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Minimally invasive distal metatarsal osteotomy (DMMO). a Very distal introduction of the burr. b Osteotomy at the level of the neck
Source publication
Minimally invasive and percutaneous techniques used to repair deformities of the forefoot have considerably developed recently. Like standard osteotomies, these techniques must take advantage of the mechanical advances made in the restoration of the foot’s architecture. Instead of an endpoint, these techniques represent an additional tool implement...
Citations
... It consists of making a bony cut at the level of the metaphysis of the affected metatarsal through a small lateral incision without a direct soft tissue approach [9]. This shortening or dorsiflexing osteotomy [5,10] aims to redistribute plantar pressures by modifying the biomechanics of the forefoot. However, evidence on its concrete effects is still scarce. ...
Background: Metatarsalgia is a common pathology that is initially treated conservatively, but failure to do so requires surgery, such as the minimally invasive distal metatarsal osteotomy (DICMO). Methods: In this prospective study of 65 patients with primary metatarsalgia who underwent DICMO, plantar pressures, American Orthopaedic Foot and Ankle Society MetaTarsoPhalangeal-InterPhalangeal scale (AOFAS-MTP-IP) and Visual Analog Scale (VAS) were evaluated pre-operatively and post-operatively and there was a subgroup in which an inclinometer was used to observe the importance of the inclination of the osteotomy. Results: The results show a significant reduction in plantar pressures after DICMO surgery without overloading the adjacent radii, especially in the subgroup with an inclinometer to guide the osteotomy. The AOFAS-MTP-IP scale evidenced a marked improvement in metatarsal function and alignment with scores close to normal. The VAS scale showed a substantial decrease in pain after DICMO osteotomy. Conclusions: DICMO, with an inclinometer for a 45° osteotomy, proved to be a safe and effective procedure for primary metatarsalgia, although further comparative studies are needed to confirm its superiority.
... Previous studies demonstrated the equivalence of patient satisfaction after Weil osteotomy with and without screw fixation [5,10,11]. Minimally invasive techniques, in particular, have become established [12]. ...
Weil osteotomy is a proven procedure to restore the harmonic distal parabola of the forefoot. In addition to the proximal displacement of the head in the sagittal plane, a displacement in the transverse plane may be necessary, with the refixation of the displaced metatarsal head historically performed by screw fixation. We aimed to determine the radiological differences among 136 feet of 127 patients with 256 Weil osteotomies retrospectively enrolled and divided into groups with (n = 182) and without (n = 74) screw fixation. Demographic data, radiographic union, pre- and postoperative metatarsal angles, and differences in the dorsoplantar view were evaluated. The mean follow-up period was 3.6 months. The mean preoperative metatarsophalangeal angle was 9.24°, and the mean postoperative angle was 12.99°. The restoration of the transversal alignment plane was equally successful in both groups, with a mean extent of angle correction of 10.58°. No nonunions of the osteotomized metatarsals were observed. The radiographic comparisons revealed no significant difference between the groups (p > 0.05). However, visibility of the joint space of the metatarsophalangeal joint was achieved significantly more often in the group without screw fixation (p < 0.05). In the absence of bony malunion and the satisfactory restoration of a harmonious parabola of the forefoot, apparently there does not appear to be a necessity for regular screw fixation after Weil osteotomy based on the available data from the present study.
... Clinical experience suggests, there is usually sufficient stability in the area of the metatarsal osteotomy if one bicortical screw is inserted and translation of the MTH is less than 100% of the shaft width [5]. Hence, the routine insertion of the second monocortical screw, as described in the classical technique, could be omitted. ...
... The results of the present study show that if the osteotomy is classified stable intraoperatively after insertion of one bicortical screw, the insertion of the distal metatarsal screw can be dispensed without jeopardizing the consolidation. This finding is not new, since several authors reported already on MICA techniques, where positioning of a single metatarsal screw was sufficient to stabilize the osteotomy [4][5][6]. Nevertheless, in the quoted papers, only images with single-screw MICA (or modified techniques of MIS hallux corrections) are pictured and no scientific work-up of this technique was conducted. Hence, to the best of our knowledge, the present study is the first to prove that a single metatarsal screw is often enough to stabilize the Chevron osteotomy in third-generation MICA. ...
