Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome?

BackgroundTranslation and shortening of Scarf osteotomy allows correction of severe hallux valgus deformity. Shortening may result in transfer metatarsalgia.AimTo evaluate outcome of patients undergoing shortening Scarf osteotomy for severe hallux valgus deformities.Materials and MethodsFifteen patients (20 feet, mean age 58 years) underwent shortening Scarf osteotomy for severe hallux valgus deformities. Outcomes were pre and postoperative AOFAS scores, IM and HV angles, patient satisfaction.ResultsMean follow-up was 25 months (range 22–30). The IM angle improved from a median of 18.60 (range 13.4–26.20) preoperatively to 9.70 (range 8.0–13.70) postoperatively (8.9; 95% CI = 7.6–10.3; p < 0.001). The HV angle improved from a mean of 43.2 (range 27.4–68.2) preoperatively to 13.6 (range 3.0–37.4) postoperatively (29.6; 95% CI = 26.1–33.2; p < 0.001).The median AOFAS score improved from 29.2 (range 14–60) preoperatively to 82.2 (range 55–100) postoperatively (53.0; 95% CI = 48.0–58.5; p < 0.001). All patients rated their satisfaction as either satisfied or very satisfied. None had symptoms of transfer metatarsalgia at final follow-up. All osteotomies united.ConclusionsShortening Scarf osteotomy is a viable option for treating severe hallux valgus deformities with no transfer metatarsalgia.     

Minimally invasive hallux valgus correction: Is it better than open surgery?

BackgroundThe aim was to compare the minimally invasive (MIS) chevron osteotomy to the well-established open chevron osteotomy for the correction of hallux valgus deformity.MethodsTwo retrospective cohorts of patients treated with MIS or open chevron osteotomy for hallux valgus correction, matched for age and gender with a minimum follow up of six months were reviewed. Functional outcomes were evaluated using pre and post-operative Manchester Oxford Foot and Ankle Questionnaire (MOXFQ), Visual Analog Score (VAS) for pain and the Unified Elective Orthopaedic Score (UnEOS). Two independent, blinded examiners evaluated the radiographic correction of hallux valgus (HV) and intermetatarsal (IM) angle.ResultsA Total of 54 cases (27 per study group) with a mean follow-up of 25.9 months were included in the study. Pre-operatively, VAS (p = 0.76) and MOXFQ (p = 0.46) scores and HV angle (p = 0.1) were comparable in both groups. However, IM angle was significantly larger in the MIS group (p = 0.005). Post-operatively there was significant improvement in VAS and MOXFQ scores as well as significant correction of the HV and IM angles (p < 0.0001) for both groups. Comparing the two procedures, there was no significant difference between groups for VAS (p = 0.34), MOXFQ scores (p = 0.56) and HV angles (p = 0.069) but the MIS technique was significantly better in improving the IM angle (p = 0.016). The post-operative UnEOS score and the Satisfaction UnEOS domain reached excellent levels for the entire cohort with no statistical difference between the two groups (p = 0.2 and 0.28 respectively).ConclusionResults show MIS chevron osteotomy provides better radiographic correction of the IM angle but functional outcomes for all parameters were comparable to the open technique. It can therefore be considered at least equivalent to standard open surgery when compared using validated Patient Reported Outcome Measures (PROMs).     

Is bilateral hallux valgus chevron osteotomy a safe procedure for ambulatory surgery?

