Akin Osteotomy Research Articles

Early Results with the Use of Synthetic Cartilage Implant Augmented with 3D Printed Baseplate to Prevent Implant Subsidence for Treatment of Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) of the first metatarsophalangeal joint (MTPJ) is a common arthritic disease which causes pain and stiffness. Synthetic cartilage implant (SCI) resurfacing has become a popular treatment option since it has similar biomechanical properties as native cartilage, reduces pain, and preserves MTPJ motion. However, recent studies have reported on implant subsidence leading to SCI treatment failure and subsequent revision surgery. A novel solution involves proximally inserting a custom 3D printed baseplate in the metatarsal head to prevent SCI subsidence. The purpose of this study is to evaluate the clinical and radiographic outcomes of patients who underwent SCI resurfacing augmented with a 3D printed beasplate for the treatment of HR by a single surgeon. Methods: Electronic health records were queried from August 2017 to August 2021 for patients who were treated with SCI (Cartiva Synthetic Cartilage Implant; Cartiva Inc., Alpharetta, GA) augmented with a custom 3D printed baseplate by a single surgeon. Through a dorsal approach to the MTPJ, the custom 3D printed baseplate is inserted in the metatarsal head and the SCI implant is positioned two millimeters proud from the cortex. An akin osteotomy is then performed and fixed with a staple. For the study, surgical indications included symptomatic HR and revision of previously failed SCI treatment. Patient demographics, body mass index (BMI), medical comorbidities, and followup periods were recorded. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and x-ray imaging were compared. Descriptive and univariate statistics were used to analyze data. Results: Twenty-one patients underwent SCI resurfacing augmented with a 3D printed baseplate. The cohort consisted of 18 females, and presented with a mean BMI of 30.4+-5 Kg/m2, mean age of 56.4+-10 years, and mean followup of 9.8+-13 months since the procedure. Patients experienced a significant improvement in VAS pain (P=0.002) scores. The SCI augmented with 3D printed baseplate survivorship was 90.4%, with only two (9.5%) patients requiring revision to first MTPJ arthrodesis for SCI subsidence and sesamoidal arthritis. Two (9.5%) patients additionally underwent reoperation for staple removal and infection. The first MTPJ space was maintained on x-ray imaging for 19 (90.5%) patients, with only two (9.5%) patients demonstrating implant subsidence. Conclusion: SCI resurfacing augmented with a custom 3D printed baseplate demonstrated significant improvements in pain and prevented implant subsidence in patients suffering from symptomatic HR. Future prospective studies should be performed to expand upon the clinical outcomes data analyzing this novel technique to prevent SCI subsidence in the treatment for HR.

Hallux Valgus Multiplanar Correction Surgery Through a Minimally Invasive Technique: Our First 100 Patients Experience

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Recently, minimally invasive surgery for hallux valgus correction has regained popularity. The minimally invasive Chevron and Akin (MICA), has been proved to be as satisfactory for patients as conventional open techniques. However, due to its design, it is difficult to correct the coronal plane malalignment, which could lead to the recurrence of the deformity. Instead, a Bösch-type osteotomy allows multiplanar correction, and with an upgrade in its fixation we can create a stable third- generation percutaneous osteotomy. We report our first 100 patients results using the minimally invasive Bösch and Akin osteotomy (MIBA). Methods: This was a prospective case series of our first 100 patients (137 feet) undergoing MIBA procedure. Outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), the AOFAS Forefoot Score, and the visual analog scale (VAS) for pain assessment. There was also a significant improvement in all radiographic parameters (p < 0.05). Mean HVA decreased from 30.5° to 7.8°, mean IMA decreased from 13° to 4.5°, and the mean DMAA decreased from 13.8° to 4.0° (p<0.05). All complications and emitted radiation dosage were reported as well. Results: At 12 months MOXFQ and AOFAS improved from 57.3 to 0.73 (p=0.00) and 45.2 to 99.2 (p=0.00), respectively. The mean preoperative VAS was 4.6, and improved during the first week to 1.3 (p<0.05). There was also a significant improvement in all radiographic parameters. We had three significant and 13 minor complications. Conclusion: The MIBA procedure is a safe and effective option to achieve a multiplanar hallux valgus correction.

