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Objective Joint-preserving procedure with plantarization of the 1st metatarsal and improvement of range of motion. Indications Mild and moderate arthrosis of the 1st metatarsophalangeal joint with pain and shoe discomfort due to elevation of 1st ray and failed conservative treatment. Contraindications Severe degenerative conditions 1st metatarsophalangeal joint with significant loss of range of motion preoperatively. General contraindications for surgical treatment/anesthesia. Surgical technique Dorsomedial approach to 1st metatarsophalangeal joint, mild cheilectomy and arthrolysis, v‑shaped osteotomy of metatarsal 1 from dorsal with plantarization of the metatarsal head, screw fixation from proximal dorsal to distal plantar. Postoperative management Full weightbearing in rocker bottom shoe for 6 weeks. Results Improvement of range of motion from 35° dorsal extension to 50° in all cases after 6 months. Reduction of painful movement from VAS 6-7 to VAS 2-3 in 80% of patients.

Background:Bunionette is a common foot disorder, and several types of corrective surgery have been described. With the popularization of minimally invasive surgeries, the forefoot region has become a suitable area for this type of technique. The aim of this study was to evaluate the results of oblique distal osteotomy of the fifth metatarsal adapted for a percutaneous approach.Methods:We prospectively evaluated 31 consecutive tailor’s bunion patients who underwent operative correction on a total of 42 feet between 2017 and 2019 after failure of conservative treatment. Clinical outcomes such as pain (visual analog scale [VAS]), function (American Orthopaedic Foot & Ankle Society [AOFAS] Lesser Toe Metatarsophalangeal-Interphalangeal Scale scoring system), personal satisfaction, and complications were evaluated. Radiographic aspects were also examined. Shapiro and Mann-Whitney statistical tests were conducted. The average age of the patients was 69.5 years, and the average follow-up was 13.1 months.Results:After the operative procedure, there was a decrease of 6.6 points on the VAS for pain ( P < .001) and an increase of 34.9 in the AOFAS score ( P < .001). Radiographic correction was achieved for both the fifth metatarsophalangeal angle ( P < .001) and the intermetatarsal angle ( P < .001), which showed decreased values. There was 1 case of superficial infection and 2 cases of nonunion (asymptomatic). A large majority of patients regarded the procedure outcome as satisfactory.Conclusion:This percutaneous oblique distal osteotomy of the fifth metatarsal for bunionette deformity produced improvements in pain and function and a high rate of satisfaction, with a low incidence of complications and a high capacity for correcting the deformity.Level of Evidence:Level II, prospective cohort study.

Background: This study was aimed at assessing clinical and radiographic outcomes of the Minimally Invasive Intramedullary Nail Device (MIIND) to correct moderate to severe hallux valgus (HV) and the long-term persistence of its effects. Methods: This case series study involved 100 patients, 84 women and 16 men (mean age, 59 years), who underwent the MIIND procedure with a mean follow-up of 97 months. Assessment was performed preoperatively, postoperatively, at 6 and 12 months, and at last follow-up. Clinical outcomes were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS), and patient satisfaction. Intermetatarsal angle (IMA), metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and tibial sesamoid position were assessed. Statistical analysis was performed. Results: The mean AOFAS score improved from 57.9 to 90.5 points, VAS scale was 1.5 ± 2.0, and patients’ satisfaction was 8.7 ± 1.4. The mean correction of the HVA and IMA showed a significant correction; however, the effect of time was not statistically significant on DMAA. Sex ( P = .047), severity ( P = .050), associated procedures ( P = .000), and preoperative angle ( P = .000) showed significant association with HVA correction and its persistence over time. Age was not statistically significant. Complications were 9 cases of superficial wound infection and 6 recurrences. Conclusions: The MIIND technique proved a viable procedure to correct moderate to severe HV with a low rate of complications and recurrence, producing significant correction of most radiographic parameters assessed and their persistence, even at long term. Level of Evidence: Level IV, case series study.

