Fourth-Generation Percutaneous Transverse Osteotomies for Hallux Valgus

Abstract

Background: Fourth-generation percutaneous, or minimally invasive, hallux valgus surgery utilizes a transverse osteotomy to achieve deformity correction. There are only a small number of studies reporting the clinical and radiographic outcomes of transverse osteotomies, many of which have methodological limitations such as small sample size, limited radiographic follow-up, or use of non-validated outcome measures. The aim of this study was to provide a methodologically robust investigation of percutaneous transverse osteotomies for hallux valgus deformity.

Methods: We studied a prospective series of consecutive patients undergoing fourth-generation metatarsal extracapsular transverse osteotomy performed by a single surgeon (P.L.) between November 2017 and January 2023. The primary outcome was clinical foot function assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated patient-reported outcome measure. Secondary outcomes included the radiographic deformity (the hallux valgus angle [HVA], 1-2 intermetatarsal angle [IMA], and sesamoid position) assessed according to American Orthopaedic Foot & Ankle Society (AOFAS) guidelines as well as a visual analog scale for pain and radiographic evidence of deformity recurrence (defined as an HVA of >20° at final radiographic follow-up). P values of <0.05 were considered significant.

Results: Seven hundred and twenty-nine feet (483 patients; 456 female and 27 male; mean age, 57.9 ± 11.9 years) underwent fourth-generation metatarsal extracapsular transverse osteotomy. Radiographic data were available at a vminimum of 12 months postoperatively for 99.7% of the feet, which were followed for a mean of 2.6 ± 1.3 years (range, 1.0 to 5.7 years). There was a significant improvement (p < 0.05) in both the HVA (from 29.5° ± 8.5° preoperatively to 7.3° ± 6.7° at final follow-up) and the IMA (from 12.9° ± 3.3° to 4.6° ± 2.5°). All MOXFQ domains showed significant improvement (p < 0.05), with the MOXFQ Index improving from 36.9 ± 18.9 to 13.4 ± 15.8, Pain improving from 40.5 ± 22.0 to 17.2 ± 18.3, Walking/Standing improving from 32.3 ± 23.1 to 12.0 ± 18.2, and Social Interaction improving from 40.4 ± 20.4 to 11.0 ± 15.2. The recurrence rate was 4.5% (n = 33). The complication rate was 6.1%, which included a screw removal rate of 2.9%.

Conclusions: This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence.

Level of evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Preoperative and 18-month postoperative weight-bearing radiographs (anteroposterior, oblique, and lateral) demonstrating bilateral percutaneous hallux valgus correction with the fourth-generation percutaneous transverse osteotomy technique.

Fig. 2

A flowchart demonstrating patient participation in this study.

Fig. 3

Mean preoperative and 2.6-year postoperative MOXFQ domain scores for patients treated with fourth-generation percutaneous transverse osteotomy for hallux valgus deformity correction. Error bars indicate 95% confidence intervals.

Fig. 4

Preoperative (Fig. 4-A), 6-week postoperative (Fig. 4-B), 9-month postoperative (Fig. 4-C), and 24-month postoperative (Fig. 4-D) radiographs showing nonunion and subsequent revision in the right foot.

Fig. 5

Prevalences of sesamoid coverage (top) and round sign (bottom) in 2 groups of patients defined by whether or not they had recurrent hallux valgus deformity (defined as an HVA of >20°) at final radiographic follow-up.

Fig. 6

Radiographs demonstrating recurrence of hallux valgus deformity (hypothesized to be due to stretching of medial soft tissues and progressive subluxation of the first MTPJ). From left to right: preoperative, 6 weeks postoperative, 6 months postoperative, and 30 months postoperative.