Welcome. My name is Oliver Schipper and I'm here to discuss what's new in Halox valgus surgery over the past year. Here are my disclosures. So we'll first start by discussing a paper on opioid-free versus opioid-containing protocol for Halox valgus surgery. We'll then discuss short-term positive outcomes on the third-generation PICA or MICA technique. Next, we'll discuss short-term outcomes for the PICA-MICA technique for moderate to severe Halox valgus deformity. We'll then discuss medium-term outcomes for the MICA-PICA technique. We'll discuss short-term outcomes for the fourth-generation PICA or MITA technique. And then finally, we'll end with clinical applications. So the first paper here is a paper about 51 patients, and it's a prospective cohort study. This paper had a protocol for the opioid-free patients. Can you pause, please? One second, Jennifer. Three, two, one. Welcome. My name is Oliver Schipper and I'm here to discuss what's new in Halox valgus surgery over the past year and a half. I think it's a really exciting time to discuss Halox valgus surgery because we've seen a boon in literature on the minimally invasive PICA or MICA technique that the percutaneous Chevron-Akin bunionectomy or minimally invasive Chevron-Akin bunionectomy. Here are my disclosures. So first, we'll discuss a paper that describes outcomes after opioid-free versus opioid-containing protocol for Halox valgus surgery. We'll then discuss short-term outcomes for the third-generation PICA or MICA technique. We'll look at short-term outcomes for the PICA or MICA technique for even moderate to severe Halox valgus deformities. We'll look at medium-term outcomes for the PICA or MICA technique. And finally, we'll discuss a paper on short-term outcomes for the fourth-generation PITA or MITA technique, and that refers to using a transverse osteotomy of the distal first metatarsal with an Akin osteotomy instead of the previously described Chevron osteotomy. Then we'll end with some clinical applications based on learning points from these papers. So the first paper is based on 51 patients. It was a prospective cohort study comparing patients with an opioid-free post-op protocol and then an opioid-containing post-op protocol. For the opioid-free patients, they had 10 milligrams of oral Ketorolac three times a day for five days, followed by a course of Naloxicam, 500 milligrams of Tylenol, and then 300 milligrams of Gabapentin three times a day for two weeks. And what the authors found was that the opioid-free protocol was statistically non-inferior to the opioid-containing protocol. So this certainly validates, as we all know, the opioid epidemic is real and affects many patients, but this validates this as a great option for, you know, avoiding opiates for hallux valgus surgery. And especially when we, you know, move on to talk about minimally invasive hallux valgus correction with the PITA or MITA technique, you know, these patients only take about two to three opiates on average. So, you know, it's very reasonable that you'd be able to just reduce or remove opioids from your hallux valgus surgery practice with this protocol. This is the largest prospective case series looking at the third-generation MICA technique in hallux valgus surgery. It had two-year follow-up with a mean of 3.1 years, and what it showed is that there were excellent post-op MOX-FQ scores and VAS scores, and it also showed significant or statistically significant improvement in the 1-2 IM angle and hallux valgus angle. There were a few complications in the cohort, so there was a 6.3% chance of screw removal, a 0.9% recurrence rate, and I think that's important because, again, very low rate of recurrence with this technique. There was a 1.8% rate of cutout or fracture, which can occur soon after procedure, a 1.2% rate of nonunion, and again, you can see very low rate of nonunion compared to older minimally invasive techniques, which used a one-to-one speed versus torque burr, which generate more heat, and finally, there was a 1.5% rate of FHL, flexor loose lungs injury, that did not require operative intervention, and I would tell you that a simple way to avoid FHL injury and EHL injury is that, you know, when you're doing your dorsal limb of your either dorsal first metatarsal cut or your aching osteotomy, you dorsiflex the hallux at the MTP joint and the IP joint to protect that EHL tendon, and vice versa, when you're doing your plantar cuts, you plantar flex the hallux interphalangeal joint and the metatarsal phalangeal joint to protect that flexor luceus fungus tendon, because it's very hard to cut a tendon when it's off tension. Again, this is the largest series, short-term follow-up, it's still the largest series that produced to date for this technique, so there were some limitations. Again, this is a single-experience MIS surgeon, so this is not a surgeon in their learning curve, and unfortunately, they did not have preoperative comparative patient-reported outcome measures. They did, again, have pre-op and post-op radiograph comparisons, but again, did not have PROMs to compare pre-op. So this is the next paper, we'll switch gears here, and this is looking at, well, can we do the MICA technique or PEAK technique for moderate and severe