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Minimally Invasive and Open Distal Chevron Osteotomy compared at 2-year follow-up for the correction of Mild-Moderate Hallux Valgus.

Authors:

Abstract

ABSTRACT INTRODUCTION Minimally invasive surgical (MIS) techniques are increasingly being used in foot and ankle surgery but it is important that they are adopted only once they have been shown to be equivalent or superior to open techniques. We believe that the main advantages of MIS are found in the early post-operative period but in order to adopt it as a technique longer term studies are required. The aim of this study is to compare the 2-year outcomes of a 3rd generation MIS distal chevron osteotomy with a comparable traditional open distal chevron osteotomy for mild-moderate hallux valgus. Our null hypothesis is that the two techniques yield equivalent clinical and radiographic results at 2 years. METHODS This was a retrospective cohort study. 81 consecutive feet (49 MIS and 32 open distal chevron osteotomies) were followed up for a minimum 24 months (range 24-58). All patients were clinically assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ). Radiographic measures included hallux valgus angle (HVA), the intermetatarsal angle (IMA), hallux interphalangeal angle (HIA), metatarsal phalangeal joint angle (MPJA), distal metatarsal articular angle (DMAA), tibial sesamoid position (TSP), shape of the first metatarsal head (MHS), and plantar offset. Statistical analysis was done using Student’s t-test or Wilcoxan rank-sum test for continuous data and Pearson’s chi-squared test for categorical data. RESULTS Clinical and radiological post-operative scores, in all domains, were significantly improved in both groups (p<0.001), but there was no statistically significant difference in improvement of any domain between open and MIS groups (p>0.05). There were no significant differences in complications between the two groups (p>0.5). CONCLUSION The mid-term results of this third generation technique show that it is a safe procedure with good clinical outcomes and comparable to traditional open techniques for symptomatic mild-moderate hallux valgus.
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This!is!a!level!3!retrospective!cohort!study!with!comparison!group.!39!
(40!
aObM.E0C!41!
Hallux!valgus,!Bunion,!Minimally!invasive,!MIS,!Chevron(
42!
(
43!
)FDE.0G2D).F(
44!
Hallux!valgus!is!a!common!condition!with!over!150!procedures!described!for!the!45!
treatment,!but!as!yet!there!is!no!consensus!on!the!best!method.!!!Distal!metatarsal!
46!
chevron!osteotomy!is!a!good!option!in!mild-to-moderate!hallux!valgus!providing!47!
good!results!in!the!correction!of!deformity!and!symptoms.25!!In!the!last!decade!there!48!
has!been!a!growing!interest!in!the!use!of!minimally!invasive!techniques!for!the!
49!
treatment!of!this!condition!but!a!recent!review!article!concluded!that!there!was!not!
50!
enough!evidence!to!favour!MIS!over!traditional!open!techniques.17,28!!This!was!
51!
!
3!
largely!owing!to!the!fact!that!the!majority!of!studies!included!in!the!reviews!were!52!
case!series!without!comparison!or!control!groups.!!Indeed!MIS!forefoot!surgery!is!
53!
the!subject!of!much!controversy!at!present!in!the!literature23!with!some!series!
54!
reporting!high!complication!rates!with!MIS!surgery,!for!example!Myerson!et!al.!
55!
described!a!high!dorsal!malunion!rate.14!56!
!57!
Minimally!invasive!techniques!are!being!adopted!in!all!surgical!specialties!58!
essentially!because!of!the!advantages!of!less!operative!trauma!and!preserving!the!59!
blood!supply!of!the!healing!soft!tissues.!!This!has!the!theoretical!advantages!of!60!
decreasing!recovery!and!rehabilitation!times!thereby!reducing!the!morbidity!61!
associated!with!both!the!disease!process!and!the!operative!intervention.!!However,!62!
it!is!important!not!to!adopt!new!techniques!simply!because!of!perceived!advantages!63!
without!comparison!to!a!well-established!and!proven!technique.!64!
!65!
The!majority!of!the!perceived!advantages!occur!in!the!early!post-operative!phase!as!66!
a!result!of!less!soft!tissue!trauma.!!However,!in!order!to!adopt!a!new!operative!
67!
technique,!it!is!important!to!look!at!longer-term!outcomes!and!compare!these!with!
68!
established!techniques.!!The!aim!of!this!study!is!to!compare!a!third!generation!MIS!
69!
distal!chevron!osteotomy5!with!a!cohort!of!patients!who!received!a!traditional!open!70!
distal!chevron!osteotomy.!!The!null!hypothesis!is!that!there!will!be!no!difference!in!
