Distal Metatarsal Articular Angle Research Articles

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

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. 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 twoyears, we compared various clinico-radiographic parameters of patients whose HVA exceeded 15° at the final follow-up. 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). 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.

A Joy-Stick Assistant Three-Dimensional Modified Technique of Minimally Invasive Surgery for Mild or Moderate Hallux Valgus.

Minimally invasive surgery (MIS) such as minimally invasive chevron osteotomy and Akin osteotomy (MICA) has become popular in the treatment of hallux valgus. However, how to correct three-dimensional deformities in hallux valgus effectively and simply in MICA is still difficult. Special equipment is required in MICA as has been reported before. It is meaningful and necessary to reduce the reliance on special equipment in MICA. From January 2021 to July 2022, patients with mild or moderate hallux valgus were treated with a joy-stick assistant three-dimensional modified technique (Joy-stick 3D technique) of MIS. VAS, AOFAS Hallux MTP-IP scores, hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured pre- and postoperatively at the last follow-up of at least 6 months. Scores and radiologic angles were compared using paired sample t-test. A total of 36 cases were included. HVA, IMA, and DMAA were (22.3 ± 6.1)°, (14.0 ± 3.2)°, and (8.9 ± 3.2)° preoperatively, and decreased to (7.0 ± 1.8)°, (3.7 ± 1.0)°, and (3.3 ± 1.1)° postoperatively. VAS decreased from 4.3 ± 1.7 to 0.7 ± 0.7. AOFAS Hallux MTP-IP scores improved from 68.6 ± 7.6 to 92.9 ± 6.1. Comparing mild and moderate cases, though HVA, IMA, and DMAA were significantly different preoperatively, the angles became statistically similar after surgery. A joy-stick assistant three-dimensional modified technique is proposed to control the three-dimensional position of the metatarsal head and to reduce dependence on special tools. Mild and moderate hallux valgus deformities are effectively corrected using Joy-stick 3D technique.

Intermetatarsal and Metatarsal-Phalangeal Angles Can Be Corrected by an Isolated Akin Osteotomy in Patients with Hallux Valgus Deformity

Introduction/Purpose: Akin osteotomy is a surgical technique commonly used in conjunction with osteotomies of the first metatarsal for correction of hallux valgus (HV) deformity. The main indication for an Akin osteotomy is the presence of hallux valgus interphalangeus (HVIF), defined as a HVIF angle &gt;10º. Given that distal osteotomies can change the tendon vector forces, we hypothesize that in a patient with a mobile medial column, an isolated akin osteotomy could improve proximally some radiologic parameters of HV. The purpose of this study was to evaluate whether the isolated Akin osteotomy is able to correct proximally the intermetatarsal angle (IMA) and hallux valgus angle (HVA) in patients with HV deformity. Methods: Case series of consecutive patients with HV deformity treated with an isolated Akin osteotomy, were included in this study. The indications for this surgery were having a mild HV and overlapping of the hallux with the second toe as the main symptom. Patients with fractures, infections, prior surgeries in the forefoot, and concomitant metatarsal osteotomy or first tarsometatarsal fusion were excluded. Two independent evaluators measured the following parameters pre and post-operatively in anteroposterior(AP) feet x-rays: traditional and modified HVA (the latter defined as angle between the long axis of the 1st metatarsal and a line from the center of the base of the proximal phalanx and the tip of the distal phalanx), IMA, distal metatarsal articular angle (DMAA), and HVIF angle. Paired t-test was performed to compare the radiological parameters pre and post- surgery. The absolute intraclass correlation coefficient (ICC) was used to determine the interobserver agreement. P&lt; 0.05 was considered significant. Results: Twenty AP feet x-rays of 12 females and 1 male with a mean age of 44.0 years (range 15 to 85) were included in the final analysis. The preoperative mean and standard deviation (SD) of traditional HVA, modified HVA, IMA, DMAA, and HVIF were 17.0º(7.5), 23.7º(6.5), 11.3º(1.6), 12.6(9.2), and 13.5º(6.0), respectively. The corresponding postoperative values were 9.8º(7.0), 14.4º(7.0), 9.5º(2.0), 11.2º(7.6), and 9.9º(4.9). There was a significant reduction in the traditional HVA (7.2º, p&lt; 0.001), and modified HVA (9.3º, p&lt; 0.001). Also, there was a significant decrease in the IMA (1.8º, p&lt; 0.001), and HVIF (3.5º, p=0.001). Conversely, the DMAA did not change after the osteotomy. The interobserver agreement was moderate to excellent for all radiologic parameters. Conclusion: In this case series, an isolated Akin osteotomy significantly reduced the HVA and IMA. These results challenge the traditional knowledge that Akin only corrects the interphalangeal angle, and could help for a better biomechanical understanding of this deformity, including the effect in proximal correction of distal procedures. An isolated Akin osteotomy could be a plausible alternative for the correction of HV, especially for mild deformities.