Minimally Invasive Chevron Akin (MICA) Osteotomy for Severe Hallux Valgus

Category: Bunion Introduction/Purpose: The minimally invasive Chevron Akin (MICA) osteotomy have been widely used treating hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure, and to evaluate the clinical and radiographic outcomes Methods: Sixty consecutive feet (52 patients) undergoing MICA for severe HV were included. Patients were assessed pre and postoperatively. Clinically evaluation was realized by visual analogue pain scale (VAS) and American Orthopaedic Foot & Ankle Society Score (AOFAS). Radiographic assessments included measurement of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length and plantar offset of MT head. Results: The mean age was 59.9 years and follow-up were 18.5 months. The average AOFAS increased from 41.2 to 90.9 points and the VAS decreased from 8.1 to 1.3 at the last follow up. Average HVA decreased from 41.2° to 11.6° and IMA reduced from 17.1° to 6.8°. Average shortening of the first metatarsal and the plantar offset of MT head was 3.9 mm and 2.8 mm respectively. There was significant improvement (p<0.001) in all clinical and radiographic parameters (p<0.001). The most observed complication was hardware discomfort, observed in four feet (6.6%). Conclusion: The MICA technique is a safe and reproducible method to treat severe HV.

Forefoot Width Correction in Hallux Valgus after Rotational Scarf Osteotomy

Category: Bunion; Other Introduction/Purpose: Hallux valgus is a common deformity represented by a wider forefoot, associated with pain, shoe restrictions, and cosmetic problems. The goal of hallux valgus surgery is to achieve a painless foot by realigning the deviated first ray, thereby reducing friction between bony prominences and regular footwear. There is limited evidence on the effect of osseous procedures after hallux valgus surgery on the width of the resulting foot. Methods: We retrospectively performed measurements of forefoot width (bony and soft tissues) on AP standard x-ray from the first metatarsal head to the fifth metatarsal head, pre-and postoperatively at 3 months. Results: Thirty patients met the inclusion criteria, with a total of 42 feet. Radiographically, the preoperative mean 1-5 metatarsal bony width was 89.30mm SD (5.8) to 80.42mm postoperative SD (3.5). Regarding the soft tissue width, the preoperative average was 102.45mm SD (6.4) to 98.3mm postoperative SD (5.1). The ICC between both observers was 'excellent' in most measures (range, 0.884-0.973). Values obtained had a significance of p<0.001. Size effect was considered medium-high, with 0.87 power. Conclusion: We report an objective reduction in the forefoot width, both bony and soft tissue, by means of 8.88mm (10%) and 4.12mm (4.1%), respectively after scarf akin osteotomy. These results are represented by better shoe comfort and aesthetics.

The Effect of Minimally Invasive Hallux Valgus Correction on Sesamoid Position and Rotation

