Minimally invasive hallux valgus surgery: a critical review of the evidence.

This systematic review aims to illustrate the published results of "minimally invasive" procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were "hallux valgus", "bunion", "percutaneous surgery", "minimally invasive surgery", "arthroscopy", "Bosch" and "SERI". Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one's own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for the treatment of stage II posterior tibial tendon dysfunction: kinematic and functional results of fifty one feet.

PURPOSE: Stage II posterior tibial tendon dysfunction (PTTD) can be treated by flexor digitorum longus (FDL) tendon transfer and medial displacement calcaneal osteotomy (MDCO). Numerous authors have studied the clinical and radiographic results of this procedure. However, little is known about the kinematic changes. Therefore, the purpose of this study was to assess plantar-pressure distribution in these patients. METHODS: Seventy-three patients with PTTD stage II underwent FDL tendon transfer and MDCO. Plantar pressure distribution and American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed 48 months after surgery. Pedobarographic parameters included lateral and medial force index of the gait line, peak pressure (PP), maximum force (MF), contact area (CA), contact time (CT) and force-time integral (FTI). RESULTS: In the lesser-toe region, PP, MF, CT, FTI and CA were reduced and MF in the forefoot region was increased. These changes were statistically significant. We found statistically significant correlations between AOFAS score and loading parameters of the medial midfoot. CONCLUSIONS: Study results reveal that FDL tendon transfer and MDCO leads to impaired function of the lesser toes during the stance phase. However, there seems to be a compensating increased load in the forefoot region.

Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome.

PURPOSE: Ankle arthrodesis (AAD) and total ankle replacement (TAR) are the major surgical treatment options for severe ankle arthritis. There is an ongoing discussion in the orthopaedic community whether ankle arthrodesis or ankle fusion should be the treatment of choice for end stage osteoarthritis. The purpose of this study was to compare the participation in sports and recreational activities in patients who underwent either AAD or TAR for end-stage osteoarthritis of the ankle. METHODS: A total of 41 patients (21 ankle arthrodesis /20 TAR) were examined at 34.5 (SD18.0) months after surgery. At follow-up, pre- and postoperative participation in sports and recreational activities has been assessed. Activity levels were determined using the ankle activity score according to Halasi et al. and the University of California at Los Angeles (UCLA) activity scale. Clinical and functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. The percentage of patients participating in sports and recreational activities, UCLA score and AOFAS score were compared between both treatment groups. RESULTS: In the AAD group 86% were active in sports preoperatively and in the TAR group this number was 76%. Postoperatively in both groups 76% were active in sports (AAD, p = 0.08). The UCLA score was 7.0 (± 1.9) in the AAD group and 6.8 (± 1.8) in the TAR group (p = 0.78). The AOFAS score reached 75.6 (± 14) in the AAD group and 75.6 (± 16) in the TAR group (p = 0.97). The ankle activity score decrease was statistically significant for both groups (p = 0.047). CONCLUSIONS: Our study revealed no significant difference between the groups concerning activity levels, participation in sports activities, UCLA and AOFAS score. After AAD the number of patients participating in sports decreased. However, this change was not statistically significant.

Biomechanics of postoperative shoes: plantar pressure distribution, wearing characteristics and design criteria: a preliminary study.

BACKGROUND: Modern concepts in the postoperative treatment of first metatarsal osteotomies include special shoes that should decrease stress in the forefoot region. The purpose of this study was to determine plantar pressure distribution, wearing characteristics and stress-reducing effectiveness of five different types of commonly used postoperative shoes. Additionally, we wanted to modify the shoe that revealed the most favourable results in a way that improves forefoot relief as well as provides comfort to the patients. METHODS: Eight persons consented to participate in the study. Plantar pressure distribution in five different types of postoperative shoes (Rathgeber(®) normal, Rathgeber(®) modified, 4. Darco(®) flat, Darco(®) VFE, Wocker(®)) was assessed using Mediologic(®) insoles. Also, subjective criteria considering wearing comfort, stability and rolling characteristics were evaluated. Based on the postoperative shoe revealing the most favourable results, further prototypes were developed. Each new model was targeted to meet the given requirements, minimal forefoot pressure, in a different way. RESULTS: The Rathgeber(®) modified model revealed the most favourable results concerning plantar pressure distribution as well as subjective wearing characteristics. Therefore, it was chosen for further modifications. After adding an extra layer of high elastic and springy material for shock absorption at the hallux region, forefoot relief and wearing characteristics showed improved results. CONCLUSION: The results of the present study indicate that damping material in the hallux region of postoperative shoes minimises stress in this region and improves patient's comfort.

