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 Dorsal cheilectomy and Hallux metatarsophalangeal joint arthroscopy for the treatment of Hallux Rigidus.

BACKGROUND: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up. METHODS: This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0-3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. RESULTS: A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001). CONCLUSION: We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR. LEVEL OF EVIDENCE: IV.

Clinical outcomes of subtalar arthroereisis for the treatment of stage 1 flexible progressive collapsing foot deformity.

BACKGROUND: The use of subtalar arthroereisis as an adjunct to the surgical treatment of stage 1 flexible progressive collapsing foot deformity (PCFD) is controversial. The aim was to investigate the clinical outcomes and report the implant removal rate of subtalar arthroereisis as an adjunct for stage 1 PCFD. METHODS: A retrospective study of 212 consecutive feet undergoing operative management of stage 1 PCFD with adjunctive subtalar arthroereisis between October 2010 and April 2018. The primary outcome was the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included Foot and Ankle Disability Index (FADI), Euroqol-5D-5L Index and implant removal rate. RESULTS: Post-operative clinical FAOS outcomes were collected for 153 feet (72.2%). At mean 2.5-year follow-up, the mean ± standard deviation FAOS for each domain was as follows; Pain: 81.5 ± 18.5, Symptoms: 79.5 ± 12.9, Activities of Daily Living: 82.5 ± 15.4 and Quality of Life: 64.2 ± 23.7. EQ-5D-5L Index was 0.884 ± 0.152. Pre-operative scores were available for 20 of these feet demonstrating a statistically significant improvement in all FAOS, FADI and EQ-5D-5L domains (p < 0.05). The implant removal rate for persistent sinus tarsi pain was 48.1% (n = 102). CONCLUSION: Use of a subtalar arthroereisis implant as an adjunct to conventional procedures in stage 1 flexible PCFD can result in significant improvement in pain and function. Patients should be counselled as to the relatively frequent rate of subsequent implant removal. LEVEL OF EVIDENCE: IV.

Does Minimally Invasive Surgery Provide Better Clinical or Radiographic Outcomes Than Open Surgery in the Treatment of Hallux Valgus Deformity? A Systematic Review and Meta-analysis.

