Interventional procedure overview of minimally invasive percutaneous surgical techniques with internal fixation for correcting hallux valgus

Alimy AR, Polzer H, Ocokoljic A et al. (2023) Does Minimally Invasive Surgery Provide Better Clinical or Radiographic Outcomes Than Open Surgery in the Treatment of Hallux Valgus Deformity? A Systematic Review and Meta-analysis. Clinical orthopaedics and related research. 481, 6, 1143-1155.

Systematic Review and Meta-analysis

7 studies (395 feet), consisting of 6 RCTs and 1prospective comparative study, were included.

MIS versus open surgery.

This meta-analysis found that hallux valgus treated with minimally invasive surgery did not result in improved clinical or radiologic outcomes compared with open surgery. Methodologic shortcomings of the studies in this meta-analysis likely inflated the apparent benefits of minimally invasive surgery, such that in reality it may be inferior to the traditional approach. 

Includes a variety of techniques, such as the Bosch and SERI osteotomy, mini-SCARF and MICA osteotomy.

Bia A, Guerra-Pinto F, Pereira BS et al. (2018) Percutaneous osteotomies in hallux valgus: a systematic review. J Foot Ankle Surg; 57:123–130.

Systematic review

n=18 studies (1534 procedures for percutaneous HV surgery on 1397 patients). 14 were level IV, 2 were level III, and 2 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%.

Different types of MIS -mainly those with temporary or no fixations were included in the analyses.

Boksh K, Qasim S, Khan K, Tomlinson C, Mangwani J. (2018) A Comparative Study of Mini-Scarf Versus Standard Scarf Osteotomy for Hallux Valgus Correction. J Foot Ankle Surg. 57(5):948-951. 

N=37

Prospective non-randomised study

16 mini-scarf versus traditional 21 scarf osteotomy 

12 weeks post-operative follow-up.

The medial sesamoid position had improved in all patients, with similar satisfaction between the 2 procedures (p = .43). The results of the present study have shown that the mini-scarf osteotomy for mild to moderate hallux valgus is as effective as the standard approach, with the potential benefit of a smaller scar and less soft tissue disruption.

Higher level evidence included in table 2.

Brogan K, Lindisfarne E, Akehurst H, et al. (2016) Minimally invasive and open distal chevron osteotomy for mild to moderate hallux valgus. Foot Ankle Int; 37:1197–1204.

Retrospective cohort study

N=81 feet

49 minimally invasive versus and 32 open distal chevron osteotomies.

Follow-up 24 months

Clinical and radiologic postoperative scores in all domains were substantially improved in both groups but there was no statistically significant difference in improvement of any domain between open and MIS groups. There were no significant differences in complications between the two groups.

Larger and higher quality studies included in table 2.

Brogan K, Voller T, Gee C et al. (2014) Third-generation minimally invasive correction of hallux valgus: technique and early outcomes. International Orthopaedics (SICOT) 38:2115–2121.

Case series

N=45 feet underwent a third-generation MIS distal chevron osteotomy

6 month follow-up

There were significant improvements in all three domains of the MOXFQ (p<0.001) There was also significant improvement in all radiographic parameters (p<0.001). Mean HVA decreased from 30.54° to 10.41°, and the mean IMA decreased from 14.55° to 7.11°. Shortening of the first metatarsal had no effect on clinical outcomes. There was a very low rate of complications.

Higher quality studies included in table 2.

Caravelli S, Mosca M, Massimi S et al. (2018) Percutaneous treatment of hallux valgus: What's the evidence? A systematic review. Musculoskelet Surg 102:111–117

Systematic review

4 papers, a total of 464 hallux valgus has been treated with a properly percutaneous distal first metatarsal osteotomy.

There are different aspects that the foot and ankle non-experienced surgeon must consider about percutaneous surgery: limitation of the tools, radio-exposure, lack of direct visual control of the osteotomy and higher costs and patient risk due to surgical time.

Different types of MIS -mainly those with temporary fixations were included in the analyses.

Castellini JLA, Grande Ratti MF, Gonzalez DL. (2022) Clinical and Radiographic Outcomes of Percutaneous Third-Generation Double First Metatarsal Osteotomy Combined With Closing-Wedge Proximal Phalangeal Osteotomy for Moderate and Severe Hallux Valgus. Foot & Ankle International 43(11) 1438–1449

Retrospective case series

N= 156 percutaneous double first metatarsal osteotomy (PEDO) and first phalanx osteotomy in 128 patients.

median follow-up was 22.6 months.

