Distal Metatarsal Osteotomy Research Articles

Effect of Mini-invasive Floating Metatarsal Osteotomy on Plantar Pressure in Patients With Diabetic Plantar Metatarsal Head Ulcers.

Background:Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study’s purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers.Methods:We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year.Results:Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa (P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s (P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics.Conclusion:This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence.Level of Evidence:Level III, retrospective case series of prospectively collected data.

Hallux Valgus Correction: Comparison of Minimally Invasive Transverse and Chevron Distal Metatarsal Osteotomy Constructs

Category:Basic Sciences/Biologics; BunionIntroduction/Purpose:Hallux valgus is one of the most common surgically corrected forefoot deformities. Compared to open procedures, minimally invasive treatment of hallux valgus has resulted in decreased operative time, reduced complication rates, and greater patient satisfaction. Until recently in the United States, distal chevron osteotomies have been the standard for hallux valgus correction of moderate deformity. To the best of the authors’ knowledge, no studies have evaluated biomechanical strength of transverse and chevron distal metatarsal osteotomy constructs. The purpose of this study was to evaluate the biomechanical strength of transverse and chevron minimally invasive osteotomy techniques using 9 matched cadaveric pairs.Methods:A total of nine matched cadaveric specimens were randomized to transverse or chevron distal metatarsal osteotomies. Each minimally invasive surgical technique was performed by a fellowship trained orthopedic foot and ankle surgeon. Anterior- posterior and lateral radiographic images were obtained following surgical fixation. Biomechanical testing was performed on an Instron Mechanical System. Ultimate load to failure, yield load, and stiffness were assessed across the fixation construct with fulcrum within the metatarsal shaft proximal to screw fixation and compression load at the sesamoid bones. A pre-load of 10N was applied to the sesamoid bones by the compression post to stabilize the sample. Subsequently, a compression rate was applied to the sample at 10mm/min until failure was observed. Mean and standard deviations were assessed and compared across cohorts.Results:All nine cadaveric specimens were male. There was no difference in average percent metadiaphyseal shift among transverse (36%) and chevron (38%) osteotomies. The most common mode of failure among transverse and chevron osteotomies was fracture at screw insertion site (55.6%), followed by failure at osteotomy site (44.4%). One paired sample was noted to have poor bone quality prior to biomechanical testing. There was a trend towards increased ultimate load to failure (p=0.480) and stiffness (p=0.438) among transverse osteotomy compared to chevron osteotomy, however, no statistically significant difference was observed.Conclusion:Biomechanical testing demonstrates no statistical difference in ultimate load to failure and stiffness between minimally invasive transverse and chevron distal metatarsal osteotomy constructs. A trend towards increased ultimate load and stiffness in the transverse osteotomy cohort was observed. Chevron osteotomies violate the entire plantar cortex and may result in early failure by relative ease of cutout through cancellous bone compared to transverse osteotomies in which failure would require cortical bone cutout. Future studies are required to evaluate strength of construct in a larger sample. Analysis is limited, healing may provide additional strength that is not simulated in cadaveric studies.

Outcomes after Minimally Invasive Chevron/Akin Procedure and Strategies to Optimize Outcomes

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:Minimally invasive surgery (MIS) is being increasingly used for bunion deformity correction. New third generation minimally invasive chevron/akin (MICA) techniques are used but limited data on patient outcomes have been reported. The goal of this IRB-approved study was to look at outcomes of percutaneous, extra-articular distal metatarsal osteotomies for mild to moderate bunion deformity, including the degree of deformity correction obtained, patient pain control, and complication rates. We also describe strategies for avoiding the intra-operative and post-operative complications that may arise with MIS bunion surgery.Methods:The participants were the treating surgeon’s first 75 consecutive patients 18 years and older who were treated with MICA procedures. Via retrospective chart review, outcome measures including pre and final post-operative intermetatarsal angles (IMA), hallux valgus angles (HVA), visual analogue scale (VAS) score, and complication rates were assessed. Statistical analysis was done utilizing student’s t-test for continuous variables and chi square test for categorical variables.Results:Average follow-up was 105.0 days. VAS scores dropped one week post-operatively, from 5.4 pre-operatively to 2.5 (p< 0.05). IMA angles improved from 12.7 degrees (range 6.1-18.1) pre-op to 6.1 (range 1.2-12.5) at final follow-up (p< 0.05). HVA angles improved from 27.2 degrees (range 9.7-43.4) to 10.4 (range 1.3-25.9) (p<0.05). A major infectious complication occurred in one patient, requiring operative irrigation/debridement and hardware removal. Another patient had a DVT treated successfully with medication. Minor complications included intra-operative fracture (3 patients), persistant paresthesias (3), cellulitis (1), minor loss of reduction (2), hardware prominence/backout (3) and medial prominence pain (3). One patient had surgical removal of a prominent screw head one year after surgery. Complication rates were similar between the first and second half of patients chronologically.Conclusion:Our data suggests that MICA osteotomies are associated with rapid, significant improvement in pain scores, significant deformity correction, and low frequency of major complications. While there is a learning curve, MICA is a reproducible technique, is safe, and allows immediate post-operative weightbearing. All osteotomies achieved union, and there were no tendon injuries. Only two patients required a second surgery. We also present strategies to avoid and limit pitfalls and complications encountered with the procedure. Although our data is exciting, additional studies looking at long-term outcomes, larger sample sizes, and more physicians should be conducted.

