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Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes
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Foot and Ankle Surgery xxx (2018) xxx–xxx
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Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes Federico Maria Liunia,* , Luca Bernia , Alberto Fontanarosaa , Riccardo Cepparuloa , Alberto Guardolia , Andrea Pellegrinia , Andrea Bianchib , Aldo Guardolia a b
Department of Orthopaedics and Traumatology, Santa Maria Hospital, Borgo Val di Taro, PR, Italy Orthopaedics and Traumatology, PBS Group, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2017 Received in revised form 2 November 2018 Accepted 6 November 2018 Available online xxx
Background: Many procedures and different osteotomies have been described for percutaneous hallux valgus correction. Percutaneous techniques may lead to reduced morbidity, surgery, and recovery time. The aim of this study is to evaluate the clinical and radiographic outcome of a new percutaneous procedure (PBS-Percutaneous Bianchi System). Methods: Fifty-eight cases were treated with Percutaneous Bianchi System procedure for correction of mild, moderate or severe hallux valgus deformity. All patients were clinically assessed preoperatively and then followed up by weight-bearing x-rays, AOFAS (American Orthopedic Foot and Ankle Score), VAS (Visual Analog Scale) pain score, and patient satisfaction. Results: AOFAS scores improved from 28.6 at the preoperative assessment to 91.7 at the latest follow-up. The VAS pain score improved from 6.7 before surgery to 0.6 at the latest follow-up. The mean Hallux valgus angle (HVA), Intermetatarsal angle (IMA) and Distal metatarsal articular angle (DMAA) significatively decreased from the preoperative assessment to the latest follow-up. Conclusions: The PBS technique is a safe, reliable, and effective procedure for the correction of symptomatic mild-to-severe hallux valgus. © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus PBS Percutaneous Correction Osteotomy
1. Introduction
2. Methods
Hallux valgus is a common deformity of the forefoot. It is often bilateral and it affects most frequently adult women, especially between 40 and 60 years old. Surgical correction is indicated for symptomatic cases and difficulty with footwear. Many procedures and several first-metatarsal osteotomy procedures have been described [1,2,3,4,5], but the interest of a percutaneous technique lies in the reduced morbidity, surgery time, and recovery time. Its limitations concern the quality of deformity correction and the long-term stability. The PBS (Percutaneous Bianchi System) technique is performed with a complete, extra-articular and not linear osteotomy. These features guarantee more stability and could allow treating mild-to-severe hallux valgus forms. The aim of our study was to evaluate the PBS technique in the treatment of hallux valgus from mild-to-severe forms.
From January 2014 to August 2016, 118 consecutive patients underwent hallux valgus surgery with PBS procedure for correction of their mild, moderate, or severe deformity; of these 118 patients, 52 were willing to participate in the study after signing informed consent. The inclusion criteria were: failure of conservative treatment to alleviate pain during stance and gait and when wearing shoes, radiographic evidence of an HVA angle > 15 and intermetatarsal angle > 8 . Exclusion criteria were: metatarsophalangeal laxity or hypermobility, previous hallux valgus surgery, stiffness or metatarsophalangeal osteoarthritis, diabetes mellitus with peripheral neuropathy, rheumatoid arthritis or other autoimmune disease, peripheral vascular disease. In our population there were 22 (38%) Akin procedures performed. Most of the patients were female (94.8%), that is 55 over a total of 58 operated feet. Their ages ranged from 28 to 82 years of age, the average being 64. The cohort included 6 bilateral cases and 46 unilateral cases, for a total of 58 feet. A statistical description of the cohort is given in Table 1. The average follow-up time was 25 months (time range 12–48 months). All the patients were clinically and radiologically
* Corresponding author. E-mail addresses: [email protected], [email protected] (F.M. Liuni).
https://doi.org/10.1016/j.fas.2018.11.003 1268-7731/© 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Table 1 Demographics. Age, years, mean (range) Gender, female, n (%) Bilateral cases
64 (28–82) 55 (94.8%) 6
Mean age and range, female patients, bilateral cases.
evaluated. Radiographic analysis was performed preoperatively, after surgery, at two months and at the latest follow-up on standard weight-bearing anteroposterior and lateral radiographs. We evaluated the hallux valgus angle, inter-metatarsal angle and distal metatarsal articular angle. Hallux valgus angle (HVA) is the angle between the proximal phalanx axis and first metatarsal axis. Intermetatarsal angle (IMA) is the angle between the first and second metatarsal axis. Distal metatarsal articular angle (DMAA) is the angle between the first metatarsal axis and the distal articular surface of the first metatarsal [6]. HVA was categorized as mild (15–20 ), moderate (21–39 ) and severe (40 ). IMA was categorized as mild (9–11 ), moderate (12– 17 ) and severe (18 ) [7]. In our cohort, 13 patients had a severe HVA and 5 had a severe IMA. We also evaluated radiographic hallux valgus recurrence at the latest follow-up. Recurrent hallux valgus was defined as one or more of the following: an increase in HVA > 5 at the latest follow-up compared to the postoperative assessment, HVA > 20 at the latest follow-up, an increase in IMA > 2 at the latest follow-up compared to the postoperative assessment. The radiographic analysis was performed by a single observer.