Plantar loading after chevron osteotomy combined with postoperative physical therapy.

BACKGROUND: Recent pedobarographic studies have demonstrated decreased loading of the great toe region and the first metatarsal head at a short- and intermediate-term followup. The purpose of the present study was to determine if a postoperative rehabilitation program helped to improve weightbearing of the first ray after chevron osteotomy for correction of hallux valgus deformity. MATERIALS AND METHODS: Twenty-nine patients with a mean age of 58 years with mild to moderate hallux valgus deformity who underwent a chevron osteotomy were included. Postoperatively, the patients received a multimodal rehabilitation program including mobilization, manual therapy, strengthening exercises and gait training. Preoperative and one year postoperative plantar pressure distribution parameters including maximum force, contact area and force-time integral were evaluated. Additionally the AOFAS score, ROM of the first MTP joint and plain radiographs were assessed. The results were compared using Student's t-test and level of significance was set at p < 0.05. RESULTS: In the great toe, the mean maximum force increased from 72.2 N preoperatively to 106.8 N 1 year after surgery. The mean contact area increased from 7.6 cm(2) preoperatively to 8.9 cm(2) 1 year after surgery and the mean force-time integral increased from 20.8 N(*)sec to 30.5 N(*)sec. All changes were statistically significant (p < 0.05). For the first metatarsal head region, the mean maximum force increased from 122.5 N preoperatively to 144.7 N one year after surgery and the mean force-time integral increased from 42.3 N(*)sec preoperatively to 52.6 N(*)sec 1 year postoperatively (p = 0.068 and p = 0.055, respectively). The mean AOFAS score increased from 61 points preoperatively to 94 points at final followup (p < 0.001). The average hallux valgus angle decreased from 31 degrees to 9 degrees and the average first intermetatarsal angle decreased from 14 degrees to 6 degrees (p < 0.001 for both). CONCLUSION: Our results suggest that postoperative physical therapy and gait training with a Chevron osteotomy may help to improve weightbearing of the great toe and first ray. Therefore, we believe there is a restoration of more physiological gait patterns in patients who receive this postoperative regimen.

Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Learning Curve.

BACKGROUND: Minimally invasive surgery has a shorter surgical time, and in this study we focus on minimally invasive distal metatarsal metaphyseal osteotomy (DMMO). The operation seems to be less complex but requires a high learning curve. We report on our first patients to underline the need for extensive training and great awareness for the risks in the early learning stages. METHODS: We evaluated 27 patients (mean age = 60.9 years) with a mean follow-up time of 7.2 months. Indication was metatarsalgia, intractable plantar keratosis, and the (sub-)luxation of the metatarsophalangeal joint. Clinical results were evaluated with the 12-item Short Form (SF-12), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), and the American Orthopaedic Foot and Ankle Score (AOFAS). Radiographs and pedobarographic analysis were obtained. RESULTS: Scores ranged closely to standard value (AOFAS 88.07 points; FFI 93%; FAAM 36.4 points; SF-12 31.27 points). Pedobarography showed significant differences in several forefoot areas. We encountered nonunion/malunion and necrosis of the metatarsal head. CONCLUSIONS: The aim of this study was to demonstrate the need for intensive training before practicing DMMO. Results show that minimally invasive DMMO requires a high learning curve. Correct handling of the burr is associated with a lot of training. Wrong handling can lead to nonunion/malunion or necrosis. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Transverse medial slide osteotomy for bunionette deformity: long-term results.

BACKGROUND: Bunionette deformity of the fifth metatarsal infrequently requires operative treatment. This study presents the long-term results of a simple operative technique. METHODS: Forty-four distal metatarsal medial slide osteotomies with pin fixation were performed for symptomatic bunionette deformity in 30 patients. After an average of 7 years and 8 months (range 69 to 110 months), 30 feet in 21 patients were available for clinical and radiographic evaluation. RESULTS: The patients' subjective assessment was excellent and good in 81% and fair and poor in 19% of feet. The mean pain score on a visual analogue scale was 1.8 (range 0 to 7) and the mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 88.2 (range 47 to 100). Postoperative complications included pin track infection in three feet and delayed union in one. One patient developed transfer metatarsalgia and another patient had repeat surgery for recurrent symptoms on both feet after 5 years. CONCLUSIONS: This procedure combines technical simplicity with satisfactory and predictable long-term results in the operative treatment of bunionette deformity in the lateral forefoot.

The Scarf Osteotomy with Minimally Invasive Lateral Release for Treatment of Hallux Valgus Deformity: Intermediate and Long-Term Results.