Radiographic Comparison of Open and Minimally Invasive Distal Chevron Metatarsal Osteotomy in Patients With Hallux Valgus

This study aimed to compare radiographic outcomes of open and minimally invasive surgery (MIS) in patients with hallux valgus. We reviewed data of patients with hallux valgus who underwent open or minimally invasive distal chevron osteotomy at our institution. Radiographic assessment was completed preoperatively, immediate postoperatively, and one year postoperatively using eight weight bearing parameters . The classic distal chevron osteotomy method was used for open surgery and a modified method that added percutaneous K-wire fixation to the minimal invasive Chevron-Akin (third-generation MIS) was used for correction of the distal metatarsal articular angle (DMAA). A total of 65 feet (33 open surgeries and 32 MIS) were included. The HVA, IMA, and DMAA improved significantly following surgery regardless of surgical method (p<0.001). Other radiographic indicators showed no statistically significant differences after surgery. DMAA improved by 71.0±14.2% after surgery, and the open surgery group showed less significant reduction in DMAA (49.7±25.7%, p<0.001). Other parameters showed no difference between the two groups regarding relative postoperative changes. The MIS group showed shorter operation time (p<0.001) and hospitalization period (p=0.034) than did the open surgery group. Therefore, the MIS group is expected to be cost-effective. Radiographic measurements revealed comparable outcomes of MIS compared with open surgery. Additionally, adding percutaneous K-wire fixation during MIS had an advantage in correcting DMAA compared with open surgery. Furthermore, the correction of DMAA could reduce recurrence of valgus deformity of the hallux.

Comparison of triplanar chevron osteotomy with chevron osteotomy in hallux valgus treatment for the prevention of transfer metatarsalgia.

Hallux valgus (HV) is often accompanied by metatarsalgia. This study compared the radiological and clinical outcomes of new triplanar chevron osteotomy (TCO) and chevron osteotomy (CO) in the treatment of HV, especially for patients with plantar callosities and metatarsalgia. In this retrospective analysis, 90 patients (45 patients per group) with mild to moderate HV and plantar callosities were treated with TCO and CO from July 2020 to January 2022. In both procedures, the apex was located in the center of the head of the first metatarsal bone, and the CO was oriented towards the fourth MTPJ at a 60° angle. Plantar-oblique chevron osteotomy was defined as chevron osteotomy and a 20° plantar tilt; TCO was defined as plantar-oblique chevron osteotomy-based metatarsal osteotomy with a 10° tilt towards the metatarsal head. Primary outcome measures included preoperative and postoperative hallux valgus angle, 1 to 2 intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal length (FML), and second metatarsal head height X-ray images; clinical measurements, including visual analogue scale and American Orthopaedic Foot & Ankle Society (AOFAS) scores; changes in callosity grade and area; and changes in the number of people with metatarsalgia. Secondary outcomes included complications, recurrence rates, and cosmetic appearance. The hallux valgus angle, IMA, and DMAA were significantly lower after surgery (P < .001) in all patients. In the TCO group, the mean FML and second metatarsal head height increased significantly postoperatively (P < .001). The AOFAS and visual analogue scale scores improved postoperatively in both groups (P < .001). All patients experienced satisfactory pain relief and acceptable cosmesis. The plantar callosity areas were smaller postoperatively in both the TCO and CO groups, but the change in the area (Δarea) in the TCO group significantly differed from that in the CO group (P < .001). The number of postoperative patients with metatarsalgia and the plantar callosity grade were both significantly lower in the TCO group than in the CO group after osteotomy (P < .05). TCO prevents dorsal shift of the metatarsal head and preserves and even increases FML, thereby preventing future metatarsalgia in patients. Therefore, compared with CO, TCO has better orthopedic outcomes and is an effective method for treating mild to moderate HV and preventing transfer metatarsalgia.