hallux valgus deformities? Again, this paper was a two-year follow-up, it included 70 feet with 28 moderate and 42 severe deformities. So this paper, again, showed a significant improvement in the DMAA, the hallux valgus angle, and the 1,2 intermetatarsal angle. It also showed significant improvement in VAS scores and the AOF-AS-MTP-IP score when you compared pre-op to post-op. Again, it showed a rate of complication of 15%, secondary to painful hardware, and the authors noted that 9 out of 10 of those patients that had to have screws removed had a non-beveled screw. So this shows you definitely need to have a chamfered or a beveled screw head. Again, patients will definitely feel those screws along the medial cortex with shoewear as their swelling improves. Number two, there was a 2.85% rate of neuropathic pain, and that resolved after three months in the patients it affected. And again, it should be noted that this was using a Chevron technique, which typically is performed with more of a dorsomedial incision at the junction of the middle and dorsal third of the medial distal first metatarsal at the base of the first metatarsal head flare. And finally, they had a loss of correction rate of 4.28%, and two out of three of these required surgical intervention. Next, this paper looked at the PICA technique, now a little longer follow-up with mean three-year follow-up here, but this looked at just severe hallux valgus deformity. So these were patients with a hallux valgus angle of greater than 40 degrees, a 1-2 intermetatarsal angle greater than 20 degrees. There were 59 feet total, and they had a minimum one-year follow-up. The recurrence rate here was 7.5%, which again, considering these are severe hallux valgus deformities is still very reasonable and I think acceptable. Now they did define recurrence as a change in the hallux valgus angle greater than 2.6 degrees between any two postoperative radiographs and a hallux valgus angle of greater than or equal to 15 degrees. But they did note that about 24.5% had residual deformity, and that was defined as a hallux valgus angle greater than or equal to 15 degrees within the first six months. So again, not perfect results, but I think these seem very reasonable, and this does show us an option for patients with severe hallux valgus deformity. This is our longest-term follow-up for this technique, and this was looking at the PICA technique, and this was a five-year follow-up with the third-generation PICA technique. There were 78 feet of note. All patients did receive a lateral release. There was a significant improvement in hallux valgus angle and intermetatarsal angle. Complications included a 7.7% chance of recurrence, and again, they defined that as hallux valgus angle greater than 15 degrees. There was one hallux varus as a complication, and I will tell you from experience, you just really don't see that without doing a formal lateral release of either the adductor hallucis or the lateral phalangeal sesamoid ligament. And then finally, there was a 4% screw removal rate in this cohort. So this study really validates that even with five-year follow-up, the recurrence rate is still relatively low, and I think the results are certainly acceptable with this percutaneous Chevron-Akin technique. So now I say the majority of us doing a lot of minimally invasive bunionectomy surgery have really moved toward doing the transverse osteotomy of the distal first metatarsal with our Akin osteotomy, and so now we've kind of moved to calling this the META, which stands for minimally invasive extra-articular transverse distal first metatarsal osteotomy and Akin osteotomy. It's also been called the PETA technique, but this was a prospective study. It included 50 feet, and it showed a significant improvement with fourth-generation technique in the MOX-FQ, the inner metatarsal angle, the hallux valgus angle, the DMA, and then the EQ5D5L and EQBAS scores. So again, this study shows that using our kind of newest fourth-generation technique, really great outcomes and significant improvement in radiographic correction that was maintained at one-year post-op. Again, the follow-up is relatively short here, but at least, you know, there was a very low risk of early recurrence in this cohort. The complications included one superficial cellulitis. There were two first metatarsal lateral wall fractures, and that can happen when someone's being maybe too aggressive when they're attempting to shift the first metatarsal head lateral relative to the shaft. And there was also a 10% screw removal rate. And so the authors in this paper advocated for a transverse osteotomy over the chevron osteotomy for a few reasons. Number one, it's easier to obtain rotational correction of the pronation deformity with hallux valgus. Number two, as depicted in this photo to the right here, with a transverse osteotomy, there's more bone on either side of the osteotomy for screw purchase. And so you can see here, they're showing with the lower image at the bottom that with a chevron osteotomy, there's less of a cortical bridge to prevent screw cut out and therefore loss of correction of your bunionectomy with a chevron osteotomy compared to transverse osteotomy. Again, this paper didn't truly answer