Clinical and radiographic parameters improved significantly, with a minimum of 12 months of follow-up in moderate and severe hallux valgus. The satisfaction rate was 97% in the total sample. Recurrence rate (HVA ≥20 degrees) was 7.7%. Hallux varus (HVA<0 degrees) occurred in 5.8%, acute osteomyelitis in 1.3%, partial avascular necrosis in 0.6%, screw removal in 0.6%, and reoperation in 1.9%. No non-union was observed.

Higher level evidence included in table 2.

Frigg A, Zaugg S, Maquieira G, Pellegrino A. (2019) Stiffness and range of motion after minimally invasive chevron-akin and open scarf-akin procedures. Foot Ankle Int. 40(5):515–25.

Prospective cohort (non-randomised, comparative) study

N=48 PECA versus 50 open Scarf Akin technique.

Follow-up 2 years.

MICA showed no advantages over scarf other than a shorter scar. The observed gain in extension could be related to the increased shortening of the first metatarsal because of the size of the burr.

Study included in systematic review added to table 2.

Lu J, Zhao H, Liang X et al. (2020) Comparison of Minimally Invasive and Traditionally Open Surgeries in Correction of Hallux Valgus: A Meta-Analysis. The journal of foot and ankle surgery. 59, 4, 801-806.

Meta-analysis

N=11 studies with 1166 patients treated with MIS and 1035 patients treated with traditionally open surgery.

The pooled data (OR 6.28, 95% CI 3.20 to 12.32, Z = 5.35, p < .01) indicated that patients treated with MIS had a significantly higher rate of excellent-good radiographic angular results than did patients treated with open surgery. However, the incidences of complications (OR 0.67, 95% CI 0.24 to 1.91, Z = 0.75, p = .45), recovery time (standard mean difference ‒3.09, 95% CI ‒7.98 to 1.80, Z = 1.24, p = .22), and patient-reported satisfaction (OR 2.76, 95% CI 0.72 to 10.65, Z = 1.48, p = .14) were similar between patients with hallux valgus treated with MIS and patients treated with open surgery.

Different types of MIS -mainly those with temporary fixations were included in the analyses.

Fukushi JI, Tanaka H, Nishiyama T et al (2022) Comparison of outcomes of different osteotomy sites for hallux valgus: A systematic review and meta-analysis. Journal of Orthopaedic Surgery 30(2) 1–8.

Systematic review and meta-analysis of RCTs.

N=10 studies with a total of 793 feet in the qualitative synthesis.

For the management of mild to moderate HV deformity, we found no significant clinical and radiological differences between patients treated with scarf and chevron osteotomies. Further controlled trials comparing different sites of osteotomies for moderate to severe HV deformity are needed.

Only one RCT with percutaneous technique included. All other studies are open/mini osteotomies.

Di Giorgio L, Touloupakis G, Simone S et al. (2013) The Endolog system for moderate-to-severe hallux valgus. Journal of Orthopaedic Surgery; 21(1):47-50.

Case series

N=25 patients underwent minimally invasive surgery using the Endolog system.

Mean follow-up 18.2 months.

The mean hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the proximal articular set angle (PASA) and the mean AOFAS score improved significantly after surgery (all p<0.0001). Periosteal reaction was noted by week 4, and callus formation after 3 months. There were no delayed or non-union or other complications.

Higher quality studies included in table 2.

Harrasser N, Hinterwimmer F, Baumbach SF et al. (2023) The distal metatarsal screw is not always necessary in third-generation MICA: a case-control study. Arch Orthop Trauma Surg.143(8):4633-4639.

Case control study

n=55 MICA procedures (50 patients with hallux valgus deformities) 22 with two screws (MICA2), 33 with one screw (MICA1)

12 months follow-up

Fixation of the first MTH with a single bicortical screw in MICA with moderate lateralization of MTH shows stable anchoring and good clinical results. The routine use of a second metatarsal screw can be omitted.

Variation of the MICA procedure

Holme TJ, Sivaloganathan SS, Patel B et al. (2020) Third-Generation Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus. Foot & Ankle International, 41(1) 50–56.

