What Is the Ideal Repair for Hallux Valgus?

Percutaneous. As this author argues, the third-generation percutaneous hallux valgus correction creates a biomechanically stable first ray, promotes quick weight-bearing, and leads to less postoperative pain.

By Brian Loder, DPM, FACFAS

The treatment of hallux valgus first appeared in literature in the late 1800s. Since that time there have been over 100 different procedures reported with no apparent clear leader. The goal of all procedures should be to create a rectus, biomechanically stable first ray without sacrificing other anatomy. The goals should also aim for a quick return to weight-bearing status, retaining range of motion of the first metatarsophalangeal joint and minimizing postoperative pain as much as possible. To date, procedures that accomplish all of these tenets have been rare. Recently, in my observation and experience, the third-generation percutaneous hallux valgus approach appears to fill this void and is gaining popularity quickly.

A Look at the History of Percutaneous Hallux Valgus Correction

Percutaneous foot surgery first appeared in the 1950s as a way for podiatrists to perform surgical procedures.¹ At that time, it was rare for hospitals to grant surgical privileges to podiatrists. These procedures were commonly performed without fixation and even sometimes without the use of fluoroscopy. Due to the inherent complications of this approach and the fact that podiatrists began obtaining hospital privileges, the percutaneous approach to foot pathology went quickly out of favor. In 1991, Isham reintroduced percutaneous hallux valgus correction by publishing a modification of the Reverdin procedure in which he used the percutaneous approach with no osteosynthesis.² In 2003 Giannini published a modification of the Reverdin-Isham procedure in which he used percutaneous K-wire fixation, coining the procedure SERI (simple, effective, rapid and inexpensive).³ Giannini’s technique used a 1-cm incision just proximal to the medial eminence and a sagittal saw to create a transverse osteotomy, fixated with a percutaneous Kirschner wire. The utilization of this technique did not catch on due to noting a high infection rate and first MTPJ stiffness postoperatively.³ In 2011 Vernois and Redfern modified this approach by using high torque, low speed burrs and internal fixation to introduce the third-generation of percutaneous hallux valgus correction.⁴ Since 2011, there have been multiple publications addressing radiologic and patient-reported outcomes. Through the years there have been modifications of the Vernois and Redfern approach, most notably Lamm, who suggested a transverse osteotomy would provide more stable fixation than the originally described chevron-like osteotomy.⁵

Understanding the Benefits of Third Generation Percutaneous Hallux Valgus Correction

Currently, third-generation percutaneous hallux valgus correction has survived the criticism that its younger generation versions did not. This is due in part to the published outcome studies by the likes of Gordon, Lewis, Ray, Lamm and many others.⁶ In my experience, this modern-day percutaneous approach touts some attributes that make it attractive to foot and ankle surgeons, including immediate weight-bearing, early return to shoe gear, maintenance of post-surgical range of motion of the first MTPJ, low rates on infection and nonunion, and reduction in procedure time. The reduction in procedure time has come into debate due to the high learning curve. The learning curve can be anywhere between 27–40 cases depending on the study published.^7-9 I, as well as many other leaders in the field, believe that this is dependent more on the initial training the surgeon receives, and not the inherent difficulty of the procedure itself. In my observation, one can mitigate the high learning curve by standardizing the approach and through close adherence to the steps described by the pioneers of the procedure.

The benefits of the percutaneous approach are many. First and foremost is the reduction in initial pain scores reported with this approach. I find this is even more obvious in patients who had undergone an open procedure on the contralateral side. Most patients in my practice report pain scores in the range of 2–4/10 in the first 5 days. This has an even greater significance with the current opioid epidemic in the United States. The reduction in postoperative edema that I see is another benefit of the percutaneous approach, since it allows an early return to normal shoe gear, an attractive point to the patient undergoing the procedure. Of all the benefits that the percutaneous approach offers, the most appreciated by the patient that I’ve noted has been the retention of range of motion post-surgically at the first metatarsophalangeal joint. The percutaneous approach avoids violation of the first MTPJ, which in turn reduces or eliminates arthrofibrosis. Since there is no incision over the first MTPJ, range of motion exercises can begin as early as the first postoperative day.

