Minimally invasive hallux valgus surgery using 3D printed patient specific instrumentation.

In this technical report study, we describe technique for performing the osteotomy and screw passage in minimally invasive fourth-generation hallux valgus surgery with transverse and akin extra-articular metaphyseal osteotomy (META) using a 3D-printed patient-specific surgical instrumentation guide. In an effort to minimize the learning curve and address the variability associated with technical corrections and screw placement, we have initiated the creation of personalized patient-specific instrumentation guides using 3D printing. Our hypothesis is that this approach will enhance safety, precision, decrease surgical time, and reduce exposure to radiation. Level of Evidence: Level V, expert opinion.

Minimally invasive Chevron-Akin (MICA) osteotomies without Akin fixation in hallux valgus correction: a case series with 2-year follow-up.

PURPOSE: The minimally invasive Chevron-Akin (MICA) is considered the third generation of minimally invasive hallux valgus (HV) surgery, and its original description included fixation of the Akin osteotomy with a screw. The aim of this study is to evaluate a series of patients undergoing HV correction using the MICA technique without screw fixation of the Akin osteotomy. METHODS: We retrospectively evaluated 58 consecutive patients who underwent surgical correction for HV between August 2018 and March 2020. A total of 69 feet were evaluated with a minimum follow-up of 2 years. Clinical outcomes such as pain (VAS), function (AOFAS), range of movement, criteria personal satisfaction and complications were evaluated. RESULTS: The AOFAS score (mean ± standard deviation) significantly improved from 57.0 ± 8.6 preoperatively to 93.9 ± 8.7 postoperatively (p < .001) with a minimum follow-up of 2 years. The VAS score improved from 6.0 ± 1.8 preoperatively to 0.6 ± 1.4 at 2-year follow-up (p < .001), and the hallux valgus angle reduced from 39.7 ± 6.9 to 8.9 ± 9.0 (p < .001). The majority of patients (95.6%) reported the result as excellent or good, and the most common complication was the need to remove the screw (7.2%). CONCLUSIONS: The use of MICA without Akin osteotomy fixation resulted in successful correction of hallux valgus with improvements in clinical and radiographic parameters. LEVEL OF EVIDENCE: IV, case series.

Minimally Invasive Chevron Akin Osteotomy: Preoperative Planning Using the Radiographic First-Ray Squeeze Test.

Background: Recognizing preoperative first-ray hypermobility is important to planning hallux valgus (HV) surgery. A recent study showed the minimally invasive chevron Akin (MICA) osteotomy increased varus displacement of the proximal fragment of the first metatarsal osteotomy. The present study aims to evaluate the ability of the radiographic first-ray squeeze test to predict the varus displacement of the proximal fragment of the first metatarsal osteotomy when performing the MICA procedure. Methods: A prospective case series of patients with moderate to severe HV who underwent MICA was performed. The HV deformity correction was analyzed by comparing the preoperative and 12-week postoperative hallux valgus angle (HVA) and the intermetatarsal angle between the first and second rays (1-2 IMA). The ability of the radiographic first-ray squeeze test to predict the varus displacement of the first metatarsal was done by comparing the preoperative 1-2 IMA measured in the AP radiographic first-ray squeeze test (IMA-ST) with the intermetatarsal angle between the second metatarsal and the axis of the first metatarsal osteotomy proximal fragment (IAPF) taken 12 weeks postoperatively. Results: Between July 2022 and May 2023, a total of 39 feet in 28 patients underwent MICA. The mean IMA improved from 13.8 (SD = 2.2) to 3.8 degrees (SD = 1.5) (P < .001), and the mean HVA improved from 27.8 (SD = 6.1) to 4.9 degrees (SD = 2.5) (P < .001). A linear regression analysis revealed that IMA-ST is highly associated with the 12 week assessed IAPF (P < .001). Conclusion: The preoperative radiographic first-ray squeeze test appears to predict with high fidelity the varus displacement of the proximal fragment of the first metatarsal that can occur after the MICA procedure.Level of Evidence: Level III, prospective cohort study.

Impact of Sesamoid Coverage on Clinical Foot Function Following Fourth-Generation Percutaneous Hallux Valgus Surgery.