IntroductionSeveral osteotomies of the first metatarsal have been described for treatment of hallux valgus but chevron osteotomy is one of the most common and well-established procedure for treating this deformity. Although there is a trend towards considering bilateral surgery there is lack of publications addressing bilateral treatment in ambulatory units. The aim of this study is to analyze results of bilateral and unilateral distal chevron osteotomies associated with lateral soft tissue release as ambulatory procedures.Materials and MethodsA retrospective review was made about the patients treated at our ambulatory unit over a period of five years. Initially, general information as patient’s satisfaction’s rate and return to normal activity’s time and evaluation of standardized follow-up charts and records made by the surgeon were recorded. Secondly, the hallux metatarsophalangeal interphalangeal scale developed by the American Orthopedic Foot & Ankle Society was used.ResultsA total of 194 patients with 230 feet operated were included in this study. We found 29 patients that didn’t meet the inclusion criteria and were excluded. The unilateral group was composed by 139 feet and the bilateral group by 52 feet. The improvement between preoperative and discharge clinical and radiographic results was significant independently in both groups. A total of 14% of complications were found in our study, 19% in the unilateral group and 12% at the bilateral group. None of them required revision surgery.ConclusionBilateral distal chevron osteotomies, associated with lateral soft tissue release, are safe and effective ambulatory procedures. It was found a satisfactory deformity correction in moderate HV. Both patients that underwent unilateral and bilateral procedures had similar clinical and radiological outcomes with no increase in complications or return to normal activity time. With this study it was demonstrated that bilateral chevron osteotomies can be performed as ambulatory procedures.     

Patient-reported outcome after hallux valgus surgery — a two year follow up

BackgroundPatients with hallux valgus deformity may require surgery but prospective patient-reported data is scarce.MethodsWe evaluated 53 patients with a mean age of 55.3 years (SD 14.1, 50 women), who underwent surgery due to hallux valgus. They completed the PROMs SEFAS, EQ-5D and SF-36 before and 6, 12 and 24 months after surgery.ResultsAll patient-reported outcomes improved at 6, 12 and 24 months compared with the preoperative status. The greatest improvement occurred at 6 months: SEFAS Δ 10.0 (95% confidence interval 7.8–12.2), EQ-5D Δ 0.22 (0.15–0.29), EQ-VAS Δ 8.4 (4.4–12.4), PF SF-36 Δ 22.0 (14.6–29.3) and BP SF-36 Δ 30.6 (23.1–38.1).ConclusionsHallux valgus surgery considerably reduced pain and improved function already within 6 months after surgery. The improvement between 6 and 24 months’ follow-up was minimal measured with PROMs.Level of clinical evidenceIII — prospective observational cohort study.     

Minimally invasive hallux valgus correction with Internal Hallux Fixator® — A comparative cadaver study

BackgroundThe Internal Hallux Fixator® (IHF®; Waldemar Link, Hamburg, Germany) was designed for open surgical hallux valgus correction. It allows a defined lateralisation of the first metatarsal head after V-shaped, Chevron-like distal metatarsal osteotomy in order to correct mild to middle hallux valgus deformities. The intramedullary fixation provides dynamic compression of the osteotomy and thus postoperative full weight bearing mobilization is an integral part of the therapy.This comparative cadaver model study investigates the feasibility of implanting the device using a minimally invasive technique and compares its capability of first metatarsal head lateralisation to the established 3rd generation MICA (Minimally Invasive Chevron and Akin osteotomy) technique.Methods16 fresh frozen cadaveric feet (8 left, 8 right) of 8 body donors received either MICA (Group 1), or an IHF® in a minimally invasive technique (Group 2). The achievable first metatarsal head lateralisation and operating time were measured and pitfalls recorded.ResultsThis cadaver model study confirmed, the minimally invasive implantation of the Internal Hallux Fixator® can be performed reliably via 10 mm mini incision with V-shaped distal metatarsal osteotomy. The mean first metatarsal head lateralisation was comparable between the groups with no statistically significant difference (7.2 (±1.9) mm in G1, or 8.3 (±0.8) mm in G2; p = 0.09).The IHF® was inserted and fixed in mean 3.7 (±0.6) min, whereas double screw fixation needed 10 (±3.7) min.Level of Clinical Evidence5, Cadaver model study.     

Does the length of the plate affect the failure rate of hallux MTP joint arthrodesis for severe hallux valgus?