Weightbearing Imaging Assessment of Midfoot Instability in Patients with Confirmed Hallux Valgus Deformity: A Systematic Review of the Literature.

Hallux valgus deformity (HVD) involves subluxation of the first metatarsophalangeal joint. While HVD is primarily considered a forefoot condition, midfoot instability may play a significant role in its development and severity. However, very few studies have placed a heavy emphasis on studying this phenomenon. Therefore, this review had a particular focus on understanding midfoot instability based on weightbearing imaging assessments of the TMT joint. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched five databases for studies on midfoot instability in HVD patients. The severity of HVD was defined by hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA). Data was extracted, and articles were graded using the Methodological Index for Non-Randomized Studies (MINORS). Of 547 initially retrieved articles, 23 met the inclusion criteria. Patients with HVD showed higher HVA and DMAA on weightbearing radiographs (WBRG) and weightbearing computed tomography (WBCT) compared to healthy individuals. Midfoot instability was assessed through intermetatarsal angle (IMA) and tarsometatarsal angle (TMT angle). Patients with HVD exhibited greater IMA and TMT angles on both WBRG and WBCT. This review highlights the importance of weightbearing imaging assessments for midfoot instability in HVD. IMA and TMT angles can differentiate between healthy individuals and HVD patients, emphasizing the significance of midfoot assessment in understanding HVD pathology. These findings validate the limited evidence thus far in the literature pertaining to consistent midfoot instability in HVD patients and are able to provide ample reasoning for physicians to place a larger emphasis on midfoot imaging when assessing HVD in its entirety.

Combined Distal Metatarsal and Akin Osteotomies for Concomitant Metatarsophalangeal and Interphalangeal Hallux Valgus: Clinical and Radiological Outcomes

Combined metatarsal and Akin-type proximal phalanx osteotomies represent a surgical solution for concomitant metatarso-phalangeal and inter-phalangeal hallux valgus. This retrospective observational study aimed to evaluate clinical and radiographic outcomes following combined distal linear metatarsal and Akin osteotomies. The study included 42 feet from 37 patients, with a mean follow-up of 27.1 (range 24-37) months. Mean surgical time was 16.54 ± 4.17 minutes. Pre- and postoperative clinical scores and radiological parameters were collected. Positive outcomes with a low recurrence and complications rates were reported. A statistically significant improvement in the Manchester–Oxford foot questionnaire, the EuroQol 5D-5L dimensions instrument, the visual analogue scale, the intermetatarsal angle, the hallux valgus angle, the distal metatarsal articular angle, and the interphalangeal angle correction was observed. Despite the results reported, further prospective studies are needed to identify the most suitable patients for this combined osteotomy approach.

Intramedullary locking mini-plate screw system in Lindgren osteotomy: a more effective fixation technique in mild and moderate hallux valgus cases.

In the treatment of mild and moderate hallux valgus (HV) cases, the Lindgren distal osteotomy (LDO) technique has been one of the most frequently preferred methods, and screw fixation has been the most preferred material for surgery. However, considering the implant removal operations due to the reaction to the material, the risk of unsteadiness, retarded union, and malunion has limited the amount of safe application of lateralization of the distal fragment in distal osteotomy surgery and has yielded the researchers for a better alternative. This study compared the results of the LDO cases using headless cannulated screws and intramedullary plate fixation materials. The retrospective study included 31 files of patients operated for HV between January 1, 2018, and December 31, 2022, in Adana City Training and Research Hospital Orthopedics Clinic, Adana, Turkey. In the radiological evaluation, the hallux valgus angle (HVA), the intermetatarsal angle (IMA), the length of the first metatarsal (ML), and the distal metatarsal articular angle (DMAA) recorded preoperatively and postoperatively were analyzed. The functional results of the operations were evaluated by using the Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and EuroQol (EQ-5D) scores. Postop HVA, IMA, MU, and DMMA values were significantly higher in patients in Group 1 than in patients in Group 2 (p<0.001; p=0.004; p=0.004; p=0.049; p<0.001, respectively). The change in Delta (∆) HVA and EQ-5D values was significantly higher in patients in Group 2 compared to patients in Group 1 (p=0.020; p=0.016, respectively). The easily available and low-cost locking plates produced for mini-fractures may safely be used in distal osteotomy surgery of mild and moderate HV successfully combined with screws if intramedullary-placed, allowing accurate lateralization and improving overall outcome.

