[Experimental cadaveric study assesing protection and osteotomy guide system (BARU) in hallux valgus surgery using Reverdin-Isham technic]. / Estudio experimental cadavérico para valorar el sistema de protección y guía de osteotomía (BARU) en cirugías de hallux valgus con técnica de Reverdin-Isham.

INTRODUCTION: Hallux valgus is a high frequency disorder, affecting the first ray. Operative correction techniques have grown popularity lately. One of them is the Reverdin-Isham technique (first metatarsal medial incomplete osteotomy). Recently, a protection and osteotomy cutting guide has been developed: the BARU system. OBJECTIVE: To test the usefulness of the BARU system as a protective factor for soft structures adjacent to the surgical site and guidance for osteotomy. MATERIAL AND METHODS: Experimental cadaveric study. Six cadaveric feet (two fresh-frozen and four in formaldehyde solution), unapproached. Feet were numbered and intervened with RI technique, three of them with BARU system and three without it. Afterwards, dissection by two dissectors who did not know whether the BARU system had been used or not, establishing a single-blinded model. 13 structures were evaluated in each foot. Data was recovered into Microsoft Office Excel and processed with SPSS. 2 test (significative if p value < 0.05) and relative risk were calculated. RESULTS: Approach using BARU system was satisfactory, with usual-size operation-ports. BARU system colocation was simple and radiological control showed adequate spatial location. The device contributed as reference for cutting direction and depth. 65 out of the 78 searched structures were found (83.3%). Six injuries were found among the assessed structures: plantar medial nerve (one injury), plantar medial artery (one injury), flexor brevis muscle (three injuries), abductor muscle (one injury). Five of these injuries occurred in non-utilizing BARU system feet. CONCLUSION: Promising results in terms of protection of nearby structures, cutting guide, and ease of intervention. Avoids X-rays exposure. Not significant statistical calculations, the sample should be enlarged.

INTRODUCCIÓN: El hallux valgus es una patología con alta prevalencia en la población. Técnicas de corrección quirúrgica han crecido en popularidad últimamente. Una de ellas es la de Reverdin-Isham (RI: osteotomía incompleta medial en primer metatarsiano), se desarrolló un dispositivo de protección y guía de corte para dicho procedimiento: el sistema BARU. OBJETIVO: Probar la utilidad del sistema BARU como factor protector de estructuras blandas adyacentes al sitio de abordaje y guía para osteotomía. MATERIAL Y MÉTODOS: Estudio cadavérico; seis pies (dos frescos y cuatro formolados) sin abordajes previos. Tres con el sistema BARU y tres sin éste. Posteriormente disección por dos disectores con enmascaramiento simple ciego. Se evaluaron 13 estructuras en cada pie. Los datos fueron recabados con Microsoft Office Excel y procesados en SPSS. Se realizó test de 2 (valor p < 0.05 significativo) y se calculó el riesgo relativo. RESULTADOS: El sistema BARU fue satisfactorio. Su colocación fue sencilla y el control radiológico mostró adecuada ubicación espacial. Ayudó como referencia para la dirección y profundidad del corte. Se encontraron 65 de las 78 estructuras buscadas (83.3%). En las estructuras evaluadas hubo seis lesiones: nervio plantar medial (uno dañado), arteria plantar medial (uno dañado), músculo flexor corto (tres dañados), músculo abductor (uno dañado). Cinco de estas lesiones ocurrieron en pies donde no se utilizó el sistema BARU. CONCLUSIÓN: Resultados prometedores en cuanto a protección de estructuras cercanas, guía de corte y facilidad para la intervención. Cálculos estadísticos no significativos, la muestra debería ampliarse.

Midterm Results Following Minimally Invasive Distal Chevron Osteotomy: Comparison With the Minimally Invasive Reverdin-Isham Osteotomy by Means of Meta-analysis.