Eine distale Osteotomie (Chevron-Osteotomie) ist die Operationsmethode der Wahl bei milden bis moderaten Fehlstellungen. Bei der klinischen Untersuchung zeigt sich das klassische Bild eines Spreizfuses mit auseinanderweichenden Metatarsalia (Metatarsus primus varus) und schmerzhafter Pseudoexotose. Die radiologische Diagnostik beinhaltet ein Rontgenbild des gesamten Fuses in 2 Ebenen im Stehen. Radiologisch sollten praoperativ der intermetatarsale Winkel (IM), der Hallux-valgus-Winkel (HAV) und der distale Gelenkflachenwinkel (DMAA) bestimmt werden. Die operative Korrektur beinhaltet eine weichteilige und knocherne Komponente. Modifikationen der Osteotomie erlauben eine verkurzende, verlangernde oder neutrale Korrektur des Metatarsale I. Auch ein erhohter DMAA kann gut korrigiert werden.

Hallux and first MTP joint have a fundamental role in the transfer of the weight-bearing load during the normal ambulation. The aim of this paper is to review and analyze the available literature about the percutaneous surgical management of the hallux valgus to highlight its strengths and weakness, also comparing with other minimal invasive techniques. A systematic search of PubMed and Google Scholar databases has been performed, covering the period between 1981 and 2016. Various combinations of the keyword terms "PDO," "hallux valgus," "bunion," "percutaneous," "surgery," "non-invasive," "minimal invasive," "burr," "osteotomy," "distal," "linear," "saw" have been used.Four papers, published from 2005 to 2015, fulfilled the inclusion criteria. A total of 464 hallux valgus has been treated with a properly percutaneous distal first metatarsal osteotomy. Mean AOFAS score, retrieved from the 4 studies included in our review, has been recorded. There are different aspects that the foot and ankle non-experienced surgeon has to consider about percutaneous surgery: limitation of the tools, radioexposure, lack of direct visual control of the osteotomy and higher costs and patient risk due to surgical time.

WOS: 000400884400015 PubMed ID: 28258948 We compared the outcomes of the distal oblique metatarsal (DOM) osteotomy, which is parallel to the articulation surface of the proximal phalanx, with those of the chevron osteotomy and evaluated whether displacement and shortening of the first metatarsal have any effect on the incidence of metatarsalgia and patient satisfaction. Patients treated with the DOM osteotomy (n = 30) or distal chevron osteotomy (n = 31) were evaluated retrospectively. The chevron and DOM osteotomies both provided significant improvement in the first intermetatarsal angle (p

Purpose The purpose of this study is to evaluate the results of distal osteotomy of lesser metatarsals carried out through a percutaneous technique. Materials and methods Forty-four feet in 37 patients were reviewed, which the same surgeon had subjected to 110 percutaneous osteotomies between November 2002 and July. 2006. Metatarsalgias of general or traumatic origin were excluded from the study. All patients were assessed functionally (by means of the AOFAS [American Orthopaedic Foot and Ankle Society] Lesser Metatarsophalangeal-Interphalangeal Scale) and radiographically. Results Alter a mean 15-month’ follow-up, a satisfactory functional result was obtained in 93.2% of cases (41 feet), with a mean final score of 91 (range: 65-100) on the AOFAS scale. The condition recurred in 5 patients, and 2 developed transfer metratarsalgia (these required an osteotomy of the affected metatarsals). Mobility of the metatarsophalangeal (MTP) joint was not significantly disturbed in any of the cases and 7 patients developed a “floating toe” deformity. Radiologically a mean shortening of 2.9 mm was observed. There were 3 cases of delayed healing, but eventually healing was achieved by all patients. Conclusion Percutaneous osteotomy affords satisfactory clinical and cosmetic results and leads to no problems in terms of healing or MTP joint stiffness. These results indicate that it is an effective and safe surgical technique that can be recommended for lesser ray metatarsalgia, whether in association with other forefoot procedures or not.