Clinical study of Youngswick versus distal oblique osteotomy in the treatment of grade Ⅲ and Ⅳ hallux rigidus

Objective: To investigate the clinical outcomes and effects of distal oblique osteotomy and the Youngswick osteotomy in the treatment of grade Ⅲ and Ⅳ hallux rigidus. Methods: Totally 29 patients (33 feet) suffered from grade Ⅲ and Ⅳ hallux rigidus who received the distal first metatarsal osteotomy in Ningbo NO.6 Hospital from May 2013 to December 2018 were analyzed retrospectively. Among them, there were 10 males and 19 females. The average age was (56±6) years. Seventeen cases (18 feet) underwent distal oblique osteotomy of the first metatarsal, 12 cases (15 feet) underwent the Youngswick osteotomy. The overall clinical evaluations were investigated before the operation and at the final follow-up, included the visual analogue scale (VAS) of the pain, American Orthopedic Foot & Ankle Society (AOFAS) scores, the motionrange of the first metatarsophalangeal joint and the first metatarsophalangeal joint space. The data before and after operation were compared by paired t test and non-parametric rank sum test. Results: The operation time were (1.1±0.2) hours and (1.3±0.1) hours, and the intraoperative bleeding was 35 (25, 36) ml and 35 (30, 40) ml in the distal oblique osteotomy and Youngswick osteotomy respectively. All patients were followed up for 12 to 46 months. No nonunion or delayed union occurred in all patients. All patients did not need to be operated again, and no complications such as transferring metatarsalgia, infection and osteonecrosis occurred. In the two groups, the pain VAS score decreased significantly (Z=-3.8, -3.5, both P<0.01), the first metatarsophalangeal joint dorsal extension activity increased (Z=-3.7, -3.4, both P<0.01), the AOFAS score increased (t=28.0, 15.4, both P<0.05) and the first metatarsophalangeal joint space also improved significantly (t=17.7, 14.6, P<0.05) after the operation. There was no significant difference in VAS score, the first metatarsophalangeal joint activity and Horton index between the two groups(Z=-1.3, -0.3, -0.4, all P>0.05), and there was no statistical difference inAOFAS score (t=0.1, P>0.05). But compared with it in the first distal oblique metatarsal osteotomy, the joint space with the Youngswick osteotomy after the operation was larger ((2.4±0.3) mm vs (2.1±0.4) mm, t=2.2, P=0.04). Conclusions: The oblique metatarsal osteotomy and Youngswick osteotomy can effectively relieve the pain of the hallux rigidus, increase the dorsal extension activity and joint space of the first metatarsophalangeal joint, sink the first metatarsal head, and improve the living conditions of the patients. The results of the distal metatarsal osteotomy and the Youngswick osteotomy in the treatment of stage Ⅲ and Ⅳ patients with rigid are similar, which can delay the progress of the disease.

Minimally invasive vs open distal metatarsal osteotomy for hallux valgus - A systematic review and meta-analysis