BACKGROUND/AIM: To date, multiple different surgical techniques have been established for hallux valgus surgery, with each technique having its unique advantages and limitations. The open distal chevron osteotomy is widely accepted, but increasing patient demands have led several minimally invasive (MIS) techniques to be described in recent years. The aim of this study was to compare outcomes after minimally invasive (MIS) distal chevron osteotomy and the minimally invasive Reverdin-Isham method. PATIENTS AND METHODS: We assessed clinical and radiographic outcomes after MIS chevron osteotomy in 57 feet of 49 consecutive patients with a mean follow-up of 58.9 (range=39.0-85.4) months. Outcomes after MIS Reverdin-Isham osteotomy were analyzed by means of a systematic literature review with a minimum follow-up of 6 months. RESULTS: Radiographic outcomes were significantly better in the MIS chevron cohort for intermetatarsal angle (p<0.001), hallux valgus angle and distal metacarpal articular angle (p<0.05). Concerning clinical outcomes, both methods provided comparable improvement. CONCLUSION: MIS distal chevron osteotomy in mild to moderate hallux valgus deformity correction results in superior radiographic outcomes compared to the MIS Reverdin-Isham osteotomy. Sufficient correction of IMA cannot be achieved with the MIS Reverdin-Isham osteotomy.

Estudio experimental cadavérico para valorar el sistema de protección y guía de osteotomía (BARU) en cirugías de hallux valgus con técnica de Reverdin-Isham / Experimental cadaveric study assesing protection and osteotomy guide system (BARU) in hallux valgus surgery using Reverdin-Isham technic

Resumen: Introducción: El hallux valgus es una patología con alta prevalencia en la población. Técnicas de corrección quirúrgica han crecido en popularidad últimamente. Una de ellas es la de Reverdin-Isham (RI: osteotomía incompleta medial en primer metatarsiano), se desarrolló un dispositivo de protección y guía de corte para dicho procedimiento: el sistema BARU. Objetivo: Probar la utilidad del sistema BARU como factor protector de estructuras blandas adyacentes al sitio de abordaje y guía para osteotomía. Material y métodos: Estudio cadavérico; seis pies (dos frescos y cuatro formolados) sin abordajes previos. Tres con el sistema BARU y tres sin éste. Posteriormente disección por dos disectores con enmascaramiento simple ciego. Se evaluaron 13 estructuras en cada pie. Los datos fueron recabados con Microsoft Office Excel y procesados en SPSS. Se realizó test de χ2 (valor p < 0.05 significativo) y se calculó el riesgo relativo. Resultados: El sistema BARU fue satisfactorio. Su colocación fue sencilla y el control radiológico mostró adecuada ubicación espacial. Ayudó como referencia para la dirección y profundidad del corte. Se encontraron 65 de las 78 estructuras buscadas (83.3%). En las estructuras evaluadas hubo seis lesiones: nervio plantar medial (uno dañado), arteria plantar medial (uno dañado), músculo flexor corto (tres dañados), músculo abductor (uno dañado). Cinco de estas lesiones ocurrieron en pies donde no se utilizó el sistema BARU. Conclusión: Resultados prometedores en cuanto a protección de estructuras cercanas, guía de corte y facilidad para la intervención. Cálculos estadísticos no significativos, la muestra debería ampliarse.

Abstract: Introduction: Hallux valgus is a high frequency disorder, affecting the first ray. Operative correction techniques have grown popularity lately. One of them is the Reverdin-Isham technique (first metatarsal medial incomplete osteotomy). Recently, a protection and osteotomy cutting guide has been developed: the BARU system. Objective: To test the usefulness of the BARU system as a protective factor for soft structures adjacent to the surgical site and guidance for osteotomy. Material and methods: Experimental cadaveric study. Six cadaveric feet (two fresh-frozen and four in formaldehyde solution), unapproached. Feet were numbered and intervened with RI technique, three of them with BARU system and three without it. Afterwards, dissection by two dissectors who did not know whether the BARU system had been used or not, establishing a single-blinded model. 13 structures were evaluated in each foot. Data was recovered into Microsoft Office Excel and processed with SPSS. χ2 test (significative if p value < 0.05) and relative risk were calculated. Results: Approach using BARU system was satisfactory, with usual-size operation-ports. BARU system colocation was simple and radiological control showed adequate spatial location. The device contributed as reference for cutting direction and depth. 65 out of the 78 searched structures were found (83.3%). Six injuries were found among the assessed structures: plantar medial nerve (one injury), plantar medial artery (one injury), flexor brevis muscle (three injuries), abductor muscle (one injury). Five of these injuries occurred in non-utilizing BARU system feet. Conclusion: Promising results in terms of protection of nearby structures, cutting guide, and ease of intervention. Avoids X-rays exposure. Not significant statistical calculations, the sample should be enlarged.