Addressing Ideal Procedure Selection

Initial thinking dictated that the percutaneous approach was limited to mild-to-moderate hallux valgus deformities, but literature has supported its use in moderate-to-severe deformities as well.^10,11 In my practice I have successfully used the percutaneous approach in over 90% of all hallux valgus deformities, removing the need to perform more proximal procedures like basal osteotomies and the Lapidus procedure. Thus I am contending its superiority over open procedures like the Lapidus. Like the open procedure, one should avoid percutaneous osteotomy in patients with moderate-to-severe arthrosis of the first MTPJ. In my initial consultation with a patient for percutaneous hallux valgus correction, I make sure that I can partially reduce the deformity clinically if I plan on performing a percutaneous osteotomy correction.

Although a topic for a different day, percutaneous first MTPJ arthrodesis works extremely well, in my experience, in rigid hallux valgus deformities. Recurrent hallux valgus corrections are also well within the bailiwick of a percutaneous correction, I find. The retained hardware can be left in place if the osteotomy and new screw placement can avoid it, since overzealous dissection of the first MTPJ capsule to remove retained hardware could destabilize the capital fragment and prevent the use of the percutaneous approach. The use of rigid internal fixation is a staple of the success of the modern-day percutaneous approach. This relies on at least one of the fixatives being bicortical in the proximal first metatarsal segment. This inherent stability allows translocations of the capital fragment greater than 100%, in my experience. This inherent stability and the retention of the soft tissue envelope has produced only 1 nonunion over 500 percutaneous hallux valgus corrections I have performed at the time of this publication.

Radiographic evaluation is perhaps the greatest predictor of the most appropriate procedure given a particular hallux valgus deformity. Most foot and ankle surgeons choose the surgical procedure based on the values of the intermetatarsal and hallux valgus angles.

Conversely, the percutaneous decision-making stems from the width of the first metatarsal head and the width of the space between the first and second metatarsal heads. If the width of the metatarsal head is greater than the space between the first and second metatarsal head, then a percutaneous approach will likely correct the deformity completely. If the space between the first and second metatarsal head is greater than the width of the metatarsal head, then a more proximal procedure, like a Lapidus, should be performed. However, the versatility and broad applicability of the percutaneous metatarsal osteotomy is superior, in my experience. Radiographic evaluation of the extent of any arthrosis of the first MTPJ, first metatarsocuneiform joint, and the sesamoid apparatus should take, and alternative procedures should be considered as indicated.

Concluding Thoughts

The third-generation percutaneous hallux valgus correction seems to have solved the problems suffered by previous generations. It also seems to avoid some of the major issues that have plagued the open distal metatarsal procedures and approaches deformities of magnitude that might otherwise warrant more proximal intervention. The ability to correct moderate-to-severe deformities, reduction in postoperative pain, and early return to normal shoe gear and normal function, I contend makes for an ideal approach for modern day foot and ankle surgeons. I believe the popularity will increase as more surgeons are exposed to peer-to-peer training. It will not be uncommon for patients to begin to request percutaneous correction as the preferred approach and those surgeons who are late to the party will find it hard to meet the demand of the public.

Dr. Loder practices at Detroit Foot and Ankle and is board certified in reconstructive foot and ankle surgery. He is Residency Director and Former Chief of Staff at Henry Ford Macomb Hospital. Dr. Loder is also the Medical Director of the Henry Ford Macomb Hospital Wound Care Center.