BACKGROUND: Hallux valgus is the most common foot deformity and affects 23% to 35% of the general population. More than 150 different techniques have been described for surgical correction. Recently, there has been increasing interest in the use of minimally invasive surgery to correct hallux valgus deformities. A variety of studies have been published with differing outcomes regarding minimally invasive surgery. However, most studies lack sufficient power and are small, making it difficult to draw adequate conclusions. A meta-analysis can therefore be helpful to evaluate and compare minimally invasive and open surgery. QUESTIONS/PURPOSES: We performed a systematic review and meta-analysis of randomized controlled trials and prospective controlled studies to answer the following question: Compared with open surgery, does minimally invasive surgery for hallux valgus result in (1) improved American Orthopaedic Foot and Ankle Society (AOFAS) scores and VAS scores for pain, (2) improved radiologic outcomes, (3) fewer complications, or (4) a shorter duration of surgery? METHODS: The systematic review and meta-analysis was conducted according to the guidelines of the Cochrane Handbook for Systematic Reviews of Intervention and the Preferred Reporting Items for Systematic Reviews and Meta-analyses. A search was performed in the PubMed, Embase, Scopus, CINAHL, and CENTRAL databases on May 3, 2022. Studies were eligible if they were randomized controlled or prospective controlled studies that compared minimally invasive surgery and open surgery to treat patients with hallux valgus. We defined minimally invasive surgery as surgery performed through the smallest incision required to perform the procedure accurately, with an incision length of approximately 2 cm at maximum. Open surgery, on the other hand, involves a larger incision and direct visualization of deeper structures. Seven studies (395 feet), consisting of six randomized controlled studies and one prospective comparative study, were included in the qualitative and quantitative data synthesis. There were no differences between the minimally invasive and open surgery groups regarding age, gender, or severity of hallux valgus deformity. Each included study was assessed for the risk of bias using the second version of the Cochrane tool for assessing the risk of bias in randomized trials or by using the Newcastle-Ottawa Scale for comparative studies. Most of the included studies had intermediate quality regarding the risk of bias. We excluded one study from our analysis because of its high risk of bias to avoid serious distortions in the meta-analysis. We performed a sensitivity analysis to confirm that our meta-analysis was robust by including only studies with a low risk of bias. The analyzed endpoints included the AOFAS score (range 0 to 100), where higher scores represent less pain and better function; the minimum clinically important difference on this scale was 29 points. In addition, the VAS score was analyzed, which is based on a pain rating scale (range 0 to 10), with higher scores representing greater pain. Radiologic outcomes included the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle. Complications were qualitatively assessed and evaluated for differences. A random-effects model was used if substantial heterogeneity (I 2 > 50%) was found; otherwise, a fixed-effects model was used. RESULTS: We found no clinically important difference between minimally invasive and open surgery in terms of the AOFAS score (88 ± 7 versus 85 ± 8, respectively; mean difference 4 points [95% CI 1 to 6]; p < 0.01). There were no differences between the minimally invasive and open surgery groups in terms of VAS scores (0 ± 0 versus 0 ± 1, respectively; standardized mean difference 0 points [95% CI -1 to 0]; p = 0.08). There were no differences between the minimally invasive and open surgery groups in terms of the hallux valgus angle (12° ± 4° versus 12° ± 4°; mean difference 0 points [95% CI -2 to 2]; p = 0.76). Radiographic measurements of the intermetatarsal angle did not differ between the minimally invasive and open surgery groups (7° ± 2° versus 7° ± 2°; mean difference 0 points [95% CI -1 to 1]; p = 0.69). In addition, there were no differences between the minimally invasive and open surgery groups in terms of the distal metatarsal articular angle (7° ± 4° versus 8° ± 4°; mean difference -1 point [95% CI -4 to 2]; p = 0.28). The qualitative analysis revealed no difference in the frequency or severity of complications between the minimally invasive and the open surgery groups. The minimally invasive and open surgery groups did not differ in terms of the duration of surgery (28 ± 8 minutes versus 40 ± 10 minutes; mean difference -12 minutes [95% CI -25 to 1]; p = 0.06). CONCLUSION: This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery. Methodologic shortcomings of the source studies in this meta-analysis likely inflated the apparent benefits of minimally invasive surgery, such that in reality it may be inferior to the traditional approach. Given the associated learning curves-during which patients may be harmed by surgeons who are gaining familiarity with a new technique-we are unable to recommend the minimally invasive approach over traditional approaches, in light of the absence of any clinically important benefits identified in this meta-analysis. Future research should ensure studies are methodologically robust using validated clinical and radiologic parameters, as well as patient-reported outcome measures, to assess the long-term outcomes of minimally invasive surgery.

Role of lateral soft tissue release in percutaneous hallux valgus surgery: a systematic review and meta-analysis of the literature.

BACKGROUND: It is unclear whether lateral soft tissue release (LSTR) is required as part of percutaneous hallux valgus (PHV) surgery. The primary aim of this systematic review was to assess whether LSTR reduces the risk of recurrence of hallux valgus deformity. The secondary aims were to assess if LSTR increases the risk of complications, improves the clinical outcome and leads to a greater radiographic correction. METHODS: We performed a PRISMA-compliant PROSPERO-registered systematic review, pooling clinical papers reporting results after PHV surgery into two categories (PHV with (Group 1, G1) and without LSTR (Group 2, G2)) and comparing them. Data regarding the study design, demographics, the surgical procedure and the clinical and radiological outcome were extracted and compared. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). RESULTS: Sixteen studies were selected (G1:594 feet; G2:553 feet). The pooled proportion of recurrence at a minimum 21-month follow-up (2%, 95%CI 0-3 vs 2%, 95%CI 0-5; p = 0.70) did not differ in the two groups. Similarly, the pooled proportion of complications (27%, 95%CI 17-38 vs 25%, 95%CI 12-37; p = 0.79) was similar. The pre- (p = 0.23) and post-operative AOFAS scores (p = 0.16), the pre-(HVA: p = 0.23) (IMA: p = 0.94) and post-operative radiological angles (HVA: p = 0.47) (IMA: p = 0.2) and the methodological quality of studies (p = 0.2) did not differ either between G1 and G2. CONCLUSION: There is no evidence that LSTR performed during percutaneous HV surgery reduces the risk of recurrence of the deformity at a mean 4-year follow-up nor improves the clinical and radiological outcome. LEVEL OF EVIDENCE: Level IV systematic review of Level I to IV studies.

Symmetry of bilateral hallux valgus deformity: A radiographic study.