Case series

N=40 patients undergoing third-generation MICA

Follow up 12 months.

At 12 months, the MOXFQ score improved and the AOFAS score improved, with 70% of patients reporting excellent outcomes and 30% good ones. Hallux valgus angles improved from 32 degrees to 12 degrees, and intermetatarsal angles improved from 13 degrees to 7 degrees. There were 4 cases of Akin screw removal for soft tissue irritation. There were no other complications, including recurrence.

Higher quality studies included in table 2.

Jowett CRJ, Bedi HS. (2017) Preliminary Results and Learning Curve of the Minimally Invasive Chevron Akin Operation for Hallux Valgus. J Foot Ankle Surg. 56(3):445-452.

Case series

n=78 consecutive feet underwent minimally invasive Chevron Akin (MICA) for symptomatic hallux valgus.

Follow-up mean of 25 (range 18 to 38) months.

The mean AOFAS score improved from 56 preoperatively to 87 postoperatively (p < 0.001). The mean hallux valgus and intermetatarsal angles preoperatively were 29.7° and 14.0°. The postoperative angles were 10.3° and 7.6° (p < 0.001). The patients were satisfied in 87% of cases (92/106). The incidence of reoperation was 14% (15/106). They display a steep associated learning curve, and the learning curve is comparable to that for open hallux valgus surgery.

Learning curve

Higher level evidence included in table 2.

Karry LK-L, Siu-Wah K, Yuen-Hon C. (2015) Percutaneous Chevron Osteotomy in Treating Hallux Valgus: Hong Kong Experience and Mid-Term Results. Journal of Orthopaedics, Trauma and Rehabilitation 19 (1), 25-30.

Case series

N= 23 percutaneous chevron osteotomies with screw fixation in 20 patients.

Follow-up 18 months

At 18 months, the mean hallux valgus angle (HVA) was corrected from 31.68° to 14.39°, mean intermetatarsal angle (IMA) from 13.77° to 7.98° and mean American Orthopaedic Foot and Ankle Society (AOFAS) score from 59.26 to 88.35. There were 4 cases of medial plication stitch impingement and 4 cases with screw impingement but no other complications.

Higher quality studies included in table 2.

Lai MC, Rikhraj IS, Woo YL et al. (2018) Clinical and radiological outcomes comparing percutaneous chevron-akin osteotomies vs open scarf-akin osteotomies for hallux valgus. Foot Ankle Int; 39(3):311–7.

Retrospective analysis of prospective data.

29 feet had PECA and 58 feet had open Scarf Akin osteotomies.

Follow-up 24 months.

Both groups showed comparable clinical and radiological outcomes at 24 months. The percutaneous group demonstrated less pain and shorter length of operation. there were no complications in percutaneous group, but 3 wound complications were reported in the open group.

Higher quality studies included in table 2. Study included in systematic review added to table 2.

Lee M, Walsh J, Smith MM et al. (2017) Hallux valgus correction comparing percutaneous chevron/Akin (PECA) and open SCARF/Akin osteotomies. Foot Ankle Int; 38:838–846.

Prospective RCT

N=50

25percutaneous Chevron/Akin (PECA) versus 25 open SCARF/Akin osteotomies

Follow-up 6 months.

Both groups showed significantly improved clinical and radiological results. The PECA group showed significantly lower pain level (visual analogue scale) in the early postoperative phase. No serious complications were observed in either group.

Study included in systematic review added to table 2.

Lewis TL, Robinson PW, Ray R et al. (2023) The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus. The Journal of Foot & Ankle Surgery 62, 162−167.

Retrospective review of the first 58 consecutive PECA cases of a single surgeon.

Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p < .05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p > .05). In conclusion, the mean number of cases required to reach technical proficiency in third generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed.

Studies reporting similar outcome included in table 2.

Lewis TL, Ray R, Robinson P, Dearden PMC, Goff TJ, Watt C, Lam P. Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up. Foot Ankle Int. 2021 Oct;42(10):1231-1240.

Retrospective review of 50 patients (59 feet) with HVA >40 degrees or IMA >20 degrees had PECA.

Mean follow-up 3.1 years.

Mean postoperative MOXFQ index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA after surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%.

Studies with longer follow-up included in table 2.

Lewis TL, Ray R, Gordon DJ. (2022) Minimally invasive surgery for severe hallux valgus in 106 feet. Foot Ankle Surg. 28(4):503-509.

