The field of orthopaedics continually seeks to improve our ability to help patients return to optimal function as quickly and efficiently as possible. New surgical techniques aimed at better outcomes, faster recovery, and smaller (and hopefully less painful) scars are regularly being developed and evaluated. The concept of minimally invasive surgery (MIS) has been around for some time, with newer techniques being utilized in multiple subspecialties. Foot and ankle surgery is no exception, with procedures including MIS for hallux valgus deformity correction. While early generations of such procedures were fraught with complications, newer, third-generation MIS (involving screw fixation of a distal metatarsal osteotomy site) has shown promising early results, with a documented learning curve of 20 to 50 cases.
In the July 7, 2021 issue of JBJS, Lewis et al. present their results from a consecutive series of third-generation minimally invasive chevron and Akin osteotomies (MICA) in the treatment of hallux valgus. Patient-reported outcome measures (PROMs) collected preoperatively and at a minimum of 2 years postoperatively as well as radiographic outcomes and complications were evaluated.
From the initial series of 333 feet (230 patients), PROMs data were available for 292 feet, or 87.7% (200 patients). PROMs utilized included the Manchester-Oxford Foot Questionnaire (MOXFQ), a tool specifically validated for patients undergoing hallux valgus surgery; the EuroQol-5 Dimensions-5 Level (EQ-5D-5L) Index and EuroQoL visual analogue scale (EQ-VAS), validated quality-of-life measures; and a VAS for pain.
The authors found a significant improvement (greater than the minimal clinically important difference) in each domain of the MOXFQ. They also noted a significant improvement in the VAS-pain score and the EQ-5D-5L Index.
There was an overall 21.3% complication rate, with only 7.8% of the cases requiring a return to the operating room, most frequently for screw removal (6.3%). The operating surgeon was outside the reported learning curve, having previously performed approximately 100 MICA procedures, but there were still complications that can help guide the physician-patient discussion regarding the use of the MICA.
Although radiographic follow-up did not routinely go beyond 6 weeks, the authors found significant improvement in radiographic measures. With >25% of the preoperative deformities being classified as “severe,” the findings suggest the potential utility of the procedure for patients with a range of deformity severity.
This series—which the authors note is the largest of the third-generation MICA technique— opens the door for possible head-to-head comparison with traditional hallux valgus surgery via a randomized trial to further define the role of MICA in the treatment of patients with hallux valgus.
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Matthew R. Schmitz, MD
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