Hallux valgus (HV) is a common anatomical deformity leading to pain and difficulty with footwear and mobility. Bilateral HV deformity is much more common than unilateral although it remains unclear whether the severity of deformity is equal between feet. The objective was to investigate the severity and symmetry of HV in patients with bilateral symptomatic deformity presenting for surgery. Weight-bearing radiographs of patients presenting with symptomatic bilateral HV were reviewed. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured and classified as mild, moderate, or severe. Left-to-right comparison was undertaken to assess whether the degree of deformity was similar for each foot. The relationship between age, HVA, and IMA was also assessed. Between July 2014 and June 2020, 322 ft (161 patients with bilateral deformity) underwent corrective HV surgery. Of those, 6.8%, 64.6%, and 28.4% were classified as mild, moderate, and severe, respectively on the left side, and on the right 6.2%, 67.7%, and 26.1% were classified as mild, moderate, and severe respectively. There was no statistically significant difference between feet for either IMA (p = 0.06) or HVA (p = 0.85). There was a moderate correlation (R = 0.41, p ≤ 0.001) between HVA and IMA. There was only a 'weak' or 'very weak' correlation between age and HVA or IMA. Patients presenting for surgery with symptomatic bilateral HV have symmetrical moderate radiographic deformity at the time they present for consideration of surgical intervention.

Tibiotalar Incongruency in Clubfoot Treated Operatively Is a Predictor of Worse Outcome at a Mean of 26 Years.

The traditional approach to congenital talipes equinovarus (CTEV) has relied on stepwise manipulations, followed by surgery in severe or recurrent cases. The 3 aims of this study were: (1) to report long-term results of clubfoot treated by posterior capsulectomy and selective release (PCSR); (2) to determine the reliability of a visual scale in the assessment of intraoperative tibiotalar incongruency (TTI); and, (3) to assess the role of TTI as a prognostic factor. We reviewed data regarding 95 CTEV (65 patients) treated by PCSR at a minimum follow-up of 20 years. Patients underwent a physical and radiographic examination, and were assessed through multiple clinical scores. The inter- and intraobserver reliability for TTI evaluation was calculated on clinical photographs. Based on TTI, 52 CTEV were divided in 2 groups (30 congruent vs 22 incongruent) and compared. At a mean follow-up of 26.8 (from 24 to 31) years, 52 CTEV (38 patients) were available for the analysis. Functional results were globally satisfactory. The inter- (κ = 0.748) and intraobserver analysis (κ = 0.688) for the TTI visual assessment showed substantial agreement. In patients with incongruency, patient reported outcomes were significantly worse, with also a greater development of subtalar (p = .02), talonavicular and calcaneocuboid arthritis (p < .001 for both). In treating severe CTEV, the surgical PCSR performed in the first year of life obtains satisfactory clinical and patient-recorded outcomes at over 25 years of follow-up. The visual assessment of TTI is reproducible and potentially represents a long-term prognostic factor.

Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis.

BACKGROUND: The primary aim of this study was to present the incidence of clinically significant end stage osteoarthritis (cOA) after syndesmotic fixation of ankle fractures. The secondary aim was to and identify independent predictors of cOA. METHODS: A retrospective review of consecutive patients presenting to a single University affiliated institution between March 2008 and May 2010 was undertaken. Inclusion criteria were ankle fractures with syndesmotic stabilisation. Patients were excluded if pre or postoperative radiographs were missing or were lost to follow up. Data were gathered regarding demographics, fracture pattern, fixation methods, reduction parameters, screw removal, revision surgery, complications and cOA up to seven years post injury. RESULTS: Data were available for 120 patients (86%). In total, 13 patients (11%) developed cOA. Univariate analysis showed that increasing age, open fracture, malreduction of the syndesmosis, removal of symptomatic screws, revision surgery and complications were predictors of developing cOA. Cox regression analysis revealed increasing age (hazard ratio (HR) 1.09, p=0.006), and malreduction (HR 45.5, p=0.001) were independent predictors of developing cOA. CONCLUSIONS: Ankle fractures with syndesmotic stabilisation represent a severe injury with a high rate of cOA. The only modifiable risk factor for developing cOA in this large series of patients was radiological malalignment. When syndesmotic stabilisation is required, careful intraoperative assessment should be undertaken to ensure the syndesmosis is reduced.

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.

