Clinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus

Abstract

Background: The treatment for severe hallux valgus deformity presents a challenge with high risk of complications. Third generation MIS techniques have increased their publications in recent years. The aim was to compare clinical and radiologic outcomes in moderate and severe cases and report minor and major complications. Methods: Retrospective series of cases with prospective data collection of 156 consecutive feet that underwent percutaneous double first metatarsal osteotomy (PEDO) and first phalanx osteotomy between 2008 and 2019 for moderate (hallux valgus angle [HVA] between ≥20 and <40 degrees and/or intermetatarsal angle [IMA] <16 degrees) and severe (HVA ≥40 degrees and/or IMA ≥16 degrees) hallux valgus deformities. Primary outcomes included radiographic and clinical parameters. Secondary outcomes included minor and major complications. Results: A total of 156 procedures were performed in 128 patients. Mean age was 54.3 years (SD 14.3) (range, 19-82 years), median follow-up was 22.6 months (range, 12-96 months). Radiographic changes pre- to postoperation were as follows: HVA changed from 38.2 (SD 10.1) degrees to 11.2 (SD 8.3) degrees ( P < .001), IMA from 14.7 (SD 3.2) degrees to 7.9 (SD 3.7) degrees ( P < .001), and distal articular metatarsal angle from 19.7 (SD 6.3) degrees to 8.8 (SD 5.7) degrees ( P < .001) after PEDO technique. Clinical changes pre- to postoperation were as follows: American Orthopaedic Foot & Ankle Society ankle-hindfoot scale scores improved from 47.3 (SD 16.5) to 87 (SD 11.6) ( P < .001) and visual analog scale scores from 5 (2.7) to 0.9 (1.3) ( P < .001). The satisfaction rate was 97% in the total sample. Recurrence rate (HVA ≥20 degrees) was 7.7%. Hallux varus (HVA <0 degrees) occurred in 5.8%, acute osteomyelitis in 1.3%, partial avascular necrosis in 0.6%, screw removal in 0.6%, and reoperation in 1.9%. No nonunion was observed. Conclusions: Clinical and radiographic parameters improved significantly, with a minimum of 12 months of follow-up in moderate and severe hallux valgus. Long experience in percutaneous surgery and specific instruments are needed for this technique. Recurrence was linked to preoperative HVA ≥40 degrees and postoperative tibial sesamoid position; Hallux varus was linked to lateral soft tissue release. Level of Evidence: Level IV, case series.

Fourth-Generation Minimally Invasive Hallux Valgus Surgery With Metaphyseal Extra-Articular Transverse and Akin Osteotomy (META): 12 Month Clinical and Radiologic Results

“…52 This study reported on significant improvement in lateral sesamoid position and round sign, which is not commonly reported in other studies of third-generation MIS HV surgery. Tay et al 50 and Castellini et al 7 demonstrated improvement in the tibial sesamoid position following MICA and percutaneous double osteotomy respectively. We believe that the nature of a transverse osteotomy (ie, META) facilitates correction of the pronation HV deformity and thus correction of the sesamoid position and round sign, although readers should be aware of the limitations of assessment of these parameters on radiographs alone (pseudo-sesamoid-subluxation).…”

“…5,21,24,28,29,[31][32][33]35,42,45,50 Studies have suggested the radiographic deformity correction that can be achieved using certain MIS techniques in severe deformities is potentially greater than reported in a range of open techniques with similar complication rates. 7,12,31,35 Comparing third-generation MIS techniques is challenging given that there are a broad spectrum of techniques 3,6,19,22,26,37 used with different osteotomies, 17 different zones of fixation (eg, percutaneous intra-articular chevron osteotomy [PEICO] vs minimally invasive chevron and Akin osteotomy [MICA]), number of screws, and different inclusion/ exclusion criteria, which are all considered "third-generation." Even when procedures are described using specific acronyms, surgeons cannot agree on what constitutes the important aspects of the procedure.…”

“…5,21,24,28,29,31-33,35,42,45,50 Studies have suggested the radiographic deformity correction that can be achieved using certain MIS techniques in severe deformities is potentially greater than reported in a range of open techniques with similar complication rates. 7,12,31,35…”

Five-Year Follow-up of Third-Generation Percutaneous Chevron and Akin Osteotomies (PECA) for Hallux Valgus

“…1,8,30,31,34,45 Previous studies of severe hallux valgus have found that recurrence is associated with initial severity and incomplete deformity correction at the time of surgery. 8,31,42 We did not find a clinically significant change in radiographic deformity between 6-month and final radiographs.…”

“…This is similar to the rates reported in other series of mixed severity of hallux valgus deformity at shorter-term follow-up and lower than studies of severe hallux valgus deformity treated with MIS. 1,8,30,31,34,45 Previous studies of severe hallux valgus have found that recurrence is associated with initial severity and incomplete deformity correction at the time of surgery. 8,31,42 We did not find a clinically significant change in radiographic deformity between 6-month and final radiographs.…”