71!
both!radiological!and!clinical!outcomes!at!2!years!post-op.!!!72!
!73!
!ADOE)A]C(AF0(!OD<.0C(
74!
In!this!retrospective!comparison!study!two!cohorts!of!consecutive!patients!were!
75!
followed!up!for!a!minimum!of!2!years.!!The!initial!group!was!the!standard!open!
76!
!
4!
distal!chevron!and!then!subsequently!the!senior!authors!practice!changed!to!the!77!
MIS!procedure.!!49!feet!in!the!MIS!group!were!followed-up!for!a!mean!of!31!months!
78!
(range!26-39!months,!SD!3.5).!32!feet!in!the!open!group!were!followed-up!for!a!
79!
mean!of!37!months!(range!24-58!months,!SD!11.8).!!There!were!no!significant!
80!
differences!between!the!groups!in!terms!of!demographics!or!radiological!and!81!
clinical!severity!(tables!1!and!2).!!Hallux!valgus!angle!(HVA)!was!categorised!as!mild!82!
(15-20!degrees),!moderate!(21-39!degrees)!and!severe!(≥40!degrees).!!83!
Intermetatarsal!angle!(IMA)!was!categorised!as!mild!(9-11!degrees),!moderate!(12-84!
17!degrees)!and!severe!(≥18!degrees).!!Table!1!summarises!the!radiological!85!
severity.!In!the!MIS!group!6!patients!had!a!severe!IMA!and!7!had!a!severe!HVA;!2!86!
patients!would!be!classified!as!severe!on!both!parameters.!!In!the!open!group!6!87!
patients!had!a!severe!IMA!and!4!had!a!severe!HVA;!but!no!patients!would!be!88!
classified!as!severe!on!both!parameters.!!!Whilst!it!is!generally!accepted!that!distal!89!
osteotomies!are!for!mild!hallux!valgus,!at!the!senior!authors!discretion,!some!90!
patients!with!more!severe!deformities!were!also!offered!distal!osteotomies.!!!91!
!
92!
There!were!no!patients!undergoing!revision!surgery,!although!these!would!have!
93!
been!excluded!from!the!study.!!Patients!were!excluded!from!the!MIS!group!if!they!
94!
had!any!other!foot!procedures!performed,!such!as!cheilectomy!or!lesser!toe!95!
correction,!in!order!to!concentrate!on!the!MIS!technique!itself.!!In!the!open!group,!
96!
patients!were!excluded!with!other!foot!procedures,!except!for!Akin!procedures,!97!
which!was!deemed!part!of!the!correction!of!the!hallux!valgus.!!There!were!12/32!98!
(40%)!Akin!procedures!performed!in!the!open!group!and!no!Akin!procedures!in!the!
99!
MIS!group.!
100!
!
101!
!
5!
The!senior!author!performed!all!procedures.!!All!patients!were!clinically!assessed!102!
pre!and!post-operatively!with!the!Manchester-Oxford!Foot!Questionnaire!(MOXFQ).!!103!
This!scoring!system!was!originally!designed!as!an!outcome!measure!following!104!
hallux!valgus!surgery!and!has!been!shown!to!be!reliable!and!correlates!with!both!105!
the!AOFAS!and!SF-36.7-9!!There!are!three!domains:!walking/standing!score!(W!106!
score)!(7!items);!pain!score!(P!score)!(5!item);!and!a!social!interaction!score!(SI!107!
score)!(4!items).!!Response!options!consist!of!a!5-point!Likert!scale!ranging!from!no!108!
limitation!to!maximal!limitation.!!An!individual!score!is!used!for!each!domain!and!109!
converted!into!a!metric!score!0!to!100,!where!100!is!the!most!severe.!The!MOXFQ!110!
was!designed!to!be!interpreted!as!three!separate!scores!although!a!combined!score!111!
(similar!to!the!AOFAS!scoring!system)!has!also!been!validated.22!!112!
Equal!group!sample!sizes!of!33!were!calculated!to!provide!70%!power!to!detect!a!113!
clinically!significant!difference!in!improvement!of!MOXFQ!index!score!of!20!points!114!
at!the!0.05!significance!level,!based!on!previously!published!variance.21!115!
!
116!
Radiographic!analysis!was!performed!on!standard!weightbearing!anteroposterior!
117!
(AP)!and!lateral!radiographs!by!the!lead!author!(KB).!!All!measurements!were!taken!
118!
as!per!Laporta!et!al.:15!hallux!valgus!angle!(HVA),!intermetatarsal!angle!(IMA),!119!
hallux!interphalangeal!angle!(HIA),!metatarsal!phalangeal!joint!angle!(MPJA),!distal!
