A modified minimally invasive osteotomy for hallux valgus enables reduction of malpositioned sesamoid bones

Background: Current minimally invasive distal metatarsal osteotomy for hallux valgus (HV) is V-shaped, which prevents correcting the rotational metatarsal head deformity and reduction of sesamoid bones. We aimed to determine the optimal method for sesamoid bone reduction in HV surgery.Methods: We reviewed the records of 53 patients who underwent HV surgery by a single surgeon from 2017 to 2019 according to one of three techniques: open chevron osteotomy (n=19), minimally invasive V-shaped osteotomy (n=18) and a modified, straight minimally invasive osteotomy (n=16). Sesamoid position was graded using the Hardy and Clapham method based on standing radiographs. Results: Postoperative sesamoid position scores were significantly lower (better) following the modified osteotomy than following open chevron osteotomy and V-shaped osteotomy (1.44±0.81, 3.74±1.48 and 4.61±1.09, respectively, P<0.001); and the mean change in score was greater (P<0.001). Conclusion: Modified minimally invasive osteotomy was superior to the two other techniques, in the correction of HV deformity in all planes, including sesamoid reduction.

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

Category: Basic Sciences/Biologics; Bunion Introduction/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.

A Modified Minimally Invasive Osteotomy for Hallux Valgus Allows Reduction of Malpositioned Sesamoid Bones

Background: Current minimally invasive distal metatarsal osteotomy for hallux valgus (HV) is V-shaped, which prevents correcting the rotational metatarsal head deformity and reduction of sesamoid bones. Methods: We retrospectively reviewed the records of 53 patients that underwent HV surgery by a single surgeon from 2017 to 2019 to compare outcomes of three techniques: open chevron osteotomy (n=19), minimally invasive V-shaped osteotomy (n=18), and a modified, straight minimally invasive osteotomy (n=16). Sesamoid position was graded using the Hardy and Clapham method based on standing radiographs. Results: Postoperative sesamoid position scores were significantly lower (better) following the modified osteotomy, compared with the two other techniques (1.44±0.81 vs 3.74±1.48 and 4.61±1.09, P<0.001), and mean change in score was greater (P<0.001). The modified technique yielded the largest improvements in inter-metatarsal and HV angles (P<0.05).Conclusion: The modified minimally invasive osteotomy was superior in the correction of HV deformity in all planes, including sesamoid reduction.Level of Evidence: IV

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

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

Category: Bunion Introduction/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.