In this paper, the Authors suggest the performance of percutaneous distal osteotomy of the fifth metatarsal neck by a rapid, mini-invasive technique, without joint capsule procedures for the correction of fifth ray deformities with a valgus fifth metatarsal and a varus fifth toe. The procedure was carried out in 25 foots who underwent surgery between January 2002 and May 2005, with an 8-month to 4-year follow-up. The clinical results were evaluated by the AOFAS score which identified an improvement of the obtained score, with over 90% of the results classified between excellent and good.

Background Hallux valgus (HV) is a complex deformity of the forefoot altering the kinematics of walking. Many different treatment alternatives exist for the correction of hallux valgus, but to date, none has been shown to be more effective than any other. The rate of complications following hallux valgus surgery is variable and has been reported as ranging from 1 to 55 % in the scientific literature. The purpose of this preliminary prospective study was to evaluate the result of the Endolog device, an innovative titanium endomedullary nail, for the treatment of HV. Methods Thirty patients with mild-to-severe HV were treated with the Endolog device. Clinical evaluation was assessed preoperatively, as well as at 3, 6, 12, 24, and 48 months after surgery with a final follow-up at 4 years, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Computer-assisted measurement of weight-bearing antero-posterior radiographs was taken preoperatively and postoperatively, as well as at 3, 6, 12, 24, and 48 months after surgery. Non-weight-bearing radiographs were taken before the patients were discharged. The radiological parameters measured included the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the tibial sesamoid position. Statistical analysis was carried out using the paired t test (p < 0.05). Results The mean AOFAS score was 93.98 points at the 48-month follow-up. The postoperative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections for each angular value at the last follow-up were as follows: IMA 5.95°; HVA 16.81°; DMAA 10.70°; and tibial sesamoid 1.36°. Conclusion The Endolog is a safe and effective technique for the correction of HV deformity, to relieve pain and to preserve joint movement.

Distal osteotomies are the original osteotomies performed in the first metatarsal for bunion surgery. Many of these can be fashioned to improve an abnormal DMAA. Correction of an abnormally wide first-second IM angle is a goal of the newer procedures. Lateral transposition at the osteotomy site first performed by Mitchell helps accomplish this goal. The chevron modification improves stability and offers sufficient correction for mild-to-moderate deformities. Fixation is recommended after metatarsal osteotomy. The distal chevron procedure has been associated with lower degrees of correction, but the risk of transfer metatarsalgia is minimized. Shortening is less likely compared with some distal osteotomies but can occur. Advanced age is not a contraindication for distal metatarsal osteotomy. Avascular necrosis is highly unusual after this procedure.