Introduction
To evaluate the clinical and radiological results after fixation of the first metatarsal head (MTH) with one or two screws as part of the third-generation minimally invasive Chevron–Akin osteotomy (MICA) for hallux valgus deformities.
Materials and methods
Between August 2020 and November 2021, 55 MICA procedures (50 patients, male:female = 7:43), 22 with two (MICA2), 33 with one screw (MICA1) were performed for mild to severe hallux valgus deformities. Exclusion criteria were a concomitant pes adductus (Sgarlato angle > 20°) or hindfoot/midfoot deformities requiring treatment. In 27 cases, additional procedures on the forefoot (small toe corrections or metatarsal osteotomies II–V) were necessary. Pre- and post-operatively, hallux valgus angle (HVA) and intermetatarsal I/II angle (IMA) were measured. Clinically, subjective satisfaction, range of motion (ROM) of the first metatarsophalangeal joint (MTPJ), and pain level (NRS score) were evaluated. The minimum follow-up was 12 months.
Results
Displacement of MTH was 70–90% on average, all osteotomies showed full consolidation at latest follow-up. In one case of either group, a slight subsidence of MTH was documented. The radiological and clinical parameters showed no differences between the groups. The pain level improved by an average of three points. The mobility of the MTPJ showed a slight reduction in nine cases after three months (4 MICA2, 5 MICA1) which persisted in three cases. Fifty-two of 55 patients (95%) would opt again for the operation.
Conclusions
Fixation of the first MTH with a single bicortical screw in MICA with moderate lateralization of MTH shows stable anchoring and good clinical results. The routine use of a second metatarsal screw can be omitted.
... However, associations have been reported linking FRHM to several pathological events such as hallux valgus recurrence after surgery [5][6][7][8][9][10]. Thus, Lapidus or modified Lapidus TMT1 fusion, the reference standard treatment for FRHM, has been suggested for patients with failed hallux valgus surgery [5,11,12]. ...
Impaired mechanical stimuli during hindlimb unloading (HLU) are believed to exacerbate osteocyte paracrine regulation of osteoclasts. We hypothesized that bone loss and deterioration of the osteocyte lacuno-canalicular network are attenuated in HLU mice housed at thermoneutrality (28 °C) compared with those housed at ambient temperature (22 °C). Following acclimatization, 20-week-old male C57BL/6J mice were submitted to HLU or kept in pair-fed control cages (CONT), for 5 days (5d) or 14d, at 22 °C or 28 °C. In the femur distal metaphysis, thermoneutral CONT mice had higher bone volume (p = 0.0007, BV/TV, in vivo μCT, vs. 14dCONT22) whilst osteoclastic surfaces of CONT and HLU were greater at 22 °C (5dCONT22 + 53 %, 5dHLU22 + 50 %, 14dCONT22 + 186 %, 14dHLU22 + 104 %, vs matching 28 °C group). In the femur diaphysis and at both temperatures, 14dHLU exhibited thinner cortices distally or proximally compared to controls; the mid-diaphysis being thicker at 28 °C than at 22 °C in all groups. Expression of cortical genes for proteolytic enzyme (Mmp13), markers for osteoclastogenic differentiation (MCSF, RANKL), and activity (TRAP, Ctsk) were increased following 22 °C HLU, whereas only Ctsk expression was increased following 28 °C HLU. Expression of cortical genes for apoptosis, senescence, and autophagy were not elevated following HLU at any temperature. Osteocyte density at the posterior mid-diaphysis was similar between groups, as was the proportion of empty lacunae (<0.5 %). However, analysis of the lacuno-canalicular network (LCN, fluorescein staining) revealed unstained areas in the 14dHLU22 group only, suggesting disrupted LCN flow in this group alone. In conclusion, 28 °C housing influences the HLU bone response but does not prevent bone loss. Furthermore, our results do not show osteocyte senescence or death, and at thermoneutrality, HLU-induced bone resorption is not triggered by osteoclastic activators RANKL and MCSF.