120!
metatarsal!articular!angle!(DMAA),!tibial!sesamoid!position!(TSP),!shape!of!the!first!
121!
metatarsal!head!(MHS),!and!plantar!offset!(amount!of!plantar!translation!of!
122!
metatarsal!head!following!osteotomy).!!All!clinical!and!radiological!complications!123!
were!recorded,!including!revision,!non-union,!infection,!pain,!numbness,!metalwork!124!
failure.!
125!
!
126!
!
6!
MIS technique 127!
The!technique!and!early!outcomes!of!our!technique!have!already!been!published.5!128!
This!technique!can!be!seen!to!be!a!modification!of!the!minimally!invasive!chevron!129!
and!akin!(MICA)!technique!described!by!Redfern!and!Vernois,30!whilst!also!utilizing!130!
some!parts!of!the!original!"Bosch"!!technique,!which!was!one!of!the!first!MIS!131!
techniques!used!in!bunion!surgery!to!improve!initial!stability!of!the!osteotomy.4,11!!132!
!133!
If the neutral alignment of the great toe cannot be achieved with varus pressure on the toe 134!
then a percutaneous soft tissue release is undertaken using image intensifier, in 135!
approximately 10% of cases.20 Neutral alignment of the toe with relocation of the 136!
sesamoids under the metatarsal head is then checked using the image intensifier. A stab 137!
incision is made adjacent to the medial proximal nail fold and a 1.8mm titanium wire is 138!
inserted superficial to the periosteum of the distal phalanx of the toe, stopping short of the 139!
medial eminence of the first metatarsal (Fig 4). A 5mm extensile incision is made over 140!
the first MT neck and the soft tissues are carefully spread down to bone. A mini
141!
periosteal elevator is passed around the first MT neck superiorly and inferiorly to create a
142!
safe working area for the burr.
143!
144!
A 2 x 20 mm Shannon Burr (WG Healthcare, UK) on a console set at 50NM torque and
145!
250 rpm is used to create a perpendicular hole in the first MT neck. Under image control
146!
this is angled distally towards the 3rd MT head and plantarward by 20 degrees (Figure 1).
147!
The inferior limb of the chevron is cut longer than the superior limb (Figure 2) and a 148!
1.8mm titanium wire is introduced into the intramedullary canal of the first MT causing 149!
lateral, distal and plantar displacement of the 1st MT head thereby creating a three-
150!
dimensional correction of the deformity as seen in other described techniques16 with good
151!
!
7!
outcomes. The position is checked under X-ray and the wire is advanced to the base of 152!
the first MT. 153!
154!
A 1.1mm guide wire is inserted through a separate stab incision and advanced across the 155!
osteotomy site into the metatarsal head, remaining outside the joint surface, and an 156!
appropriate Barouk type screw is inserted (Figure 3). An AP and lateral view is taken at 157!
the end of the procedure. The osteotomy site wound is closed with a No. 4-0 nylon 158!
mattress suture after irrigation and the screw incision is closed with a steristrip. The 159!
1.8mm wire is bent and cut short distally. The wire is dressed with gelanet and 160!
gentamicin sponge, the foot is dressed with gauze, wool and crepe. 161!
162!
Open technique 163!
The!open!technique!is!performed!using!a!traditional!technique6!with!a!longitudinal!164!
incision!from!the!midportion!of!the!proximal!phalanx!to!1cm!proximal!to!the!medial!165!
eminence.!!The!capsular!flap!is!created!to!facilitate!medial!plication!at!the!end!of!the!
166!
procedure!whilst!carefully!maintaining!the!plantar!blood!supply!to!the!head.!!A!
167!
lateral!soft!tissue!release!is!performed!under!direct!vision!if!required!based!on!the!
168!
same!indications!as!described!above!for!the!MIS!procedure.!!The!medial!eminence!is!169!
first!resected!with!a!sagittal!saw!in!an!oblique!direction!to!the!1st!metatarsal!shaft!in!
170!
order!to!create!a!broad!base!to!the!distal!fragment.!!A!2mm!drill!hole!is!used!to!mark!
171!
the!apex!of!the!osteotomy!and!drilled!across!parallel!to!the!bottom!of!the!foot!and!
172!
articular!surface.!!The!chevron!cut!is!then!made!with!an!angle!of!approximately!60!173!
degrees!using!a!fine!sagittal!saw!to!ensure!that!the!plantar!limb!exits!proximal!to!the!174!
sesamoids.!!The!distal!fragment!is!displaced!by!approximately!one!third!and!the!