BACKGROUND: Little is known about the long-term results of surgical correction of hallux valgus deformity, in particular, the recurrence rate and factors leading to recurrence. METHODS: Of one hundred and eight patients (115 feet) who underwent a Scarf osteotomy, ninety-three patients (ninety-three feet) were examined at an average duration of follow-up of 124 months. Clinical examination before surgery and at the time of final follow-up included an evaluation of range of motion, pain as measured with a visual analog scale, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. The Foot and Ankle Outcome Score (FAOS) was also assessed postoperatively. Radiographic data were evaluated preoperatively, at six weeks postoperatively, and at the time of final follow-up. Additional radiographic data were available for seventy-nine patients of the same patient cohort at an average of twenty-seven months postoperatively. RESULTS: The median overall AOFAS score improved from 57 points preoperatively to 95 points at the time of final follow-up. All radiographic measurements (hallux valgus angle [HVA], intermetatarsal angle [IMA], distal metatarsal articular angle [DMAA], and sesamoid bone position) showed significant (p < 0.05) improvement at the time of final follow-up compared with preoperatively. The rate of recurrence (an HVA of ≥20°) at the time of final follow-up was 30%. We were unable to determine if recurrence resulted in functional impairment or consequences for quality of life. CONCLUSIONS: The recurrence rate after ten years was 30%, and a higher final HVA resulted in higher pain levels. The limitations imposed by nonvalidated outcome measures precluded conclusions about the influence of HVA on function or quality of life.

Plantar pressure characteristics in hallux valgus feet.

Due to the pathoanatomical changes in hallux valgus feet, the plantar flexion moment of the first metatarsophalangeal joint is reduced. Therefore, load bearing of the hallux is decreased during push-off. We assessed loading parameters in hallux valgus feet. Based on dorsal-plantar weight bearing radiographs of 61 feet, the intermetatarsal-, hallux valgus-, distal metatarsal articulation-angle, and sesamoid position were evaluated. Plantar pressure assessment was performed with the emed® system during level walking. We found negative correlations between hallux valgus angle and peak pressure in the great toe (r=-0.301, p<0.023), the maximum force of the hallux (r=-0.481, p<0.001), and contact time of the great toe (r=-0.448, p<0.001), and positive correlations for force time integral (r=0.348, p<0.001), contact area (r=0.307, p<0.020), maximum force (r=0.430, p<0.001), and peak pressure (r=0.361, p<0.006) of the fifth metatarsal head. A positive correlation between the sesamoid and the metatarsal subluxation regarding maximum force (r=0.294, p<0.034), and a negative correlation between the contact area of the hallux (r=-0.232, p<0.020) was shown. Depending on the severity, hallux valgus angle, and sesamoid subluxation, load shows significant lateral transmission in hallux valgus feet.

Kinematic changes in patients with double arthrodesis of the hindfoot for realignment of planovalgus deformity.

Double fusion (i.e., fusion of the subtalar and talonavicular joint) represents a modification of triple arthrodesis preserving integrity of the calcaneocuboidal joint. Our aims were (1) to evaluate dynamic plantar pressure distribution in patients undergoing double arthrodesis, (2) to obtain a comparison of kinematic changes to healthy feet, (3) to evaluate the influence of radiographic alignment, and (4) to assess functional outcome. Sixteen feet (14 patients) treated by double fusion due to fixed planovalgus deformity were included. Dynamic plantar pressure distribution was assessed using a capacitive pressure platform. Results were compared with a demographically matched control group. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and radiographic assessment included measurement of talometatarsal, calcaneal pitch, and talocalcaneal (TC) angle on lateral radiographs. Significant differences in plantar pressure distribution were found for maximum force of the hindfoot, midfoot, and big toe region: While the hindfoot and hallux represented decreased load in the double arthrodesis patients, load increased in the midfoot region compared with healthy controls. The lateral talus-first metatarsal-angle increased from -16.3° to -8.2°, and the TC angle decreased from 41.3° to 35.8° (p < 0.05). The pre- and post-operative AOFAS score increased from 37 points (SD, 16.3) to 70 points (SD, 16.7). These results revealed that double arthrodesis represents a reliable method for correction of planovalgus deformity. Compared with healthy feet, force transmission of the midfoot is increased whereas push-off force decreases.

Metatarsalgia: distal metatarsal osteotomies.

