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Minimally invasive distal linear metatarsal osteotomy for correction of hallux valgus: a preliminary study of clinical outcome and analytical radiographic results via a mapping system.
Angthong C, Yoshimura I, Kanazawa K, Hagio T, Ida T, Naito M.
Arch Orthop Trauma Surg. 2012 Dec 8
To date, actual results of a minimally invasive distal linear metatarsal osteotomy (DLMO) via more explicit radiographic delineation are poorly understood and radiographic findings and clinical results have not been systematically correlated. Purposes of this study were (1) to evaluate the effectiveness of DLMO using a precise radiographic mapping system; and (2) to determine the relationship between radiographic outcomes and clinical results.
MATERIALS AND METHODS:
In 2008-2011, DLMO was performed in 30 patients (36 feet) who had reducible symptomatic hallux valgus. Clinical data were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed at preoperative and final follow-up for delineations of first ray construct, hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle, and other radiographic profiles. Correlation between postoperative AOFAS score and degree of malalignment was also analyzed.
A total of 36 feet had predominantly moderate hallux valgus (26 feet with HVA: 21-39°; 23 feet with IMA: 12-17°). Mean preoperative and postoperative AOFAS scores were 70.2 ± 11.3 and 95 ± 6.4, respectively (p < 0.001). Mapping system revealed improvements of first ray construct deformity (p < 0.05). Significant reductions in all angular measurements were observed at final follow-up period (p < 0.001) and correlated significantly with changes in AOFAS score (p < 0.001). Nine feet (25 %) were observed with recurrence of deformity which showed HVA >15°. Significant sesamoid lateralization was observed (p < 0.05). Twenty-four feet (66.7 %) showing overall sagittal malunions were found with significant plantar angulation (p = 0.026) and non-significant plantar displacement compared with preoperative reference (p = 0.43). These radiographic abnormalities were not related to clinical outcomes including postoperative AOFAS scores (p > 0.05).
DLMO is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity. Sagittal malunion, recurrence, and sesamoid lateralization are possibly radiographic abnormalities but are not associated with clinical impairments.
The potential advantages of minimal incision surgery for hallux valgus (HV) correction are the following: reduced surgical exposure, diminished soft-tissue stripping, and less blood supply impairment. These advantages imply fewer complications. We retrospectively reviewed patients who were consecutively treated with a modified minimally invasive osteotomy from January 2006 until December 2009 for HV deformity. We radiographically assessed the HV angle, 1-2 intermetatarsal (IM) angle, and tibial sesamoid position. Clinical outcomes were determined using the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal Interphalangeal (AOFAS HMI) Clinical Rating Scale. A paired Student’s t test was used to determine significance, with P < .01. There were 126 patients (146 feet) with an average age of 52.6 years and an average postoperative follow-up of 29.1 months. Preoperatively, the average HV angle was 32.3°, and postoperatively, it was 4.5° (P < .01). The preoperative average IM angle was 14.4°, whereas postoperatively, it was 4.8° (P < .01). The average tibial sesamoid position was 6.3 preoperatively and 2.5 postoperatively (P < .01). The average AOFAS HMI score was 54.6 preoperatively and 85.3 postoperatively (P < .01). There were 15 postoperative complications (10.3%) that included hallux varus, painful hardware, and delayed union. The results are comparable with those of traditional open techniques, with the additional advantages of a minimally invasive procedure.
Midterm Results and Complications After Minimally Invasive Distal Metatarsal Osteotomy for Treatment of Hallux Valgus.
Iannò B, Familiari F, De Gori M, Galasso O, Ranuccio F, Gasparini G. Foot Ankle Int. 2013 Mar 5.
Minimally invasive distal metatarsal osteotomy (MIDMO) is a common technique used to correct the hallux valgus deformity, but controversy remains regarding the expected outcomes of this surgery.
Seventy-two patients (85 feet) suffering from hallux valgus underwent MIDMO with a modified Bösch technique. Patients were prospectively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and the AOFAS recovery rate was calculated. Before surgery and at follow-up, the hallux valgus (HVA), intermetatarsal (IMA), and distal metatarsal articular (DMAA) angles were measured, and the severity of disease was categorized according to the preoperative HVA. The tibial sesamoid position and articular congruence were evaluated. Postoperative complications were noted.