the question because it was not a comparative paper. But nonetheless, I would say the vast majority of us have moved to using a transverse osteotomy for our distal first metatarsal cut over the chevron. And so now we'll switch gears a little bit. I'll talk about some clinical pearls based on these papers. So first, with the transverse osteotomy, another benefit is that you can start mid-axial. And really with the transverse osteotomy, seeing nerve issues is really, really uncommon. Not that it was common in the prior paper using the MECA technique, given it was a low rate of 2.85%, but it's really rare to see nerve irritation when you start mid-axial. Again, starting dorsomedial, we know the nerve on dorsomedial with a chevron osteotomy, the nerve is certainly very close. With the transverse osteotomy, you can start mid-axial and just stay away from that nerve. And again, we all sleep better when patients don't have nerve pain. And on the right side here, this is what I do typically before every bunion is I just mark out the central mid-axial line of the first metatarsal. I don't necessarily draw out the entire metatarsal as shown here, but that's a great marker for not only where you're going to put your incision, but also where you'll place your proximal screws. It can also be used when using a jig to align the jig. Next, we'll discuss burr trajectory. So everyone should understand that the burr itself typically for the distal first metatarsal osteotomy is a two millimeter, give or take a few, or sorry, it can be 2.2 millimeters, two millimeters, but anyway, it's around two millimeters. And so there's a curve of two millimeters that you lose. So you're shortening the first ray by two millimeters. And as our goal always is to maintain length of the first ray. And so the tendency for surgeons doing these minimally invasive techniques is they tend to always angle distal. And that's the right thing to do, but you want to be careful to avoid angling too distal. The soft tissue can only stretch so far. And so the more distal you angle, the more you're going to lengthen the first ray as you shift the first metatarsal head lateral relative to the shaft. And so it can become very challenging to shift the head. When you've angled too distal, it can over tension the first ray, and this can lead to early development of first TMT or tarsal metatarsal joint instability, right? And obviously you want to avoid that. So what I use as my guide is I use the perpendicular line or a perpendicular line to the second metatarsal. And then I go about five to 10 degrees distal to that line. That seems to allow me to obtain a large shift without, I think, putting the first ray or risk for developing early first TMT instability. And so this is just showing that here on the right, you can see the head, the more I angle distal, the more it will translate distal. And then down below here, if I angle less, it'll translate distal less, and therefore I'll lengthen the first ray less. And this is just showing an example in the top right corner, you can see the patient with a moderate hallux valgus deformity. Maybe if I'm critical, there might be about a millimeter medial subluxation of the first TMT joint here pre-op, but you can see post-op after a large shift, which was about a hundred percent. And again, you can see the bony remodeling here, this is once it's healed, but there is some mild recurrence here. Again, you can see this, this is secondary to the subluxation or the instability down at the first tarsometatarsal joint. This next issue is probably one of the most important, if you're considering doing the PETA or META technique, minimally invasive bunionectomy is just your K-wire and therefore screw placement are just essential. And this is really important, number one, for the stability of this construct. So the reason older minimally invasive techniques really failed early and didn't have lasting outcomes is that, you know, they relied on minimal fixation constructs, K-wires alone. These newer techniques, it's a very stable construct, but the stability comes from the proximal screw, right? And so what I'm showing on the left image here is that your start point, number one, should be down at the base of the first metatarsal through your proximal wire. It should then exit the distal lateral cortex of the first metatarsal shaft at least eight to 10 centimeters from your osteotomy site. And what that does is that gives a very, or that leaves a very strong cortical bridge to maintain stability of the osteotomy and correction and allow early immediate weight bearing with this technique. Also by starting down the base of the first metatarsal with your proximal screw, you have a much better angle to capture as much of the first metatarsal head as possible and ride right up along that strong lateral cortex. Then my second wire is really, this is more for torsional control, the second screw. This will either straddle the osteotomy site as shown here on the left, or if it's a larger correction, a moderate or severe bunion, sometimes you can also be bicortical with that wire as well. But again, that's not essential for the distal wire. You can see there's a nice spread between the two wires. They can either be parallel or slightly