Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus

Comparative analysis between Reverdin-Isham Osteotomy (RIO) and minimally invasive intramedullary nail device (MIIND) in association with AKIN osteotomy for Hallux valgus correction

BACKGROUND

Hallux valgus (HV) is a widespread condition that leads to discomfort in daily life. There are different surgical techniques for HV. This retrospective and comparative study aimed to compare the clinical and radiographic outcomes of the Reverdin-Isham osteotomy (RIO) and the Minimally Invasive Intramedullary Nail Device (MIIND) surgical techniques.

METHODS

One hundred ninety-six patients with mild-to-severe HV were enrolled and divided into two groups: 98 patients with mild-moderate HV and 98 with moderate-severe HV, treated with the RIO and MIIND techniques, respectively. Radiographic and clinical evaluations were assessed preoperatively at 3, 12 and 60 months after surgery. Radiologically, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), Distal Metatarsal Articular Angle (DMAA) and Tibial Sesamoid Position (TSP) were evaluated. Clinically, the AOFAS hallux metatarsophalangeal-interphalangeal scale and the Numeric Rating Scale (NRS-11) for pain were assessed. A propensity score matching (PSM) model was implemented to compare the two techniques.

RESULTS

In the RIO group, the mean HVA correction from preoperative value to 60 months of follow-up was 8.69° (p < 0.0001), the mean IMA correction was 2.42° (p < 0.0001), and the mean DMAA correction was 0.09°. In the MIIND group, the mean HVA correction was 24.92° (p < 0.0001), the mean IMA correction was 8.75° (p < 0.0001), and the mean DMAA correction was 6.28° (p < 0.0001). The mean AOFAS score improved over time, and NRS-11 decreased in both groups. After PSM model application, the variables that impacted the allocation to RIO or MIIND techniques were age, preoperative HVA values and HV severity.

CONCLUSION

Our study demonstrates the efficacy of RIO for mild-moderate HV and MIIND for moderate-severe HV. Radiographic and clinical outcomes improved in both groups, but older patients with higher HVA and severe HV should be treated with the MIIND technique to achieve satisfactory outcomes.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Comparative biomechanical study of different screw fixation methods for minimally invasive hallux valgus surgery: A finite element analysis

BACKGROUND

There are different screw configurations utilised for minimally invasive hallux valgus (HV) deformity despite limited biomechanical data assessing the stability and strength of each construct. We aimed to compare the strength of various screw configurations for minimally invasive HV surgery using finite element analysis (FEA).

METHODS

A FEA model was developed from a CT of a female with moderate HV deformity. Five screw configurations utilizing one or two bicortical or intramedullary screws were tested. Stress analysis considered osteotomy displacement, maximum and minimum principal stresses, and von Mises stress for both implants and bone for each screw configuration.

RESULTS

Fixation with two screws (one bicortical and one intramedullary) demonstrated the lowest values for osteotomy displacement, minimum and maximum total stress, and equivalent von Mises stress on the bone and screws in both loading conditions.

CONCLUSION

The optimal configuration when performing minimally invasive surgery for moderate HV is one bicortical and one intramedullary screw.

LEVEL OF EVIDENCE

Level III.

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

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

Current concepts of fourth-generation minimally invasive and open hallux valgus surgery

