten studies were included, comprising 696 feet in 745 patients. Data pooling and metanalysis was not possible due to overall low quality of evidence. Four implants were reported (Endolog, ISO Plate, V-Tek Plate, Link Fixator) and used with distal first metatarsal osteotomies, with improvement in HVA, IMA, and clinical outcome scores comparable to other fixation techniques. There were no reported cases of non-union. Complication rates were variable (all cause range of 0-21%) across all studies, with an overall low rate.

CONCLUSION

Intramedullary devices are viable and safe to use for hallux valgus first metatarsal osteotomies, with comparable radiological and functional outcomes to other techniques. Current evidence base is of low methodological quality, therefore high quality studies are required to further evaluate these devices.

Rotation scarf + Akin osteotomy for severe hallux valgus with a new evaluation index: distance between the first and second metatarsals

BACKGROUND

Although rotation scarf + Akin osteotomy has been described for correcting hallux valgus deformity, the treatment efficacy of rotation scarf + Akin osteotomy for severe hallux valgus should be further studied. The purpose of our study was to evaluate the outcomes of rotation scarf + Akin osteotomy on severe hallux valgus.

METHODS

We conducted a retrospective study of patients with hallux valgus who underwent surgery using rotation scarf + Akin osteotomy in our hospital between June 2014 and January 2020. The parameters evaluated include (1) the hallux valgus angle (HVA), (2) intermetatarsal angle (IMA), (3) distal metatarsal articular angle (DMAA), (4) tibial sesamoid position (TSP), (5) the length of first metatarsal bone and (6) ratio between the vertical distance from the lateral of the first metatarsal head to the medial of the second metatarsal head and the vertical distance of lateral of the second metatarsal head to the medial of the third metatarsal head (MT-I to II/II to III distance). A visual analog scale (VAS) was used to evaluate the degree of pain before and at the last follow-up after the operation. The American Orthopaedic Foot & Ankle Society (AOFAS) Forefoot Score wasassessed before and at the last follow-up after the operation. Patient satisfaction assessment was also conducted at the time.

RESULTS

All radiological parameters including, HVA, IMA, DMAA and TSP,, significantly improved (p < 0.001). The length of the first metatarsal was shortened 3.1 mm on average. The MT-I to II/II to III distance was also reduced to 1.8 after surgery and 3.3 before surgery. The VAS score and AOFAS score was also statistically significant before operation and at the last follow-up after the operation (p < 0.001). Forty-one (82%) feet in patients were very satisfied or satisfied.

CONCLUSION

Rotation scarf + Akin osteotomy is demonstrated to be safe, effective, and feasible for correcting severe hallux valgus. It can obtain good long-term correction with a low incidence of recurrence and metatarsalgia. Postoperative satisfaction and functional recovery of patients are significantly improved. The MT-I to II/II to III distance, a new evaluation indicator, can be better evaluate the correction of hallux valgus.

3rd generation MICA with the "K-wires-first technique" - a step-by-step instruction and preliminary results

BACKGROUND

Minimally-invasive techniques for hallux valgus correction are becoming increasingly popular. In the last decades, multiple techniques for minimally-invasive hallux valgus correction have been described. MICA (Minimally-invasive Chevron & Akin), representing the 3rd generation of minimally-invasive hallux valgus correction, combines the advantages of an extraarticular osteotomy, stable internal fixation, and high potential for correction. This report aims to provide a step-by-step instruction of the surgical technique with the "K-wires-first" MICA modification, illustrated by detailed imaging of both intraoperative fluoroscopy and clinical imaging as well as corresponding sawbone models for each step. Preliminary results including radiological outcome and complications of the first 50 cases will be discussed.

METHODS

Between May 2018 and May 2021, 50 consecutive MICAs in 47 patients were performed with the K-wires-first technique. There were 40 women and 7 men with an average of 57.4y (range 25-78). The mean preoperative IMA was 16.2° (range 11.0-21.5), the HVA 30.6° (range 21.8-42.1).

RESULTS

There was one intraoperative conversion to an open surgical bunion correction corresponding to a 2% conversion rate respectively (1/50). On 3 feet (2 patients), removal of the Chevron screws was performed after 7, 9, and 12 months due to prominent and disturbing screw heads at the level of the medial cortex, accounting for a revision rate of 6% (3/50). There were no other secondary revision surgeries. The IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°, demonstrating MICA's high potential for correction.

CONCLUSIONS

Compared to other MICA techniques, the K-wires-first modification helps to reduce hardware malpositioning and the risk of conversion to open surgery. Furthermore, our preliminary results demonstrate a high potential for correction even for severe hallux deformities.

TRIAL REGISTRATION

Retrospectively registered, swissethics BASEC-ID 2021-01537, July 16th, 2021 ( www.raps.swissethics.ch ).

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

Background

Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups.

Methods

A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed.

Results

One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction.

Conclusions

Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up.

Trial registration

Clinical Trial NCT02886221. Registered 1 September 2016.

Normative Distribution of First Metatarsal Axial Rotation

BACKGROUND

First metatarsal (M1) axial rotation is recognized as a clinically relevant component of hallux valgus deformity. Methods to realign the M1 in 3 dimensions have been developed. One goal of these operations is to restore normal rotation of the first ray. The aim of this study is to provide estimates for the normal distribution of M1 rotation in patients without relevant anatomic pathology.

METHODS

Using stringent clinical and radiographic criteria, we evaluated a set of plain radiograph and weightbearing computed tomography (WBCT) images of 62 feet from a consecutive patient database. Subjects included had normal foot alignment without bunion symptoms. M1 rotation of each foot was measured using 2 unique methods (Saltzman et al and Kim et al methods). Measurement of rotation was performed by 2 observers from coronal WBCT images. Mean values and confidence intervals (CIs) of M1 rotation were calculated for each method. Inter- and intraobserver reliability values were also reported.

RESULTS

Mean M1 rotation values of 2.1 degrees (95% CI: 0.9-3.4) and 6.1 degrees (95% CI: 4.4-7.8) were identified using the Saltzman et al and Kim et al methods, respectively. Inter- and intraobserver reliability values were interpreted as excellent for both methods.

CONCLUSION

In this study, we describe the natural distribution of the M1 axial rotation in subjects without bunion or other identifiable bony foot deformities. This information should provide a normative reference for surgeons correcting rotational issues of the first metatarsal.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

Surgical Reconstruction of Nonunion after Iatrogenic Scarf Osteotomy

We present the case of a young patient, 32 years old, with nonunion in the diaphysis of the first metatarsal after scarf osteotomy for correction of hallux valgus. After removal of the failed osteosynthesis material and preparation of the bone fragments, a calcaneal bone autograft, previously extracted from the patient, was placed in the nonunion area. The new physiological position of the first metatarsal in the three planes was checked intraoperatively, and autograft and fragment fixation was performed using a combination of a low-profile plate with six screws and two interfragmentary screws. The advantage of using an autogenous graft is that it provides corticocancellous bone and great osteogenic capacity with little antigenic capacity. This makes it an excellent option in many situations in foot and ankle surgery. Regarding the fixation method, we used the two most commonly used techniques for osteosynthesis of bone grafts in cases of bone nonunion, combining plates with locking screws and two interfragmentary screws. This provides greater stability of the bone fragments in the three planes and makes it possible to bring forward when the patient starts postsurgical loading.