All patients were clinically assessed preoperatively and at the latest follow-up with the hallux metatarsophalangeal-interphalangeal scale proposed by the American Orthopedic Foot and Ankle Society (AOFAS) [8]. All patients were also evaluated with VAS (Visual Analog Scale) scale for pain preoperatively and at the latest follow-up. Patient degree of satisfaction was also recorded at the latest follow-up. We asked the patients if they were completely satisfied, moderately satisfied or unsatisfied with the procedure. All clinical and radiologic complications were recorded. 2.1. Surgical technique The procedure was performed using a new minimally invasive technique (Percutaneous Bianchi System — PBS), and ankle block anesthesia. A dorsal skin incision of about 2 mm was made at the first metatarso-phalangeal joint, on the lateral side. With this incision, partial capsulotomy and tenotomy of the hallux adductor tendon were performed with a beaver blade, until an adequate varus reduction of the hallux was achieved (Fig. 1). A skin incision of 4–5 mm was then made slightly proximal and plantar to the metatarsal head, on the medial side; the plantar and dorsal articular capsule was detached with mosquito forceps. The exostosectomy was performed from this incision with a wedge burr (4.1 mm in diameter and 13 mm in length) (Fig. 2). The medial prominence was removed from the first metatarsal head until a flat surface was obtained; it is necessary to not resect too much bone, to avoid articular damage and postoperative stiffness. Resection was verified with manual evaluation and fluoroscopic control (Fig. 3). After the resection, we removed intracapsular bone debris
Fig. 1. Partial capsulotomy and tenotomy of hallux adductor tendon.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 2. Skin incision for exostosectomy, performed with a wedge burr.
with saline solution and with the use of specific rasps. From the same incision we then performed the first metatarsal osteotomy. The osteotomy is extra-articular and is performed using a Shannon straight burr (2 mm in diameter and 12 mm in length). It begins subcapital and dorsal to the first metatarsus, with a slightly oblique line to the longitudinal axis of the first metatarsus in the coronal plane. The first incision should be incomplete, maintaining the lateral cortex intact. The dorsal cortex is interrupted with a vertical cut, then the osteotomy is continued from distal to proximal in the sagittal plane, allowing shortening and plantarization of the head of the first metatarsal (Fig. 4). The lateral cortex of the first metatarsal should then be interrupted with a second passage, slightly more oblique than the first in the coronal plane, to perform a minimal bone step which helps to maintain the translation of the metatarsal head (Figs. 5 and 6). During the exostosectomy and osteotomy, we irrigate the bone with a saline solution to reduce the risk of thermal necrosis. If considered necessary, a percutaneous Akin osteotomy is performed to obtain a better correction. A 2– 3 mm incision is made at the metaphysis of the proximal phalanx. An incomplete osteotomy of proximal metaphysis is performed with a Shannon burr (2.2 mm in diameter and 12 mm in length) from dorsal to plantar, without breaking the lateral cortex. A
3
manual varus correction is then applied on the hallux to compact the medial cortex (Fig. 7). Fluoroscopy images were obtained and the wounds were closed. After the surgical procedure, a functional rigid taping (bandage) was used in order to maintain the metatarsal head translation obtained; (Fig. 8) this taping was left for four weeks, with an intermediate follow-up and dressing change at 15 days. Weight bearing was allowed from the first day after surgery, with appropriate flat stiff-soled footwear. This procedure requires a medium-long learning curve, having some peculiarities that distinguish it from other hallux valgus correction techniques. It requires good skills in percutaneous surgery, and a thorough knowledge of anatomical structures. The main pitfall of the procedure is to properly reproduce the triplanar orientation of the metatarsal head osteotomy and to create the lateral cortical step to improve intrinsic stability. This technique requires the use of fluoroscopy as well as the exposure to radiation. These requirements decrease very markedly over time as the experience of the surgeon increases. Another limitation of this procedure is the remarkable importance of the postoperative dressing must be prepared with high accuracy, due to the absence of an internal device. As a matter of fact, the intrinsic stability of the osteotomy and the postoperative dressing are the two main elements which maintain the deformity correction. 2.2. Statistical analysis The statistical analysis was performed with the IBM-SPSS statistical package, version 22. Descriptive analysis has included the main position, dispersion and form indexes, such as mean, median, mode, 5% trimmed mean, variance, standard deviation, interquartile difference, minimum, maximum, range, asymmetry coefficient and kurtosis. Where relevant, standard errors and 95% confidence intervals were also reported. Parametric tests (Student t test, repeated measures ANOVA) and equivalent non parametric tests were used for comparisons between the groups. Results were considered statistically significant for a p-value less than 5% (p < 0.05). 3. Results 3.1. Clinical Table 2 shows clinical results of AOFAS and VAS scores. AOFAS scores were substantially improved from the preoperative (mean: 28.6 14.1) to the latest assessment (mean: 91.7 10.6), with statistically significative difference (P < 0.001). VAS pain score improved from 6.7 1.1 before surgery to 0.59 1.1 at the latest follow-up (P < 0.001). 55 cases (95%) were completely satisfied at the latest follow-up, while 3 cases (5%) were moderately satisfied. 3.2. Radiologic
Fig. 3. Resection after exostosectomy evaluated with fluoroscopic control.