175!
position!maintained!with!a!1.6mm!Kirschner!wire.!!The!prominent!medial!flare!is!
176!
!
8!
then!resected!and!the!medial!capsular!flap!is!repaired!whilst!holding!the!toe!in!a!177!
neutral!position.!The!wound!is!closed,!protected!with!dressings!and!the!great!toe!is!178!
placed!in!a!J-slab.!179!
180!
Postoperative management 181!
For the MIS procedure patients are allowed to heel weightbear in a surgical shoe and the 182!
k-wire is removed at four weeks in clinic, at which point they can begin fully weight-183!
bearing. A removable ValguLoc® (Bauerfind, Germany) splint is applied at 4 weeks but 184!
the patient is encouraged to remove this eight to ten times per day to mobilise the 1st 185!
MTPJ. The splint is worn full time for first two weeks and then at night for a further 2 186!
weeks. Every patient has a series of weightbearing X-rays at eight weeks (Figure 4). 187!
188!
For the open chevron procedure patients are allowed to heel weightbear in rigid surgical 189!
shoe for first four weeks, then full weightbearing for two weeks in surgical shoe. The J-190!
slab is removed at two weeks, along with sutures and a removable ValguLoc® splint is
191!
applied and worn for four weeks, removed for exercises through the day. The
192!
ValguLoc® splint is then maintained at night for two more weeks. Every patient has a
193!
series of weightbearing X-rays at eight weeks (Figure 4). 194!
195!
(
196!
C1%1"+1"6+(
197!
All!data!were!descriptively!summarized!and!analyzed!in!R!version!3.0.0.1!198!
Continuous!data!were!formally!analyzed!with!Student's!t-tests!or!Wilcoxon!rank-199!
sum!test!for!normally!distributed!and!nonparametric!data!respectively,!determined!
200!
!
9!
with!the!Shapiro-Wilk!normality!test.!Categorical!data!were!analyzed!with!Pearson’s!201!
Chi-squared!test,!with!continuity!correction!where!required.!!202!
(203!
EOCG]DC(204!
]5++(15(95&&5:8;/(205!
1!patient!in!the!open!group!and!3!in!the!MIS!group!did!not!complete!a!minimum!24-206!
month!clinical!follow-up!and!were!excluded!from!clinical!analysis.!!8!patients!in!the!207!
open!group!and!8!in!the!MIS!group!did!not!have!complete!radiographic!follow-up!208!
and!were!excluded!from!radiological!analysis!(table!2).!!!209!
2&"#"6%&(210!
Table!3!shows!the!clinical!results!of!the!MOXFQ.!!Preoperative!scores!were!similar!211!
across!all!domains.!Postoperative!scores!in!all!domains!were!substantially!improved!212!
in!both!groups,!but!there!was!no!statistically!significant!difference!in!improvement!213!
of!any!domain!(including!the!combined!score)!between!open!and!MIS!groups.!!In!the!214!
MIS!group!the!preoperative!walking!score!improved!from!42.64!to!9.226!(p!<!.001),!
215!
the!pain!score!from!49.17!to!16.46!(p!<!.001),!the!social!interaction!score!from!49.09!
216!
to!13.41!(p!<!.001).!!In!the!open!group!the!preoperative!walking!score!improved!
217!
from!51.79!to!14.73!(p!<!.001),!the!pain!score!from!51.72!to!13.4!(p!<!.001),!and!the!218!
social!interaction!score!from!53.52!to!21.09!(p!<!.001).!!
219!
E%-"5&5?"6%&(!
220!
Table!4!shows!the!radiographic!results!with!all!pre-operative!radiological!
221!
parameters!being!very!similar!between!the!two!groups.!!The!majority!of!the!post-222!
operative!radiological!parameters!showed!no!significant!differences!between!the!223!
groups.!!The!only!significant!postoperative!difference!between!the!two!groups!was!
224!
the!HIA!(p!<0.01)!and!plantar!offset!(p!<.001).!!Mean!change!in!IMA!was!4.92°!in!the!
225!
!
10!
MIS!group!(p!<!.001)!and!6.74°!in!the!open!group!(p!<!.001).!Mean!change!in!HVA!226!
was!16.23°!in!the!MIS!group!(p!<!.001†)!and!20.53!in!the!open!group!(p!<!0.001).!227!
Mean!change!in!HIA!was!5.72°!in!the!MIS!group!(p!<!.001)!and!1.25°!in!the!open!228!
group!(p!=!.45).!Mean!change!in!MT!length!was!0.5!mm!in!the!MIS!group!(p!<!.001†)!229!
and!0.75!mm!in!the!open!group!(p!=!.007).!230!
