Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Clinical, Radiologic, and Pedobarographic Outcomes.

BACKGROUND: The minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) is a percutaneous operative technique with the aim to relieve the symptoms of metatarsalgia. To our knowledge, no previous research has analyzed both pre- and postoperative pedobarographic data including the changes in plantar pressure. METHODS: Thirty patients (31 feet) were operated on with a DMMO and included in a prospective study. Clinical, radiologic, and pedobarographic outcomes were evaluated in comparison with the preoperative parameters. The American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS), and a visual analog scale (VAS) for pain were used in order to assess clinical parameters. Radiographs were taken to compare metatarsal lengths. The pedobarographic analysis served to determine plantar peak pressure (PPP) beneath the metatarsophalangeal (MTP) joints. RESULTS: All scores indicated a significant mean pre- to postoperative improvement (AOFAS = 31.9 points, FAOS = 16.3%, FFI = 24.3%, VAS pain = 4.1 points, VAS general limitation = 3.3 points) (P < .05). PPP was substantially reduced in the relevant area (M6 [plantar area beneath the second and third MTP joint] had a mean pre to post PPP = 14.15 N/cm2) and concurrently higher in the lateral and medial MTP joint areas (M5 mean pre to post = +14.37, M7 pre to post = +7.11). Our mean metatarsal shortening was 6.6 mm. However, our findings do not demonstrate a significant correlation between metatarsal length relationships and the prevalence of metatarsalgia. CONCLUSION: Our results demonstrate a significant improvement in clinical scores and PPP. A statistically significant relation between metatarsal length and the prevalence of metatarsalgia was not found in this prospective case series. LEVEL OF EVIDENCE: Level IV, case series.

Short-Term Results of Endoscopic Percutaneous Longitudinal Tenotomy for Noninsertional Achilles Tendinopathy and the Presentation of a Simplified Operative Method.

PURPOSE: This study was aimed to review the short-term results of endoscopic percutaneous longitudinal tenotomy for noninsertional Achilles tendinopathy using the Centerline Endoscopic Carpal Tunnel Release instrument (Arthrex). This method simplifies the operation technique, allows a good endoscopic visualisation of the Achilles tendon with very promising results. METHODS: We performed multiple percutaneous longitudinal tenotomies under local anesthesia in 24 patients (25 tendons) with Achilles tendinopathy or peritendinitis that had failed conservative treatment between January 2013 and September 2016. All ambulatory procedures consisted of paratenon release and longitudinal tenotomies. The results were reviewed in 22 patients (23 tendons) at an average follow-up period of 22.5 months (range 10-36 months). Patients' satisfaction and functional outcomes were evaluated using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, the pain visual analog scale (VAS), and the functional foot index. RESULTS: Initial results are very promising with excellent results in 12 patients, good results in 9 patients, and fair result in 1 patient. One patient developed a postoperative thrombosis of the operated limb. Another patient developed a hypertrophic painful scar of the incision wound. The VAS for pain decreased drastically after the index procedure and averaged to 0.2 (SD 0.447). The VISA-A questionnaire score had improved from 42 ± 7.2 points preoperatively to 96.8 ± 14.3 points postoperatively (P = .004). The functional foot index decreased from 84 (SD 30.517) to 33.4 (SD 6.452) on the follow-up examination. CONCLUSIONS: The endoscopic-assisted longitudinal tenotomies procedure of the Achilles tendon is easily feasible and can be performed on an outpatient basis, produces minimal complications and shows excellent results. The described technique is recommended for all surgeons especially for those familiar with endoscopy of the Achilles tendon. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Series.

Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Learning Curve.

BACKGROUND: Minimally invasive surgery has a shorter surgical time, and in this study we focus on minimally invasive distal metatarsal metaphyseal osteotomy (DMMO). The operation seems to be less complex but requires a high learning curve. We report on our first patients to underline the need for extensive training and great awareness for the risks in the early learning stages. METHODS: We evaluated 27 patients (mean age = 60.9 years) with a mean follow-up time of 7.2 months. Indication was metatarsalgia, intractable plantar keratosis, and the (sub-)luxation of the metatarsophalangeal joint. Clinical results were evaluated with the 12-item Short Form (SF-12), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), and the American Orthopaedic Foot and Ankle Score (AOFAS). Radiographs and pedobarographic analysis were obtained. RESULTS: Scores ranged closely to standard value (AOFAS 88.07 points; FFI 93%; FAAM 36.4 points; SF-12 31.27 points). Pedobarography showed significant differences in several forefoot areas. We encountered nonunion/malunion and necrosis of the metatarsal head. CONCLUSIONS: The aim of this study was to demonstrate the need for intensive training before practicing DMMO. Results show that minimally invasive DMMO requires a high learning curve. Correct handling of the burr is associated with a lot of training. Wrong handling can lead to nonunion/malunion or necrosis. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Minimally invasive hallux valgus surgery: a critical review of the evidence.

This systematic review aims to illustrate the published results of "minimally invasive" procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were "hallux valgus", "bunion", "percutaneous surgery", "minimally invasive surgery", "arthroscopy", "Bosch" and "SERI". Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one's own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.