Table 3 and Figs. 9 and 10show the radiographic results. The mean preoperative HVA was 34.0 9. Its mean value at the follow-up 2 months after surgery was 9.3 5.0 and at the latest follow-up was 10.6 6. The difference was statistically significant between the preoperative and 2 month postoperative assessment (P < 0.001), between the preoperative and latest assessment (P < 0.001), and between the 2 month postoperative and latest assessment (P < 0.05). The mean preoperative IMA was 13.5 3. Its mean value at the 2 month postoperative assessment was 8.0 2, and at the latest follow-up was 8.5 3. The difference was statistically significant between the preoperative and the 2 month postoperative assessment (P < 0.001), and between the preoperative and the latest follow-up (P < 0.001).
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 4. Metatarsal osteotomy first step, performed using a Shannon straight burr.
Fig. 5. Metatarsal osteotomy second step, performed using a Shannon straight burr.
Fig. 6. Schematic direction of PBS (Percutaneous Bianchi System) first metatarsal osteotomy on postoperative antero-posterior and lateral x-rays.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 7. Akin osteotomy performed with a Shannon burr (A). Varus correction to compact the medial cortex (B).
Fig. 8. Postoperative functional rigid taping (bandage) showed step-by-step. First step with sterile gauze (A); second step with rigid surgical tape (B); third step with a second sterile gauze between hallux and second toe (C); fourth step with another rigid surgical tape (D); fifth step with another sterile gauze between hallux and second toe (E); sixth step with tenso-elastic bandage (F). Sterile adhesive strips were placed on second and third toe for extensor tenotomy procedure.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Table 2 Clinical results.
AOFAS, score (SD) VAS, score (SD)
Preoperative
Last follow-up
p Value
28.6 (14.1) 6.7 (1.1)
91.7 (10.6) 0.59 (1.1)
<0.001 <0.001
AOFAS (American Orthopedic Foot and Ankle Society) score and VAS (Visual Analog Scale) for pain. SD: standard deviation.
The mean preoperative DMAA was 14.6 6. Its mean value at the 2 month postoperative assessment was 4.2 3, and at the latest follow-up was 6.5 5. The difference was statistically significant between the preoperative and the 2 month postoperative assessment (P < 0.001), between the preoperative and the latest follow-up (P < 0.001), and between the 2 month postoperative assessment and the latest follow-up (P < 0.001). 3.3. Complications In our cohort there were 9 minor complications. 5 cases of metatarsalgia at the latest follow-up (9%), 3 cases of severe
stiffness (ROM < 30 ) (5%), and 1 case of persistent paresthesia (2%). There was no reoperation for metatarsalgia. All patients were treated with orthotics for pain resolution. There were neither recurrences, postoperative infections, avascular necrosis, hallux varus, nor first metatarsal malunion on the AP view. 4. Discussion In the last few years, the studies regarding the percutaneous surgery of hallux valgus have exponentially increased. There is growing evidence in literature which suggests that percutaneous hallux valgus surgery is safe and reliable. Several studies showed that there are long term benefits although only few studies have a comparison group treated with open osteotomies [9,10,11,12]. A minimally invasive technique that used k-wire to maintain correction was described by Bosch et al. in 2000 [13]. Later another technique using two-screw fixation and a chevron distal osteotomy was described by Vernois and Redfern [14]. This is the first retrospective single center study that evaluated the data of a new percutaneous technique with a mean follow-up
Table 3 Radiologic results.
HVA, degrees (SD) IMA, degrees (SD) DMAA, degrees (SD)
Preoperative
Two months
Last follow-up
34.0 (9) 13.5 (3) 14.6 (6)
9.3 (5) 8.0 (2) 4.2 (3)
10.6 (6) 8.5 (3) 6.5 (5)
Difference preop.-last follow-up 23.4 5.0 8.1
P value <0.001 <0.001 <0.001
HVA (Hallux Valgus Angle), IMA (Intermetatarsal Angle) and DMAA (Distal Metatarsal Articular Angle) at preoperative, two months and at last follow-up. SD: standard deviation.
Fig. 9. Preoperative and postoperative x-rays (antero-posterior and lateral) after PBS (Percutaneous Bianchi System) procedure.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 10. Preoperative and 24 months follow-up x-rays (antero-posterior and lateral) after PBS (Percutaneous Bianchi System) procedure.