25$/&"6%1"5#+(231!
In!the!MIS!group!there!were!4!screw!removals,!0!revisions,!1!recurrence!232!
(radiographically!mild,!clinically!asymptomatic)!and!4!patients!with!paraesthesia.!!233!
In!the!open!group!there!was!1!screw!removal,!no!revisions,!1!recurrence,!1!234!
paraesthesia!and!1!patient!with!on-going!pain.!There!was!no!reoperation!for!235!
metatarsalgia!in!either!group!at!final!follow!up.!!There!was!no!statistical!significance!236!
between!the!groups!in!terms!of!screw!removal!(p!.6535),!revision!(p!1.00),!237!
recurrence!(p!1.00),!paraesthesia!(p!.6535),!pain!(p!.829),!or!stiffness!(p!.6709).!(238!
!239!
There!was!no!avascular!necrosis,!postoperative!infection,!hallux!varus,!nonunion,!or!
240!
dorsal!malunion!of!the!distal!fragment.!
241!
!
242!
0)C2GCC).F(243!
The!predominant!finding!in!this!study!is!that,!at!2-year!follow-up,!MIS!bunion!
244!
surgery!is!equivalent!to!a!comparable!open!procedure!both!radiographically!and!
245!
clinically.!!There!were!significant!post-operative!improvements!in!both!radiological!
246!
and!clinical!outcome!criteria!with!both!techniques.!!We!observed!a!similar!safety!247!
profile!in!terms!of!complications!between!open!and!percutaneous!surgery.!!There!248!
were!however,!no!significant!differences!between!the!groups!either!radiologically!or!
249!
clinically,!excepting!the!HIA!angle!and!plantar!offset.!The!significant!difference!in!
250!
!
11!
the!HIA!between!the!two!groups!pre!and!postoperatively!probably!reflects!the!extra!251!
Akin!procedures!that!were!performed!in!the!open!group.!!In!the!MIS!procedure!252!
fewer!Akin!procedures!were!required!as!the!wire!slightly!overcorrects!causing!253!
stretching!of!the!lateral!capsule!and!adductor.!!Once!the!wire!is!removed!the!HV!254!
angle!is!then!restored.!!255!
!256!
Another!interesting!finding!was!the!TSP!being!more!medial!in!the!MIS!group,!which!257!
probably!reflects!the!slightly!smaller!hallux!valgus!angle!preoperatively!in!this!258!
group.!!There!was!also!a!significant!difference!in!plantar!offset!between!the!two!259!
groups!in!favour!of!the!MIS!groups!and!this!is!because!using!the!burr!to!make!the!260!
osteotomy!makes!controlling!the!angles!easier!so!that!when!the!displacement!261!
occurs!there!is!plantar!displacement.!!!Whilst!not!significant!(p!0.3)!there!was!a!262!
difference!in!DMAA!in!favour!of!the!MIS!group.!!This!is!due!to!the!effect!of!the!wire!263!
causing!slight!varus!displacement!of!the!head!fragment.!264!
!
265!
The!main!strength!of!this!study!is!that!a!direct!comparison!is!made!with!an!
266!
equivalent!open!procedure.!!There!are!several!limitations!to!this!study.!!Firstly,!all!
267!
procedures!were!performed!by!the!senior!author!who!has!a!large!experience!in!MIS!268!
techniques.!There!is!no!doubt!that!MIS!hallux!valgus!surgery!has!a!steep!learning!
269!
curve!and!therefore!these!results!may!be!difficult!to!reproduce.!!Secondly,!whilst!it!
270!
is!important!to!look!at!mid!and!long-term!outcomes!of!any!new!operative!procedure!
271!
it!is!probably!true!that!the!real!benefits!of!MIS!surgery!are!in!the!early!post-272!
operative!period!and!therefore!this!should!be!considered!in!any!future!studies.!!This!273!
was!not!a!randomised!study!thereby!introducing!possible!selection!bias,!although!
274!
the!pre-operative!clinical!and!radiological!measures!were!similar!in!both!groups.!
275!
!
12!
!276!
It!should!be!noted!that!MIS!bunion!correction!is!not!a!single!technique!rather!a!277!
philosophical!approach!to!the!surgery!that!often!reproduces!existing!established!278!
bony!techniques.!!Despite!a!recent!review!article,17!there!is!still!a!growing!body!of!279!
evidence!to!suggest!that!MIS!bunion!surgery!is!safe.3,10,11,19,24,26!!There!are!several!280!
studies!showing!that!the!early!benefits!remain!in!the!longer!term!although!few!of!281!
these!studies!was!with!a!comparison!group.!!Giannini!et!al.11!looked!at!641!patients!282!