PurposeThe purpose of this study was to investigate the effect of the length of the dorsal locking plate on the failure rate of first MTP joint arthrodesis for severe hallux valgus deformities.MethodsA retrospective review was conducted for all patients who underwent first MTP joint arthrodesis using solely a specific locked plating system (Depuy-Synthes, Raynham, MA) for severe hallux valgus deformities between January 2014 to June 2017. Patients were divided into subgroups according to the length of the plate and the failure rate was investigated. Furthermore, radiographic parameters including intermetatarsal angle (IMA) and hallux valgus angle (HVA) were evaluated in weightbearing AP foot radiographs.ResultsA total of 25 patients were included in this study. There were 16 (64%) patients in the medium-sized plate cohort and 9 (36%) patients in the small-sized plate cohort. We found a significant difference in the failure rate between the two groups; only 1 (6.25%) failure case occurred in the medium-sized plate cohort while 4 (44.44%) failure cases occurred in the small-sized plate cohort (P = .040, Odds ratio (OR) = 12.000, 95% Confidence Interval (CI) = 1.074, 134.110). The mean postoperative IMA and HVA were significantly improved in both cohorts. However, significant differences were found between the two cohorts in final follow-up IMA and HVA (P = .002 and P < .001, respectively).ConclusionsFor severe hallux valgus deformities, the use of longer plates to gain additional purchase in the diaphyseal bone may help mitigate the increased stresses placed on the fixation constructs for first MTP joint arthrodesis and decrease failure rate.Level of EvidenceLevel III, case control study.     

Is obesity a risk factor in percutaneous hallux valgus surgery?

BackgroundObesity and its relationship with higher rate of complications in orthopedic surgeries have been reported. There is no evidence of the relation between obesity and percutaneous foot surgery. Our objective was to evaluate obesity as a risk factor for complications and reoperations in percutaneous surgery of the hallux valgus.MethodsA total 532 feet were retrospectively reviewed in which a percutaneous hallux valgus correction was performed. Complications and surgical reoperations were recorded. Patients were divided into 2 groups: BMI less and greater than 30 kg/m².ResultsThere were no differences in the rate of complications or reoperations. The total complication rate was 8%. Obesity as an isolated risk factor, presented aOR = 1.14 (95%CI 0.54–2.4, p = .714). The overall rate of reoperations was 9%. Obesity presented an aOR = 0.64 (95%CI 0.27–1.49, p = .31).ConclusionObesity has not been associated with a higher rate of complications and reoperations in percutaneous hallux valgus surgery. It is a safe procedure and BMI should not influence in the prognosis.Level of evidence: Level III, retrospective comparative study.     

Bösch technique for hallux valgus surgery in a tropical setting

ObjectivesTo evaluate the early clinical and radiological results using the Bösch technique to treat hallux valgus.Material and methodsWe reviewed retrospectively four patients with 6 feet undergoing the Bösch technique for mild and moderate hallux valgus from 2009 to 2012 with an average follow-up of 10.8 months. All patients complained of pain around the first metatarsophalangeal joint. They had cosmetic concerns, and difficulty in wearing shoes. At final follow-up patients were asked about the improvement of pain, cosmetic appearance of the foot, problems with wearing shoes, the ability to walk, and their satisfaction with the operation. Complications encountered were also recorded. The radiographic evaluation considered osteotomy site union, the hallux valgus angle, and the intermetatarsal angle.ResultsAll patients complained of mild or no pain. They had a satisfactory cosmetic result, wore normal shoes without problems with no limitation of walking ability. They were satisfied with the procedure. One case of superficial infection was noticed. All osteotomies healed primarily within three months. The average hallux valgus angle improved from 32.7° preoperatively to 14.8° at final follow-up and the average intermetatarsal angle from 17.5° to 9.2°.ConclusionThe Bösch technique is a cost effective procedure that yields good clinical and radiological results while correcting mild and moderate symptomatic hallux valgus with reduced risk of surgery related complications.     