After an average follow-up of 73.3 ± 38.1 months, the total AOFAS score improved from 47.6 ± 13.3 to 87.3 ± 11.5 (P < .001). The HVA decreased from 34.7 ± 8.2 to 14.8 ± 7.8 degrees, the IMA from 14.7 ± 4 to 6.6 ± 3.6 degrees, and the DMAA from 20.9 ± 9.8 to 9 ± 6.6 degrees (P < .001 for all). Postoperative improvement in AOFAS was inversely related to the preoperative severity of disease (P < .001, β = -.378). Sixteen (18.8%) deformity recurrences were noted, 9 of which were observed in patients with preoperative HVA more than 40 degrees. Worse preoperative congruence of the metatarsophalangeal joint and tibial sesamoid position correlated with a higher rate of recurrence of the disease after surgery (P = .001, β = -.353 and P < .001, β = .427, respectively).
Satisfactory clinical and radiological results can be expected after MIDMO, but caution should be exercised when using this technique because of the likelihood of possible complications (29.4% overall complication rate). Predictors of surgical outcomes can be used to select the best candidates for this surgery.
This systematic review aims to illustrate the published results of “minimally invasive” procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were “hallux valgus”, “bunion”, “percutaneous surgery”, “minimally invasive surgery”, “arthroscopy”, “Bosch” and “SERI”. Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one’s own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.
To evaluate the early clinical and radiological results using the Bösch technique to treat hallux valgus.
Material and methods
We reviewed retrospectively four patients with 6 feet undergoing the Bösch technique for mild and moderate hallux valgus from 2009 to 2012 with an average follow-up of 10.8 months. All patients complained of pain around the first metatarsophalangeal joint. They had cosmetic concerns, and difficulty in wearing shoes. At final follow-up patients were asked about the improvement of pain, cosmetic appearance of the foot, problems with wearing shoes, the ability to walk, and their satisfaction with the operation. Complications encountered were also recorded. The radiographic evaluation considered osteotomy site union, the hallux valgus angle, and the intermetatarsal angle.
All patients complained of mild or no pain. They had a satisfactory cosmetic result, wore normal shoes without problems with no limitation of walking ability. They were satisfied with the procedure. One case of superficial infection was noticed. All osteotomies healed primarily within three months. The average hallux valgus angle improved from 32.7° preoperatively to 14.8° at final follow-up and the average intermetatarsal angle from 17.5° to 9.2°.
The Bösch technique is a cost effective procedure that yields good clinical and radiological results while correcting mild and moderate symptomatic hallux valgus with reduced risk of surgery related complications.
There is growing evidence supporting minimally invasive surgical (MIS) techniques for correction of symptomatic hallux valgus. The aim of this study was to present a hybrid third-generation technique and assess the safety and efficacy from the first 45 procedures.
Forty-five consecutive feet underwent a third-generation MIS distal chevron osteotomy with a minimum six month follow-up (range six to 17 months). This technique uses both first- and second-generation techniques plus a distal chevron osteotomy and screw for improved control and stabilisation of the metatarsal head. All patients were clinically assessed using the Manchester–Oxford Foot Questionnaire (MOXFQ). Radiographic measures included hallux valgus angle (HVA), intermetatarsal angle (IMA), first metatarsal length and overall toe length.
There were significant improvements in all three domains of the MOXFQ (p <0.001). There was also significant improvement in all radiographic parameters (p < 0.001). Mean HVA decreased from 30.54° to 10.41°, and the mean IMA decreased from 14.55° to 7.11°. Shortening of the first metatarsal had no effect on clinical outcomes. There was a very low rate of complications.
The short-term results of this third-generation technique show that it is a safe procedure with good clinical outcomes and compares favourably with earlier techniques.
To evaluate the clinical and radiological results in the surgical treatment of moderate and severe hallux valgus by performing percutaneous double osteotomy.