(1000!feet)!and!found!their!results!acceptable!at!5!years.!!Faour-Martin!et!al.!10!283!
looked!at!115!feet!and!also!found!the!results!of!their!MIS!technique!were!sustained!284!
over!a!10!year!period.!!!285!
!286!
However,!as!with!all!new!techniques!there!have!been!criticisms!due!to!unacceptably!287!
high!complication!rates!in!other!series!14,23.!!!The!first!generation!minimally!invasive!288!
techniques!were!originally!described!by!Bosch,4!and!later!a!second!generation!289!
modification!using!a!screw!for!fixation!was!described.30!!The!originators!of!this!
290!
technique!have!changed!the!fixation!method!four!times!to!address!this!problem.!!
291!
However,!the!original!Bosch!technique!of!using!an!axial!wire!is!a!very!powerful!way!
292!
of!displacing!and!maintaining!the!metatarsal!head!in!the!initial!few!weeks!and!is!293!
further!enhanced!with!the!application!of!a!screw!and!a!chevron!shaped!bone!cut!to!
294!
improve!the!stability!and!also!to!compress!the!osteotomy!site.!!This!also!reduces!the!
295!
risk!of!dorsal!malunion!as!described!by!Myerson!et!al.14!
296!
!297!
There!have!been!concerns!about!the!the!fact!the!osteotomy!is!created!with!a!2mm!298!
burr!which!can!cause!relative!shortening!thereby!decompressing!the!osteotomy!and!
299!
possible!rendering!it!more!mobile.23!!The!issue!with!this!is!that!excessive!shortening!
300!
!
13!
of!the!first!ray!can!lead!to!transfer!metatarsalgia,13!although!there!is!no!consensus!301!
on!the!amount!of!shortening!that!might!lead!to!pain.!!In!Turnbull!and!Grange’s29!302!
series!they!found!shortening!of!up!to!8mm!acceptable!and!our!previous!study!found!303!
no!correlation!between!degree!of!shortening!and!clinical!outcome.27!!In!our!series!304!
MIS!and!open!surgery!had!no!mean!differences!in!shortening!(Open!3.7mm,!MIS!305!
5mm!p!0.55)!and!there!were!no!cases!of!transfer!metatarsalgia.!!If!the!burr!is!306!
directed!in!a!distal!direction!then!when!the!lateral!translation!occurs!there!is!a!307!
relative!restoration!in!length!of!the!metatarsal,!which!also!helps!to!reload!the!1st!308!
metatarsal!reducing!the!risk!of!transfer!metatarsalgia.!!Another!major!concern!is!the!309!
lack!of!medial!capsular!plication!but!we!feel!that!a!stable!union!in!a!reduced!310!
anatomically!favourable!position!mitigates!the!need!for!this!procedure.!!It!does!311!
however,!remain!to!be!seen!whether!or!not!the!lack!of!soft!tissue!repair!causes!the!312!
deformity!to!recur.!!!313!
!314!
The!potential!advantages!of!the!described!technique!include!the!fact!we!use!a!high!
315!
torque!low-speed!burr!to!reduce!the!risk!of!thermal!damage!to!the!bone.!It!has!been!
316!
observed,!in!this!series,!that!being!a!closed!procedure!the!swath!generated!from!the!
317!
burr!aids!radiologically!earlier!union!(a!separate!study!is!currently!being!conducted!318!
to!better!evaluate!this!observation),!rather!analogous!to!the!use!of!a!bone!graft.!!
319!
Over-correction!into!hallux!varus!is!not!a!problem!that!has!been!reported!with!MIS!
320!
hallux!valgus!surgery!and!this!may!be!due!to!the!absence!of!medial!soft!tissue!
321!
tightening.!!Because!the!amount!of!translation!can!be!as!much!as!90%!the!adductor!322!
hallucis!tendon!is!relaxed!and!therefore!we!only!perform!a!lateral!soft!tissue!release!323!
if!the!hallux!is!not!clinically!reducible.!We!had!no!cases!of!avascular!necrosis!and!
324!
this!has!only!been!reported!as!a!problem!in!one!series.14!!It!is!not!generally!
325!
!
14!
associated!with!MIS!bunion!surgery!because!it!is!an!extra-capsular!procedure!and!326!
therefore!protects!the!blood!supply!to!the!metatarsal!head.4!!Being!an!extra-327!
articular!procedure!it!is!relatively!protected!from!postoperative!stiffness,!being!328!
reported!as!high!as!38%!with!open!techniques.2!329!