BackgroundNumerous publications of the late 20th century have presented the radiological outcome of open technique for distal metatarsal osteotomy for mild to moderate hallux valgus and the clinical outcomes by means of well-established scoring systems which have been published and make these open techniques today’s benchmark and gold standard. Minimally invasive procedures reduce surgical trauma because they are performed without large incisions, and injury to the soft tissues is limited. This has the theoretical advantages of improved recovery and decreased rehabilitation times. There is however limited literature to prove the same for minimally invasive surgery for hallux valgus.Our aim was thus to pool all available comparative literature on minimally invasive hallux valgus surgery done for mild to moderate hallux valgus versus open surgical approaches. MethodsA PubMed, Embase and Scopus search was performed using the keywords (‘hallux valgus’ OR bunion) AND (‘minimally invasive’ OR percutaneous) AND osteotomy. A total of 473 records were identified and out of which nine studies were included in the final review. ResultsMost available studies are either randomized control trials, or prospective cohort studies providing good level of evidence. Radiological analysis showed similar correction with both MIS and open osteotomies. In functional analysis results were different with open techniques providing better results in terms of AOFAS score. (p < 0.0001). VAS score and complication rate were similar in both groups. Discussion/conclusionWe conclude that based on available literature MIS provides equivalent radiological outcomes with respect to open surgery but functionally despite the promising results (good to excellent in most series), the outcomes in terms of function are not as good as open surgery. MIS techniques provide satisfactory outcomes for mild-to-moderate severity of hallux valgus though not as good as open surgery. There is evolving literature for this relatively new procedure. Longer duration of follow up and bigger numbers would allow for more meaningful data analysis and conclusions to be drawn as more studies come forward.

Treatment of Adolescent Hallux Valgus With Percutaneous Distal Metatarsal Osteotomy.

Background. Hallux valgus is a complex deformity of the first ray of the foot, and a significant number of adolescents develop this deformity. More than 130 surgical procedures have been described to treat hallux valgus, but there is no compelling evidence to prefer one method over another. Minimal invasive techniques have been proposed and reported to be successful and cost-effective. The objective of this study was to describe the clinical course of adolescent patients treated with percutaneous distal metatarsal osteotomy. Methods. A retrospective study included patients who had a percutaneous hallux valgus correction during the years 2008 to 2015. The following measurements were compared before surgery up to last follow-up: AOFAS Hallux-Metatarsophalangeal-Interphalangeal questionnaire and radiological measurements (HVA, IMA, DMAA). Any postoperative complications were extracted from the medical records. Results. The procedure was performed on 32 feet (27 patients). All patients were <18 years of age. There were 10 male patients (12 feet) and 17 female patients (20 feet). Average age at surgery was 15.8 years (range = 13-18 years). Average follow-up time was 43 months (range= 24-94 months). The average AOFAS score before surgery was 66, and after surgery, at last follow-up was 96. This difference was significant (P value <.0001). Most patients were pain free after the procedure and returned to appropriate age functioning. Significant improvement was noted in all radiological criteria. Conclusions. Percutaneous distal metatarsal osteotomy is safe, reliable, and effective for the correction of mild to moderate symptomatic hallux valgus in adolescents.Levels of Evidence: Level IV.

Functional outcomes of percutaneous correction of hallux valgus in not symptomatic flatfoot: a case series study.

Hallux valgus (HV) and Pes Planus (PP) are two common conditions characterized by aesthetic dissatisfaction with or without pain. The aim of the study was to assess clinical and functional outcomes at two years follow-up of percutaneous surgery in patients with HV and concomitant not-symptomatic PP. From January 2014 to May 2015 a total of 12 females and 2 males (14 feet) were enrolled in the study (mean age 41.9±13.28). The inclusion criteria were patients with HV surgically treated with the percutaneous approach, mild or moderate not symptomatic PP at 24 months follow-up. Percutaneous distal metatarsal osteotomy and exostectomy is performed for all patients and followed by a weekly bandage. American Orthopaedic Foot and Ankle Society (AOFAS) score for HV (AOFAS-HV), patient satisfaction, and preoperative and postoperative X-ray at 6 weeks follow-up were evaluated. Numerical data are reported as the mean± SD and 95% confidence intervals. The pre-operative hallux valgus angle (HVA) was 30.14°±11.26°, the post-operative HVA was 18.36°±10.13 with a mean correction of 11.79°±2.67° with p<0.0001. Mean AOFAS-HV increased from 42.07±10.82 pre-operatively to 83±8.96 post-operatively with p<0.0001. One out of 14 patients had recurrence of HV without needing revision surgery at the last follow-up. All patients were satisfied with the clinical outcomes. Our results suggested that percutaneous osteotomy with the mini-burr is an effective treatment for patients with HV despite PP presence, even if the mean functional score was slightly worse when compared with the literature. (www.actabiomedica.it)

Radiographic Outcomes of a Percutaneous, Reproducible Distal Metatarsal Osteotomy for Mild and Moderate Bunions: A Multicenter Study