Background: The impact of pronation and sesamoid coverage on clinical outcomes following percutaneous hallux valgus surgery are not currently known. The aim of this study was to investigate if sesamoid coverage was associated with worse clinical outcomes at 12-month follow-up following percutaneous hallux valgus surgery. Methods: Retrospective comparative observational study of clinical and radiographic outcomes based on a previously published prospective dataset. Patients were stratified into 3 cohorts based on the degree of sesamoid coverage (normal, mild, or moderate) on 12-month weightbearing radiographs following fourth-generation percutaneous hallux valgus surgery. Primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included Euroqol-5D, VAS Pain, and radiographic deformity correction. Results: Forty-seven feet underwent primary fourth-generation HV surgery and were stratified into 3 cohorts. There were 19, 16, and 12 feet in the normal, mild, and moderate cohorts respectively. There was no significant difference in either pre- or postoperative foot function (all MOXFQ domains, P > .05) or health-related quality of life (EQ-5D Index or VAS, P > .05). The MOXFQ Index preoperatively was as follows: normal cohort, 56.1 ± 26.9; mild cohort, 54.1 ± 17.9; and severe cohort, 49.6 ± 23.8; and postoperatively was as follows: normal cohort, 15.6 ± 21.5; mild cohort, 11.4 ± 15.5; and severe cohort, 11.4 ± 13.6 (P = .737-.908). There was significantly worse hallux valgus angle (HVA) and intermetatarsal angle (IMA) between the cohorts (P < .01). Although HVA and IMA were corrected to normal parameters following surgery in all cohorts, there was a significantly worse postoperative HVA in the moderate sesamoid coverage (5.3 ± 3.9 vs 7.9 ± 5.3 vs 11.4 ± 3.7, P < .01); however, IMA was not significantly different (3.4 ± 2.2 vs 4.1 ± 2.7 vs 5.2 ± 2.9, P = .168). Conclusion: This study found that cases where the sesamoids were not reduced had a poorer correction and had worse preoperative deformity. Clinical outcomes and foot function following fourth-generation percutaneous hallux valgus surgery were not affected by sesamoid coverage at the 12-month follow-up. The long-term implications in the difference in radiographic deformity between the 3 cohorts are not known, and further work should explore the relationship of first ray pronation and sesamoid position, particularly with regard to recurrence. Level of evidence: Level III, retrospective comparative study of prospectively collected data.

High body mass index is not a contraindication for an arthroscopic ligament repair with biological augmentation in case of chronic ankle instability.

PURPOSE: Obesity remains frequently mentioned as a contraindication for lateral ankle ligament repair. The aim of the study was to compare the clinical results of an arthroscopic lateral ligament repair with biological augmentation between patients with a body mass index (BMI) of more than 30 and less than 30. METHODS: Sixty-nine patients with an isolated lateral ankle instability were treated with an arthroscopic anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER). Patients were divided into two groups according to their BMI: ≥ 30 (Group A; n = 26) and < 30 (Group B; n = 43). Patients were pre-and post-operatively evaluated, with a minimum of 2 years follow-up, and using the Karlsson Score. Characteristics of the patients, complications, ankle instability symptoms recurrence, and satisfaction score were recorded. RESULTS: In group A, the median Karlsson Score increased from 43.5 (Range 22-72) to 85 (Range 37-100) at follow-up. Complications were observed in seven patients (27%). Nineteen patients (73%) reported that they were "very satisfied". One patient (4%) described persistent ankle instability symptoms. In group B, the median Karlsson Score increased from 65 (Range 42-80) to 95 (Range 50-100) at follow-up. Complications were observed in four patients (9%). Thirty-three patients (77%) reported that they were "very satisfied". Two patients (5%) described persistent ankle instability symptoms. Pre-operative and at last follow-up Karlsson Score, results were significantly different between the two groups. There was no significant statistical difference in favour of satisfaction score, complications and recurrence of ankle instability between the two groups. CONCLUSION: ATFL repair with biological augmentation using IER gives excellent results for patients with BMI ≥ 30. Compared to patients with BMI < 30, they present a slightly lower preoperative and postoperative Karlsson score, however, with a similar satisfaction rate, but are at higher risk of transient superficial peroneal nerve dysesthesia. LEVEL OF EVIDENCE: Level III.