MATERIAL AND METHOD:
A retrospective study was conducted on 45 feet of 42 patients diagnosed with moderate-severe hallux valgus, operated on in a single centre and by the same surgeon from May 2009 to March 2013. Two patients were lost to follow-up. Clinical and radiological results were recorded.
An improvement from 48.14±4.79 points to 91.28±8.73 points was registered using the American Orthopedic Foot and Ankle Society (AOFAS) scale. A radiological decrease from 16.88±2.01 to 8.18±3.23 was observed in the intermetatarsal angle, and from 40.02±6.50 to 10.51±6.55 in hallux valgus angle. There was one case of hallux varus, one case of non-union, a regional pain syndrome type I, an infection that resolved with antibiotics, and a case of loosening of the osteosynthesis that required an open surgical refixation.
Percutaneous distal osteotomy of the first metatarsal when performed as an isolated procedure, show limitations when dealing with cases of moderate and severe hallux valgus. The described technique adds the advantages of minimally invasive surgery by expanding applications to severe deformities.
Percutaneous double osteotomy is a reproducible technique for correcting severe deformities, with good clinical and radiological results with a complication rate similar to other techniques with the advantages of shorter surgical times and less soft tissue damage.
Previous attempts at small incision hallux valgus surgery have compromised the principles of bunion correction in order to minimise the incision. The Minimally Invasive Chevron/ Akin (MICA) is a technique that enables an open modified Chevron/ Akin to be done through a 3mm incision, facilitated by a 2mm Shannon burr.
This is a consecutive case series performed between 2009 and 2012. This includes the learning curve for minimally invasive surgery. All cases were performed by a single surgeon at two different sites, one centre where minimally invasive surgery is available and the other where it is not. The standard procedure in both centres is a modified Chevron osteotomy. Regardless of whether the osteotomy was performed open or minimally invasive two-screw fixation was performed.
Retrospective analysis includes the intermetatarsal angle (IMA), hallux valgus angle (HVA), metatarsal 1 (M1) length, forefoot width and forefoot: hindfoot ratio. Clinical outcomes include the Manchester Oxford Foot Questionnaire (MOXFQ), American Orthopaedic Foot and Ankle Surgeons (AOFAS) questionniare, and assessment of complications.
There were 70 cases in each arm. Follow-up was 4 years to 6 months. The radiological outcomes were similar in both groups. There was an increased rate of screw removal in the MICA group. There were also cases of hallux varus, these occurred in the cases with severe pre-operative IMA angles that also had a lateral release and an Akin. There was high satisfaction in both groups.
This is the only comparison of minimally invasive and open techniques that has been performed, providing a direct comparison of the utility of a burr compared to a saw. These early results demonstrate the efficacy of a Minimally Invasive Chevron/ Akin in terms of achieving radiological correction. The clinical outcomes are excellent but there is a learning curve and this needs to be managed.
Minimally invasive techniques have been used successfully in mild to moderate hallux valgus (HV) deformity, while controversy exists for their use in cases with more severe involvement. The purpose of this prospective study was to evaluate the outcomes of a modified less invasive technique for management of severe HV deformity.
Patients and methods
Between January 2010 and 2013, a total of 15 active patients (20 ft) met our selection criteria for symptomatic severe HV deformity and treated by a modified double metatarsal osteotomy technique. The procedure implied simple transverse-osteotomy, with lateral translation, of the first metatarsal both distally and proximally combined with selective distal soft-tissue procedure. Average patient’s age was 43.9 years. Radiologically, HV angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, and joint congruity were assessed preoperatively and at the final follow-up. Clinically, the American Orthopedic Foot and Ankle Society scale and the subjective patient’s satisfaction were also evaluated. All data were statistically analyzed, and the complications were reported.
The average follow-up was 22.6 months (range 16–30 months). Union was achieved in all osteotomies in a mean of 6.22 ± 0.79 weeks. Each clinical and radiological parameter showed a statistically significant improvement (P < 0.001), with a negligible first-ray shortening (P = 0.617) and a few complications. At final follow-up, none of the patient was dissatisfied.
