Reply to comments by Wu et al. regarding our manuscript titled: A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Abstract

Dear Editor, We gratefully acknowledge the letter from Wu et al. commenting on our manuscript titled: "A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)" [1]. In fact, we trust that one of the main reasons to report surgical results and technique is to begin a discussion that can further clarify concepts to the scientific community. We welcome the opportunity to reply to Wu et al.'s comments on a point-by-point basis: . We believe that manual stretching of the lateral soft tissues, when performed by skilled surgeons, provides results comparable with surgical release. We acknowledge that not all patients may benefit from this manoeuvre in the same fashion. In most postmenopausal women with mild to moderate hallux valgus, it is easy to achieve soft tissue release using a gentle and progressive manoeuvre of the metatarsophalangeal joint, which after osteotomy and head translation results in repositioning of the metatarsal head over the sesamoids. In younger patients and in those with the lateral sesamoid which is completely dislocated in the intermetatarsal space, a lateral soft tissue release is performed using a percutaneous approach. At the end of surgery, when the metatarsal head is correctly displaced, the sesamoids will appear in the correct position: it is not always necessary to perform open surgery. Therefore, in contrast from what occurs in open procedures, minimally invasive procedures are accompanied by a lateral soft tissue release only in carefully selected cases. Subcapital osteotomies, in particular, despite usually not being associated with lateral soft tissue release, allow repositioning of the metatarsal head and properly repositioning the sesamoids and are associated with good long-term results [3]. 2. A 1-cm-long incision is sufficient to perform the osteotomy with a direct line of visualization; the osteotomy can be directed according to patient requirements and according to pre-operative planning, with the aim of recovering the lateral dislocation of the sesamoids. It also allows cutting the small bone tip at the medial edge of the diaphyseal osteotomy and eventually addressing small osteophytes of the exostoses with a small rongeur. Usually, exostoses are not the expression of newly formed bone, and once the head is corrected, it they disappear. Only rarely is it necessary to remove a small dorsal osteophyte. Finally, we do not cut the bunion on the medial side, as it is structurally part of the sesamoid sling [4]. (a) The SERI osteotomy is subcapital and extra-articular. In this sense, no direct effect on the capsular tissue is expected. (b) The SERI osteotomy is not meant for patients with hallux rigidus, and we agree with Wu et al. that in patients with hallux rigidus, SERI osteotomy should not be performed. We already reported our surgical guidelines for treating hallux rigidus [5] and

Distal Chevron Osteotomy vs The Simple, Effective, Rapid, Inexpensive Technique (SERI) for Mild to Moderate Isolated Hallux Valgus: A Randomized Controlled Study

“…Patients in the SERI group and Chevron osteotomy group received a similar postoperative protocol to that described by Giannini et al 1 . After the operation, immediate weight bearing was allowed with a DARCO MedSurg™ shoe for 4 to 6 weeks, until signs of bone healing appeared on radiographs.…”

“…Hallux Valgus is an acquired anatomical deformity of the foot. The pathological process starts with a medial deviation of the first metatarsal at the first metatarsophalangeal joint (MPJ), lateral deviation of the first phalanx, and subluxation of the metatarsophalangeal joint 1 2 . Hallux valgus is classified as mild when the IMA is between 9-12 degrees and the HVA≤40, moderate with an IMA between 13-15 degrees and HVA > 40, and severe with an IMA above 20 degrees and HVA > 41 2 .…”

“…Risk factors for the development of hallux valgus include family history, connective tissue disorders, pes planus, age, hypermobility of the first-ray, and the use of high-heeled shoes 3 . Hallux valgus may cause impaired function of the first metatarsophalangeal joint with bursitis or callosities, pain, and transfer metatarsalgia 1 . Pain may develop due to irritation of the dorsal cutaneous nerve and inflammation of the bursa over the medial eminence 3 .…”

“…Various surgical procedures have been successfully used to treat mild to moderate hallux valgus including distal chevron osteotomies. The goals of surgery in these cases includes reorientation of the first MPJ and first ray 1 . The distal chevron osteotomy has been associated with complications such as pain, fibrosis, hallux valgus recurrence, transfer metatarsalgia, and osteonecrosis of the metatarsal head 1,3−6 .…”

“…While a PDO has a distal incision, the SERI technique uses a proximal incision. The advantages of the SERI technique include reduced recovery and rehabilitation times, reduced revisions surgeries, and avoiding lateral cortex penetration [1][2][3]6 . Furthermore, there is minimal soft tissue dissection, which decreases the risk of vascular damage as the technique causes minimal capsular disruption, ultimately resulting in rapid bony union 7 .…”