Hallux valgus is a prevalent condition. Many open surgical methods of correction have been described. We performed a percutaneous, extra-articular distal metatarsal osteotomy for mild to moderate bunion deformity. The minimally invasive technique was used in 217 feet (180 patients; age 49 ± 4.7 years, mean ± standard deviation) at 4 centers in North America (Center 1: November 2012 to March 2017; Center 2: January 2010 to May 2016; Center 3: October 2013 to June 2016; Center 4: January 2015 to June 2017). The procedure was used in simultaneous bilateral cases in 28 patients (15.6%) and in nonsimultaneous bilateral cases in 9 patients (5.0%). Immediate postoperative weightbearing was used in all cases. The mean preoperative intermetatarsal angle, hallux abductus angle, and tibial sesamoid position were 14.6° ± 3.5°, 30.7° ± 7.8°, and 5.4 ± 1.4, respectively. At final follow-up of 9.3 ± 6.1 months, the mean intermetatarsal angle, hallux abductus angle, and tibial sesamoid position were 4.7° ± 2.8°, 8.4° ± 6.1°, and 2.0 ± 1.0, respectively (p < .0001 for all comparisons). No major complications were noted. All 217 osteotomies achieved union; 3 feet (1.4%) in 3 patients (1.7%) experienced asymptomatic malunion. Superficial pin-site infection was seen in 42 (19.4%) of the 217 feet (39 patients, 21.7%). The radiographic results of this percutaneous technique appear to be reproducible across multiple centers, and the technique is useful when correcting intermetatarsal and hallux abductus angles. This percutaneous osteotomy for realignment of the first ray allows immediate postoperative weightbearing and, in this initial review, appears to be safe and effective, even in simultaneous bilateral cases.

Radiographic Outcomes after Fixation of Distal Metatarsal Osteotomy for Hallux Valgus Using a Tension Band Construct

Category:BunionIntroduction/Purpose:Hallux valgus is a common deformity of the forefoot. There are over 130 procedures described to correct hallux valgus. Classically, the treatment of mild to moderate hallux valgus is with a distal metatarsal osteotomy. A variety of fixation techniques have been described for use with this osteotomy most of which require partial or non-weight bearing until the osteotomy is healed. Tension Band fixation is a well-known principle in orthopedic surgery. The goal of the present study is to radiographically assess the maintenance of distal first metatarsal osteotomy fixation using a novel tension band device (Re+Line tension band bunion plate system, Nextremity Solutions) with immediate post-operative weight-bearing.Methods:The patient database for one surgeon was retrospectively reviewed for patients that underwent hallux valgus correction with the Re+Line tension band device between 2014 and 2017. Postoperative protocol included a soft dressing, firm surgical shoe, and weight-bearing as tolerated with a cane. Patients were excluded if fixation was achieved with something other than a tension band construct. Radiographs were obtained and reviewed retrospectively by 3 authors. Pre and postoperative hallux valgus (HVA) and intermetatarsal angles (IMA) were measured as described previously in the literature, and the changes in correction compared. Maintenance of correction and hardware integrity were assessed at final follow-up after weight bearing as tolerated in a surgical shoe in the postoperative period. Statistical analysis was performed using a Wilcoxon signed-rank test for the changes in HVA and IMA.Results:There was a total of 72 patients and 76 toes that underwent hallux valgus correction with a tension band construct, at a mean follow-up of 4.36 months. 68 of 72 patients were female. The average age was 60.8 years old. The mean preoperative HVA was 27.1 degrees. The mean postoperative HVA was 6.14 degrees, with a mean correction of 20.22 degrees (p<0.001). The mean preoperative IMA was 14.14 degrees. The mean postoperative IMA was 6.10 degrees, with a mean correction of 7.98 degrees (p<0.001). There was loss of reduction found in 6 of 76 toes (7.89%).There were zero cases of hardware failure. All osteotomies healed at final follow-up.Conclusion:This study shows successful radiographic outcome after hallux valgus correction using a tension band construct and allowing immediate full weight-bearing in a surgical shoe in the postoperative period. Significant deformity correction was achieved and maintained and all osteotomies healed. The Re+Line tension band bunion correction system can be safely used as a successful option to fix distal first metatarsal osteotomies, while allowing patients to fully weight bear in a surgical shoe postoperatively and potentially return to activities faster than when using traditional fixation methods. Future studies are needed to assess functional outcomes and patient satisfaction with this novel technique.