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive hallux valgus correction is increasing in popularity. Third generation minimally invasive chevron / Akin (MICA) techniques have low complication rates and high patient satisfaction. The MICA technique utilizes burrs to make percutaneous osteotomies of the distal first metatarsal and base of the first proximal phalanx. Deformity correction is achieved through lateral translation of the metatarsal head and closure of the Akin osteotomy. In open hallux valgus procedures, derotation of the first metatarsal and reduction of the sesamoids has shown to be essential to optimizing outcome. To our knowledge, the impact of the MICA technique on sesamoid and first metatarsal rotation has not been evaluated. In this study, we attempt to quantify the correction of metatarsal rotation and sesamoid rotation following MICA bunion correction. Methods: A cohort of patients undergoing minimally invasive hallux valgus correction at a single center were prospectively followed. All bunion deformities were corrected utilizing the MICA technique. Demographic information including age, sex, BMI, and laterality were collected. Concomitant procedures and any complications were recorded. All patients underwent a weight bearing CT scan and had weight bearing radiographs performed both before surgery and at a minimum of 6 months after surgery, after the osteotomy sites had healed. Weight bearing CTs were utilized to compare sesamoid station, sesamoid rotation, and metatarsal rotation (alpha angle). Radiographs were used to compare HVA, IMA, and sesamoid station pre and postoperatively. PROMIS scores were also collected from patients before surgery and at their most recent follow-up visit to assess the impact of minimally invasive bunion correction on patient outcomes. Results: Twelve patients, all female, with an average age of 49.8 +- 13.5 years were included. There were no major complications and all osteotomies healed. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) improved significantly from 29.4 +- 5.00 and 13.6 +- 1.38 to 13.6 +- 7.13 and 5.92 +- 3.99 respectively (p<.05). Alpha angle did not significantly change pre and postoperatively (p=.715). Rotation of the fibular sesamoid (p=.011) was significantly different postoperatively, while tibial sesamoid rotation trended towards significance (p=.136). Average sesamoid station significantly improved on CT scan from 1.45 preoperatively to 0.5 postoperatively (p=.001). PROMIS scores did not differ significantly from pre to postoperatively. Conclusion: MICA correction of hallux valgus deformity offers powerful correction of the IMA and HVA. The MICA technique, using a translational chevron osteotomy, does not significantly change first metatarsal rotation but does lead to reduction of the sesamoids, as measured by sesamoid station and improved sesamoid rotation. While differences in PROMIS scores were not seen in this study, larger studies are required to delineate the relationship between patient outcome measures and degree of sesamoid reduction in MICA hallux valgus correction.

Hallux Valgus Interphalangeus Measurement: Comparison of the Two Radiographic Methods

Category: Midfoot/Forefoot Introduction/Purpose: To determine the reliability of Delta PP (difference in medial and lateral proximal phalanx wall length) compared to HIA (hallux interphalangeal angle) in the assessment of HVI (hallux valgus interphalangeus) in both pre and postoperative radiographs. Methods: This was a retrospective observational study of 186 feet with hallux valgus. The number of cases required to adequately power the study was 128. Preoperative and postoperative hallux alignment were evaluated by two different radiological parameters, Delta PP and HIA. Inter-observer variability was assessed independently by two authors and compared using a intraclass correlation coefficient. Results: The intra-class correlation coefficient was more than 0.8 for all parameters, thus both HIA and Delta PP measurement provide reliable and reproducible data. Mean HIA significantly increased following surgical correction of hallux valgus. In comparison, the mean Delta PP decreased after correction. This postoperative increase in HIA indicates that pre-operative HIA underestimates the magnitude of HVI and therefore is an inaccurate tool for measuring HVI's contribution to the TVDH (total valgus deformity of the hallux) and to preoperative planning. However, the Delta PP was a greater determinant of the phalanx deformity's contribution to the TVDH. Conclusion: The outcome of our study shows that both HIA and Delta PP are reproducible when assessing the hallux valgus interphalangeus deformity, however, Delta PP quantifies the amount of correction obtained more precisely. The additional benefit of measuring the Delta PP is that it allows for accurate planning in determining the dimensions of the medial based wedge of the Akin osteotomy that needs to be resected.

Outcomes of V-cut Osteotomy on the First Metatarsal Head Combined with Fixation in Mortise-shaped Bone Groove-Plasty and Akin Osteotomy on the First Toe for Hallux Valgus Correction.