Lapidus Arthrodesis for Correction of Hallux Valgus Deformity: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of this study was to evaluate and compare different fixation methods to achieve Tarsometatarsal joint I (TMT-1) arthrodesis in patients with hallux valgus regarding radiographic correction, complication profile, and clinical outcomes. METHODS: A systematic review and meta-analysis included primary literature results of evidence level 1 to 3 studies in German and English. Inclusion and exclusion criteria were established and applied, along with parameters suitable for comparison of data. RESULTS: 16 studies with a total of 1176 participants met the inclusion criteria for this analysis. Twelve evaluation criteria were compared among 3 fixation techniques; comprised of a screw-only, dorsomedial plating- and plantar plating cohort. There was no statistical difference in deformity correction (both intermetatarsal- and hallux valgus angle), or AOFAS score between the cohorts. The complication rate was 13% in the plantar-, 19.5% in the dorsomedial-, and 24.5% in the screw cohort. Nonunion was seen in 0.7% of participants in the plantar, 1.4% in the dorsomedial, and 5.3% in the screw group. The time until complete weightbearing correlated positively with the development of nonunion, with a coefficient of 0.376 (P = .009). Hardware removal was performed in 11.8% of patients in the dorsomedial cohort, 7.7% in the screw cohort, and 3.6% in the plantar cohort. CONCLUSION: Based on the results of meta-analysis of heterogeneous studies, plantar plating facilitated early weightbearing and patient mobilization compared to the other fixation methods, while carrying the lowest nonunion, hardware removal, and general complication risk. However, owing to the relatively small number of patients in the plantar plating group, more work is necessary to elucidate the benefits of plantar plating for a first tarsometatarsal joint arthrodesis. Development of complications appears to be largely dependent on the fixation model, rather than patient mobilization alone.Level of Evidence: 3.

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.

The Role Of Minimally Invasive Osteotomies In Cavovarus Foot Reconstruction: Detailed Technique And Evidence For Procedures.

Percutaneous correction of cavus foot deformity can be achieved with satisfactory correction of foot anatomy and biomechanics. Surgical management of cavovarus foot reconstruction is an individualized combination of surgical procedures designed to correct deformity. Minimally invasive procedures using high-torque low-speed burr can facilitate large deformity correction without extensive soft tissue stripping. This article presents the operative technique for percutaneous cavus foot correction including a lateralizing calcaneal osteotomy and proximal first ray osteotomy. However, methodologically robust evidence to support this procedure is lacking at present, and further research, particularly, focusing on long-term clinical outcomes and follow-up is required.

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

BACKGROUND: Fourth-generation minimally invasive surgery (MIS) includes the multiplanar rotational deformity correction achieved through manipulation of an extra-articular distal first metatarsal osteotomy that is held with rigid fixation using 2 fully threaded screws, of which one must be bicortical to provide rotational and biomechanical stability. The aim of this study is to report the clinical and radiologic outcomes of an evolved fourth-generation MIS hallux valgus technique. METHODS: A prospective single-surgeon series of consecutive patients undergoing fourth-generation MIS was performed using a distal transverse osteotomy with a minimum 12-month follow-up. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated clinical patient-reported outcome measure (PROM). Secondary outcomes included radiographic deformity correction, clinical assessment, and EuroQol-5D-5L PROMs. RESULTS: Between September 2019 and June 2021, 50 feet underwent fourth-generation MIS. The mean age was 55.8±15.3 years with a mean follow-up of 1.4 years. Preoperative and minimum 12-month primary outcome data were available for 100% of feet. There was a significant improvement in all MOXFQ domain scores, with the index domain improving from 53.4 to 13.1 (P < .001). There was a significant improvement (P < .001) in hallux valgus angle (32.7 to 7.9 degrees), intermetatarsal angle (14.0 to 4.2 degrees) and distal metatarsal articular angle (18.5 to 5.6 degrees). There was a significant improvement in general health-related quality of life EQ-5D-5L index and EQ-VAS scores (P < .05). CONCLUSION: The fourth-generation MIS technique is a safe and effective approach to hallux valgus deformity correction with significant improvement in clinical and radiographic outcomes. LEVEL OF EVIDENCE: Level IV, prospective case series.