A Novel Technique for Moderate Hallux Valgus Correction: The BC Osteotomy

Category:BunionIntroduction/Purpose:Surgical correction of hallux valgus rebalances the first ray, correcting the various features of the deformity. While several surgical methods are available, consensus regarding the best management has yet to be established.In the last decades, there was an increasing interest in mini-invasive procedures. In this scenario the Bosch technique appears to be a reproducible DMO to achieve proper correction. Theoretically, it allows for fast and safe correction of the deformity, however it was criticized for its unstable nature.We describe a new distal metatarsal osteotomy (DMO) that it is a combination of the (traditional) chevron and the (mini-invasive) Bosch-SERI techniques.The purpose of this investigation is to describe the surgical technique and report the results of this modified procedure at a minimum 2-year follow-up.Methods:Between January 2016 and June 2018, 63 consecutive patients, with mild to moderate hallux valgus deformity underwent corrective surgery using the BC technique.Preoperatively, each patient’s data was recorded and all patients underwent an assessment of functional limitation and pain level as well as a physical examination that included measurement of the passive range of motion of the first metatarsophalangeal joint. At final follow up, the patients were assessed using the American Orthopaedic Foot & Ankle Society’s (AOFAS) hallux- metatarsophalangeal and interphalangeal scale. Additionally, patients were asked to rate their satisfaction with regard to the overall result of the operation according to the Coughlin overall satisfaction scale. Anteroposterior and lateral weight-bearing radiographs were made preoperatively as well as at the short-term and intermediate-term follow-up evaluations. The HVA, the first IMA, and the congruency of the first metatarsophalangeal joint were measured with the technique recommended by the AOFAS.Results:BC osteotomy was performed in 62 patients, including 33 right feet and 29 left feet, with no bilateral procedures. The patient population consisted of 50 females (79%), with an average age of 50.4 years (range 19 to 75) years. The mean follow-up time was 36.5 months (range 23 to 59). The mean AOFAS score improved from 69.3 preoperatively to 88 postoperatively (p<0.001).IMA and HVA pre and postoperative improved from a median of 30.7 degrees to 11.1 degrees for HVA and 13.9 degrees to 6.5 degrees for the IMA (p<0.001).82.5% of patients were very satisfied / satisfied with the procedure. There were no cases of infection, however we observed two cases of complex regional pain syndrome and two screws that required removal.Conclusion:We believe this osteotomy has a number of advantages: (1) one mini-invasive approach is used; (2) a large correction can be obtained in all directions including the frontal and sagittal planes; (3) blood supply to the metatarsal head is preserved; and (4) intrinsically stable OT, allowing immediate full weight bearing. The merge, of percutaneous techniques and classic stable fixed approach may seems to offer a stable, effective and reproducible correction of hallux valgus deformity with the advantages of a minimally-invasive technique

The Hallux Metatarsophalangeal Capsule: An Anatomic Study with Respect to Percutaneous Hallux Valgus Correction

Category:BunionIntroduction/Purpose:Minimally invasive surgery for the treatment of hallux valgus deformities has become increasingly popular. Knowledge of the location of the hallux MTP proximal capsular origin on the metatarsal neck is critical for surgeons in planning and executing extra-capsular corrective osteotomies. A cadaveric study was undertaken to further study this anatomic relationship.Methods:Ten nonpaired fresh-frozen frozen cadaveric specimens were used for this study. Careful dissection was performed, and the capsular origin of the hallux MTP joint was measured from the central portion of the metatarsal head in the medial, lateral, dorsal, plantarmedial, and plantarlateral dimensions.Results:The ten specimens had a mean age of 77 years, five female and five male. The mean distances from the central hallux metatarsal head to the MTP capsular origin was 15.2 mm dorsally, 8.4 mm medially, 9.6 mm laterally, 19.3 mm plantarmedially, and 21.0 mm plantarlaterally.Conclusion:The MTP capsular origin at the hallux metatarsal varies at different anatomic positions. Knowledge of this capsular anatomy is critical for orthopaedic surgeons when planning and performing minimally invasive distal metatarsal osteotomies for the correction of hallux valgus.

Efficacy of Intramedullar Locking Plate in Mild to Moderate Hallux Valgus Deformity: Early Outcomes

Aim: Hallux valgus is a complex deformity of the first metatarsophalangeal joint characterized by varus deformity of the first metatarsal bone, valgus deformity of the big toe, and lateral deviation of the extensor tendons and sesamoid bones. Several surgical methods have been described for correction of the deformity. Distal metatarsal osteotomy is a commonly used procedure in mild-to moderate hallux valgus. Different materials have been used for the fixation of osteotomy. The aim of this study was to evaluate radiological and clinical efficacy of intramedullar locking plate in hallux valgus surgery.Material and Methods: Postoperative 6th month data of patients with mild-to moderate hallux valgus deformity who underwent distal metatarsal osteotomy using an intramedullary locking plate between 2012 and 2014 were evaluated retrospectively. The surgical procedure was applied by Mitchell technique. Clinical and radiological features of the patients were analyzed.Results: Thirty-six (29 female, 7 male) patients whit a mean age of 51.00±12.96 years were enrolled the study. Eight patients underwent bilateral surgery. There were statistically significant improvement in hallux valgus angle, distal metatarsal articular angles, and American Orthopaedic Foot and Ankle Society hallux valgus scores in the postoperative 6th month (all p values &amp;lt;0.001). No statistically significant difference were found between the preoperative and postoperative 6th month inter-metatarsal angle values (p=0.058).Conclusion: The intramedullar locking plate usage in surgery of mild-to moderate hallux valgus deformity is an effective method providing strong fixation and quick recovery that led patients to gain an early improvement in the daily life activities.