Hallux valgus (HV) presents as a common forefoot deformity that causes problems with pain, mobility, footwear, and quality of life. The most common open correction used in the UK is the Scarf and Akin osteotomy, which has good clinical and radiological outcomes and high levels of patient satisfaction when used to treat a varying degrees of deformity. However, there are concerns regarding recurrence rates and long-term outcomes. Minimally invasive or percutaneous surgery (MIS) has gained popularity, offering the potential for similar clinical and radiological outcomes with reduced postoperative pain and smaller scars. Despite this, MIS techniques vary widely, hindering comparison and standardization. This review evaluates the evidence for both open Scarf and Akin osteotomy and newer-generation MIS techniques. Fourth-generation MIS emphasizes multiplanar rotational deformity correction through stable fixation. While MIS techniques show promise, their evidence mainly comprises single-surgeon case series. Comparative studies between open and MIS techniques suggest similar clinical and radiological outcomes, although MIS may offer advantages in scar length and less early postoperative pain. MIS may afford superior correction in severe deformity and lower recurrence rates due to correcting the bony deformity rather than soft-tissue correction. Recurrence remains a challenge in HV surgery, necessitating long-term follow-up and standardized outcome measures for assessment. Any comparison between the techniques requires comparative studies. Surgeons must weigh the advantages and risks of both open and MIS approaches in collaboration with patients to determine the most suitable treatment.

Where Minimal Incision Surgery Can Have Maximum Results with Charcot Reconstruction

Minimally invasive surgery (MIS) continues to develop as a viable alternative to traditional open surgery for various foot and ankle pathologies. The neuropathic foot is one area where MIS can be very beneficial to surgeons and their patients. Improving wound healing and decreasing the surgical footprint and thus reducing complications associated with soft tissue in this population is advantageous. Further research is necessary; however, the early successful outcomes in neuroarthropathy reconstruction via MIS are encouraging.

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

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

Results of Modified Minimally Invasive Hallux Valgus Surgery, Factors for the First Metatarsal Shortening, and Patients' Satisfaction

Background: Hallux valgus is a prevalent foot deformity conventionally treated with open surgical techniques, which carry risk of complications due to extensive soft tissue dissection. Minimally invasive surgeries (MISs) as alternatives offer comparable outcomes, reduced pain, and faster recovery; however, their challenges include the risk of shortening of the first metatarsal. This study aimed to assess the efficacy of our modified MIS hallux valgus correction technique and investigate the factors that affect first metatarsal shortening. Methods: Twenty-nine feet treated with modified MIS hallux valgus surgery between 2017 and 2022 were included with an average follow-up of 29 months. Clinical outcomes were evaluated with the Manchester-Oxford Foot Questionnaire (MOXFQ), Foot Function Index (FFI), and visual analog scale for pain. Radiographic evaluations included the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), first metatarsal length, and sesamoid grade. Results: Functional and radiographic outcomes were significantly improved (p < 0.0001 and p < 0.001, respectively). Significant correlations between patient satisfaction and the MOXFQ, FFI, and VAS scores were found, with no significant correlations between patient satisfaction and radiographic outcomes. Non-purchasing of the lateral cortex of the proximal osteotomy site was identified to increase risk of first metatarsal shortening (odds ratio [OR] = 22.09, p = 0.0064). Conclusions: Our modified MIS for hallux valgus correction showed favorable radiographic and functional outcomes. Proximal lateral cortex purchasing should be targeted to reduce postoperative shortening of the first metatarsal.

Comparison of the Minimally Invasive Reverdin-Isham Lateral Translation Osteotomy Versus the Standard Reverdin-Isham Technique: A Pilot Prospective Cohort Study

Background/Objectives: Reverdin-Isham osteotomy is effective in correcting moderate hallux valgus deformity but has certain limitations when correcting a deformity in the sagittal plane. This study aimed to evaluate the impact on pain, functionality, and radiological measures of angular corrections, and the safety of the Reverdin-Isham lateral translation technique through minimally invasive surgery in the treatment of a moderate hallux valgus compared to Reverdin-Isham standard osteotomy. Methods: A pilot 6-month prospective cohort study was conducted on adults over 18 years old with a hallux valgus in at least one foot. The study exposure was the use of the Reverdin-Isham lateral translation technique. The outcome variables were pain and functionality through VAS and AOFAS scales, respectively, and radiological measurements of the first toe metatarsophalangeal angle (MPA), first space intermetatarsal angle (IMA), proximal articular set angle (PASA), distal articular set angle (DASA), metatarsal formula, and position of sesamoids in the AP projection. Results: The study involved 60 participants. Results indicate significant reductions in pain and radiological measures in both cohorts: MPA improved by 23.13 degrees, IMA by 5.93 degrees, and sesamoid position by 4.23 degrees in patients who underwent the lateral translation technique versus 13.20, 3.30, and 1.57 degrees, respectively, in patients who experienced the standard Reverdin-Isham technique. The lateral translation method showed greater reductions in these metrics compared to the standard Reverdin-Isham technique (p < 0.05). Conclusions: Percutaneous Reverdin-Isham techniques, both standard and with lateral translations, effectively corrected moderate hallux valguses. However, the lateral translation method provided greater reductions in MPA, IMA, and sesamoid positions, making it more suitable for deformities with IMAs over 15 degrees.