References
1.     Polokoff M. Raspostectomy. Reduction of exostoses and hypertrophied condyles with files and rasps. J Am Podiatry Assoc. 1962;52:599-602.
2.    Isham SA. The Reverdin-Isham procedure for the correction of hallux abducto valgus. A distal metatarsal osteotomy procedure. Clin Podiatr Med Surg. 1991;8(1):81-94.
3.    Giannini S, Cavallo M, Faldini C, Luciani D, Vannini F. The SERI distal metatarsal osteotomy and Scarf osteotomy provide similar correction of hallux valgus. Clin Orthop Relat Res. 2013;471(7):2305-2311.
4.    Vernois J. The treatment of the hallux valgus with a percutaneous chevron osteotomy. J Bone Joint Surg Br. 2011;2011:482.
5.    Khosroabadi A, Lamm B. Modified percutaneous hallux abductovalgus correction. J Foot Ankle Surg. 2016;55(6):1336-1342.
6.    Lewis TL, Ray R, Miller G, Gordon DJ. Third-generation minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery: two-year follow-up of 292 cases. J Bone Joint Surg Am. 2021;103(13):1203-1211.
7.    Palmanovich E, Ohana N, Atzmon R, et al.  MICA: a learning curve. J Foot Ankle Surg. 2020;59(4):781-783.
8.    Toepfer A, Strässle M. The percutaneous learning curve of 3rd generation minimally-invasive Chevron and Akin osteotomy (MICA). Foot Ankle Surg. 2022;28(8):1389-1398.
9.    Lewis TL, Robinson PW, Ray R, et al. The learning curve of third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus. J Foot Ankle Surg. 2023;62(1):162-167.
10.    Choi JY, Kim BH, Suh JS. A prospective study to compare the operative outcomes of minimally invasive proximal and distal chevron metatarsal osteotomy for moderate-to-severe hallux valgus deformity. Int Orthop. 2021;45(11):2933-2943.
11.    de Carvalho KAM, Baptista AD, de Cesar Netto C, Johnson AH, Dalmau-Pastor M. Minimally invasive chevron-Akin for correction of moderate and severe hallux valgus deformities: clinical and radiologic outcomes with a minimum 2-year follow-up. Foot Ankle Int. 2022 Oct;43(10):1317-1330.

Triplanar correction. These authors argue for the superiority of triplanar correction for hallux valgus repair by arthrodesis of the tarsometatarsal joint, noting the potential downsides of MIS hallux valgus deformity correction.

By Anna Kakizadi, DPM; and Michael Theodoulou, DPM, FACFAS

Procedures for surgical correction of hallux valgus deformity can be dated back to the late 1800s. Since then, there have been well over 100 different types of methods recorded. All of the techniques aim to restore the architecture of the first ray as close to normal as possible.¹ Surgeons often choose approaches based on a severity algorithm focusing on radiographic findings of increased intermetatarsal angle, increased hallux valgus angle, etc. Based on angular measures and perceived severity, reconstructive approaches have been applied along the first ray, with milder deformities addressed distally and severe deformities increasingly more proximal anatomically. Surgeons have continued to debate the best method for this deformity correction, and there has yet to be a consensus. In recent years, minimally invasive surgical (MIS) deformity correction, which addresses the correction at the distal metatarsal, has been again popularized with its advanced technology, which has become a topic for debate.

Here, we will argue against the now popularized MIS technique for hallux valgus deformity correction by emphasizing the importance of identifying the center of rotation and angulation and following the basic principles of deformity correction.

A Closer Look at Deformity Correction

When we discuss any deformity correction of the lower extremities, we consider the principles defined by Paley. The center of rotation and angulation (CORA) should be specified when choosing the right site for correction.² In hallux valgus deformity, the identified CORA would be located at the tarsometatarsal joint, or some will argue more proximally. When breaking down between the anatomical and mechanical axis, the anatomical apex of deformity would be between the medial cuneiform and first metatarsal. When focusing on the mechanical axis, the deformation peak is more proximal in the midfoot.³

Ideally, the CORA and the correctional osteotomy would lie in the exact location. The osteotomy would allow angulation correction without translation. When the performance of an osteotomy lies in a different area than the CORA, translation is required to realign the mechanical axis. This is the concept of metatarsal osteotomies, as we translate the capital fragment or metatarsal head to the desired position. Distal osteotomies require further translation. The correction is executed farther away from the CORA.² This can be especially seen in the now popularized minimally invasive distal metatarsal osteotomy, as the capital fragment requires a significant shift laterally, in more severe deformities requiring a “100% shift.” This creates the appearance of the capital fragment within the first interspace, and once this osteotomy heals, we are left with an iatrogenic deformity of the first metatarsal. Like many other long bones, such as the tibia, the normal first metatarsal anatomic and mechanical axis are the same. MIS procedures sacrifice the anatomic axis to restore mechanical alignment. Why not support a strategy that does not destroy the typical metatarsal structure?