Evaluation of results after distal metatarsal osteotomy by minimal invasive surgery for the treatment of metatarsalgia: patient and anatomical pieces study

BackgroundMetatarsalgia of the lesser toes is a common cause of consultation in the podiatric clinic. However, there continues to be a controversy with respect to which is the best surgical technique, and there is few information in the literature regarding objectively comparable results in percutaneous surgery.MethodsThe second metatarsal bones of 30 feet belonging to patients who had attended the podiatric clinic were studied before and after distal metatarsal pecutaneous osteotomy. The degree of shortening of the second metatarsal (RX) and the degree of functional recovery and perception of the well-being of the patient (AOFAS) were evaluated retrospectively.The same bones of 10 cadaveric feet were also studied. The surgical procedure was identical to that used on patients, and electronic callipers were employed to take measurements of the second metatarsal. The integrity of the plantar plate was checked visually.ResultsThe mean shortening of the second metatarsal bone, as determined by the radiological study, was 2.76 mm. After an average follow-up period of 1.5 years, the final mean score on the AOFAS scale was 95.26 points. In none of the cases was the mobility of the metatarsophalangeal (MTP) joint affected. The mean shortening in the cadaveric feet was 2.10 mm, and in all cases, the plantar plate and flexor apparatus were perfectly preserved.ConclusionsPercutaneous osteotomy achieved, in our study, a lower degree of shortening than Weil’s surgery, according to the data published in the literature. However, it shows good clinical results without causing problems of consolidation or rigidity in the MTP joint. Neither, with the caution that should be taken due to the use of experimental cadaver models, damage of the flexor apparatus of the foot is observed. These results suggest that this could be a safe and effective surgical procedure to be considered for metatarsalgias of the lesser rays.

New Persistent Opioid Use Following Common Forefoot Procedures for the Treatment of Hallux Valgus.

Orthopaedic surgeons are the fourth highest on the list of top prescribers of opioid analgesics by specialty and have a direct impact on opioid-related morbidity in the United States. Operative bunion correction is one of the most commonly performed elective foot surgical procedures in this country. We sought to determine the rate of new persistent opioid use following exposure to opioids after surgical treatment of hallux valgus (bunionectomy) and to identify associated risk factors. A nationwide U.S. insurance claims database, Truven Health MarketScan, was used to identify opioid-naïve patients who underwent surgical treatment of hallux valgus employing 3 common procedures from January 2010 to June 2015. The rate of new persistent opioid use (i.e., fulfillment of an opioid prescription between 91 and 180 days after the surgical procedure) among patients who filled a perioperative opioid prescription was then calculated. A logistic regression model was used to examine the relationship between new persistent use and risk factors, including surgical procedure, patient demographic characteristics, and patient comorbidities. A total of 36,562 patients underwent surgical treatment of hallux valgus and filled a perioperative opioid prescription. The rate of new persistent opioid use among all patients who filled a perioperative opioid prescription was 6.2%. Patients who underwent treatment with a first metatarsal-cuneiform arthrodesis were more likely to have new persistent opioid use compared with the distal metatarsal osteotomy control group (adjusted odds ratio, 1.19 [95% confidence interval, 1.03 to 1.39]; p = 0.021). Factors independently associated with new persistent opioid use included prescribing patterns, coexisting mental health diagnoses, and certain pain disorders. New persistent opioid use following surgical treatment of hallux valgus affects a substantial number of patients. Understanding factors associated with persistent opioid use can help clinicians to identify and counsel at-risk patients and to mitigate this public health crisis. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sliding Distal Metatarsal Minimally Invasive Osteotomy (S-DMMO) for the Treatment of Tailor’s Bunion

Bunionette, or Tailor’s bunion, refers to a painful lateral prominence at the fifth metatarsal head. Metatarsal osteotomies have proved to be a successful treatment, and have been described at the distal, diaphyseal, and proximal levels. Distal metatarsal osteotomies have been reported as effective in bunionette correction in several clinical studies. In the last decade, there has been a growing interest in the use of percutaneous or minimally invasive surgery for the treatment of this condition. Minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) has proved to be successful when treating metatarsalgia. We present a surgical technique consisting in a distal osteotomy of the fifth metatarsal, which resembles DMMO, but requires a lateral displacement. We retrospectively investigated 38 feet from 32 patients with symptomatic bunionette deformity and showed good to excellent functional and clinical results. The S-DMMO proved to be a safe (low complication rate) and effective (adequate clinical results and powerful radiologic correction) procedure for the treatment of bunionette deformity.Level of Evidence:Diagnostic Level 4. See Instructions for Authors for a complete description of levels of evidence.