... Type I is defined by the size of the fifth metatarsal head and its lateral projection, type II is identified by a marked lateral concavity of the fifth metatarsal metaphysis, and type III is characterized by an increase in the intermetatarsal angle between the fourth and fifth metatarsals. Several open surgical techniques have been proposed for treating symptomatic bunionette 15 ; however, since the development of minimally invasive surgery described by de Prado, 23 many surgeons have opted for percutaneous surgery owing to its lower number of complications, 2,5,8,9,12,[14][15][16][17] in addition to maintaining the same satisfactory results. Hence, this retrospective study aimed to analyze the clinical and radiologic results of a new minimally invasive surgical treatment in patients with symptomatic bunionette in order to find an effective technique with fewer complications. ...
Background
Bunionette is a common forefoot deformity that usually leads to significant discomfort. Multiple surgical techniques have been described for correcting bunionette. The purpose of this study is to analyze the clinical and radiologic outcomes of a new surgical technique via minimally invasive distal Chevron osteotomy of the fifth metatarsal without fixation, trying to find an effective technique with fewer complications.
Methods
We retrospectively analyzed the data of 28 patients (31 feet) who presented with symptomatic bunionette that was resistant to conservative treatment and who underwent surgery at our center from February 2018 to February 2020. A minimum follow-up of 20 months was obtained (mean follow-up 26 months, range 20–37). Clinical results were evaluated using the visual analog scale (VAS) and the American Orthopaedic Foot & Ankle Society (AOFAS) score; 5 different radiologic parameters were analyzed.
Results
After surgery, the mean AOFAS score increased by 29 points ( P < .001) and the mean VAS scores decreased by 6 points ( P < .001). An adequate radiologic correction was observed with a decrease in the M4–M5 intermetatarsal angle from 10.3 to 4.8 degrees ( P < .001), metatarsophalangeal angle by a mean of 16.05 degrees ( P < .001), and lateral deviation angle of the fifth metatarsal from 8.5 to 0.97 degrees ( P < .001). Moreover, the length of the fifth metatarsal and the forefoot width was reduced ( P < .001). The only complication was an asymptomatic delay in bone healing, but a complete bone consolidation was achieved after therapy.
Conclusion
The proposed surgical technique shows a good correction capacity with excellent clinical and radiologic results and low complication rates. Level of Evidence: Level IV, retrospective case series.
... By addressing these issues, minimally invasive surgery of the forefoot is becoming an extensively used approach. 20 It involves using a low-speed burr through stab wounds to create osteotomies. In the hallux, it usually involves performing a distal, chevron-like osteotomy, with rigid fixation using screws. ...
This study aims to assess a novel minimally invasive surgical technique that addresses hallux valgus accompanied by metatarsus adductus.
We retrospectively analysed the results of 20 patients (21 feet) that underwent a newly developed percutaneous osteotomy procedure of the lesser metatarsal bones in order to correct hallux valgus deformities accompanied by metatarsus adductus. We used x-ray studies in order to evaluate changes in the hallux valgus angle, the first inter-metatarsal angle, and the metatarsal angle (using the modified Sgarlato method). We also compared the pre- and post-operative AOFAS scores when available. The paired sample t-test was used to compare variables.
At a one-year follow-up the mean hallux valgus angle, inter-metatarsal angle and the metatarsal angle have been reduced by 31.62 (-3 to 9), 3.86 (11 to 52) and 14.69 (4 to 36) respectively (P<0.001 for all). The mean AOFAS score (n=15 feet available) has been improved by a mean of 44.53 (22 to 72, P<0.001). In addition, the patient satisfaction rates were high. Patients suffered from mild to moderate midfoot pain during the first few weeks following surgery, which resolved when union occurred. No cases of lesser metatarsal nonunion have been documented.
The presented minimally invasive method can be used effectively to correct hallux valgus that is associated with metatarsus adductus. Proximal minimally invasive metatarsal osteotomy can effectively correct hallux valgus accompanied by metatarsus adductus.
... However, associations have been reported linking FRHM to several pathological events such as hallux valgus recurrence after surgery [5][6][7][8][9][10]. Thus, Lapidus or modified Lapidus TMT1 fusion, the reference standard treatment for FRHM, has been suggested for patients with failed hallux valgus surgery [5,11,12]. ...