[Introduction][1] Percutaneous distal metaphyseal osteotomy, a subcapital linear osteotomy of the fifth metatarsal performed through a minimally invasive percutaneous approach and stabilized with a single Kirschner wire, without soft-tissue procedures, enables the surgeon to achieve consistently good correction of a fifth metatarsal bunionette deformity. [Step 1: Wire Insertion][2] It is mandatory to place the wire in a parosteal position to allow medial displacement of the metatarsal head at the osteotomy site. ![Figure][3] ![Figure][3] [Step 2: Skin Incision][4] Make a short skin incision directly to the bone on the lateral side of the distal metaphysis of the fifth metatarsal. ![Figure][3] [Step 3: Periosteal Detachment][5] Detach the periosteum surrounding the bone at the site of the planned osteotomy with a small scissors inserted percutaneously, dorsally initially and then plantarly. ![Figure][3] ![Figure][3] [Step 4: Osteotomy][6] Perform the osteotomy with a micromotorized Lindemann bone cutter, avoiding damage to the surrounding structures by drilling the lateral cortex first and then the medial cortex, keeping the bone cutter in the same lateral entry hole and its tip inside the medullary canal. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 5: Correction][7] The correction is usually satisfactory when contact between the lateral aspect of the metatarsal head and the medial cortex of the metatarsal neck is achieved in the frontal plane. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 6: Stabilization][8] Stabilize the osteotomy site with the 2-mm Kirschner wire, driven distal to proximal into the medullary canal of the fifth metatarsal as far as its base. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 7: Postoperative Care][9] Apply adhesive tape with a plantar, kidney-shaped pad. ![Figure][3] ![Figure][3] [Results][10] In our study of this technique[24][11], the American Orthopaedic Foot & Ankle Society (AOFAS) score improved from a mean and standard deviation of 51.9 ± 10.2 points preoperatively to 98.4 ± 2.6 points at the time of final follow-up. In 73% of the feet, there was complete resolution of pain at the fifth metatarsophalangeal joint without any functional limitation (AOFAS score of 100). In 20% of the cases, the AOFAS score was 95 points with some decrease in function and a need to use comfortable shoes. In the remaining 7% of the patients, the AOFAS score was 93 points with mild asymptomatic malalignment. No nonunions or recurrences were observed. [What to Watch For][12] [Indications][13] [Contraindications][14] [Pitfalls & Challenges][15] [Introduction][1] Percutaneous distal metaphyseal osteotomy, a subcapital linear osteotomy of the fifth metatarsal performed through a minimally invasive percutaneous approach and stabilized with a single Kirschner wire, without soft-tissue procedures, enables the surgeon to achieve consistently good correction of a fifth metatarsal bunionette deformity. [Step 1: Wire Insertion][2] It is mandatory to place the wire in a parosteal position to allow medial displacement of the metatarsal head at the osteotomy site. ![Figure][3] ![Figure][3] [Step 2: Skin Incision][4] Make a short skin incision directly to the bone on the lateral side of the distal metaphysis of the fifth metatarsal. ![Figure][3] [Step 3: Periosteal Detachment][5] Detach the periosteum surrounding the bone at the site of the planned osteotomy with a small scissors inserted percutaneously, dorsally initially and then plantarly. ![Figure][3] ![Figure][3] [Step 4: Osteotomy][6] Perform the osteotomy with a micromotorized Lindemann bone cutter, avoiding damage to the surrounding structures by drilling the lateral cortex first and then the medial cortex, keeping the bone cutter in the same lateral entry hole and its tip inside the medullary canal. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 5: Correction][7] The correction is usually satisfactory when contact between the lateral aspect of the metatarsal head and the medial cortex of the metatarsal neck is achieved in the frontal plane. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 6: Stabilization][8] Stabilize the osteotomy site with the 2-mm Kirschner wire, driven distal to proximal into the medullary canal of the fifth metatarsal as far as its base. ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] ![Figure][3] [Step 7: Postoperative Care][9] Apply adhesive tape with a plantar, kidney-shaped pad. ![Figure][3] ![Figure][3] [Results][10] In our study of this technique[24][11], the American Orthopaedic Foot & Ankle Society (AOFAS) score improved from a mean and standard deviation of 51.9 ± 10.2 points preoperatively to 98.4 ± 2.6 points at the time of final follow-up. In 73% of the feet, there was complete resolution of pain at the fifth metatarsophalangeal joint without any functional limitation (AOFAS score of 100). In 20% of the cases, the AOFAS score was 95 points with some decrease in function and a need to use comfortable shoes. In the remaining 7% of the patients, the AOFAS score was 93 points with mild asymptomatic malalignment. No nonunions or recurrences were observed. [What to Watch For][12] [Indications][13] [Contraindications][14] [Pitfalls & Challenges][15] [1]: #sec-11 [2]: #sec-12 [3]: pending:yes [4]: #sec-13 [5]: #sec-14 [6]: #sec-15 [7]: #sec-16 [8]: #sec-17 [9]: #sec-18 [10]: #sec-19 [11]: #ref-24 [12]: #sec-20 [13]: #sec-21 [14]: #sec-22 [15]: #sec-23

The treatment of hallux valgus by distal osteotomy of the first metatarsal may be performed by a percutaneous technique with a burr. Fixation of the displaced position of the fragments by a single K wire is used as recommended by Kramer-Lamprecht. Immobilization by plaster is not necessary. 63 feet were followed up for an average period of 16 months. The average valgus angle of 36° was corrected to 19°, the intermetatarsal angle from 13° to 8°. The average shortening of the first metatarsal was 3 mm. Postoperative complaints were diminished after 9 weeks. 92% of the patients were free from pain, wearing normal shoes postoperatively, and stated the result to be excellent or good. Four infections caused premature removal of the wire but did not prevent early healing. One non-union was seen after 8 months, but was completely painless. The results of this percutaneous technique are comparable to those of open procedures. Advantages of this technique are the extremely short operation time of a few minutes, the absence of significant scars and the quick postoperative rehabilitation.