Reverdin-Isham procedure for mild or moderate hallux valgus: clinical and radiographic outcomes.

BACKGROUND: In the last decade, interests in minimal incision surgery have been growing. Theoretically, this kind of procedure could decrease time to recovery and rehabilitation, with a reduction in morbidity. The present study assessed clinical and radiological outcomes and complications of percutaneous surgery for mild-to-moderate hallux valgus using Reverdin-Isham and Akin osteotomies without fixation after 60 months of follow-up. METHODS: A series of 48 patients (57 cases) with medium-to-moderate hallux valgus underwent the same percutaneous surgery, between 2003 and 2011. Data collection involved preoperative dorsal flexion, plantar flexion, M1P1, M1M2, DMAA angles, AOFAS scale score, and subjective satisfaction. RESULTS: AOFAS scale score rose from a preoperative median of 55.9-89.2/100 postoperatively (p < 0.001); 51 surgical procedures (89.5%) were considered as satisfactory or very satisfactory by patients at the end of follow-up. Hallux valgus and distal metatarsal articular angle (DMAA) were significantly reduced (29.3° and 14.1°-15.4° and 7.7°, p < 0.001, respectively). There was a significant increase in MTPJ 1 stiffness (p < 0.001). DISCUSSION: Percutaneous correction by Reverdin-Isham and Akin osteotomies seems to be effective in isolated medium-to-moderate hallux valgus. Stiffness observed is comparable to other percutaneous and open procedures but needs to be compared in a randomized controlled clinical trial to extra-articular percutaneous procedures without capsule detachment in association with an internal fixation which allows an early mobilization. LEVEL OF CLINICAL EVIDENCE: IV.

Percutaneous Osteotomies in Hallux Valgus: A Systematic Review.

Percutaneous and minimally invasive surgery is one of the greatest advances in the operating field of orthopedic since the late 1990s. The potential advantages include a shorter operative time, quicker recovery, and reduced hospital stay compared with traditional open surgery. However, scientific validation of the safety and efficacy of hallux valgus (HV) percutaneous surgery remains inconclusive. The objective of the present study was to systematically review the published data and clinical evidence for percutaneous HV surgery, evaluate the scientific method of the reports, and clarify the indications, safety, efficacy, and potential risks of these surgical techniques. Two reviewers independently identified the studies using a PubMed search, with the keywords "hallux valgus," "osteotomy," "minimally invasive," and "percutaneous." Quality assessment was performed using the Coleman methodology scale, and each study was assigned a level of evidence and grade of recommendation. Eighteen studies were included and reported a total of 1534 procedures for percutaneous HV surgery on 1397 patients. Of the 18 studies, 14 (77.8%) were level IV, 2 (11.1%) were level III, and 2 (11.1%) were level II. Overall, the average angle correction of the HV deformity improved postoperatively. Regarding the complications, although some investigators revealed no major complications, others described deformity recurrence in 7.8%, stiffness of the first metatarsophalangeal joint in 9.8%, malunion in 4% to 8.7%, and infection rates ranging from 1.9% to 14.3%. The main indication for percutaneous HV surgery is the correction of mild deformities. The complication rate was elevated even in experienced surgeons. In conclusion, future research in percutaneous techniques should include adequately sized randomized control trials, standardization of treatment protocols, and the use of validated tools for the measurement of clinical outcomes.

Percutaneous Triple and Double Osteotomies for the Treatment of Hallux Valgus.