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.

Changes in Radiographic Alignment Following Metatarsophalangeal Fusion, Distal Metatarsal Osteotomy, and Lapidus.

The purpose of this study is to evaluate the effect of the different surgical treatments for hallux valgus on various radiographic measures of bunion correction. A retrospective cohort study was conducted at a single academic medical center involving 2 fellowship-trained foot and ankle surgeons. One hundred and nineteen feet (110 patients) were included. Procedures included first metatarsophalangeal (MTP) arthrodesis (n = 88), Chevron and/or Scarf osteotomy (n = 23), and Lapidus (n = 8). Overall, 78.2% of patients were female, mean age was 60.49 (range, 16-81) years, and mean follow-up was 1.20 (range, 0.25-3.92) years. Hallux valgus angle (HVA) significantly differed preoperatively (MTP = 33.33°, Chevron/Scarf = 27.03°, Lapidus = 32.56°; P = .026). There was no difference in distal metatarsal articular angle (DMAA) preoperatively (MTP = 18.87°, Chevron/Scarf = 17.80°, Lapidus = 14.39°; P = .629). At final follow-up, DMAA was significantly greatest among the Lapidus bunionectomy cohort (MTP = 9.63°, Chevron/Scarf = 13.51°, Lapidus = 17.45°; P = .005). There was no difference in infection (MTP = 6.8%, Chevron/Scarf = 4.4%, Lapidus = 0.0%; P = 1.00) or reoperation (MTP = 19.3%, Chevron/Scarf = 21.7%, Lapidus = 12.5%; P = .921) rates between cohorts, although both rates were highest in the first MTP arthrodesis group. Among the 3 hallux valgus corrections studied, Lapidus bunionectomy fared the worst regarding DMAA correction at first follow-up and final follow-up, compared with MTP fusion and distal metatarsal osteotomies. Other radiographic measures showed no significant difference among the groups. Level III: Retrospective cohort study.

Correction of Distal Metatarsal Articular Angle in Hallux Valgus Surgery Utilizing a Minimally Invasive Percutaneous First Metatarsal Distal Transverse Osteotomy

Category: Midfoot/Forefoot; Other Introduction/Purpose: Hallux valgus, a common deformity treated by orthopedic foot and ankle surgeons, can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to the hallux valgus deformity. Minimally invasive (MIS) percutaneous hallux valgus surgery is becoming more popular and often used in patients with increased DMAA. Additional recent literature has shown low rates of recurrence, minimal pain and high patient functional outcomes with MIS hallux valgus correction. Thus, we investigated the efficacy of MIS percutaneous distal transverse first metatarsal osteotomy procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery. We hypothesize that give the ability to obtain a triplanar correction with this osteotomy no additional osteotomy will be needed to correct the DMAA. Methods: A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a MIS percutaneous distal transverse first metatarsal osteotomy between September 2021 to December 2022. Exclusion criteria included patients with inadequate follow up and all patients not undergoing MIS percutaneous distal transverse first metatarsal osteotomy for hallux valgus correction. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre- operative and 2-week post-operative radiographs to assess immediate correction of these angles. Univariate analysis was used to describe pre- and post- measurements for DMAA, HVA, and IMA. Differences in pre- and post- measurements were evaluated using paired t-test. Results: In total, 43 minimally invasive surgery (MIS) hallux valgus corrections on 39 patients were included. On average, the DMAA decreased from 9.5 degrees pre-operatively to 4.8 degrees two weeks post-operatively (decrease of 4.7 degrees, p-value &lt; 0.001). The average HVA decreased from 29.9 degrees pre-operatively to 4.2 degrees two weeks post-operatively (decrease of 25.7 degrees, p-value of &lt; 0.001). Lastly, the average IMA decreased from 15.1 degrees pre-operatively to 2.9 degrees 2 weeks post-operatively (decrease of 12.2 degrees, p-value &lt; 0.001). Conclusion: Our study showed that utilizing a MIS percutaneous distal transverse first metatarsal osteotomy for hallux valgus correction was able to significant reduce the DMAA without the need for supplementary metatarsal osteotomies. Additionally significant correction of the IMA and HVA was also obtained. MIS hallux valgus correction may be considered by orthopedic foot and ankle surgeons for those patients that need surgical correction for hallux valgus deformity that also requires DMAA correction.