Hallux valgus (HV) is a common foot deformity, and recurrence is one of the most serious complications after HV correction. As a result, the surgical technique with a lowerrecurrence rate is a dream. The purpose of the article should be to observe the correction effect of hallux valgus using a novel "V-cut" osteotomy on the first metatarsal head combined with fixation in mortise-shaped bone groove-plasty technique. Twenty-three consecutive patients (40 feet) with HV were included from March 2019 to May 2020, who were all treated using single screw fixation with V-cut osteotomy on the first metatarsal head combined with mortise-shaped metatarsal bone groove-plasty and Akin osteotomy on the first toe for hallux valgus correction. With a mean follow-up time of 21.7 months, the visual analogue scale (VAS) score and American Orthopedic Foot and Ankle Society (AOFAS) forefoot score and the changes of the hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were evaluated during the clinical follow-up. The paired t test was used for analytical statistics. The VAS score improved from 6.78 ± 1.74 to 1.87 ± 1.45 and the AOFAS score improved from 53.9 ± 12.3 preoperatively to 94.7 ± 6.8 in the latest follow-up postoperatively (P < 0.01). Besides, the HVA improved from 30.0 ± 6.1° to 5.7 ± 2.8° (P < 0.01); the IMA changed from 13.1 ± 2.8° into 3.3 ± 1.6° (P < 0.01); and the DMAA ameliorated from 27.0 ± 8.4° to 5.9 ± 3.5° (P < 0.01). Only five toes had slight numbness and stiffness in early postoperative period, and these symptoms disappeared completely at 6 months after the surgery. Only one foot was corrected to excess. One screw stern protruding beneath the skin happened, which needed secondary screw removal under local anesthesia. Single screw fixation with V-cut osteotomy on the first metatarsal head combined with fixation in mortise-shaped metatarsal bone groove-plasty and Akin osteotomy on the first toe is an effective way with low recurrence rate for HV correction.

Early efficacy analysis of minimally invasive Chevron-Akin osteotomy for the treatment of mild to moderate hallus valgus

To explore early efficacy of minimally invasive Chevron Akin(MICA) osteotomy for the treatment of mild to moderate hallux valgus. From June 2019 to April 2021, a total of 26 patients (29 feet) with mild to moderate hallux valgus, including 1 male and 25 females aged from 19 to 78 years old with an average of(38.3±19.5) years old, were treated with MICA. Preoperative and postoperative hallux valgus angle(HVA), intermetatarsal angle(IMA) and shortening of the first metatarsal were observed and compared. American Orthopedic Foot and Ankle Society (AOFAS) forefoot scoring system and visual analogue scale (VAS) were applied to evaluate clinical outcome at the final follow-up, and complications were also recorded. All patients obtained followed up from 12 to 33 months with an average of(19.6±5.1) months. HVA and IMA was improved from (32.3±6.6)° and (11.7±3.2)° pre-operatively to (13.0±5.3)° and (6.1±3.2)° post-operatively, respectively, which had a significant difference (P<0.01). The average shortening of the first metatarsal was (2.7±1.1) mm. AOFAS and VAS was improved from (55.7±7.4) and (6.5±1.5) preoperatively and to (88.5±7.9) and (0.7±0.4) respectively at the final follow-up, which also had a significant difference(P<0.01). According to AOFAS score, 15 feet achieved an excellent result, 11 good and 3 moderate. MICA osteotomy is a safe and reliable surgical technique for mild to moderate hallux valgus with advantages of minimally invasive, rapid recovery, low complication rate and an effect improvement of hallux valgus deformity.

A Better Treatment for Moderate to Severe Hallux Valgus: Scarf + Akin Osteotomy Combined with Lateral Soft Tissue Release in a Single Medial Incision.