Distal osteotomy of the first metatarsal with a step lateral displacement has been used in the treatment of 34 feet with hallux valgus. Stability of the osteotomy is achieved by a dorsomedial capsulorrhaphy. Suturing through drilled holes or internal fixation were not necessary. One case was complicated by dorsal tilt of the head of the metatarsal bone and required revision.

To prevent patella infera in open wedge high tibial osteotomy, a new operation technique was developed. Instead of a proximal tibial tuberosity osteotomy, a distal osteotomy was performed and the tuberosity was fixed with one screw to the tibia. Initial experience in 17 patients was evaluated and compared with results of 20 patients with open wedge high tibial osteotomy with proximal tuberosity osteotomy. Distal tuberosity osteotomy in open wedge high tibial osteotomy appears effective in preventing patella infera.

A long-term retrospective review of a long oblique distal osteotomy of the fifth metatarsal for correction of a tailor's bunion deformity is presented. The technique, results, and follow-up of this procedure are described. The long oblique distal osteotomy was performed on 25 feet on 16 patients. Follow-up ranged from 11 to 110 months with an average of 64.4 months. The average preoperative intermetatarsal 4-5 angle and lateral deviation angle improved from 10.88° and 4.24°, respectively, to 5.52° and −4.24° postoperatively, respectively. A modified scoring scale for lesser metatarsal procedures was used, showing an average postoperative score of 94 out of 100 possible points. Subjectively, 96% (24 of 25) of feet that underwent surgery were rated as excellent or good. Complications included one patient with paresthesias, one soft-tissue infection, and 2 patients had irritation from screws. The authors conclude that the long oblique distal osteotomy is a viable alternative in the correction of tailor's bunion deformity. (The Journal of Foot & Ankle Surgery 42(1):36–42, 2003)

The principle of prebending plates is recommended for intertrochanteric osteotomies to reach satisfactory primary stability. This can be done by conventional or functional prebending. Because of the shape of an overbent plate in conventional prebending, when the tension device is used a sliding of the medial wedge of the proximal fragment medially on the distal osteotomy plane takes place. In functional prebending, the final shape of the plate results in almost no movement of the bone fragments. Therefore the measurable interfragmentary compression of functional prebending is better than in the conventional procedure. The functional prebending also causes no loss of primary installed medialisation and there is no need for an additional- procedure for the prebending during the operation.

A retrospective analysis was done of 52 rotational tibial osteotomies (RTOs) performed on 35 patients with severe idiopathic tibial torsion. Thirty-nine osteotomies were performed at the proximal or midtibial level. Thirteen were performed at the distal tibial level with a technique previously described by one of the authors. Serious complications occurred in five (13%) of the proximal and in none of the distal RTOs. For severe and persisting idiopathic tibial torsion, the authors recommend correction by RTO at the distal level. Proximal level osteotomy is indicated only when a varus or valgus deformity required concurrent correction.

The results of a distal chevron (V-)osteotomy in 31 adolescent patients are reported. The distal V-osteotomy of the first metatarsal appeared to provide excellent correction of hallux valgus deformities. The surgical technique and the advantages over other forms of distal osteotomy are described. The authors recommend that distal V-osteotomy be considered as an alternative to other forms of distal osteotomy when treating hallux valgus in adolescents and growing children.

If surgery is indicated for metatarsalgia, osteotomy of the metatarsals should be considered. In the years 1967-1977 we have operated on 35 feet. The first 17 we performed a proximal V-shaped osteotomy, the next 18 we performed a distal oblique osteotomy. The results were excellent in 18 cases, good in 13 cases and poor in 4 cases. We recommend the oblique distal osteotomy because the operation is simple, recovery is rapid and symptoms are well relieved.