Can Distal First Metatarsal Supination Osteotomy, Varization Osteotomy, or a Combination of Both Improve HV Surgical Outcomes? Preliminary Results of a Multicenter Randomized Control Trial

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The outcomes of Hallux Valgus (HV) surgical treatment are perfectible. First ray dysmorphia in HV appears to incorporate a first metatarsal (M1) hyperpronation and a valgus deviation of M1 distal articular surface. Those could play a role in first ray destabilization and misalignment in HV. However, we do not know whether correction of these deformities could improve HV surgical treatment outcomes. Therefore, we performed a study to assess the impact of M1 distal supination osteotomy, M1 distal varization osteotomy, and combination of both on HV clinical and radiological outcomes. We hypothesized that M1 distal supination osteotomies would improve surgical outcomes in HV. Methods: We conducted an IRB-approved multicenter randomized control trial. HV with an indication for surgical correction were included. HV requiring surgery of the lesser metatarsals were excluded. Feet were randomly divided into 4 groups corresponding to 4 different types of surgery (Figure): 1. Control, classical M1 distal chevron. 2. Supination M1 distal chevron 3. Varization M1 distal chevron 4. Combination of the latter two. Preoperative evaluation and 6-months follow-up were performed. Demographics, AOFAS score, complications, and patient satisfaction (Likert Scale) were collected. On conventional weight-bearing radiographs before and 6 months after surgery, we measured the Hallux Valgus Angle(HVA), the Intemetatarsal Angle(IMA) the Distal Metatarsal Articular Angle(DMAA), the Okuda's M1 head shape classification(from round to angular) and the sesamoid position according to Hardy and Clapham. Normality of different variables was assessed using the Shapiro-Wilk test. Groups were compared using ANOVA for normal and Kruskall Wallis for nonnormal variables. Post-hoc pairwise analyses were performed with Dunn-Bonferoni’s test. Results: 100 HV were included. 8 were lost to follow-up. The Control (n=24), Supination (n=20), Varization (n=26) and Combination (n=22) groups were comparable on age, gender, BMI, and preoperative radiological parameters. At 6 months, there was no difference on AOFAS improvement (p=0.39) and patients satisfaction (p=0.14) whereas there were significant differences on HVA (p &lt; 0.001), IMA (p &lt; 0.001), DMAA (p &lt; 0.001), Okuda's classifcation (p &lt; 0.001) and sesamoid position (p &lt; 0.001) between groups. We found lower HVA values for Combination VS Control (p &lt; 0.001), Combination VS Varization (p &lt; 0.001), Supination VS Control (p &lt; 0.001) and Supination VS Varization (p = 0.005). Asymptomatic recurrences (HVA&gt;15°) were present in 5 cases in Control (20.8%), and 2 in Varization (7.7%). Asymptomatic Hallux Varus (HVA &lt; 0°) were present in 4 cases in Combination (18.2%), and 1 in Supination (5%). Conclusion: Distal M1 supination osteotomies showed better improvement in radiological parameters without showing clinical benefit. The combination of supination and varization osteotomies could lead to overcorrection while the classic M1 distal chevron could lead to insufficient corrections. Routinely performing a supination osteotomy in HV surgical management may lead to erroneous correction and we recommend an à la carte treatment. These results are preliminary and we recommend more patients and longer follow-up to confirm these findings.

Minimally Invasive Transverse Distal Metatarsal Osteotomy for Hallux Valgus Correction: Is there a Difference in Outcome Between Moderate and Severe Deformities?