ObjectiveTraditional lateral soft tissue release (LSTR) was conducted by an additional dorsal first web incision, as the malformed thick scar and neuritis were common after surgery. A new method of lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) should be recommended. The objective is to investigate the clinical effectiveness and safety of scarf + Akin osteotomy (SAO) combined with lateral soft tissue release in a single medial incision via dorsal flap over the first metatarsal (LSTR‐SMI‐DFFM) for moderate to severe hallux valgus.MethodsPatients who were performed surgery for hallux valgus from April 2014 to June 2020 were retrospectively reviewed. The visual analog scale (VAS) was recorded before surgery and during follow‐up, as well as the forefoot score of the American Orthopaedic Foot and Ankle Society (AOFAS). Patient satisfaction was evaluated at the follow‐up time. The preoperative and follow‐up weightbearing X‐ray were conducted in all patients. The radiological parameters of hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured. Tibial sesamoid position (TSP) was also recorded according to seven‐part grading system. The quantitative data were performed as mean ± standard deviation or median ± interquartile range. Student's t test was performed in HVA, IMA, and DMAA. The TSP, VAS, and AOFAS were statistical analyzed by Mann–Whitney U test. p value of <0.05 was considered significant.ResultsThere were 123 feet conducted surgery in 96 patients. The AOFAS score improved a lot which was preoperative 39 to 100 at the follow‐up time and VAS was 4 to 0 (p < 0.001). A total of 63 (51.2%) patients were very satisfied, 47 (38.2%) were satisfied, five (4.1%) were undecided and eight (6.5%) were not satisfied. The HVA, IMA, DMAA, and TSP were all decreased after surgery and were statistically significant (p < 0.001).ConclusionThe SAO combined with a LSTR‐SMI‐DFFM for moderate to severe hallux valgus is effective and safe with pretty good clinical and radiographic results, as well as minimal complications. The corrections of AOFAS and VAS conformed to the minimum clinically important difference (MCID).

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

BackgroundMinimally-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. MethodsBetween 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. ResultsThe 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. ConclusionsAlthough 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.

A new suture fixation technique for the Akin Osteotomy of the Proximal Phalanx: You don’t need any implant

BackgroundVarious fixation methods have been described for Akin osteotomy, based on using metal implants or transosseous sutures. The aim of this study was to evaluate radiological outcomes and complications of closing wedge Akin osteotomy based on a crossed suture configuration of the joint capsule rather than using implants. The null hypothesis is that a crossed suture has comparable radiological results to other techniques, with no additional complications. MethodsIt’s a retrospective study. Patients who underwent Akin osteotomy fixed either with implant or joint capsule suture between 2015 and 2018 were included. Distal articular set angle corrections in pre- and postoperative anteroposterior foot x-rays were calculated by 2 observers. Complications, such as pain, infection, non-union and need of surgery revision, was compared at 1 year follow-up. Results89 patients, 30 in the implant group and 59 in the suture group. Mean distal articular set angle corrections were 6.43 (SD 5.54) and 7.36 (SD 5.48) degrees in the implant and suture groups, respectively, without statistically significant differences (p 0.454). Complications were 2 local pain and 1 wound infection cases in the suture and implant groups, respectively (p 0.138, p 0.197). ConclusionAkin osteotomy with suture fixation yields comparable radiological results to metal implant fixation methods without increasing the associated complications.

Early Radiographic Outcomes of Minimally Invasive Chevron Bunionectomy Compared to the Modified Lapidus Procedure.

Background:Minimally invasive (MIS) bunion surgery has become increasingly popular. Although early reports on outcomes have been encouraging, no study to date has compared outcomes from the MIS chevron and Akin procedures to the modified Lapidus procedure. Our primary aim was to compare early radiographic outcomes of the MIS chevron and Akin osteotomies to those of the modified Lapidus procedure in patients with comparable deformities, and secondarily to compare clinical outcomes.Methods:Patients were retrospectively reviewed for inclusion from a prospectively collected foot and ankle registry. Patients were eligible if they underwent either the MIS bunionectomy or modified Lapidus procedure and had preoperative and minimum 5-month postoperative weightbearing radiographs. Forty-one patients who underwent MIS bunionectomy were matched to 41 patients who underwent Lapidus bunionectomy based on radiographic parameters. Demographics, radiographic parameters, complications, reoperations, and PROMIS scores were compared between groups.Results:Both groups achieved similar radiographic correction. There was no significant difference in pre- or postoperative PROMIS scores between groups. Procedure duration was significantly faster in the MIS group (P < .001). Bunion recurrence (hallux valgus angle ≥20 degrees) occurred in 1 MIS patient and 2 Lapidus patients, with all patients asymptomatic. The most common reason for reoperation was removal of hardware (4 patients in the MIS group, 2 patients in the Lapidus group).Conclusion:This is the first study to our knowledge to compare early radiographic outcomes between MIS bunionectomy and the modified Lapidus procedure in patients matched for bunion severity. We found that patients with similar preoperative deformities experience similar radiographic correction following MIS chevron and Akin osteotomies vs modified Lapidus bunionectomy. Further research is needed to investigate satisfaction differences between the procedures, longer-term outcomes, and which deformities are best suited to each procedure.Level of Evidence:Level III, Retrospective case control study.