of 25 months. PBS technique is different from the other percutaneous techniques thanks to the features of the first metatarsal osteotomy; in particular our osteotomy is complete, extra-articular and with a different orientation. Being extraarticular, this osteotomy protects the blood supply to the metatarsal head [13]. Our technique does not involve the use of screws or k-wire fixation as in other percutaneous techniques. The postoperative dressing is essential to maintain the correction. This study showed that the Percutaneous Bianchi System technique enables to achieve good correction of a moderate and severe hallux valgus deformity, a finding which contradicts previously reported results in literature. Huang et al. [15], who used a MIS technique distal osteotomy fixed with a k-wire on a sample of 82 patients with 18 months of follow-up, recommended that only mild or moderate hallux valgus should be treated with percutaneous techniques. More recently Brogan et al. [7] reported a 2-year outcome of a new MIS distal osteotomy, fixed with compression screw and k-wire, compared to a traditional open distal chevron osteotomy. They stated no differences in radiographic measures and clinical scores between open and MIS groups and no differences in complications rates. In our cohort the mean AOFAS score improved from 28.6 points at the preoperative assessment to 91.7 points at the latest follow-up. Our patients showed a significant improvement between preoperative to postoperative pain at the latest follow-up, with a mean VAS score value that ranged from 6.7 preoperatively to 0.59 postoperatively. 95% of our patients were completely satisfied at the last follow-up. Our results
validate the clinical effectiveness of this new technique in terms of clinical functionality, pain, and patient satisfaction. Our osteotomy allowed the correction of the three main radiographic parameters of hallux valgus, with an improvement of HVA, IMA and DMAA. The HVA decreased from a mean value of 34.0 to 9.3 at two months and 10.6 at the latest follow-up, with a loss of correction of only 1.3 from the 2 month postoperative assessment to the latest follow-up. The IMA decreased from a mean value of 13.5 to 8.0 at the 2 month postoperative assessment and 8.5 at the latest follow-up, with a loss of correction of 0.5 from the 2 month postoperative assessment to the latest follow-up. The DMAA decreased from a mean value of 14.6 to 4.2 at the 2 month postoperative assessment and 6.5 at the latest follow-up, with a loss of correction of 2.3 from the 2 month postoperative assessment to the latest follow-up. In a recent paper Biz et al. [16] evaluated radiographic and functional outcomes in patients with mild-to-severe hallux valgus who underwent Reverdin–Isham and Akin percutaneous osteotomies. The HVA in this study decreased from 26.4 to 12.3 at the 3 month postoperative assessment and to a mean of 13.9 at the latest follow up; the IMA decreased from 12.9 to 9.0 at the 3 month postoperative assessment to the latest follow-up. Our results demonstrate a better correction of HVA and IMA with our technique even with more severe deformities. Despite the significant difference between the 2 month postoperative assessment to the latest follow-up for HVA and DMAA, our cohort showed that the overall radiographic correction was maintained
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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from the 2 month postoperative assessment to the latest followup, regarding mean HVA, IMA and DMAA. The positive changes in the radiographic parameters measured after the consolidation of the osteotomy at the latest follow-up, prove the effectiveness of such osteotomy in maintaining correction and reducing the risk of recurrences. As reported by Bauer et al. [9,17], the commonly used percutaneous Reverdin–Isham osteotomy [18] has a low impact on IMA, reporting a mean improvement of 3.0 , and a mean correction of DMAA and HVA of about 8 and 15 , respectively. According to Coughlin et al. [19], it is very important to correct DMAA, since a stable recovery can be achieved only by setting up the bone structure, reorienting articular surfaces and restoring the balance of muscle forces at the first ray, avoiding the retraction of soft tissue and peri-articular adhesions. Another potential advantage of this new technique includes the use of a high-torque, low-speed burr to reduce the risk of thermal damage. As reported before, during exostosectomy and osteotomy we irrigate the bone with a saline solution to reduce the risk of thermal necrosis. This could explain the absence of non-union or skin thermal damage in our cohort. As with every new technique, at the beginning the percutaneous techniques have been criticized for the high incidence of complications in other series [20]. In our cohort there were only 9 minor complications. 5 metatarsalgia, 3 cases of stiffness with ROM < 30 and 1 case of persistent hallux paresthesia. There were no reoperations for metatarsalgia. Cases of metatarsalgia did not need any other surgery and were all successfully treated with the use of orthotics. We did not experience any recurrence, postoperative infections, avascular necrosis or hallux varus. The incidence of metatarsalgia was recorded at the latest follow-up, however in according with the data in the literature [21]. It could be explained by the shortening of the first metatarsal obtained with our osteotomy, which in a few cases caused a transfer metatarsalgia, while in the majority of patients did not produced any mid to long-term discomfort. It is possible that an excessive shortening of the first ray could lead to a transfer metatarsalgia, although there is no consensus in literature on the amount of shortening that might lead to this complication. Turnbull and Grange [22] found shortening of first metatarsal up to 8 mm to be acceptable in their series. The main limitation of this study is the lack of a control group, which would be useful to compare the results with the more common open distal osteotomies. We also did not evaluate: radiographic parameters on weightbearing lateral view, sesamoid position on weightbearing AP view, first metatarsal shortening on weightbearing AP view, metatarsophalangeal range of motion. The follow-up period is relatively short in our series in particular to evaluate long term hallux valgus recurrence, and a longer-term follow-up study is required. Bias may also have been induced by the fact that the clinical and radiological measurements were not made by an independent assessor. We conclude that our percutaneous technique in combination with exostosectomy and lateral soft-tissue release is a safe, reliable and effective procedure for the correction of symptomatic mild-tosevere hallux valgus. Results remained consistent also at the midterm follow-up. The aspects which should encourage the use of this technique are its minimally invasive nature, the low incidence of complications, no fixation devices, early weight bearing and minimal surgical scars. A longer-term randomized controlled study would provide higher-level evidence. A larger cohort could lead to a stratification in groups to better evaluate the effectiveness of this technique even in cases of severe hallux valgus.