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

BACKGROUND: Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiologic outcomes. It remains unknown whether these clinical and radiologic outcomes are maintained in the medium to long term. The aim of this study was to investigate the minimum 5-year clinical and radiologic outcomes following third-generation MIS hallux valgus surgery in the hands of a high-volume MIS surgeon. METHODS: A retrospective observational single highly experienced MIS surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60-month clinical and radiographic follow-up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) preoperatively, 6 months, and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, EuroQol-5D visual analog scale and the visual analog scale for pain. RESULTS: Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA, with complete data available for 78 (61.9%) feet. The median follow-up was 65.0 (IQR 64-69; range 60-88) months. There was a significant improvement in radiographic deformity correction; the median IMA improved from 12.0 degrees (interquartile range [IQR]: 10.8-14.2) to 6.0 degrees (IQR: 4.2-7.3) (P < .001), and the median HVA improved from 27.2 degrees (IQR: 20.6-34.4) to 7.2 degrees (IQR: 3.4-11.6). Median MOXFQ Index score at ≥60-month follow-up was 2.3 (IQR: 0.0-7.8). The radiographic recurrence rate (defined as HVA >15 degrees) was 7.7% at final follow-up. The complication rate was 4.8%. CONCLUSION: Radiologic deformity correction for the 78 feet we were able to follow that had third-generation PECA performed by a single highly experienced MIS surgeon was found to be maintained at a mean follow-up of average 66.8 months, with a radiographic recurrence rate of 7.7%. Clinical PROMs and patient satisfaction levels were high and comparable to other third-generation studies with shorter duration of follow-up. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Current concepts in the surgical management of chronic ankle lateral ligament instability.

Background/aims: Ankle sprains are common injuries which can lead to chronic lateral ankle ligament instability (CAI). Methods: The aim of this review is to provide a comprehensive overview of the epidemiology, pathophysiology, investigation, surgical management and rehabilitation of CAI. Results: Investigation of CAI is based on history, clinical examination, and imaging. Surgical management of CAI can be defined as anatomic reconstruction, anatomic and non anatomic repair of ATFL and/or CFL. Anatomic repair has been shown to have better functional outcomes and less secondary osteoarthritis when compared to non anatomic repair. Non-anatomic methods do not replicate the normal anatomical course of ATFL/CFL and may lead to stiffness. The most common surgical treatment for CAI is the open modified Broström repair augmented with the Gould modification. There are arthroscopic techniques being developed which have reported promising clinical results. However, there are considerable areas of further research which should be carried out to improve understanding and effectiveness of current treatment options. Standardised validated patient reported outcome measures and evidence-based protocols in the rehabilitation periods are crucial for positive and reproducible outcomes. Conclusion: Surgical repair has proven to show excellent outcomes for patients suffering from CAI, however larger prospective studies should be carried out to evaluate the use of newer surgical techniques.

Valgus Second Toe Deformity Treated With a Percutaneous Extracapsular Closing-Wedge Osteotomy of the Proximal Phalanx.

BACKGROUND: Coronal and sagittal plane deformities of the lesser toes are common yet challenging to treat. Traditional open releases and translational Weil osteotomies can be unpredictable and lead to postoperative stiffness. We present the results of a percutaneous closing wedge extracapsular osteotomy of the proximal phalanx to treat valgus deformity of the second toe. METHODS: Thirty-one patients underwent 40 percutaneous osteotomies at a median age of 58.6±9.4 years. Using a small dorsomedial incision, a percutaneous proximal metaphyseal medial closing-wedge extracapsular osteotomy of the second toe is performed, leaving the dorsolateral cortex intact. An irrigated low-speed, high-torque 2- × 8-mm burr is used under image guidance. The osteotomy is then closed to correct deformity and taped for 2 weeks. Patient-reported outcomes and weightbearing radiographs were obtained. RESULTS: Questionnaire data was available for 89.7% (n=35) of cases. Most cases (91.4%) were either satisfied or extremely satisfied with the procedure. Radiographs were available for 90.0% of osteotomies, with a median length from surgery to radiographic follow-up of 1.6 years (range 0.5-6.3; SD ±1.5). Median second-toe valgus angle (STVA) decreased from 16.2±10.7 degrees to 5.0±7.0 degrees (P < .001) at final follow-up. All osteotomies united with no delayed union. There were no wound complications or infections. We found 2 cases of radiographic recurrence. CONCLUSION: Percutaneous proximal phalanx base metaphyseal closing wedge extracapsular osteotomies of lesser toes to correct coronal plane deformity is useful adjunct to first-ray corrective surgery and is associated with high levels of patient satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Convective burn from use of hairdryer for heel warming prior to the heel prick test - a case report.