!330!
This!paper!describes!our!version!of!a!minimally!invasive!approach.!!MIS!bunion!331!
surgery!has!evolved,!like!any!other!technique!and!the!rationale!behind!these!332!
evolutions!is!discussed!above.!!In!terms!of!patient!indications,!whilst!several!333!
patients!in!our!study!have!had!radiologically!severe!hallux!valgus,!we!would!334!
recommend!this!as!a!procedure!for!the!mild-moderate!symptomatic!hallux!valgus.!!335!
Our!mean!IMA!of!12!degrees!compares!with!other!studies!(11.8!–!13!degrees)!and!!336!
HVA!of!27!degrees!is!also!comparable!(26.7!–!33.3!degrees).3,12,18,24,26!!Based!on!this!337!
and!other!studies!one!can!expect!an!improvement!of!3!–!5!degrees!in!the!IMA!and!11!338!
–!21!degrees!improvement!in!the!HVA.!339!
!
340!
2.F2]GC).F(
341!
We!conclude!that!this!hybrid!MIS!technique!is!a!safe!and!effective!procedure!for!the!
342!
correction!of!symptomatic!mild-to-moderate!hallux!valgus!but!longer-term!343!
randomised!controlled!would!provide!higher!level!evidence!before!it!is!adopted!
344!
more!widely.!!We!feel!it!important!that!any!future!studies!not!only!look!at!long!term!
345!
results!but!also!at!the!short!term!results!as!we!feel!the!majority!of!the!MIS!
346!
advantages!are!in!the!early!post-operative!period.!347!
!348!
25#9&"61(59()#1,4,+1(
349!
The!authors!declare!that!they!have!no!conflict!of!interest.! !
350!
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!
447!
Table!1.!Demographics.!!ab;5-/.+5c7b5D3d7*49).b5d5.75ebfbO.*273+c7b&F1d7V-*2.b5.75bD15Fb
448!
83+51+-15Eb8322.8513+e!449!
!!
MIS!group!(n=49)!
p!
(,.bg_.*27hb4.*+bg;@hb
KMbg!#eJhb
#e!#JLab
X.+/.2b
$Qb:.4*).bgI$ihb
#e$#IQfb
!450!
!
451!
Table!2.!Pre-operative!radiological!severity.!!abO.*273+c7b&F1d7V-*2./b5.75!
452!
!!
!!
MIS!group!!(n41)!
Open!Group!(n!24)!
p!
bT=(b
Y1)/g!Kd"#b/.,2..7hb
Kb
Ib
#eI"K$ab
bb
Y3/.2*5.bg"!dMIb/.,2..7hbb
"Ib
!Ib
bb
bb
;.0.2.bgj$#b/.,2..7hb
Lb
$b
bb
b[Y(b
Y1)/bgId!!b/.,2..7hb
Qb
"b
#e$LMQab
bb
Y3/.2*5.bg!"d!Lb/.,2..7hb
"Ib
!$b
bb
bb
;.0.2.bgj!Jb/.,2..7hb
Qb
Qb
bb
!453!
Table!3.!Clinical!results.!ab;5-/.+5c7b5D3d7*49).b5d5.75ebfbA1)83G3+b2*+Sb7-4b5.75e!
454!
bb
bb
MIS!(n=48)!
!!
Open!
(n=29)!
!!
bb
Y.5218bYC\:]b
7-44*2Eb7832.7b
bb
Y.*+b
;@b
Y.*+b
;@b
p!
A*)S1+,b
O2.39.2*510.b
$"eQ$b
"!eIb
K!eLIb
"QeQb
bb
!
18!
bb
O37539.2*510.bb
Ie""Qb
!QeIb
!$eLMb
!IeKb
bb
bb
Difference!
-33.56!
29.6!
-37.05!
25.4!
0.57†!
O*1+b
O2.39.2*510.b
$Ie!Lb
!Ie"b
K!eL"b
"KeMb
bb
bb
O37539.2*510.b
!Qe$Qb
!IeQKb
!Me$b
!QeIb
bb
bb
Difference!
-32.66!
25.8!
-38.28!
23.67!
0.32†!
;381*)b[+5.2*8513+b
O2.39.2*510.bb
$Ie#Ib
"#eIb
KMeK"b
""eKb
bb
bb
O37539.2*510.b
!Me$!b
"!e!b
"!e#Ib
""eJb
bb
bb
Difference!
-36.3!
31.8!
-32.42!