Case series

N=106 feet (78 patients) had MICA with screw fixation.

Follow-up 2 years

At 2 years follow-up, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%.

Studies with longer follow-up included in table 2.

Lewis TL, Ray R, Gordon DJ. (2002) Time to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery. Foot Ankle Surg. 28(7):928-934.

Case series

N=202 feet had third-generation MICA

Follow-up 2 years

Most of the PROM improvement with MICA is gained by 6 months post-operatively but further significant improvement can be seen up to 2 years. Those patients who have not improved at 6 months, are likely to do so with time.

Larger studies with longer follow-up included in table 2.

Liszka H, Gądek A. (2020) Percutaneous Transosseous Suture Fixation of the Akin Osteotomy and Minimally Invasive Chevron for Correction of Hallux Valgus. Foot Ankle Int. 241(9):1079-1091.

103 minimally invasive chevron (MIC) Akin osteotomies, with screw stabilization (group A, n=54), and percutaneous transosseous suture (group B, n=49).

Follow-up 1 year

The minimally invasive chevron osteotomy with transosseous suture stabilization of the Akin osteotomy was a safe method with good functional results that were comparable to the outcomes achieved when using screw fixation.

Variation of the procedure.

Lucas y, Hernandez J, Golanó P et al. (2016) Treatment of moderate hallux valgus by percutaneous, extra-articular reverse-L chevron (PERC) osteotomy. Bone Joint J; 98-B:365–373.

Prospective case series

N=38 patients who underwent 45 extraarticular reverse-L Chevron (PERC) osteotomies.

Mean follow-up of 59.1 months (45.9 to 75.2).

The AOFAS score increased from 62.5 (range, 30 to 80) preoperatively to 97.1. There was a statistically significant decrease in the hallux valgus angle and the intermetatarsal angle. With a mean preoperative hallux valgus and intermetatarsal angle of 26 degrees and 11 degrees, respectively, these patients presented mainly mild deformities.

Larger and higher quality studies included in table 2.

Miranda MAM, Martins C, Cortegana IM et al. (2021) Complications on Percutaneous Hallux Valgus Surgery: A Systematic Review. 60, 3, 548-554.

Systematic review

16 studies were included and 1157 procedures reported for percutaneous HV on 1246 patients.

The mean angle correction of HV deformity improved postoperatively. Reported complications vary among the studies. The highest complication rate was joint stiffness in 18.47% of cases, followed by HV recurrence and shortening of M1, both in 15.2%, material intolerance in 10.1%, osteoarthritic changes in 9.1%, infection in 7.6%, and transfer metatarsalgia in 5.4%.

different surgical approaches, and fixation devices used those with temporary fixation or no fixation were also included.

Malagelada F. Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques. Int Orthop 2018;43:625–637

Systematic review

N=23 studies 2279 procedures in 1762 patients

There is some evidence that Chevron and Akin showed the most potential for improvement of the HVA and the Endolog for the IMA. An overall complication rate of 13% was obtained among studies. Randomized controlled trials and long-term follow up are needed to assess the efficacy of MIS techniques.

Different surgical techniques assessed- Bosch, MIS Chevron-Akin, Reverdin-Isham, Endolog system, and techniques involving distal soft tissue release and fixation.

Maffulli N, Longo UG, Marinozzi A et al. (2011) Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review. Br Med Bull 97: 149-167.

Systematic review

Given the limitations of the case series, extensive clinical heterogeneity, it is not possible to determine clear recommendations regarding the systematic use of minimally invasive surgery for hallux valgus correction, even though preliminary results are encouraging. Studies of higher levels of evidence, concentrating on large adequately powered randomized trials, should be conducted.

Different MIS techniques were included.

Mikhail CM, Markowitz J, Di Lenarda L, Guzman J, Vulcano E. (2022) Clinical and Radiographic Outcomes of Percutaneous Chevron-Akin Osteotomies for the Correction of Hallux Valgus Deformity. Foot Ankle Int. 43(1):32-41.

Retrospective cohort study

N=248 patients (274 feet) had minimally invasive chevron-Akin (MICA).

Follow-up 12.9 months.

The mean preoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean Foot Function Index (FFI) score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2.

Higher level evidence included in table 2.