Distal Linear Metatarsal Osteotomy Combined with Akin Osteotomy for Hallux Valgus with Hallux Valgus Interphalangeus

Background: Minimally invasive distal linear metatarsal osteotomy is commonly performed to correct mild-to-moderate hallux valgus. The technique is easy to perform, fast, and has a low complication rate with satisfactory clinical results. However, it has so far not been applied to hallux valgus with concomitant hallux valgus interphalangeus deformity. Objective: We aimed to investigate the short-term clinical results of distal linear metatarsal osteotomy combined with Akin osteotomy in hallux valgus with concomitant hallux valgus interphalangeus deformity. Methods: We retrospectively reviewed 10 patients (10 feet) who underwent surgery for hallux valgus with hallux valgus interphalangeus between 2012 and 2016. Akin osteotomy was performed and fixated with a screw/K-wire, followed by distal linear metatarsal osteotomy and K-wire fixation. Clinical evaluations pre- and postoperatively used the Japan Society for Surgery of the Foot (JSSF) scale and the Visual Analog Scale (VAS). Radiography pre-and postoperatively assessed the hallux valgus, hallux valgus interphalangeus, and the intermetatarsal angle. Results: The mean follow-up period was 20.2 months. Both the JSSF and VAS score improved significantly, from 64.5 to 90.0 and from 5.5 to 1.1, respectively. In all patients, bone healing was complete within four months with no osteonecrosis of the metatarsal head or malunion at the osteotomy site. The hallux valgus angle improved from 31.5° to 7.7°, the hallux valgus interphalangeus angle from 17.2° to 5.8°, and the intermetatarsal angle from 11.7° to 5.5°. Conclusion: Distal linear metatarsal osteotomy combined with Akin osteotomy safely and effectively corrects mild-to-moderate hallux valgus with hallux valgus interphalangeus deformity.

Assessment of the efficacy of SERI osteotomy for hallux valgus correction

BackgroundSERI (Simple, Effective, Rapid, and Inexpensive) osteotomy is an accepted minimally invasive distal first metatarsal osteotomy performed to correct hallux valgus (HV). In the absence of reports of efficacy of the SERI technique in the Middle East, we studied 1-year outcomes of SERI osteotomy performed at our hospital in Saudi Arabia.MethodsWe reviewed the medical charts of patients aged 20 to 60 years who underwent SERI osteotomy for HV between August 2013 and September 2016 and identified 29 patients, 2 (6.9%) men and 27 (93.1%) women, who met the criteria for inclusion in the study. Patients’ clinical and operative characteristics were examined, their pre- and postoperative (1-year) radiographic measurements were compared, and the occurrence of any postoperative complication/event was noted.ResultPatients’ mean age was 34.9 ± 13.6 years. Six patients (20.7%) were treated for severe HV. Mean operation time was 11.1 ± 2.3 min. Four patients (13.8%) reported postoperative pain. No revision surgery was done. Congruency of the hallux metatarsophalangeal joint increased significantly, documented in only 4 patients (13.8%) preoperatively but in 17 (58.6%) at 1 year. The mean hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were significantly decreased at 1 year. The HVA normalized in 20 patients (69.0%), the IMA normalized in 25 patients (86.2%), but the DMAA normalized in only 4 patients (13.8%). The number of patients with sesamoid subluxation decreased from 29 (100%) to 13 (44.8%).ConclusionOur study data indicate that SERI osteotomy reliably reduces a wide spectrum of HV deformities and it is a safe procedure with very minimal complications.Trial registrationThis study is registered in ClinicalTrials.gov under the following reference number: NCT03669900.