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.

Immediate effect of hallux valgus surgery on the biomechanical behavior of the first ray

BACKGROUND

The surgical treatment of hallux valgus (HV) deformity has been the subject of countless publications but few focus on the altered windlass mechanism or analyze the biomechanical behavior immediately after surgery.

METHODS

Patients treated for HV between January and March 2023 were included. The surgery consisted of a L-reverse first metatarsal osteotomy. To analyze the windlass mechanism we record two different measurements; the isolated first metatarsophalangeal joint (MTPJ) dorsiflexion angle (IDA) and dynamic plantarization of the first metatarsal head when performing first MTPJ dorsiflexion imprinting a mark on a modeling foam.

RESULTS

A total of 30 patients diagnosed with symptomatic HV were included. In all patients, a change in the IDA angle was evident, being overall statistically significant. About modeling foam imprinted mark, all measurements, in all planes of space, had a clear tendency to increase, which turned out to be statistically significant (p < 0.001).

CONCLUSIONS

An altered windlass mechanism may be successfully recovered immediately after hallux valgus deformity surgery. This could be evinced by an indirect measurement analyzing the imprint of the head of the first metatarsal in a modeling foam and the IDA.

LEVELS OF EVIDENCE II

None.

Outcome comparison of minimally invasive proximal and distal chevron Akin osteotomies in patients with severe hallux valgus deformity: A randomized prospective study

PURPOSE

To date, the surgical treatment of severe hallux valgus deformity remains challenging despite the various methods presented. This study aimed to compare the effectiveness of minimally invasive distal chevron Akin osteotomies (d-MICA) and minimally invasive proximal chevron Akin osteotomies (p-MICA) in correcting severe hallux valgus deformities.

METHODS

This prospective follow-up study included patients randomly assigned to undergo p-MICA or d-MICA for hallux valgus deformities with a preoperative hallux valgus angle (HVA) ≥ 40° and/or a first to second intermetatarsal angle (IMA) ≥ 16°. After a minimum follow-up period of two years, we compared various clinico-radiographic parameters of patients whose HVA exceeded 15° at the final follow-up.

RESULTS

In the p-MICA and d-MICA groups, seven of 40 cases (17.5%) and 16 of 41 cases (39.0%), respectively, exhibited HVA > 15° at the final follow-up (P = 0.048). The preoperative parameters showed no significant differences. However, at the first weight-bearing assessment, the HVA, IMA, and relative second metatarsal length were significantly smaller, and the distal metatarsal articular angle (DMAA) was greater in the p-MICA group (all P < 0.05) compared with the d-MICA group. Postoperatively, both groups exhibited significant decreases in HVA and IMA at the final follow-up (P < 0.001 for all parameters). The p-MICA group showed no significant changes in DMAA and the relative length of the second metatarsal (P = 0.253 and 0.185, respectively). However, the d-MICA group showed a significant decrease in DMAA (P < 0.001) and an increase in the relative length of the second metatarsal at the final follow-up (P = 0.01).