BACKGROUND: Blood sampling through heel lancing is the most common invasive painful procedure performed on newborn infants. CASE PRESENTATION: We report the case of a five day old infant who sustained burns to the left foot and leg after the mother's hairdryer was used by the midwife to warm the baby's heel prior to capillary blood sampling (CBS) with an automated device. CONCLUSION: Heel warming is not recommended for routine CBS although it is often practiced. If pre-warming is to be practiced, standardised devices should be used rather than improvised techniques. This will reduce the risk of injury to these infants.

Third-Generation Minimally Invasive Chevron and Akin Osteotomies (MICA) in Hallux Valgus Surgery: Two-Year Follow-up of 292 Cases.

BACKGROUND: There is interest in hallux valgus deformity correction using internal fixation with the minimally invasive chevron and Akin osteotomies (MICA) technique. The objective of this study was to assess the correction measured on postoperative radiographs and clinical outcomes, using validated outcome measures, at 2 years following third-generation MICA. METHODS: This is a prospective single-surgeon case series of 333 consecutive feet that underwent MICA surgery between July 2014 and April 2018. The primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index, EuroQol-visual analogue scale (EQ-VAS), and a VAS for pain (VAS-pain). Secondary outcome measures included radiographic parameters and complication rates. RESULTS: Preoperative and 2-year postoperative patient-reported outcome measures (PROMs) were collected for 292 feet (87.7%). At a minimum 2-year follow-up, the MOXFQ scores (mean ± standard deviation [SD]) had improved in each domain-i.e., reduced from 44.5 ± 21.0 preoperatively to 9.4 ± 15.8 postoperatively for pain (p < 0.001), from 38.7 ± 23.4 to 6.5 ± 14.6 for walking and standing (p < 0.001), and from 48.0 ± 22.3 to 6.6 ± 13.5 for social interaction (p < 0.001). The VAS-pain score improved from 31.4 ± 22.7 preoperatively to 8.4 ± 16.4 at the 2-year follow-up (p < 0.001), the 1-2 intermetatarsal angle was reduced from 15.3° ± 3.6° preoperatively to 5.7° ± 3.2° at the 2-year follow-up (p < 0.001), and the hallux valgus angle was reduced from 32.9° ± 10.2° to 8.7° ± 5.2° (p < 0.001). CONCLUSIONS: The third-generation MICA provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up.

BACKGROUND: Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known. METHODS: A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction. RESULTS: Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and follow-up radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%. CONCLUSION: Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence. LEVEL OF EVIDENCE: Level IV, case series.

Randomized Controlled Trial of Topical Skin Adhesive vs Nylon Sutures for Incision Closure in Forefoot Surgery.

BACKGROUND: There are many options for incision closure in forefoot surgery. The aim of this study was to compare topical skin adhesive (2-octyl-cyanoacrylate) to simple interrupted nylon sutures. METHODS: A prospective randomized controlled trial comparing topical skin adhesive (TSA) and nylon sutures (NSs) for elective open forefoot surgery. Primary outcome was Hollander Wound Evaluation Scale (HWES) assessed 2 weeks following surgery. Secondary objectives included time taken for wound closure, wound assessment, patient satisfaction with wound cosmesis, incision pain, and infection rate. RESULTS: Between January and December 2018, 84 feet (70 patients) underwent hallux valgus scarf/Akin osteotomy or first metatarsophalangeal arthrodesis and were randomized to receive either intervention (topical skin adhesive) or control (3/0 nylon sutures). We found worse HWES scores when using TSA compared to NSs (1.07 vs 0.60). Incision closure time was slower for TSA (mean, 272 vs 229 seconds). At 2 weeks postoperatively, wound care was faster for TSA (mean 71 secs) vs NSs (mean 120), and patient-reported pain was less with TSA (visual analog scale: TSA 1.2 vs NSs 2.1). A high degree of overall patient satisfaction was reported in both groups, without significant difference. CONCLUSION: Closure of elective forefoot surgery incisions with topical skin adhesive or interrupted nylon sutures offers high satisfaction rates, low pain scores, and low complications. However, topical skin adhesive was associated with more inflammation and areas of wound separation compared to nylon sutures. We recommend the use of sutures for wound closure in forefoot surgery. LEVEL OF EVIDENCE: Level I, randomized controlled trial.