BACKGROUND: Percutaneous surgery to correct deformities of the forefoot presents the advantages of using a minimal incision, which involves less soft tissue damage and less risk of wound complications. For severe deformities, percutaneous techniques have not been proven as effective. We propose a technique for the treatment of severe hallux valgus. METHODS: In a sample of 52 feet operated on 48 patients, we performed a double percutaneous osteotomy (closure proximal osteotomy and a distal Akin) or triple when a Reverdin-Isham osteotomy was added. We measured preoperatively the American Orthopaedic Foot & Ankle Society (AOFAS) score at the 1-year and 2-year follow-up, as well as the values of hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular ankle (DMAA), and shortening and elevation of the first metatarsal. The presence of metatarsalgia was recorded before and after the surgery. RESULTS: HVA, IMA, and DMAA improved from 39.3 ± 7.1, 17.0 ± 2.0, and 16 ± 8.7 to 11.2 ± 6.2, 8.4 ± 3.4, and 8.3 ± 6.2, respectively. In 5 cases (10%), there was an elevation of the distal metatarsal bone, but only in 2 cases did a transfer metatarsalgia develop. There were no significant correlations between the amount of shortening and the presence of postoperative metatarsalgia. Scores on the AOFAS scale improved from 47.6 ± 5.6 to 89.7 ± 10.1 points. CONCLUSION: The results are comparable to those reported with other more established techniques. Transfer metatarsalgia did not correlate with lifting or shortening of the metatarsal. We indicate the percutaneous technique for IMA above 15 degrees and increased DMAA or congruent joints. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Functional and radiographic outcomes of hallux valgus correction by mini-invasive surgery with Reverdin-Isham and Akin percutaneous osteotomies: a longitudinal prospective study with a 48-month follow-up.

BACKGROUND: Minimally invasive surgery (MIS) represents one of the most innovative surgical treatments of hallux valgus (HV). However, long-term outcomes still remain a matter of discussion within the orthopaedic community. The purpose of this longitudinal prospective study was to evaluate radiographic and functional outcomes in patients with mild-to-severe HV who underwent Reverdin-Isham and Akin percutaneous osteotomy, following exostosectomy and lateral release. METHODS: Eighty patients with mild-to-severe symptomatic HV were treated by MIS. Clinical evaluation was assessed preoperatively, as well as at 3 and 12 months after surgery and at final follow-up of 48 months, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Patient satisfaction and complications were recorded. Computer-assisted measurement of antero-posterior radiographs was taken preoperatively, as well as at 3 and 12 months after surgery and at 48-month follow-up, analysing the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA) and the tibial sesamoid position. Also, the bridging bone/callus formation was evaluated at the different radiographic follow-ups, while the articular surface congruency and the metatarsal index were calculated only preoperatively and at the last follow-up. Patient satisfaction was assessed using the visual analogue score (VAS). Statistical analysis was carried out using the paired t test. Statistical significance was set at p < 0.05. RESULTS: The mean AOFAS score was 87.15 points at the final follow-up of 48 months, and the VAS score was 8.35/10. The post-operative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections of each angular value at the last follow-up were as follows: IMA 3.90°, HVA 12.50°, DMAA 4.72° and a tibial sesamoid position of 1.10. The articular surface was congruent in 77 (96.25%) cases and incongruent only in 3 (3.75%). The complete healing of the osteotomies was achieved in all series at 3-month follow-up. However, the results obtained in the correction of the severe HV deformities were less encouraging. CONCLUSIONS: Minimally invasive surgery with Reverdin-Isham and Akin percutaneous osteotomy, in combination with previous exostosectomy and subsequent lateral soft-tissue release, is a safe, effective and reliable procedure for correction of mild-to-moderate HV. However, it requires a long learning curve because of the inherent difficulty of the mixed different surgical procedures. TRIAL REGISTRATION: ClinicalTrials.gov PRS Protocol Registration and Results System: NCT02886221.

Percutaneous hallux valgus treatment: Unilaterally or bilaterally.