... Le but de l'intervention est de transformer une articulation douloureuse et souvent peu mobile, en une articulation fusionnée, indolore et stable. De multiples modalités techniques en ont été décrites y compris par arthroscopie [6] (Fig. 4) et par voie percutanée [15][16][17] (Fig. 6), utilisant les moyens de fixation les plus divers, et même aucun comme dans la technique de Mac Keever [18] (Fig. 7). La technique la plus fiable est l'avivement des surfaces articulaires visant à obtenir deux surfaces sphériques, concaves et convexes, congruentes, soit par des fraises motorisées à guide centromédullaire, soit par avivement mécanique classique, si possible à la pince-gouge en cas d'ouverture, ce qui est très aisé du côté métatarsien, en conservant la géométrie convexe. ...
Riassunto
Da oltre un secolo e mezzo, la chirurgia dell’alluce valgo ha fortemente stimolato l’interesse dei chirurghi. Alcune tecniche, inizialmente divenute celebri, sono state abbandonate. Altre, molto più recenti, stanno aspettando la prova del tempo per convalidare i loro risultati. Lo stesso vale per la tecnica percutanea, il cui peso è in costante crescita. In generale, alcuni gesti sono comuni a diverse tecniche, e ovviamente non ce ne sono che siano universali e in grado di trattare tutte le tipologie di alluce valgo. Appare quindi essenziale prima di tutto definire un’indicazione chirurgica e scegliere la/le procedura/e terapeutica/e, caratterizzare perfettamente il tipo di deformità. Innanzitutto è necessario conoscere le principali vie d’accesso, comprese quelle più recenti. È prassi tuttora comune distinguere tra tecniche chirurgiche cosiddette “radicali”, resecanti la totalità o una parte dell’articolazione, da quelle “conservative”, tra le quali si individuano quelle che intervengono solo sui tessuti molli e quelle comprendenti osteotomie delle falangi, metatarsali, anche cuneiformi. Dovrebbe essere valutata inoltre la gestione postoperatoria del paziente. Di fronte a questa moltitudine di scelte tecniche, è necessario pensare di associare i gesti quando sono complementari e individuare le indicazioni non solo secondo imperativi radiologici e clinici, ma prendere in considerazione anche le motivazioni e i bisogni dei pazienti, elemento che rappresenta certamente una delle difficoltà maggiori di questa chirurgia.
... Cases of non-union may also occur in minimally invasive surgery; however the reported incidence is much lower compared to open surgical techniques [19,26,27]. Although bone healing is a minor problem in minimally invasive techniques, complete bony consolidation may require several months in x-ray follow up [9,28]. ...
The surgical correction of a hallux valgus deformity presenting with a pes adductus has long proven to be a difficult undertaking. The medial shift of the metatarsal bones limits the scope for surgical correction and leads to inherently high reoccurrence rates. Current invasive treatments often give rise to profound soft tissue trauma and prolonged swelling, while requiring strict relief from weight-bearing in the affected foot.
In this paper, we aim to introduce an easy and useful modification of the Distal Metatarsal Minimal-invasive Osteotomy (DMMO) to perform the effective, simultaneous correction of a pes adductus during surgical treatment of a hallux valgus.We followed-up 143 patients with a hallux valgus and simultaneous pes adductus deformity who underwent one of three additional interventions contemporaneous to the standard DMMO:
1.mini-open Lapidus arthrodesis (Hybrid LAP)
2.percutaneous, proximal MT 1 closing wedge-osteotomy (pCLW)
3.percutaneous Chevron and Akins (pCA)
The assessment of radiological and clinical outcomes after a follow-up period of 12-25 months showed a sustained and effective correction of the pes adductus with a well-aligned hallux. The surgery was characterised by a low incidence of postoperative complications and high patient satisfaction while allowing for pain-adapted, post-operative weight-bearing.
... By addressing these issues, minimally invasive surgery of the forefoot is becoming an extensively used approach. 20 It involves using a low-speed burr through stab wounds to create osteotomies. In the hallux, it usually involves performing a distal, chevron-like osteotomy, with rigid fixation using screws. ...
The combination of hallux valgus and metatarsus adductus presents a surgical challenge even for the experienced foot and ankle surgeon, as the position of the lesser metatarsals restricts the space for metatarsal head displacement. We describe the application of concepts of minimally invasive techniques to correct this deformity. Proximal metatarsal osteotomy to correct the position of lesser metatarsals, followed by minimally invasive bunion surgery, shows promising results. In a short series, proximal metatarsal osteotomy showed excellent correction of the deformity. At final follow-up, all the deformed feet consolidated in correct positions.