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: We compared the radiological and clinical outcomes of moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon. Methods: Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) greater than 40° or preoperative first-to-second intermetatarsal angle (1–2 IMA) greater than 16°; the moderate group was defined as having an HVA less than 40° and a 1–2 IMA less than 16°. Pre- and postoperative measurements of the HVA, 1–2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The Visual Analogue Scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 Physical Component Summary were used to assess clinical outcomes. Results: Both groups showed significant improvements in all radiologic parameters postoperatively with the degrees of correction greater in the severe group than in the moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups. Conclusion: This study showed that short-term radiographic results for patients with either moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. MITO with screw fixation is a satisfactory surgical option for patients with HV deformities.

Early Radiological Outcome of Minimally Invasive Bunion Correction Using a Guided Trajectory System

Category: Bunion; Other Introduction/Purpose: Hallux Valgus correction with Minimally Invasive Surgery (MIS) is a popular procedure due to its potential advantages such as shorter operative time and quicker recovery than open surgery. Third-generation Minimally Invasive Chevron Akin (MICA) osteotomy has shown excellent clinical and radiological outcomes. The optimal fixation criteria are 3-point fixation (medial cortex, lateral cortex, and the lateral half of the 1st metatarsal head) for the proximal screws and 2-point fixation (medial cortex and central position in the 1st metatarsal head) for the distal one. To address the steep learning curve of the free hand technique, we describe a new guided trajectory system for third-generation MICA to increase precision and reduce the risk of suboptimal K-wire or screw placement. Early radiological outcomes and complications were reported. Methods: From April 2022 to January 2023, 13 consecutive MICAs were performed on 11 female patients (bilateral in 2 patients) with an average age of 61 by a single fellowship-trained foot and ankle orthopaedic surgeon who developed the device. These were the 13 first cases performed with the new device. Preoperative and postoperative intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA) and tibial sesamoid position (TSP) were measured in all patients using weight-bearing radiographs. Also evaluated in the postoperative radiographs were the number of cortical purchase of the screws and their position in the metatarsal head. Additionally, any difficulties or intraoperative complications and operative time were reported. All parameters were analysed with the one-tailed non-parametric Wilcoxon test. Results: All the radiographic parameters improved significantly. The median IMA improved from 14.5 degrees (interquartile range [IQR]: 11.5-16) to 5 degrees (IQR: 4.0-6.0) (p &lt; 0.005). The median HVA also decreased from 27.5 degrees (IQR: 25.3-34.5) to 7.0 degrees (IQR: 4.0-8.5) (p &lt; 0.005). The median DMAA fell from 15.5 degrees (IQR: 13.3-19.3) to 6.0 degrees (IQR: 6.0-8.0) (p &lt; 0.005). The median TSP was 2 (IQR: 2-3) pre-operatively and 0 (IQR : 0-1) (p &lt; 0.005) post-operatively. All the proximal screws for Chevron osteotomy had 3-point fixation and the distal anti-rotation screws had 2-point fixation No intraoperative complications were reported. The mean operative time was 52 (SD:10,4) minutes. Conclusion: Our study demonstrates the successful use of a guided trajectory system for minimally invasive bunion correction with optimal screw placement, good early radiological outcomes, and without extensive operating time. The absence of intraoperative complications or difficulties further confirms the efficacy of this system. Our findings suggest that the use of a guided trajectory system can potentially improve the consistency and success of third-generation MICA procedures. These results emphasize the benefits of incorporating guided trajectory systems in bunion correction surgeries and their potential to improve patient outcomes.

Comparison of Radiographic and Clinical Outcomes between Distal and Proximal Minimally Invasive Chevron and Akin Osteotomy for Severe Hallux Valgus Deformity