INTRODUCTION: Currently there is no consensus regarding the use of bilateral simultaneous percutaneous surgery for Hallux valgus treatment. Although the technique described in M. Prado's book, recommends operating only one foot at a time there are no published studies confirming it. The aim of this study was to evaluate whether there is a difference between the results of patients that have been percutaneously operated on one foot and those operated on both feet at the same surgical time for mild to moderate Hallux valgus correction. MATERIAL/METHODS: We did a retrospective single centre evaluation of 93 feet (61 patients) with Hallux valgus operated percutaneously. 29 patients were operated unilaterally (group I) and 32 bilaterally simultaneously (group II) between 2005 and 2009. The Metatarsophalangeal angle (MPA), Intermetatarsal angle (IMA) and Distal metatarsal articular angle (DMAA) were evaluated pre- and postoperatively. The AOFAS score, the degree of patients' satisfaction and the complications were evaluated postoperatively. RESULTS: The mean follow-up was 24.0 months in group I, and 28.0 in group II. The average postoperative AOFAS score was 86.8, 82.9 in group I and 88.6 in group II (p>0.05). 90.6% were satisfied or very satisfied in group I, and 89.7% in group II (p>0.05). There was no statistically significant difference (p>0.05) in the average correction of MPA, DMAA, and IMA. The complications rate was similar in both groups. CONCLUSIONS: The similar results obtained in both groups suggest that the simultaneous bilateral percutaneous surgery gives equivalent results to the unilateral, which has an important socioeconomic impact since there is only one recovery time for both feet. Further research is needed.

Reverdin-Isham osteotomy versus Endolog system for correction of moderate hallux valgus deformity: a Randomized Controlled Trial.

OBJECTIVES: Several procedures have been described for the management of hallux valgus deformity. In this paper we would like to compare our experiences with two techniques (Endolog system and Reverdin-Isham osteotomy) with a randomized study. To our knowledge, this is the first study to be reported in the literature, that provides a detailed comparison of these two techniques to treat moderate hallux valgus. MATERIALS AND METHODS: A total of 40 consecutive patients (40 feet) with moderate symptomatic hallux valgus were randomly assigned into two groups, to compare the results of Reverdin-Isham osteotomy (group A,20 feet) and Endolog system (group B, 20 feet). RESULTS: The average follow-up was of 23.7 ±7.7months . The average correction of HVA and IMA achieved in group A was 17.1° ±6.2° and 5.2° ±2.6° respectively, while in group B, it was 14°±6.2° and 7.7°±2.6° respectively. The mean AOFAS score improved from a pre-operative of 40.5 ±15.5 points to 90.3 ±5.3 points in group A, and from 32.4 ±16.8 points to 89.2 ±10.5 in group B. CONCLUSIONS: No statistically significant differences were detected between the two groups with respect to the AOFAS score, HVA, and IMA. Both groups showed good to excellent results.

[Treatment of moderate and severe hallux valgus by performing percutaneous double osteotomy of the first metatarsal bone]. / Tratamiento del hallux valgus moderado y severo mediante doble osteotomía percutánea del primer metatarsiano.

OBJECTIVE: To evaluate the clinical and radiological results in the surgical treatment of moderate and severe hallux valgus by performing percutaneous double osteotomy. MATERIAL AND METHOD: A retrospective study was conducted on 45 feet of 42 patients diagnosed with moderate-severe hallux valgus, operated on in a single centre and by the same surgeon from May 2009 to March 2013. Two patients were lost to follow-up. Clinical and radiological results were recorded. RESULTS: An improvement from 48.14 ± 4.79 points to 91.28 ± 8.73 points was registered using the American Orthopedic Foot and Ankle Society (AOFAS) scale. A radiological decrease from 16.88 ± 2.01 to 8.18 ± 3.23 was observed in the intermetatarsal angle, and from 40.02 ± 6.50 to 10.51 ± 6.55 in hallux valgus angle. There was one case of hallux varus, one case of non-union, a regional pain syndrome type I, an infection that resolved with antibiotics, and a case of loosening of the osteosynthesis that required an open surgical refixation. DISCUSSION: Percutaneous distal osteotomy of the first metatarsal when performed as an isolated procedure, show limitations when dealing with cases of moderate and severe hallux valgus. The described technique adds the advantages of minimally invasive surgery by expanding applications to severe deformities. CONCLUSIONS: Percutaneous double osteotomy is a reproducible technique for correcting severe deformities, with good clinical and radiological results with a complication rate similar to other techniques with the advantages of shorter surgical times and less soft tissue damage.