The modified double metatarsal osteotomy technique provides a simple, reproducible, and effective alternative for correction of all components of severe HV deformity in a less invasive manner.
Results of Minimal Incision Distal Metatarsal Osteotomy for Moderate to Severe Hallux Valgus
Jung-Wook Huh, Il-Soo Eun, Young-Chul Ko, Man-Jun Park, Sook-Hyun Park J Korean Foot Ankle Soc. 2015;19:51-57
Purpose: Minimal incision distal metatarsal osteotomy (MIDMO) is known to be an effective surgical procedure for mild to moderate hallux valgus. However, the result of MIDMO on moderate to severe hallux valgus is controversial; therefore, we investigated the radiological and clinical results of MIDMO on moderate to severe hallux valgus.
Materials and Methods: We reviewed 51 feet (48 patients) with moderate to severe hallux valgus. The mean age was 67.0 years and the mean follow-up period was 32.2 months. Radiological data of hallux valgus angle, first intermetatarsal angle, and distal metatarsal articular angle on plain radiographs were analyzed. Recurrence, union, lateral translation of distal fragment and angulation were also analyzed. The clinical data were obtained using American Orthopaedic Foot and Ankle Society (AOFAS) score of preoperation and last follow-up. Receiver operating characteristic (ROC) curve was used to determine a cut-off value.
Results: The mean hallux valgus angle measured at preoperation was 37.7o and 15.9o at last follow-up. The mean first intermetatarsal angle of preoperation and last follow-up were 15.2o and 8.3o. The mean distal metatarsal articular angle changed from 12.6o at preoperation to 7.8o at last follow-up. Preoperative hallux valgus angle (p=0.0051) and distal metatarsal articular angle (p=0.0078) were statistically significant factors affecting postoperative AOFAS score. Cut-off value of each was 37o and 13o, respectively. Lateral translation of distal fragment in 5 recurrent cases was 23.0% compared to 45.3% of 46 non-recurrent cases. The result was statistically significant and the cut-off value was 38%.
Conclusion: Sufficient lateral translation over 38% in MIDMO on moderate to severe hallux valgus patients with preoperative hallux valgus angle under 37° and distal metatarsal articular angle under 13° can lead to good clinical results without recurrence.
A Better understanding of foot biomechanics coupled with technological advancement and governance to improve patient outcomes
have facilitated newer innovations in Hallux Valgus (HV) surgery. Minimally Invasive Surgery (MIS) is one of the greatest advances in modern
medicine and an emerging trend in foot and ankle surgeries. The needs to provide a quicker post- operative recovery, reduce operative time
and minimize complications have led to development of various MIS techniques in HV correction over the past decades. This systematic
review aims to establish the efficacy and safety of MIS for HV correction. A systematic search of Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Embase, Medline, Science Direct and Cochrane Central Registry of Controlled Trials from inception of database
till 28th February 2014 was conducted. A total of 27 English language articles published in peer reviewed journals with available clinical and
radiological outcome measures were deemed appropriate and were critically analyzed to determine the efficacy and safety of minimally
invasive HV surgery (MIHVS). These studies included a total of 1485 patients with 1952 surgical procedures using MIHVS. The clinical and
radiological outcomes achieved with MIHVS along the complications reported were comparable with the conventional open techniques.
The MIHVS within this review consisted of case series that differed in terms of procedure, patient selection, techniques, instrumentation,
rehabilitation protocol, use of fluoroscopy and reporting outcome measures. The complication rates were significantly lower in centers
specializing with MIHVS. Higher levels of evidence with large population studies are required to recommend MIHVS which have shorter
operating time, quicker recovery and reduced hospital stay compare to open surgery.
Endoscopic distal soft-tissue procedure is one of the minimally invasive techniques for correction of the hallux valgus deformity. It employs the same principle as the open procedure. The intermetatarsal angle is corrected by screw and interosseous suture instead of first metatarsal osteotomy. The associated procedures of first metatarsal derotation, medial collateral ligament reconstruction, and arthroscopic Lapidus arthrodesis can tackle various problems faced during the endoscopic distal soft-tissue procedure.