If we are to consider the principles discussed above, addressing the deformity closer to the apex of deformation and the CORA at the tarsometatarsal joint would be more favorable and ideal. Deformity correction at the tarsometatarsal joint was initially discovered in the early 1900s and popularized by Paul W. Lapidus in 1934. Lapidus stated, “The only mechanically sound osteotomy for metatarsus primus varus should be at the metatarsocuneiform joint which is at the apex of the angulation …”^3,4

Previously, the Lapidus procedure was used for severe deformity correction or with patients with hypermobility. However, the understanding of this deformity has also evolved in recent years. The frontal plane deformity of the first ray has been better acknowledged—pronation of the first metatarsal changes the apparent sesamoid position. Sesamoid axial views show the proper positions of the sesamoids, which also has demonstrated that eversion of the metatarsal can also lead to the abnormal sesamoid position seen on an anterior-posterior view. Lateral rounding of the first metatarsal also indicates rotation of the rotation in the frontal plane. Dayton and colleagues have described the importance of identifying the frontal plane deformity and properly realigning the sesamoid complex directly beneath the metatarsal head.^5,6

Considering these concepts, the Lapidus procedure would be the only one to address all three planes of hallux valgus deformity at the CORA, resulting in deformity correction without translation.

There is the argument from the MIS advocates that we are sacrificing a joint to achieve correction of the deformity, and appreciation of foot function impact from this fusion needs to be fully appreciated. I would argue that it is, in fact, the pathology of this joint that is likely the chief contribution to the deformity and may represent the familial predisposition often attributed to this condition’s etiology. Popularized by Hansen in Seattle, the first tarsometatarsal joint is considered to be inessential in foot function.⁷ The failure of this joint by instability or morphology should not be ignored. There is developing science that the articular morphology of this joint may be a principal cause to the development of hallux valgus. There is appreciation that number of existing facets that comprise the joint may establish inherent stability and reduce risk for deformity.⁸

Other Important Considerations Not Addressed by MIS

Metatarsus adductus. Another deformity that is commonly seen with hallux valgus deformity is the metatarsus adductus (MTA). This deformity is approximately seen in 0.1% of the general population and reported in up to 35% of the people with hallux valgus deformity.⁵ Patients with underlying metatarsus adductus deformity are known to have higher recurrence rates and patient dissatisfaction after an isolated correction of their hallux valgus deformity. The presence of MTA will hinder the anatomic correction of the first ray if used in an isolated setting, creating more surgical challenges.⁵

Hypermobility. In many circumstances, hypermobility, first ray insufficiency, or functional instability must be considered when planning surgery. Hypermobility can exist not only in the sagittal plane but also in the transverse and frontal planes. This not only influences the hallux valgus deformity but also increases the chance of recurrence and overload of the second ray.³ The minimally invasive technique itself does not address this problem. From our experience, we highly encourage identifying this pathology preoperatively but also intraoperatively. It is commonly seen where there is instability in the transverse planes within the intercuneiform, increasing the splaying between the two rays. When the instability is appreciated, a Lapidus procedure stabilizes the medial column, and an additional screw can be easily added to stabilize transverse intercuneiform instability.

Further Considerations

There is a lure for minimally invasive surgery as the incision is minimal, there is less disruption of soft tissue, and there is earlier weight-bearing. Although minimal incision and minimal disruption of soft tissue are eye-catching, the complication rates are similar in current literature.

Not much literature has compared and contrasted our preferred surgical approach, the Lapidus procedure, to the minimally invasive technique. However, there are multiple papers comparing open distal metatarsal osteotomies with the minimally invasive technique. A randomized controlled study in 2020 published by Kaufmann and colleagues compares the open vs. minimally invasive chevron osteotomy results and finds no significant differences between the two groups five years postoperatively.⁹ In a meta-analysis study from 2022, there was no statistically significant difference in the American Orthopaedic Foot and Ankle Society (AOFAS) score, the visual analog scale at final follow-up, or complication rate between the two groups.

Early weight-bearing is appealing, but this appeal can also be seen in the Lapidus procedure with new fixation methods. Current techniques harness methods of joint preparation and fixation to advance both primary and secondary bone healing. The two-plate fixation placed 90 degrees makes a delta construct allowing for multiplanar stability, which allows early weight-bearing, creating relative motion at the fusion site and aiding in healing.¹⁰ Many practitioners using this robust construct allow for early protected weight-bearing in less than two weeks.