Does preoperative deformity diminish radiographic outcome after hallux valgus correction with scarf osteotomy?: A retrospective study of 102 cases

BackgroundScarf osteotomy is a frequently used technique to correct moderate to severe hallux valgus deformities. Recurrence of a deformity is a commonly reported complication after surgery. The aim of our study was to evaluate the impact of preoperative deformity on radiological outcome in terms of postoperative loss of correction after scarf osteotomy.Methods102 patients, in which a hallux valgus deformity was corrected with an isolated scarf osteotomy were included. Weightbearing radiographs were analyzed preoperatively, postoperatively, after 6 weeks and after three months (mean 10.9 months SD 17.2 months). The following radiological parameters were used for analysis: the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), position of the sesamoids, first metatarsal length, and first metatarsophalangeal joint congruity.ResultsSignificant correction of IMA, HVA, DMAA, sesamoid position and joint congruity was achieved (p < 0.001). The IMA improved from 15.8 ± 2.3 to 4.3 ± 2.8°, the HVA from 32.6 ± 6.8 to 9.1 ± 7.2, and the DMAA from 11.4 ± 6.9 to 8.4 ± 5.2°, respectively. In contrast to DMAA, throughout followup we could detect loss of correction for HVA and for IMA amounting 6.3° ± 5.8 and 3.8° ± 2.8 respectively. Loss of HVA correction revealed a significant correlation with preoperative DMAA, but not with the other preoperative radiological parameters.ConclusionsPreoperative deformity does not correlate with postoperative loss of correction after scarf osteotomy, except DMAA.Clinical relevanceOur results may be helpful in counseling patients regarding recurrence of hallux valgus deformity after scarf osteotomy.Level of evidenceTherapeutic, Level IV, retrospective case series.     

Plaster slipper versus crepe bandage after Wilson’s osteotomy for hallux valgus

Much variability exists in the postoperative mobilization management after modified Wilson’s osteotomy for hallux valgus. This study aimed to elicit the differences, if any, between weightbearing following surgery as managed with a plaster slipper as compared to that of a crepe bandage. Fifty-four operated feet were randomly entered into a prospective trial. All feet underwent identical operations. When a crepe bandage was used there was no significant difference in the rate of complications, or in the patient’s assessment of postoperative pain relief. Patients treated with a crepe bandage were back to full activity as quickly as their plaster slipper counterparts and the patient’s overall assessment of the operation was no different.     

Short term results of dynamic splinting for hallux valgus — A prospective randomized study

Background Hallux valgus is a common diagnosis in orthopedics. Only a few studies have analyzed the effects of conservative therapy. Therefore, the current study analyzed the effect of a dynamic hallux valgus splint.Methods Seventy patients were included in this prospective randomized trial. Patients with a hallux valgus were treated using a dynamic splint or underwent no treatment. Clinical and radiological parameters were evaluated.Results We found no significant changes in hallux valgus angle, intermetatarsal I–II angle, AOFAS score, FAOS or SF-36 score between the groups. However, a significant between-group difference was found for pain during walking and running and in the FAOS subscale for pain and pain at rest at follow-up.Conclusions Wearing a dynamic hallux valgus splint does provide some pain relief in patients with a symptomatic hallux valgus, but showed no effect on hallux valgus position.Level of evidence: 1.     

Surgery of the hallux valgus in an ambulatory setting: a liability risk?

Introduction

The primary objective of the study is to make an inventory of malpractice in hallux valgus surgery in an ambulatory setting and to identify the patient characteristics for a higher risk of malpractice. The secondary objective is creating a methodology for analyzing the medicolegal aspects of a surgery in day case comparing with hospitalization.

Materials and methods

The database of the Branchet insurance company was used. A total of 11,000 claims for a period of 11 years (2002–2013) have been investigated. The files of the patients with hallux valgus surgery were isolated from the insurer’s database using CCAM codes. The medical director, a medical officer, the legal expert and finally the judge had already analyzed all these cases. The authors reviewed the various documents with a specific questionnaire.