Metatarsalgia is a common pathologic entity. It refers to pain at the MTP joints. Pain in the foot unrelated to the MTP joints (such as Morton's neuroma) must be distinguished from those disorders, which lead to abnormal pressure distribution, reactive calluses, and pain. Initial treatment options for metatarsalgia include modifications of shoe wear, metatarsal pads, and custom-made orthoses. If conservative treatment fails, operative reconstructive procedures in terms of metatarsal osteotomies should be considered. Lesser metatarsal osteotomy is an effective and well-accepted method for the management of metatarsalgia. The main purpose of these osteotomies is to decrease prominence of the symptomatic metatarsal head. The distal metatarsal oblique osteotomy (Weil osteotomy) with its modification represents the best evaluated distal metatarsal osteotomy in terms of outcome studies and biomechanical analysis. The role of the Weil osteotomy in metatarsalgia owing to a subluxed or dislocated MTP joint is to bring the metatarsal head proximal to the callus and to provide axial decompression of the toe to correct the deformity contributing to metatarsalgia.

First metatarsophalangeal arthrodesis for severe bone loss.

Severe bone loss of the first metatarsal is a significant problem in revisional surgery of the first metatarsophalangeal joint either after failed hallux valgus surgery or failed primary arthrodesis. A short first ray leads to pathologic biomechanics of the forefoot, which is treated with interpositional bone block arthrodesis. A ball-in-socket preparation performed with cup-in-cone reamers is the preferred method for modeling of the bone block. An autologous iliac crest bone graft reveals good results by bony integration. Bone block arthrodesis represents a feasible treatment for severe bone loss, leading to good clinical results at midterm follow-up.

Plantar pressure distribution after tibiotalar arthrodesis.

INTRODUCTION: Arthrodesis is a well-established treatment option for end-stage osteoarthritis of the ankle. Osteoarthritis of the ankle can alter plantar pressure distribution. However, surprisingly little is known about the effect of ankle arthrodesis to alter plantar pressure distribution. The purpose of this study was to determine plantar pressure distribution in a selected group of patients with unilateral arthrodesis of the ankle joint. METHODS: 20 patients with an average age of 60 years who underwent isolated unilateral ankle arthrodesis using a 3-crossed screw technique by a single surgeon were included. After a mean of 25 months (range 12-75 months) post surgery plantar pressure distribution was determined in five regions of the foot. The outcome was evaluated clinically, using the American Orthopaedic Foot and Ankle Society hindfoot score, as well as radiographically. The contralateral normal foot was used as a control. FINDINGS: Comparing the foot that underwent tibiotalar arthrodesis to the contralateral normal foot, differences were found in the peak pressure and maximum force in the toe region and the lateral midfoot region. In addition, a decrease in the contact time in the forefoot region and a decrease of the contact area in the toe region of the operated foot were identified. The other regions did not show a significant difference. The mean American Orthopaedic Foot and Ankle Society score of the operated leg was 79 (range 46-92) at the last follow up, and the mean fixation angle of the arthrodesis on lateral weight bearing radiographs was 90° (range 86°-100°). INTERPRETATION: Our results indicate that arthrodesis of the ankle joint can provide high levels of function with minimal changes in the plantar pressure distribution.

Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase.

BACKGROUND: Operative treatment of people with hallux valgus can yield favorable clinical and radiographic results. However, plantar pressure analysis has demonstrated that physiologic gait patterns are not restored after hallux valgus surgery. OBJECTIVE: The purpose of this study was to illustrate the changes of plantar pressure distribution during the stance phase of gait in patients who underwent hallux valgus surgery and received a multimodal rehabilitation program. DESIGN: This was a prospective descriptive study. METHODS: Thirty patients who underwent Austin (n=20) and scarf (n=10) osteotomy for correction of mild to moderate hallux valgus deformity were included in this study. Four weeks postoperatively they received a multimodal rehabilitation program once per week for 4 to 6 weeks. Plantar pressure analysis was performed preoperatively and 4 weeks, 8 weeks, and 6 months postoperatively. In addition, range of motion of the first metatarsophalangeal joint was measured, and the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot questionnaire was administered preoperatively and at 6 months after surgery. RESULTS: The mean AOFAS score significantly increased from 60.7 points (SD=11.9) preoperatively to 94.5 points (SD=4.5) 6 months after surgery. First metatarsophalangeal joint range of motion increased at 6 months postoperatively, with a significant increase in isolated dorsiflexion. In the first metatarsal head region, maximum force increased from 117.8 N to 126.4 N and the force-time integral increased from 37.9 N.s to 55.6 N.s between the preoperative and 6-month assessments. In the great toe region, maximum force increased from 66.1 N to 87.2 N and the force-time integral increased from 18.7 N.s to 24.2 N.s between the preoperative and 6-month assessments. LIMITATIONS: A limitation of the study was the absence of a control group due to the descriptive nature of the study. CONCLUSIONS: The results suggest that postoperative physical therapy and gait training may lead to improved function and weight bearing of the first ray after hallux valgus surgery.