The ATFL inferior fascicle, the CFL and the PTFL have a continuous footprint at the medial side of the fibula.

PURPOSE: Knowledge of the complex anatomy of the lateral ankle ligaments is essential to understand its function, pathophysiology and treatment options. This study aimed to assess the lateral ligaments and their relationships through a 3D view achieved by digitally marking their footprints. METHODS: Eleven fresh-frozen ankle specimens were dissected. The calcaneus, talus and fibula were separated, maintaining the lateral ligament footprints. Subsequently, each bone was assessed by a light scanner machine. Finally, all the scans were converted to 3D polygonal models. The footprint areas of the talus, calcaneus and fibula were selected, analysed and the surface area was quantified in cm2. RESULTS: After scanning the bones, the anterior talofibular ligament inferior fascicle (ATFLif), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) footprints were continuous at the medial side of the fibula, corresponding to a continuous footprint with a mean area of 4.8 cm2 (± 0.7). The anterior talofibular ligament (ATFL) footprint on the talus consisted of 2 parts in 9 of the 11 feet, whilst there was a continuous insertion in the other 2 feet. The CFL insertion on the calcaneus was one single footprint in all cases. CONCLUSION: The tridimensional analysis of the lateral ligaments of the ankle demonstrates that the ATFLif, CFL and PTFL have a continuous footprint at the medial side of the fibula in all analysed specimens. These data can assist the surgeon in interpreting the ligament injuries, improving the imaging assessment and guiding the surgeon to repair and reconstruct the ligaments in an anatomical position.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years.

BACKGROUND: Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus. METHODS: This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24 months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis). RESULTS: Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good. CONCLUSION: The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis. LEVEL OF EVIDENCE: IV, case series.

Minimally invasive Chevron Akin (MICA) osteotomy for severe hallux valgus.

INTRODUCTION: The minimally invasive Chevron Akin (MICA) osteotomy has been widely used to treat hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure and to evaluate the clinical and radiographic outcomes. MATERIALS AND METHODS: Retrospective study including 60 consecutive feet (52 patients) undergoing MICA for severe HV. The data were collected pre- and post-operatively at the last follow-up. Patients were clinically evaluated by the visual analog pain scale (VAS) and AOFAS hallux MTP-IP score. Radiographic assessments included measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length, distal metatarsal articular angle (DMAA), and plantar translation of MT head. The complications were recorded during the follow-up. RESULTS: The mean age was 59.9 years, and the mean follow-up was 20.5 months. The average AOFAS increased from 41.2 to 90.9 points, and the VAS from 8.1 to 1.3 at the last follow-up. The average HVA decreased from 41.2º to 11.6º, the IMA from 17.1º to 6.9º, and the DMAA from 17.9º to 7.8º. The average shortening of the first metatarsal and the plantar translation of the MT head was 5.1 mm and 2.8 mm, respectively. The most observed complication was hardware discomfort, observed in 5 feet (8.3%). There were two cases of recurrence (3.3%). CONCLUSION: MICA technique was demonstrated in this series of cases to be an effective procedure for severe HV, with a low rate of recurrence and an acceptable rate of complications. LEVEL OF EVIDENCE: IV; case series.

Minimally Invasive Chevron Akin: Locking The Metatarsal-Cuneiform Joint.

INTRODUCTION: Minimally Invasive Chevron Akin (MICA) can be used to treat hallux valgus (HV) associated with a hypermobility of the first metatarsal-cuneiform joint (1MTCJ). The aim of this study was to perform a radiographic analysis of the MICA, focused on evaluating the 1MTCJ. METHODS: Forty patients (50 feet) with moderate to severe HV underwent a MICA procedure. Radiographic analysis included hallux valgus angle (HVA), intermetatarsal angles between the first and second rays (IMA), the intermetatarsal angle between the proximal fragment of the osteotomy and the second ray (IAPF) and the distance between a point 3 cm distal from the base of the second metatarsal and a point located at the same height for the first metatarsal base (Dist 1-2). The IAPF was compared with the preoperative IMA, and the other parameters were compared preoperatively and postoperatively. The radiographic complications were also recorded. RESULTS: Most patients were female (92%). The mean age was 50.4 years (SD = 16.1) and the mean follow-up was 16.1 months (SD = 3.5). The average HVA improved from 32.5° to 7.3°, and the average IMA from 14.2° to 4.2°. The IAPF and Dist1-2 values showed an increase of 4.8° and 4.0 mm respectively. There were no radiographic complications. Conclusion. Minimally invasive Chevron Akin promotes a great correction of the moderate to severe HV conventional parameters and increase the transversal stability of the 1MTCJ fixing this joint as medial as possible. LEVEL OF EVIDENCE: Level IV, case series.