Category: Midfoot/Forefoot; Midfoot/Forefoot Introduction/Purpose: The surgical treatment of severe hallux valgus (HV) deformity is challenging due to the difficulty in achieving sufficient reduction and the increased risk of complications such as recurrence, delayed or non-union. Minimally invasive surgery (MIS) has been increasingly used to treat HV deformity, with the third-generation minimally invasive Chevron and Akin osteotomies (MICA) technique being widely accepted. This retrospective cohort study aimed to compare the radiographic and clinical outcomes between the distal and proximal MICA techniques for severe hallux valgus deformity. It was hypothesized that the proximal MICA technique would provide better radiographic results due to the stronger deformity correction achieved by the proximal metatarsal osteotomy. Methods: Seventy-four feet with severe HV (defined as HVA [≥40 degrees] and/or IMA [≥20 degrees]) treated with distal MICA (40 feet) or proximal MICA (34 feet) were included in this study after at least one year of follow-up. Clinical assessment included the American Orthopaedic Foot &amp; Ankle Society (AOFAS) score, pain visual analog scale (VAS), patient satisfaction rating, and complications. Radiographic assessments included HV angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Results: There were no differences in the mean AOFAS score, pain VAS score, and patient satisfaction rate at the final follow-up between the two groups (all p &gt; .05). The mean postoperative HVA, IMA, and DMAA significantly improved at the final follow-up in both groups (all p &lt; .001). There was no significant difference in the improvement of radiographic values after surgery between the two groups (all p &gt; 0.05). Although not statistically significant, there was a trend toward a higher recurrence and delayed or nonunion rate in the distal MICA group (7.5% vs. 2.9%, P =.218 and 10% vs. 2.9%, P =.072). Conclusion: Both types of minimally invasive techniques resulted in satisfactory outcomes in terms of significant improvement in clinical values, large deformity correction, and reasonable complication rates. However, the proximal MICA technique appears to provide more stable maintenance of deformity correction than the distal technique.

Long Hallucal Tendon Force Vectors and First Metatarsophalangeal Deformity After Hallux Valgus Surgery

Category: Midfoot/Forefoot Introduction/Purpose: Recurrence is one of the most common complications following hallux valgus surgery. Moreover, hallux varus occurs in cases of overcorrection. We aimed to quantitatively measure, using radiographic examination, the dynamics of the soft tissues that act on deformities (recurrence of valgus and occurrence of varus) after the surgery. Methods: This retrospective single-institution study included 60 patients (98 feet) who underwent hallux valgus surgery between 2009 and 2018. According to radiographic findings of the foot under weightbearing conditions at postoperative month 1, we examined the tendons’ pathway and calculated the forces on the first metatarsophalangeal joint, which we termed the deformity force angle (DFA). We compared whether there was a significant difference in DFAs between the groups in which deformities occurred and those in which deformities did not occur after correction. In addition, the DFA was compared to known radiographic measurements of hallux valgus recurrence (hallux valgus angle, distal metatarsal articular angle, intermetatarsal angle, and sesamoid position) to assess association with recurrence. Results: We observed a significant difference in the DFA between patients with and without hallux valgus recurrence (P &lt; .001) and between those with and without hallux varus (P &lt; .001) based on standing radiographs taken at a minimum of 6 months postoperation. For predicting the deformities, the areas under the curve were 0.863 (hallux valgus recurrence) and 0.831 (hallux varus occurrence), respectively, which was greater than other factors evaluated. The DFA values greater than 9.5 degrees and less than 5.5 degrees were associated with the recurrence of valgus and occurrence of varus, respectively. Conclusion: In our study, DFA was associated with hallux valgus recurrence when it exceeded 9.5 degrees and hallux varus when it was less than 5.5 degrees. Moreover, in the hallux valgus surgery we performed, a DFA from 5.5 to 9.5 degrees appeared to be a “safe zone” for preventing early deformity after surgery.

Minimally Invasive Distal Metatarsal Osteotomy for Juvenile Hallux Valgus Correction: A Retrospective Radiographic Evaluation