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Foot and Ankle Surgery xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes Federico Maria Liunia,* , Luca Bernia , Alberto Fontanarosaa , Riccardo Cepparuloa , Alberto Guardolia , Andrea Pellegrinia , Andrea Bianchib , Aldo Guardolia a b
Department of Orthopaedics and Traumatology, Santa Maria Hospital, Borgo Val di Taro, PR, Italy Orthopaedics and Traumatology, PBS Group, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 December 2017 Received in revised form 2 November 2018 Accepted 6 November 2018 Available online xxx
Background: Many procedures and different osteotomies have been described for percutaneous hallux valgus correction. Percutaneous techniques may lead to reduced morbidity, surgery, and recovery time. The aim of this study is to evaluate the clinical and radiographic outcome of a new percutaneous procedure (PBS-Percutaneous Bianchi System). Methods: Fifty-eight cases were treated with Percutaneous Bianchi System procedure for correction of mild, moderate or severe hallux valgus deformity. All patients were clinically assessed preoperatively and then followed up by weight-bearing x-rays, AOFAS (American Orthopedic Foot and Ankle Score), VAS (Visual Analog Scale) pain score, and patient satisfaction. Results: AOFAS scores improved from 28.6 at the preoperative assessment to 91.7 at the latest follow-up. The VAS pain score improved from 6.7 before surgery to 0.6 at the latest follow-up. The mean Hallux valgus angle (HVA), Intermetatarsal angle (IMA) and Distal metatarsal articular angle (DMAA) significatively decreased from the preoperative assessment to the latest follow-up. Conclusions: The PBS technique is a safe, reliable, and effective procedure for the correction of symptomatic mild-to-severe hallux valgus. © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hallux valgus PBS Percutaneous Correction Osteotomy
1. Introduction
2. Methods
Hallux valgus is a common deformity of the forefoot. It is often bilateral and it affects most frequently adult women, especially between 40 and 60 years old. Surgical correction is indicated for symptomatic cases and difficulty with footwear. Many procedures and several first-metatarsal osteotomy procedures have been described [1,2,3,4,5], but the interest of a percutaneous technique lies in the reduced morbidity, surgery time, and recovery time. Its limitations concern the quality of deformity correction and the long-term stability. The PBS (Percutaneous Bianchi System) technique is performed with a complete, extra-articular and not linear osteotomy. These features guarantee more stability and could allow treating mild-to-severe hallux valgus forms. The aim of our study was to evaluate the PBS technique in the treatment of hallux valgus from mild-to-severe forms.
From January 2014 to August 2016, 118 consecutive patients underwent hallux valgus surgery with PBS procedure for correction of their mild, moderate, or severe deformity; of these 118 patients, 52 were willing to participate in the study after signing informed consent. The inclusion criteria were: failure of conservative treatment to alleviate pain during stance and gait and when wearing shoes, radiographic evidence of an HVA angle > 15 and intermetatarsal angle > 8 . Exclusion criteria were: metatarsophalangeal laxity or hypermobility, previous hallux valgus surgery, stiffness or metatarsophalangeal osteoarthritis, diabetes mellitus with peripheral neuropathy, rheumatoid arthritis or other autoimmune disease, peripheral vascular disease. In our population there were 22 (38%) Akin procedures performed. Most of the patients were female (94.8%), that is 55 over a total of 58 operated feet. Their ages ranged from 28 to 82 years of age, the average being 64. The cohort included 6 bilateral cases and 46 unilateral cases, for a total of 58 feet. A statistical description of the cohort is given in Table 1. The average follow-up time was 25 months (time range 12–48 months). All the patients were clinically and radiologically
* Corresponding author. E-mail addresses: [email protected], [email protected] (F.M. Liuni).
https://doi.org/10.1016/j.fas.2018.11.003 1268-7731/© 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Table 1 Demographics. Age, years, mean (range) Gender, female, n (%) Bilateral cases
64 (28–82) 55 (94.8%) 6
Mean age and range, female patients, bilateral cases.
evaluated. Radiographic analysis was performed preoperatively, after surgery, at two months and at the latest follow-up on standard weight-bearing anteroposterior and lateral radiographs. We evaluated the hallux valgus angle, inter-metatarsal angle and distal metatarsal articular angle. Hallux valgus angle (HVA) is the angle between the proximal phalanx axis and first metatarsal axis. Intermetatarsal angle (IMA) is the angle between the first and second metatarsal axis. Distal metatarsal articular angle (DMAA) is the angle between the first metatarsal axis and the distal articular surface of the first metatarsal [6]. HVA was categorized as mild (15–20 ), moderate (21–39 ) and severe (40 ). IMA was categorized as mild (9–11 ), moderate (12– 17 ) and severe (18 ) [7]. In our cohort, 13 patients had a severe HVA and 5 had a severe IMA. We also evaluated radiographic hallux valgus recurrence at the latest follow-up. Recurrent hallux valgus was defined as one or more of the following: an increase in HVA > 5 at the latest follow-up compared to the postoperative assessment, HVA > 20 at the latest follow-up, an increase in IMA > 2 at the latest follow-up compared to the postoperative assessment. The radiographic analysis was performed by a single observer.