All-inside arthroscopic repair of the anterior talofibular ligament: a case series.

INTRODUCTION: The all-inside arthroscopic repair of the anterior talofibular ligament (ATFL) is a technically challenging and still-recent procedure to treat chronic ankle instability (CAI). Favourable clinical outcomes have been shown from originator centers, but this is one of the first series from a non-originator centre. The purpose of the present study is to present the clinical and functional results of patients with CAI underwent arthroscopic all-inside ATFL repair. METHODS: This is a series of cases of 18 consecutive patients who underwent the all-inside arthroscopic ATFL repair, for CAI, after the failure of conservative treatment performed for six months. The evaluation was made using the American Orthopaedic Foot and Ankle Score (AOFAS), visual analog pain scale (VAS), anterior drawer, and talar tilt tests. RESULTS: All 18 patients were evaluated for a mean follow-up period of 12 months. There was an improvement in the AOFAS (p < 0.001), with the mean improving from 69.6 points to 98.1, standard deviation (SD) = 11.09, and in the mean VAS score (p < 0.001), from 5.0 to 0.5 points (SD = 0.78). All ankles were stable, as assessed by the anterior drawer test and talar tilt test. The only complication found was neurapraxia of the superficial fibular nerve in one patient (5%). All of the patients classified the treatment as good or excellent and returned to sports activities without limitations. CONCLUSION: Treatment of CAI by the all-inside arthroscopic ATFL repair was able to restore ankle stability and showed good clinical results and high satisfaction rates.

Technique Tip: Medial prominence bone spur resection in the third-generation percutaneous Chevron-Akin Osteotomy Technique (PECA) for hallux valgus correction.

The third-generation percutaneous chevron and Akin osteotomy (PECA) technique for surgical management of hallux valgus has shown improvement in clinical and radiographic outcomes. During this procedure, lateral translation and fixation of the first metatarsal head results in the formation of a bony prominence on the medial side of the distal aspect of the first metatarsal which can cause pain and discomfort to the patient. We describe two techniques to address this bony prominence; either i) excision osteotomy and removal of the fragment or ii) a dorsal closing wedge osteotomy retaining the bony fragment. LEVEL OF EVIDENCE: Level V, expert opinion.

Osteonecrosis of the Intermediate Cuneiform: A Case Report.

Osteonecrosis is a disease that rarely affects the bones of the foot. When present, it is more common in the talus and in the navicular. Cases of osteonecrosis of the intermediate cuneiform are extremely rare, and after a thorough bibliographic review, we found only five reports in the literature, all of them in pediatric patients. Below, we present the case of an adult patient with osteonecrosis of the intermediate cuneiform that was resistant to conservative treatment. Thus, we proposed a surgical approach with good results. Level of Evidence V; Therapeutic Studies; Expert Opinion .

Osteonecrosis of the Intermediate Cuneiform: A Case Report / Osteonecrose do cuneiforme intermédio: Relato de caso

Abstract Osteonecrosis is a disease that rarely affects the bones of the foot. When present, it is more common in the talus and in the navicular. Cases of osteonecrosis of the intermediate cuneiform are extremely rare, and after a thorough bibliographic review, we found only five reports in the literature, all of them in pediatric patients. Below, we present the case of an adult patient with osteonecrosis of the intermediate cuneiform that was resistant to conservative treatment. Thus, we proposed a surgical approach with good results. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Resumo A osteonecrose é uma doença que raramente afeta os ossos do pé. Quando presente, ela é mais comum no tálus e no navicular. Casos de osteonecrose do cuneiforme intermédio são extremamente raros, e após uma revisão bibliográfica minuciosa encontramos apenas cinco relatos na literatura, sendo todos eles em pacientes pediátricos. A seguir, apresentamos o caso de um paciente adulto com osteonecrose do cuneiforme intermédio resistente ao tratamento conservador. Portanto, propusemos uma abordagem cirúrgica com bom resultado. Nível de Evidência V; Estudos Terapêuticos; Opinião de Especialista.