Osteotomies of the second phalanx of the great toe: A clinical experience

BackgroundAt the time of the first report on the feasibility of corrective osteotomies of the distal phalanx (DP) of the great toe there were no published studies addressing this type of surgery. Along this line, and throughout our clinical experience, this paper tries to show the clinical benefits of hallux DP osteotomies when correcting interphalangeal valgus deformities (IHV) of the great toe, either with open or percutaneous procedure. Material and MethodsThis is a review of 18 cases in which a DP osteotomy was performed in 2 different institutions, 8 cases were performed using open technique and 10 cases percutaneously. The correction obtained was analyzed by measuring the distal articular set angle (DASA), obliquity angle (AP1), asymmetry angle (AP2), and global distal phalanx deviation (GDPD) angle before and after the surgery on dorso-plantar weight-bearing radiographs in all cases. Clinical results were also recorded. ResultsExcellent clinical and radiological results were achieved with both techniques in all patients with no complications. The average DP angular deformity correction in terms of AP1, AP2 and GDPD angles were 4.58º ± 5.55º, 8.95º ± 4.77º and 16.53º ± 7.26 respectively. In 10 cases an Akin osteotomy was associated. ConclusionIn cases with valgus deviation in the hallux DP, a corrective osteotomy of the DP alone or associated to osteotomy of the PP should be considered as a useful tool. The technique is feasible and has no technical difficulties for an orthopedic surgeon with experience on feet surgery.

The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus

The learning curve to reach technical proficiency for third-generation percutaneous or minimally invasive chevron and Akin osteotomies (PECA/MICA) is recognized to be steep however it is poorly defined in the literature. This study is a retrospective review of the first 58 consecutive PECA cases of a single surgeon. The primary outcome was the number of cases required to reach technical proficiency as defined by the operation time. Secondary outcomes included radiation exposure, radiographic deformity correction, and complication rates. Between November 2017 and March 2019, 61 consecutive PECA cases were performed with outcome data available for 58 of these (95%). Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p < .05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p > .05). In conclusion, the mean number of cases required to reach technical proficiency in third-generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed, therefore surgeons interested in learning minimally invasive surgery can be reassured that there is unlikely to be an additional risk of harm to a patient during the learning curve.

Minimal-invasive Akin Osteotomie

In recent years minimal invasive Akin osteotomy has been established. Advantages of the minimal invasive Akin osteotomy could be a small incision, protection of soft tissue and maybe less fixation stability necessity. This article describes the minimal invasive Akin technique. Different fixation techniques and the results are discussed.

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

BackgroundAlthough 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.MethodsWe 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.ResultsAll 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.ConclusionRotation 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.

Reliability of intraoperative radiographic visual assessment of the hallux interphalangeal angle after hallux valgus correction

Objective: The aim of this study was to evaluate the reliability and reproducibility of visual estimation of the hallux interphalangeal angle (IPA). As a secondary aim we assessed for change in the IPA before and after hallux valgus (HV) correction. Methods: A total of 50 surgically treated HV deformities were included in the study. Two surgeons visually estimated the IPA on intraoperative fluoroscopy after correcting HV. The fellow then measured the IPA formally on a printout of the fluoroscopic image. Pre-and intraoperative HVI angles were compared to assess for change after HV correction. Results: The researchers found the interobserver reliability of radiographic visual assessment of the IPA to be 78% and intraobserver reliability to be 76% and 80% for surgeon 1 and 2, respectively. It was found that the preoperative IPA is on average 5.5 degrees less than IPA after HV correction. Conclusion: Radiographic visual assessment of the IPA of the hallux was found to be reliable intraoperatively, thus aiding in the amount of correction required by Akin osteotomy. HVI can be masked by hallux pronation in HV deformity and should be assessed intraoperatively after HV correction. Level of Evidence II; Therapeutic Studies; Prospective Comparative Study.