All patients were clinically assessed preoperatively and at the latest follow-up with the hallux metatarsophalangeal-interphalangeal scale proposed by the American Orthopedic Foot and Ankle Society (AOFAS) [8]. All patients were also evaluated with VAS (Visual Analog Scale) scale for pain preoperatively and at the latest follow-up. Patient degree of satisfaction was also recorded at the latest follow-up. We asked the patients if they were completely satisfied, moderately satisfied or unsatisfied with the procedure. All clinical and radiologic complications were recorded. 2.1. Surgical technique The procedure was performed using a new minimally invasive technique (Percutaneous Bianchi System — PBS), and ankle block anesthesia. A dorsal skin incision of about 2 mm was made at the first metatarso-phalangeal joint, on the lateral side. With this incision, partial capsulotomy and tenotomy of the hallux adductor tendon were performed with a beaver blade, until an adequate varus reduction of the hallux was achieved (Fig. 1). A skin incision of 4–5 mm was then made slightly proximal and plantar to the metatarsal head, on the medial side; the plantar and dorsal articular capsule was detached with mosquito forceps. The exostosectomy was performed from this incision with a wedge burr (4.1 mm in diameter and 13 mm in length) (Fig. 2). The medial prominence was removed from the first metatarsal head until a flat surface was obtained; it is necessary to not resect too much bone, to avoid articular damage and postoperative stiffness. Resection was verified with manual evaluation and fluoroscopic control (Fig. 3). After the resection, we removed intracapsular bone debris
Fig. 1. Partial capsulotomy and tenotomy of hallux adductor tendon.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 2. Skin incision for exostosectomy, performed with a wedge burr.
with saline solution and with the use of specific rasps. From the same incision we then performed the first metatarsal osteotomy. The osteotomy is extra-articular and is performed using a Shannon straight burr (2 mm in diameter and 12 mm in length). It begins subcapital and dorsal to the first metatarsus, with a slightly oblique line to the longitudinal axis of the first metatarsus in the coronal plane. The first incision should be incomplete, maintaining the lateral cortex intact. The dorsal cortex is interrupted with a vertical cut, then the osteotomy is continued from distal to proximal in the sagittal plane, allowing shortening and plantarization of the head of the first metatarsal (Fig. 4). The lateral cortex of the first metatarsal should then be interrupted with a second passage, slightly more oblique than the first in the coronal plane, to perform a minimal bone step which helps to maintain the translation of the metatarsal head (Figs. 5 and 6). During the exostosectomy and osteotomy, we irrigate the bone with a saline solution to reduce the risk of thermal necrosis. If considered necessary, a percutaneous Akin osteotomy is performed to obtain a better correction. A 2– 3 mm incision is made at the metaphysis of the proximal phalanx. An incomplete osteotomy of proximal metaphysis is performed with a Shannon burr (2.2 mm in diameter and 12 mm in length) from dorsal to plantar, without breaking the lateral cortex. A
3
manual varus correction is then applied on the hallux to compact the medial cortex (Fig. 7). Fluoroscopy images were obtained and the wounds were closed. After the surgical procedure, a functional rigid taping (bandage) was used in order to maintain the metatarsal head translation obtained; (Fig. 8) this taping was left for four weeks, with an intermediate follow-up and dressing change at 15 days. Weight bearing was allowed from the first day after surgery, with appropriate flat stiff-soled footwear. This procedure requires a medium-long learning curve, having some peculiarities that distinguish it from other hallux valgus correction techniques. It requires good skills in percutaneous surgery, and a thorough knowledge of anatomical structures. The main pitfall of the procedure is to properly reproduce the triplanar orientation of the metatarsal head osteotomy and to create the lateral cortical step to improve intrinsic stability. This technique requires the use of fluoroscopy as well as the exposure to radiation. These requirements decrease very markedly over time as the experience of the surgeon increases. Another limitation of this procedure is the remarkable importance of the postoperative dressing must be prepared with high accuracy, due to the absence of an internal device. As a matter of fact, the intrinsic stability of the osteotomy and the postoperative dressing are the two main elements which maintain the deformity correction. 2.2. Statistical analysis The statistical analysis was performed with the IBM-SPSS statistical package, version 22. Descriptive analysis has included the main position, dispersion and form indexes, such as mean, median, mode, 5% trimmed mean, variance, standard deviation, interquartile difference, minimum, maximum, range, asymmetry coefficient and kurtosis. Where relevant, standard errors and 95% confidence intervals were also reported. Parametric tests (Student t test, repeated measures ANOVA) and equivalent non parametric tests were used for comparisons between the groups. Results were considered statistically significant for a p-value less than 5% (p < 0.05). 3. Results 3.1. Clinical Table 2 shows clinical results of AOFAS and VAS scores. AOFAS scores were substantially improved from the preoperative (mean: 28.6 14.1) to the latest assessment (mean: 91.7 10.6), with statistically significative difference (P < 0.001). VAS pain score improved from 6.7 1.1 before surgery to 0.59 1.1 at the latest follow-up (P < 0.001). 55 cases (95%) were completely satisfied at the latest follow-up, while 3 cases (5%) were moderately satisfied. 3.2. Radiologic
Fig. 3. Resection after exostosectomy evaluated with fluoroscopic control.