Results

We identified 14 cases of claims in relation with hallux valgus 1-day surgery among a total of 138 claims for hallux valgus including all techniques (10%). All patients were female. The mean age was 42.6 years (19–64) in ambulatory patients (AG group) in comparison with 49.5 years (19–73) in hospitalized patients (HG group). Percutaneous techniques were significantly more represented in the AG group (p = 0.002) and scarfs osteotomies in the HG group (p = 0.004). The use of tourniquet seemed to be lower in the AG group, but it was a not significant trend (p = 0.085). In term of anesthesia procedures, no significant differences were seen between the two groups. The comparison of the complications common to both groups showed no significant difference except for insufficient results which were more frequent in the AG group (p = 0.026). The rate of insufficient informed consent seemed to be higher in the AG group, but it was a not significant trend (p = 0.084).

Discussion and conclusion

No specific data regarding claims in relation with hallux valgus 1-day surgery are available to our knowledge in the literature. We did not identify in our study specific complications related to ambulatory procedures except for insufficient results. Hallux valgus 1-day surgery does not seem to expose surgeons to higher medicolegal problems than classical hospitalization. Nevertheless, a specific consent form for ambulatory patients is required to limit claims regarding information.

     

Is it feasible to rely on intraoperative X ray in correcting hallux valgus?

Background

The aim of the study was to prove whether the intraoperatively taken fluoroscopy pictures compared to the X rays taken 8 weeks and 3 months postoperatively picture the achieved correction reliably.

Method

In a prospective study, the pre- and postoperative standing foot X rays as well as the intraoperatively taken fluoroscopy pictures of 31 patients were analysed. The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were measured. In all cases, a tarso-metatarsal joint I arthrodesis combined with a distal soft tissue release was performed. The mean age was 54 (17–73) years.

Results

There was no significant difference between the measured angles in intraoperative fluoroscopy and standing X rays postoperatively taken.

Conclusions

Despite the consideration that fluoroscopic pictures lack the loading criteria, we found reliable results in IMA and HVA.     

Magnesium-based bioabsorbable screw fixation for hallux valgus surgery – A suitable alternative to metallic implants

BackgroundThe primary aim of this pilot study was to prospectively evaluate outcomes of the MgYREZr bioabsorbable screw in the setting of hallux valgus corrective surgery. The secondary aim was to compare the outcomes against a control group treated with conventional titanium screws.MethodsA consecutive series of patients with hallux valgus deformity (n = 24) underwent forefoot reconstruction surgery with a scarf osteotomy to the first metatarsal using MgYREZr screws. Functional scores, radiological outcomes, and complication profile were recorded over 12 months. Results were compared against a control group of patients (n = 69) using titanium alloy screws.ResultsAt 1-year post-operative, both functional and radiological outcomes showed significant improvements. Compared to the control group, there was no significant difference in functional outcomes, yet radiological improvements were significantly better in the control group.ConclusionsThe MgYREZr bioabsorbable screw is a suitable alternative to titanium alloy screws for hallux valgus corrective surgery.     

Fixation of Mitchell’s osteotomy with bioabsorbable pins for treatment of hallux valgus deformity

We hypothesised that the use of bioabsorbable pins in Mitchell's osteotomy would improve the outcome of patients treated for hallux valgus deformity. A total of 68 patients underwent Mitchell's osteotomy to correct hallux valgus deformity: 33 patients (group A) underwent Mitchell's osteotomy augmented with bioabsorbable pins and 35 patients were treated with the classic operative procedure (group B). Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analogue score (VAS) for pain were measured preoperatively and postoperatively. There was no statistically significant difference between the two groups as far as the improvement of the IMA, HVA and AOFAS scale were concerned. Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group B. The use of the pins did not improve the final outcome of the osteotomy. However, it allowed for faster rehabilitation due to less postoperative pain.