Our MIS colleagues would also like to promote cosmesis of their procedure as another advantage to their approach. I would like to advance patient appreciation regarding foot width using current technology. In a study of 144 patients average osseous foot width decreased by 10.4 mm or 10.8% and soft tissue decrease on average 7.3 mm or 6.8%.¹¹ Similar studies in evaluation of osteotomies suggested no change in foot width and in some cases increased width.¹²

In Conclusion

Whether we are debating between open or minimally invasive surgery, it is first necessary to consider whether we are choosing the proper procedure for the patient’s deformity and whether we can obtain full deformity correction with the method we perform. While, as practitioners, we have to consider the patient history, presentation, and expectations, we still have to approach deformity correction appropriately. While a minimally invasive technique may be a viable option for a handful of patients, we argue that the most appropriate procedure to address this deformity for many patients would be the Lapidus procedure. The first impression is usually the right impression. Is it possible that historical thought, discussed in the early 1900s, may be the proper thought?

Anna Kakizadi, DPM, is the Chief Podiatric Resident at Cambridge Health Alliance.

Michael Theodoulou, DPM, FACFAS, is the Division Chief, Podiatric Surgery at Cambridge Health Alliance. He is the Assistant Professor of Surgery at Harvard Medical School.

References
1.    Galois L. History of surgical treatments for hallux valgus. Eur J Orthop Surg Traumatol. 2018; 28(8):1633–1639. https://doi.org/10.1007/s00590-018-2235-6
2.     Paley D, Herzenberg JE. Principles of Deformity Correction. Springer, 2002.
3.     Carpenter BB, Butterworth ML, Fishco WD, Marcoux JT, Vickers DF, McGlamry ED. McGlamry’s Foot and Ankle Surgery. Wolters Kluwer, 2022.
4.     Lapidus PH. Operative correction of the metasis varus primus in hallux valgus. Surg Gynecol Obstetr. 1934; 58:183.
5.     McAleer JP, Dayton P, DeCarbo WT, Hatch DJ, Smith WB, Ray JJ, Santrock RD. A systematic approach to the surgical correction of combined hallux valgus and metatarsus adductus deformities. J Foot Ankle Surg. 2021; 60(5):1048–1053. https://doi.org/10.1053/j.jfas.2020.11.010
6.     Dayton P, Kauwe M, Feilmeier M. Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy. J Foot Ankle Surg. 2015; 54(1):102-111.
7.     Hansen ST. Functional Reconstruction of the Foot and Ankle. Lippincott Williams & Wilkins, 2000.
8.     Doty JF, Coughlin MJ, Hirose C, et al. First metatarsocuneiform joint mobility: radiographic, anatomic, and clinical characteristics of the articular surface. Foot Ankle Int. 2014; 35(5):504–11.
9.     Kaufmann G, Mörtlbauer L Hofer-Picout P, Dammerer D, Ban M, Liebensteiner M. Five-year follow-up of minimally invasive distal metatarsal chevron osteotomy in comparison with the open technique: a randomized controlled trial. J Bone Joint Surg Am. 2020; 102(10):873–879. https://doi.org/10.2106/JBJS.19.00981x
10. Santrock RD, Smith B. Hallux valgus deformity and treatment: a three-dimensional approach: modified technique for Lapidus procedure. Foot Ankle Clin. 2021; 23(2): 281-295. https://doi.org/10.1016/j.fcl.2018.02.001
11.     Vaida J, Ray JJ, Shackleford TL, et al. Effect on foot width with triplanar tarsometatarsal arthrodesis for hallux valgus. Foot Ankle Orthoped. 2020; 5(3):2473011420934804.
12. Tenenbaum SA, Herman A, Bruck N, Bariteau JT, Thein R, Coifman O. Foot width changes following hallux valgus surgery. Foot Ankle Int. 2018; 39(11):1272–77.

Additional References
13. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013; 52(3):348-354.
14. Trnka HJ. Percutaneous, MIS and open hallux valgus surgery. EFORT Open Reviews. 2021; 6(6):432–438. https://doi.org/10.1302/2058-5241.6.210029