27.9!
0.56†!
&34U1+./b
O2.39.2*510.bb
$QeKJb
!QeMb
K"eM$b
"!eKb
bb
bb
O37539.2*510.b
!Me#Mb
!Qb
!Qe$"b
!JeLb
bb
bb
Difference!
-33.55!
23.8!
-35.92!
22.1!
0.98‡!
!455!
Table!4.!Radiological!results.!!ab;5-/.+5c7b5D3d7*49).b5d5.75ebbfbA1)83G3+b2*+Sb7-4b5.75e!456!
bb
bb
!!MIS!
!!
Open!
!!
bb
bb
bb
Y.*+b
;@b
Y.*+b
;@b
p!
[Y(°b
O2.39.2*510.bb
!!eLb
$e$b
!Me$b
$eQb
bb
bb
O37539.2*510.bb
QeJb
MeQb
QeLb
Me$b
bb
bb
Difference!
-4.9!
5.3!
-6.7!
5.6!
#e"#ab
T=(°b
O2.39.2*510.bb
"QeQb
!#eQb
M#eJb
!#e!b
bb
bb
O37539.2*510.b
!#e$b
KeLb
IeIb
KeIb
bb
bb
Difference!
-16.2!
10.9!
-20.5!
9.5!
#e!#ab
T[(°b
O2.39.2*510.bb
$eMb
KeMb
$eLb
!!eIb
bb
bb
O37539.2*510.bb
!#e#b
Me$b
LeMb
$eLb
bb
bb
Difference!
5.7!
5.1!
1.3!
5.6!
#e###"ab
@Y((°b
O2.39.2*510.bb
Ib
Lb
!"b
Ib
bb
bb
O37539.2*510.bb
!b
Jb
!!b
!#b
bb
bb
Difference!
8!
11!
1!
9.6!
#eMab
';Ob
O2.39.2*510.bb
MeJb
!eKb
KeLb
"eQb
bb
bb
O37539.2*510.bb
"eJb
!eMb
Me!b
!eMb
bb
bb
Difference!
1!
1.9!
2.6!
2.8!
#e!Qfb
YZ(°b
O2.39.2*510.bb
!"eKb
!$eKb
!LeQb
!MeIb
bb
bb
O37539.2*510.bb
Me$b
!#e"b
Qe!b
!$eMb
bb
bb
Difference!
9.1!
14.3!
7.8!
13.7!
#eLQab
'3.b).+,5Fb
g44hb
O2.39.2*510.bb
!!Qe!b
!"eMb
!!$eJb
Ke$b
bb
bb
O37539.2*510.bb
!!$eQb
!Me!b
!!"eIb
Je!b
bb
bb
Difference!
1.5!
6.8!
1.9!
5.5!
#eM"ab
!75bY'b
).+,5Fg44hb
O2.39.2*510.bb
Q#eKb
$eQb
KJeJb
MeKb
bb
bb
O37539.2*510.bb
KKb
Ke!b
KKe!b
$eIb
bb
bb
Difference!
5!
4.6!
3.7!
5.8!
#eKKab
O)*+5*2b
C667.5bg44hb
O37539.2*510.bb
"eLb
!eLb
#e"b
#eLb
#e######"fb
bb
bb
bb
bb
bb
bb
bb
b
bb
bb
bb
bb
bb
bb
b!457!
!
19!
Figure!1.!Operative!technique:!Under!image!control!a!burr!is!used!to!create!a!458!
perpendicular!hole!in!the!first!metatarsal!neck!angled!distally!towards!the!3rd!MT!459!
head!and!plantarward!by!20!degrees.!!!460!
!461!
Figure!2.!Operative!technique:!The!inferior!limb!of!the!chevron!is!cut!longer!than!the!462!
superior!limb!with!the!overall!shape!allowing!lateral,!distal!and!plantar!463!
displacement!of!the!1st!MT!head.!464!
(465!
Figure!3.!Operative!technique:!After!the!1.9mm!guide!wire!is!passed!into!the!466!
metatarsal!shaft,!causing!the!deformity!correction!an!appropriate!Barouk!screw!is!467!
inserted!across!the!osteotomy!site!to!stabilise!the!osteotomy.!468!
(469!
Figure!4.!Post-operative!weightbearing!anteroposterior!and!lateral!radiographs!of!470!
MIS!(R!-!right!foot,!51!year-old!female)!and!open!(L!-!left!foot,!59!year-old!female)!471!
distal!chevron!osteotomies!at!8!weeks!post!surgery.!!!
472!
ResearchGate has not been able to resolve any citations for this publication.
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