Operative Treatment of Adolescent Hallux Valgus

The hallux valgus deformity in pediatric patients is a common pathology with no definitive criteria for surgical treatment. The purpose of this study is to present mid-term postoperative results after surgical treatment of this foot deformity. The study included 43 operated feet in 29 patients, with an average age of 14.31 years. Scarf osteotomy was performed in 23 patients, combined with an Akin osteotomy in 14 of the cases; Chevron osteotomy was performed in seven patients, five patients were treated with the mini tightrope technique, two with the Ludloff osteotomy, and six patients with lateral hemiepiphysiodesis of the first metatarsal. We evaluated the change in angular radiographic parameters and the American Orthopaedic Foot &amp; Ankle Society scale for data analysis. The mean follow-up of the study was 48 ± 33.2 months. The mean preoperative hallux valgus angle showed an average improvement of 30.19° to 12.79° (p &lt; 0.001). Loss of correction of the HVA angle of 20.46° was noted at the time of final follow up (p &gt; 0.05). Favourable correction of the intermetatarsal angle was achieved with improvement of 11.44° preoperatively to 7.35° postoperatively. Significant progression was found for the American Orthopedic Foot &amp; Ankle Society score from 57 points (42–85) before surgery to 80 points (54–100) after surgery. The recurrence rate 6 months after surgery is 30.95% (13 cases). Relapse of the deformity after Scarf osteotomy was observed in nine cases; after mini tight rope technique in three cases, and in one case after Chevron osteotomy. In conclusion we state that the most important factor influencing the outcomes of treatment and postoperative recurrence rate is skeletal maturity. Surgical treatment should be indicated after growth plate fusion. Conservative treatment via orthotic devices is recommended until that time.

Hallux Valgus Interphalangeus Measurement: Comparison of the 2 Radiographic Methods.

To determine the reliability of Delta PP (difference in medial and lateral proximal phalanx wall length) compared with HIA (hallux interphalangeal angle) in the assessment of HVI (hallux valgus interphalangeus) in both preoperative and postoperative radiographs. This was a retrospective observational study of 186 feet with hallux valgus. The number of cases required to adequately power the study was 128. Preoperative and postoperative hallux alignment were evaluated by 2 different radiological parameters, Delta PP and HIA. Interobserver variability was assessed independently by 2 authors and compared using a intraclass correlation coefficient. The intraclass correlation coefficient was more than 0.8 for all parameters, thus both HIA and Delta PP measurement provide reliable and reproducible data. Mean HIA significantly increased following surgical correction of hallux valgus. In comparison, the mean Delta PP decreased after correction. This postoperative increase in HIA indicates that preoperative HIA underestimates the magnitude of HVI and therefore is an inaccurate tool for measuring HVI's contribution to the TVDH (total valgus deformity of the hallux) and to preoperative planning. However, the Delta PP was a greater determinant of the phalanx deformity's contribution to the TVDH. The outcome of our study shows that both HIA and Delta PP are reproducible when assessing the HVI deformity; however, Delta PP quantifies the amount of correction obtained more precisely. The additional benefit of measuring the Delta PP is that it allows for accurate planning in determining the dimensions of the medial-based wedge of the Akin osteotomy that needs to be resected. Level 4.

Minimally invasive surgery for severe hallux valgus in 106 feet

BackgroundThere is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1–2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA). MethodsThis was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale). ResultsBetween September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%. ConclusionThis study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.