Table 3 and Figs. 9 and 10show the radiographic results. The mean preoperative HVA was 34.0 9. Its mean value at the follow-up 2 months after surgery was 9.3 5.0 and at the latest follow-up was 10.6 6. The difference was statistically significant between the preoperative and 2 month postoperative assessment (P < 0.001), between the preoperative and latest assessment (P < 0.001), and between the 2 month postoperative and latest assessment (P < 0.05). The mean preoperative IMA was 13.5 3. Its mean value at the 2 month postoperative assessment was 8.0 2, and at the latest follow-up was 8.5 3. The difference was statistically significant between the preoperative and the 2 month postoperative assessment (P < 0.001), and between the preoperative and the latest follow-up (P < 0.001).
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 4. Metatarsal osteotomy first step, performed using a Shannon straight burr.
Fig. 5. Metatarsal osteotomy second step, performed using a Shannon straight burr.
Fig. 6. Schematic direction of PBS (Percutaneous Bianchi System) first metatarsal osteotomy on postoperative antero-posterior and lateral x-rays.
Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003
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Fig. 7. Akin osteotomy performed with a Shannon burr (A). Varus correction to compact the medial cortex (B).
Fig. 8. Postoperative functional rigid taping (bandage) showed step-by-step. First step with sterile gauze (A); second step with rigid surgical tape (B); third step with a second sterile gauze between hallux and second toe (C); fourth step with another rigid surgical tape (D); fifth step with another sterile gauze between hallux and second toe (E); sixth step with tenso-elastic bandage (F). Sterile adhesive strips were placed on second and third toe for extensor tenotomy procedure.
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Table 2 Clinical results.
AOFAS, score (SD) VAS, score (SD)
Preoperative
Last follow-up
p Value
28.6 (14.1) 6.7 (1.1)
91.7 (10.6) 0.59 (1.1)
<0.001 <0.001
AOFAS (American Orthopedic Foot and Ankle Society) score and VAS (Visual Analog Scale) for pain. SD: standard deviation.
The mean preoperative DMAA was 14.6 6. Its mean value at the 2 month postoperative assessment was 4.2 3, and at the latest follow-up was 6.5 5. The difference was statistically significant between the preoperative and the 2 month postoperative assessment (P < 0.001), between the preoperative and the latest follow-up (P < 0.001), and between the 2 month postoperative assessment and the latest follow-up (P < 0.001). 3.3. Complications In our cohort there were 9 minor complications. 5 cases of metatarsalgia at the latest follow-up (9%), 3 cases of severe
stiffness (ROM < 30 ) (5%), and 1 case of persistent paresthesia (2%). There was no reoperation for metatarsalgia. All patients were treated with orthotics for pain resolution. There were neither recurrences, postoperative infections, avascular necrosis, hallux varus, nor first metatarsal malunion on the AP view. 4. Discussion In the last few years, the studies regarding the percutaneous surgery of hallux valgus have exponentially increased. There is growing evidence in literature which suggests that percutaneous hallux valgus surgery is safe and reliable. Several studies showed that there are long term benefits although only few studies have a comparison group treated with open osteotomies [9,10,11,12]. A minimally invasive technique that used k-wire to maintain correction was described by Bosch et al. in 2000 [13]. Later another technique using two-screw fixation and a chevron distal osteotomy was described by Vernois and Redfern [14]. This is the first retrospective single center study that evaluated the data of a new percutaneous technique with a mean follow-up
Table 3 Radiologic results.
HVA, degrees (SD) IMA, degrees (SD) DMAA, degrees (SD)
Preoperative
Two months
Last follow-up
34.0 (9) 13.5 (3) 14.6 (6)
9.3 (5) 8.0 (2) 4.2 (3)
10.6 (6) 8.5 (3) 6.5 (5)
Difference preop.-last follow-up 23.4 5.0 8.1
P value <0.001 <0.001 <0.001
HVA (Hallux Valgus Angle), IMA (Intermetatarsal Angle) and DMAA (Distal Metatarsal Articular Angle) at preoperative, two months and at last follow-up. SD: standard deviation.
Fig. 9. Preoperative and postoperative x-rays (antero-posterior and lateral) after PBS (Percutaneous Bianchi System) procedure.
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Fig. 10. Preoperative and 24 months follow-up x-rays (antero-posterior and lateral) after PBS (Percutaneous Bianchi System) procedure.