Mitchell and Golden metatarsal osteotomies for the treatment of moderate hallux valgus deformity: A comparative analysis

Background/Aim. Despite bunion surgery having been performed for more than 100 years, there has yet to be a technique considered as the ?Gold Standard?. The aim of the study was to compare postoperative results of Mitchell vs. Golden methods of treating moderate hallux valgus deformity. Methods.This observational case control study included 49 patients (81 feet) who had the Mitchell distal metatarsal osteotomy performed, and 49 patients (77 feet) that had the Golden proximal metatarsal osteotomy performed. The results of treatment were evaluated using Hellal?s modification of the Bonney and McNab classification and the Hallux Metatarsophalangeal Interphalangeal Score (HMIS). The statistical analysis of the results was done, thus the values p &lt; 0.05 were considered statistically significant. Results. Both operative procedures showed successful and statistically significant postoperative results compared to the preoperative status (p &lt; 0.001). Comparative analysis of the results from the Mitchell and Golden procedures, according to the Hellal?s modification of Bonney and McNab classification, proved that there was a high statistically significant difference in favor of the Mitchell method (p &lt; 0.001), whereas the comparison based on the HMIS showed no statistically significant difference (p = 0.123) between the two methods. The estimated results analysis of both procedures, based on the values of hallux valgus angle, intermetatarsal angle, sesamoid position, length of immobilization, treatment duration and complications demonstrated that there was a highly significant difference in favor of the Mitchell method (p &lt; 0.001), whereas the value of the shortening of the first metatarsal bone indicated that the shortening was greater in the Mitchell method (p &lt; 0.001), which goes in favor of the Golden method. Regarding the flexion of the thumb of the feet operated on, there was no statistically significant difference (p = 0.723). Conclusion. The examinations performed indicated that both methods showed good postoperative results, but applying the Mitchell method they were better.

Evidence Versus Practice: Operative Treatment Preferences in Hallux Valgus

Background: There is substantial variability in the operative treatment of hallux valgus despite the existence of high quality evidence to guide treatment decisions. The purpose of this study was to determine the current trends in the treatment of mild, moderate, and severe hallux valgus and if greater degrees of consensus correlate with the presence of higher-level evidence. Methods: Members of the American Orthopaedic Foot &amp; Ankle Society completed a 14-item survey. A total of 131 (14%) of 922 members completed the survey. Three cases representing 3 stages of HV were presented, and respondents selected their preferred treatment. Preferred forms of proximal and distal metatarsal osteotomies, as well as mode of fixation for each, were inquired. Results: In the treatment of mild hallux valgus without second metatarsalgia, 80% of those surveyed chose a distal metatarsal osteotomy, while, if second metatarsalgia was present, 56% chose a distal metatarsal osteotomy with a second metatarsal-shortening osteotomy. In the treatment of moderate hallux valgus, there was generally less consensus, while, in the treatment of severe hallux valgus, a majority of those surveyed chose a Lapidus procedure, with the addition of a second metatarsal-shortening osteotomy in the presence of second metatarsalgia. The most popular distal and proximal metatarsal osteotomies, respectively, were chevron osteotomy (80%) and opening wedge osteotomy (33%). The presence of Level I evidence did not significantly correlate with higher degrees of consensus. Conclusion: Despite the existence of high-quality evidence supporting the use of certain procedures in the treatment of HV, there exists an apparent lack of consensus among surgeons about the choice of surgical procedures. Moreover, higher-level evidence was not correlated with greater consensus in hallux valgus. Level of Evidence: Level II.

Intraosseous Sliding Plate Fixation Used in Double Osteotomy Bunionectomy.

Distal chevron metatarsal osteotomy bunionectomy is a commonly performed procedure for the treatment of mild to moderate hallux valgus. We continue to use the intraosseous sliding osteotomy plate system for fixation of the distal metatarsal osteotomy. With the addition of the Akin osteotomy, we are able to obtain reliable, reproducible correction with better cosmesis and increased patient satisfaction for more advanced deformities. We prospectively evaluated 138 (145 feet) consecutive patients who underwent double osteotomy bunionectomy using the intramedullary plate system and 3.2-mm cannulated screw system. The senior author performed all operative procedures. Patients were evaluated preoperatively, postoperatively, and at the final follow-up using the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot scoring system. All osteotomy sites of operatively corrected feet healed. There were no hardware failures. A small number of patients complained of stiffness and pain related to the hardware. All patients dramatically improved their AOFAS scores compared with preoperative values. The hallux valgus angle was corrected by a mean of 17.3 degrees (range, 10 to 20 degrees), and the intermetatarsal angle was corrected by a mean of 6.8 degrees (range, 5 to 9 degrees). Chevron osteotomy paired with an Akin osteotomy (double osteotomy bunionectomy) resulted in excellent function and pain relief. We continue to recommend the use of the intramedullary plate system and 3.2-mm cannulated screw system because of its low profile, reliability of fixation, and relative ease of use. Level III, retrospective comparative series.