divergent. And if you want extra points, then you can even diverge them on the sagittal view as shown on the right, but this is not essential for stability of the technique. What is essential is that your proximal wire enters at the base of the first metatarsal and exits the distal lateral cortex around a centimeter from the osteotomy site for stability of this construct. And that is just imperative. That is the reason that we see some, again, a small percentage of early loss of correction. And if you really focus on this, you should not see early loss of correction. And so this is just comparing and contrasting screw placements. So on the left, you can see more distal screw placement, not ideal. And the other challenge with that is then you can resect less of that medial spike at the distal medial first metatarsal. And so you won't be able to narrow the foot quite as much. Whereas on the right side, you can see this is ideal screw placement and you're able to really narrow the foot. It's a really nice correction. And this shows, this is a post-op follow-up, right? This is what loss of correction looks like typically. So you can see on the right image, the sagittal, you think, oh my gosh, that looks okay. But on the left AP image here, you can see there's clearly loss of correction. This is typically due to inadequate purchase of the bone or going too close to your site of your osteotomy with your proximal screw. And finally here, when we talk about, so if you look at the papers, right, the majority of them shows a pretty decent rate of screw removal, right? I mean, it range anywhere from 4% to as high as 15%. And so what I've found really helps to reduce the risk of screw removal is that number one, we've already mentioned that you should use a beveled or chamfered screw. But secondly, if it's an odd measurement for my screw length, when I'm measuring the guide wire, I'll take off five millimeters from that measurement for my actual screw length. And if it's an even measurement, I'll take off four millimeters for screw length. And I found that's really reduced the risk of needing to remove the screws. I think it's very uncommon in my own practice where I have to remove screws at this point. And it goes without saying that obviously you want to avoid leaving the screw tip within the joint. I will wig wag the foot internal and external on a lateral or sagittal, uh, for us we view just to ensure the wire tips are not within the joint. And this is one last quick plug, but this is a paper we did on, on using chilled saline or refrigerated saline versus room temperature saline. This wasn't directly a Hallux-Valgus model. It was a minimally invasive calcaneal osteotomy model, but again, it's using the same type of Shannon burr. Uh, and it showed that there was a significant temperature increase in room temperature saline versus chilled saline. As we know, you always want to avoid generating heat with these burrs because that can lead to skin burns or, or burning the bone, which can certainly lead to non-union. And we obviously want to avoid that at all costs. So everything I do is to avoid burning the bone, avoid generating heat. Uh, my staff will put chilled saline in the fridge on any day I'm operating. So we have it readily available. And once you do this once or twice, they know, uh, but this is a great way to reduce chance of, of heat generation during a procedure, uh, which can reduce risk of non-union. So in summary, I would consider, uh, Ketorolac, Acetaminophen, and Gabapentin as an opioid-free option for Hallux-Valgus surgery. In my own practice, I tend to just give patients with five, uh, uh, opiate tablets along with ibuprofen and Tylenol. Uh, screw irritation or, or, uh, uh, screw removal is the most frequent complication in, in minimally invasive Hallux-Valgus surgery. Definitely consider taking off four to five millimeters from your guide wire measurement, depending on whether it's an odd or even measurement. And you have to use a beveled screw that goes without saying there's plenty of those available on the market now. The third generation MICA or peak technique has a low recurrence rate in the medium term and is definitely an option for the moderate to severe Hallux-Valgus deformity. Most MI surgeons have really moved toward using the fourth generation MITA or PITA technique with a transverse distal first metatarsal osteotomy and then aching osteotomy. Again, I've found that the, the risk of screw cutout, I think is lower with this technique and that's anecdotal. Uh, we need to do, you know, uh, better biomechanical papers to test those two. And I think clinical paper, clinical comparative papers would be great at this point, but again, further, further literature is necessary. And finally, that proximal first metatarsal screw must be bicortical prior to entering the lateral first metatarsal head and ideally exits the distal lateral cortex of the first metatarsal eight to 10 millimeters from your osteotomy site. Again, thank you for your time. I've really enjoyed discussing what's new in Hallux-Valgus surgery, uh, over the past year or two years. Thank you.

Hallux Valgus surgery

Opioid-free protocol

Third-generation PICA

MICA technique

Screw placement

Transverse osteotomy