of 25 months. PBS technique is different from the other percutaneous techniques thanks to the features of the first metatarsal osteotomy; in particular our osteotomy is complete, extra-articular and with a different orientation. Being extraarticular, this osteotomy protects the blood supply to the metatarsal head [13]. Our technique does not involve the use of screws or k-wire fixation as in other percutaneous techniques. The postoperative dressing is essential to maintain the correction. This study showed that the Percutaneous Bianchi System technique enables to achieve good correction of a moderate and severe hallux valgus deformity, a finding which contradicts previously reported results in literature. Huang et al. [15], who used a MIS technique distal osteotomy fixed with a k-wire on a sample of 82 patients with 18 months of follow-up, recommended that only mild or moderate hallux valgus should be treated with percutaneous techniques. More recently Brogan et al. [7] reported a 2-year outcome of a new MIS distal osteotomy, fixed with compression screw and k-wire, compared to a traditional open distal chevron osteotomy. They stated no differences in radiographic measures and clinical scores between open and MIS groups and no differences in complications rates. In our cohort the mean AOFAS score improved from 28.6 points at the preoperative assessment to 91.7 points at the latest follow-up. Our patients showed a significant improvement between preoperative to postoperative pain at the latest follow-up, with a mean VAS score value that ranged from 6.7 preoperatively to 0.59 postoperatively. 95% of our patients were completely satisfied at the last follow-up. Our results
validate the clinical effectiveness of this new technique in terms of clinical functionality, pain, and patient satisfaction. Our osteotomy allowed the correction of the three main radiographic parameters of hallux valgus, with an improvement of HVA, IMA and DMAA. The HVA decreased from a mean value of 34.0 to 9.3 at two months and 10.6 at the latest follow-up, with a loss of correction of only 1.3 from the 2 month postoperative assessment to the latest follow-up. The IMA decreased from a mean value of 13.5 to 8.0 at the 2 month postoperative assessment and 8.5 at the latest follow-up, with a loss of correction of 0.5 from the 2 month postoperative assessment to the latest follow-up. The DMAA decreased from a mean value of 14.6 to 4.2 at the 2 month postoperative assessment and 6.5 at the latest follow-up, with a loss of correction of 2.3 from the 2 month postoperative assessment to the latest follow-up. In a recent paper Biz et al. [16] evaluated radiographic and functional outcomes in patients with mild-to-severe hallux valgus who underwent Reverdin–Isham and Akin percutaneous osteotomies. The HVA in this study decreased from 26.4 to 12.3 at the 3 month postoperative assessment and to a mean of 13.9 at the latest follow up; the IMA decreased from 12.9 to 9.0 at the 3 month postoperative assessment to the latest follow-up. Our results demonstrate a better correction of HVA and IMA with our technique even with more severe deformities. Despite the significant difference between the 2 month postoperative assessment to the latest follow-up for HVA and DMAA, our cohort showed that the overall radiographic correction was maintained
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from the 2 month postoperative assessment to the latest followup, regarding mean HVA, IMA and DMAA. The positive changes in the radiographic parameters measured after the consolidation of the osteotomy at the latest follow-up, prove the effectiveness of such osteotomy in maintaining correction and reducing the risk of recurrences. As reported by Bauer et al. [9,17], the commonly used percutaneous Reverdin–Isham osteotomy [18] has a low impact on IMA, reporting a mean improvement of 3.0 , and a mean correction of DMAA and HVA of about 8 and 15 , respectively. According to Coughlin et al. [19], it is very important to correct DMAA, since a stable recovery can be achieved only by setting up the bone structure, reorienting articular surfaces and restoring the balance of muscle forces at the first ray, avoiding the retraction of soft tissue and peri-articular adhesions. Another potential advantage of this new technique includes the use of a high-torque, low-speed burr to reduce the risk of thermal damage. As reported before, during exostosectomy and osteotomy we irrigate the bone with a saline solution to reduce the risk of thermal necrosis. This could explain the absence of non-union or skin thermal damage in our cohort. As with every new technique, at the beginning the percutaneous techniques have been criticized for the high incidence of complications in other series [20]. In our cohort there were only 9 minor complications. 5 metatarsalgia, 3 cases of stiffness with ROM < 30 and 1 case of persistent hallux paresthesia. There were no reoperations for metatarsalgia. Cases of metatarsalgia did not need any other surgery and were all successfully treated with the use of orthotics. We did not experience any recurrence, postoperative infections, avascular necrosis or hallux varus. The incidence of metatarsalgia was recorded at the latest follow-up, however in according with the data in the literature [21]. It could be explained by the shortening of the first metatarsal obtained with our osteotomy, which in a few cases caused a transfer metatarsalgia, while in the majority of patients did not produced any mid to long-term discomfort. It is possible that an excessive shortening of the first ray could lead to a transfer metatarsalgia, although there is no consensus in literature on the amount of shortening that might lead to this complication. Turnbull and Grange [22] found shortening of first metatarsal up to 8 mm to be acceptable in their series. The main limitation of this study is the lack of a control group, which would be useful to compare the results with the more common open distal osteotomies. We also did not evaluate: radiographic parameters on weightbearing lateral view, sesamoid position on weightbearing AP view, first metatarsal shortening on weightbearing AP view, metatarsophalangeal range of motion. The follow-up period is relatively short in our series in particular to evaluate long term hallux valgus recurrence, and a longer-term follow-up study is required. Bias may also have been induced by the fact that the clinical and radiological measurements were not made by an independent assessor. We conclude that our percutaneous technique in combination with exostosectomy and lateral soft-tissue release is a safe, reliable and effective procedure for the correction of symptomatic mild-tosevere hallux valgus. Results remained consistent also at the midterm follow-up. The aspects which should encourage the use of this technique are its minimally invasive nature, the low incidence of complications, no fixation devices, early weight bearing and minimal surgical scars. A longer-term randomized controlled study would provide higher-level evidence. A larger cohort could lead to a stratification in groups to better evaluate the effectiveness of this technique even in cases of severe hallux valgus.
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Please cite this article in press as: F.M. Liuni, et al., Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes, Foot Ankle Surg (2018), https://doi.org/10.1016/j.fas.2018.11.003