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The minimally invasive distal metatarsal osteotomy (MIDMO) is an increasingly popular technique for hallux valgus (HV) correction in the adult population. In juveniles, however, the use of minimally invasive methods to surgically resolve HV remains a comparatively new and under-reported concept. The primary objectives of this retrospective review are to provide radiographic findings of pediatric patients who underwent surgical correction of HV via the minimally invasive distal metatarsal osteotomy (MIDMO). Secondary objectives are the utilization of the mechanical axis of the first metatarsal to measure pre- and postoperative radiographic outcomes and time to osseous consolidation. Methods: A multi-center retrospective review was performed of two institution system’s records was conducted for consecutive patients who underwent surgical correction for HV between January 2012 and June 2022. Patients were included if they underwent HV correction using MIDMO, were aged &lt; 18 years, had ≥ 3 months of clinical and radiographic follow-up, and had radiographs on file of both pre- and postoperative anteroposterior (AP) and lateral views. The first IMA (anatomic and mechanical axes), hallux abductus angle (HAA), distal metatarsal articular angle (DMAA), and tibial sesamoid position (TSP) were measured in pre- and postoperative AP and lateral views. A paired sample t-test was used to compare pre- and postoperative absolute radiographic measured angles. Results were considered statistically significant at the 5% (P &lt; 0.05) level. Results: Forty-two feet amongst 30 patients met the inclusion criteria. Twenty seven were female (90%) and 3 of whom were male (10%). Temporary pin fixation (23.8%) or screw fixation (76.2%). Mean patient age was 15.2 years. Mean follow-up was 13.7 months. Mean time to osseous consolidation was 6.7 weeks. A statistically significant reduction was noted in all the radiographic values of every angle measured from preoperative to postoperative. The mean first anatomic IMA changed from 14.52° to 3.53° postoperatively and the first mechanical IMA changed from 14.24° to 4.64° postoperatively. The mean HAA was reduced from 32.98° to 12.83° postoperatively, the mean DMAA shifted from 12.40° to 2.93° postoperatively, and the mean TSP was revised from 3.60° preoperatively to 1.07° postoperatively. Conclusion: This is the first retrospective North American radiographic review in the known literature that evaluates short-term results of juvenile HV correction utilizing the MIDMO. Our results support the conclusion that the MIDMO is an effective method for pediatric patients with HV and provides statistically significant radiographic correction. Additionally, our results support the versatility of the mechanical axis in evaluating pre- and postoperative radiographic outcomes of the first IMA. We recommend future larger efforts with greater patient populations and longer follow-up times for further investigation.

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

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. 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. 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). 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.

Comparison of Lapidus procedure fixation methods for hallux valgus: a 10-year retrospective analysis

Background: The purpose of this study was to identify the type of Lapidus fixation method used in Leeds Teaching Trust Hospital that produces the best post-operative radiographical measurements. Methods: Thirty-five patients who underwent the Lapidus procedure were reviewed. Pre-operative and post-operative X-rays were measured to obtain angles; hallux valgus angle (HVA), first intermetatarsal angle (IMA), distal metatarsal articulate angle (DMA), meary angle (MA), and metatarsal declination angle (MDA). The fixation groups compared were dorso-medial plate vs dorsal plate vs medial plate and plate-single screw versus plate-crossed screw. The change in angle (Δ-angles) between pre-operative and post-operative were measured and the groups were compared. The fixation method that resulted in the largest Δ-angles and is statistically significant will be regarded as a superior fixation type within that group. Results: Groups with plate-single screw fixation showed a statistically significant (p&lt;0.05) larger change in distal metatarsal articulate angle compared to plate-crossed screw fixation. Dorso-medial plate showed largest Δ-angles in the plate group although none were statistically significant. Conclusions: Fixation systems with single-screw result in better radiographical measurements compared to crossed-screws, significantly with the distal metatarsal articular angle. Dorso-medial plates result in better radiographical measurements followed by dorsal plate and then medial plate. However, these findings need validation with a randomized controlled trial before being generalized.

Minimally Invasive Transverse Distal Metatarsal Osteotomy (MITO) for Hallux Valgus Correction: Early Outcomes of Mild to Moderate vs Severe Deformities.

We compared the radiological and clinical outcomes of mild to moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon. Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) >40 degrees or preoperative first-to-second intermetatarsal angle (1-2 IMA) >16 degrees; the mild to moderate group was defined as having an HVA <40 degrees and a 1-2 IMA <16 degrees. Pre- and postoperative measurements of the HVA, 1-2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The visual analog scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 physical component summary were used to assess clinical outcomes. A total of 116 feet were included in this study and median follow-up period of 29.0 months (range, 24-52 months). Both groups showed significant improvements in all radiologic parameters postoperatively, with the degrees of correction greater in the severe group than in the mild to moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups. This study showed that short-term radiographic results for patients with either mild to moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. In this series, we found MITO with screw fixation to be a satisfactory surgical option for patients with mild to severe HV deformities. Level III, retrospective comparative study.