Connecting fibers between ATFL's inferior fascicle and CFL transmit tension between both ligaments.

PURPOSE: The lateral ligament complex of the ankle has been extensively studied. Recently an anatomical study described a connection between anterior talofibular ligament inferior fascicle (ATFLif) and calcaneofibular ligament (CFL). The applicability and the mechanical role of these connections have not yet been studied and need to be clarified. The purpose of this study is to evaluate the connection between ATFLif and CFL through a dynamic measurement analysis. METHODS: An anatomical study was performed in 13 fresh-frozen below-the-knee ankle specimens. Each specimen was dissected in a protocolized manner until the lateral ligaments were exposed. A complete injury to both ATFL's fascicles was created in the proximal third of the ligament. A displacement transducer specifically design was inserted in the CFL and in the lateral part of the calcaneus to test its lengthening. A traction of 1 kg weight (9.8 N) was applied to ATFLif while the transducer measured the lengthening that this force created in the CFL. RESULTS: A total of 13 ankle specimens were carefully dissected. One specimen with signals of a prior traumatic injury of the ATFLif was excluded. A total of 12 specimens were included, 7 females and 5 males with an average age of 74 years (52-88 years). The right ankle was dissected in 6 specimens. ATFL was identified as a two-fascicled ligament in all cases. The fibers connecting the ATFLif and CFL were observed in all specimens. The displacement transducer showed lengthening in the CFL in all measurements with a median of 0.59 mm (SD ± 0.34). CONCLUSION: Connecting fibers between ATFLif and CFL are robust enough to transmit tension from one structure to the other. In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.

Minimally Invasive Advances: Lesser Toes Deformities.

Minimally invasive procedures to treat lesser toes deformities are among the main surgeries of percutaneous techniques and considered mature techniques due to technical versatility and high correction potential, with low rates of complications. Although they seem technically simple procedures, there are important technical details for each of them to obtain a reliable correction. To achieve success in lesser toes percutaneous treatment, it is imperative to follow minimally invasive basic principles, especially postoperative care with specific bandages for unfixed osteotomies. Practical training is mandatory before starting the experience; the foot surgeon must learn theoretic and practical aspects to master this surgery.

Arthroscopic-Assisted Versus All-Arthroscopic Ankle Stabilization Technique.

BACKGROUND: Both the percutaneous technique with arthroscopic assistance, also known as arthroscopic Broström (AB), and the arthroscopic all-inside ligament repair (AI) are widely used to treat chronic lateral ankle instability. The aim of this study was to compare the clinical outcomes of these 2 arthroscopic stabilizing techniques. METHODS: Thirty-nine consecutive patients were arthroscopically treated for chronic ankle instability by 2 different surgeons. The AB group comprised 20 patients with a mean age of 30.2 (range, 18-42) years and a mean follow-up of 19.6 (range, 12-28) months. The AI group comprised 19 patients with a mean age of 30.9 (range, 18-46) years and mean follow-up of 20.7 (range, 13-32) months. Functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog pain scale (VAS) were assessed pre- and postoperatively. Range of motion (ROM) and complications were recorded. RESULTS: In both groups the AOFAS and VAS scores significantly improved compared with preoperative values (P < .001) with no difference (P > .1) between groups. In the AB group the mean AOFAS score improved from 67 (range, 44-87) to 92 (range, 76-100) and the mean VAS score from 6.4 (range, 3-10) to 1.2 (range, 0-3). In the AI group the mean AOFAS score changed from 60 (range, 32-87) to 93 (range, 76-100) and the mean VAS score from 6.1 (range, 4-10) to 0.8 (range, 0-3). At the final follow-up 8 complications (40%) were recorded in the AB group. In the AI group 1 complication (5.3%) was observed (P < .05). CONCLUSION: Both the AB and AI techniques are suitable surgical options to treat chronic ankle instability providing excellent clinical results. However, the AB had a higher overall complication rate than the AI group, particularly involving a painful restriction of ankle plantarflexion and neuritis of the superficial peroneal nerve. LEVEL OF EVIDENCE: Level III, retrospective comparative study.