CONCLUSIONS

p-MICA and d-MICA procedures demonstrated effective correction potential for severe hallux valgus deformities; however, the d-MICA procedure exhibited a notably higher incidence of unsatisfactory correction at the final follow-up than p-MICA. Therefore, d-MICA may be less predictable in achieving successful outcomes than p-MICA in treating severe hallux valgus deformities.

Minimally Invasive Chevron Akin Osteotomy: Preoperative Planning Using the Radiographic First-Ray Squeeze Test

Background

Recognizing preoperative first-ray hypermobility is important to planning hallux valgus (HV) surgery. A recent study showed the minimally invasive chevron Akin (MICA) osteotomy increased varus displacement of the proximal fragment of the first metatarsal osteotomy. The present study aims to evaluate the ability of the radiographic first-ray squeeze test to predict the varus displacement of the proximal fragment of the first metatarsal osteotomy when performing the MICA procedure.

Methods

A prospective case series of patients with moderate to severe HV who underwent MICA was performed. The HV deformity correction was analyzed by comparing the preoperative and 12-week postoperative hallux valgus angle (HVA) and the intermetatarsal angle between the first and second rays (1-2 IMA). The ability of the radiographic first-ray squeeze test to predict the varus displacement of the first metatarsal was done by comparing the preoperative 1-2 IMA measured in the AP radiographic first-ray squeeze test (IMA-ST) with the intermetatarsal angle between the second metatarsal and the axis of the first metatarsal osteotomy proximal fragment (IAPF) taken 12 weeks postoperatively.

Results

Between July 2022 and May 2023, a total of 39 feet in 28 patients underwent MICA. The mean IMA improved from 13.8 (SD = 2.2) to 3.8 degrees (SD = 1.5) (P < .001), and the mean HVA improved from 27.8 (SD = 6.1) to 4.9 degrees (SD = 2.5) (P < .001). A linear regression analysis revealed that IMA-ST is highly associated with the 12 week assessed IAPF (P < .001).

Conclusion

The preoperative radiographic first-ray squeeze test appears to predict with high fidelity the varus displacement of the proximal fragment of the first metatarsal that can occur after the MICA procedure.Level of Evidence: Level III, prospective cohort study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

Fourth-Generation Minimally Invasive Hallux Valgus Surgery With Metaphyseal Extra-Articular Transverse and Akin Osteotomy (META): 12 Month Clinical and Radiologic Results

BACKGROUND

Fourth-generation minimally invasive surgery (MIS) includes the multiplanar rotational deformity correction achieved through manipulation of an extra-articular distal first metatarsal osteotomy that is held with rigid fixation using 2 fully threaded screws, of which one must be bicortical to provide rotational and biomechanical stability. The aim of this study is to report the clinical and radiologic outcomes of an evolved fourth-generation MIS hallux valgus technique.

METHODS

A prospective single-surgeon series of consecutive patients undergoing fourth-generation MIS was performed using a distal transverse osteotomy with a minimum 12-month follow-up. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated clinical patient-reported outcome measure (PROM). Secondary outcomes included radiographic deformity correction, clinical assessment, and EuroQol-5D-5L PROMs.

RESULTS

Between September 2019 and June 2021, 50 feet underwent fourth-generation MIS. The mean age was 55.8±15.3 years with a mean follow-up of 1.4 years. Preoperative and minimum 12-month primary outcome data were available for 100% of feet. There was a significant improvement in all MOXFQ domain scores, with the index domain improving from 53.4 to 13.1 (P < .001). There was a significant improvement (P < .001) in hallux valgus angle (32.7 to 7.9 degrees), intermetatarsal angle (14.0 to 4.2 degrees) and distal metatarsal articular angle (18.5 to 5.6 degrees). There was a significant improvement in general health-related quality of life EQ-5D-5L index and EQ-VAS scores (P < .05).

CONCLUSION

The fourth-generation MIS technique is a safe and effective approach to hallux valgus deformity correction with significant improvement in clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level IV, prospective case series.