Neufeld SK, Dean D, Hussaini S. (2021) Outcomes and Surgical Strategies of Minimally Invasive Chevron/Akin Procedures. Foot Ankle Int. 42(6):676-688.

Retrospective analysis

treating surgeon's first 94 MICA procedures. Average patient follow-up was 11.2 months.

The MICA osteotomy was a safe and reproducible technique, associated with rapid improvement in pain scores, early weightbearing, and significant deformity correction. Complication rates and patient satisfaction scores were similar between the first and second half of patients (P > .05), suggesting the learning curve was not a factor.

Similar outcomes reported in studies added to table 2.

Palmanovich E, Ohana N, Atzmon R et al. (2020) MICA: A Learning Curve. The Journal of Foot and Ankle Surgery. 59 (4),

781-783

Case series

N= 50 patients using the minimally invasive Chevron and Akin procedure over the course of 3 years.

Results showed that surgery duration decreased from >2 hours in the first cases to a mean of 45 minutes in the third year. This learning curve plateaued by the 21st patient. The number of intraoperative fluoroscopy used decreased substantially over the first 27 surgeries, at which point the learning curve plateaued. In summary, it took about 27 procedures for an inexperienced surgeon to acquire the skill of performing minimally invasive Chevron and Akin osteotomy.

Larger studies included in table 2.

Palmanovich E, Ohana N, Tavdi A, et al. (2023) A modified minimally invasive osteotomy for hallux valgus enables reduction of malpositioned sesamoid bones. Arch Orthop Trauma Surg. 143(10):6105-6112.

N=53 patients

open chevron osteotomy (n = 19), minimally invasive V-shaped osteotomy (n = 18), and a modified straight minimally invasive osteotomy (n = 16).

Postoperative follow-up.

When compared to open chevron and V-shaped osteotomies, the modified osteotomy resulted in significantly lower postoperative sesamoid position scores (3.74 ± 1.48, 4.61 ± 1.09, and 1.44 ± 0.81, respectively, P < 0.001). Furthermore, the mean change in postoperative sesamoid position score was greater (p < 0.001).

Modified MIS osteotomy technique Higher level studies included in table 2.

Siddiqui NA, Mayer BE, Fink JN. (2021) Short-Term, Retrospective Radiographic Evaluation Comparing Pre- and Postoperative Measurements in the Chevron and Minimally Invasive Distal Metatarsal Osteotomy for Hallux Valgus Correction. The Journal of Foot & Ankle Surgery, 60 (6), 1144−1148.

Retrospective radiographic review of chevron (n=30) and MIDMO (n=31) osteotomies

Mean follow-up was 26.6 months for chevron and 18.7 months for MIDMO osteotomies.

Postsurgical retrospective radiographic review demonstrated chevron and MIDMO procedures provide comparable radiographic correction of IMA, HAA, and TSP.

Higher quality studies included in table 2.

Slullitel G, López V, Álvarez V et al. (2022) Refined Minimally Invasive Distal First Metatarsal Osteotomy for Moderate Hallux Valgus Treatment: The BC Procedure. J Foot Ankle Surg.61(5):1052-1055

Prospective case series

N= 63 patients who underwent the modified distal metatarsal osteotomy (DMO) BC technique for mild and moderate hallux valgus.

Mean follow-up was 36.5 (range 23.4-59.8) months.

The mean AOFAS score improved from a median of 47.4 points preoperatively to a median of 88 points postoperatively (p < .05). First MTPJ ROM did not change from preoperative period (mean 32.5°) to the postoperative period (mean 31.8°) (p > .65). All osteotomies went on to bony healing in the 6-week follow-up visit. Fifty-two (82%) of patients were either very satisfied or satisfied with the procedure (p < .05).

Higher level evidence included in table 2.

Singh MS, Khurana A, Kapoor D, et al. (2020) Minimally invasive vs open distal metatarsal osteotomy for hallux valgus - A systematic review and meta-analysis. J Clin Orthop Trauma. 11(3):348-356.

Systematic review and meta-analysis.

N= 9 studies were included.

Most available studies are either randomized control trials, or prospective cohort studies providing good level of evidence. Radiological analysis showed similar correction with both MIS and open osteotomies. In functional analysis results were different with open techniques providing better results in terms of AOFAS score. (p < 0.0001). VAS score and complication rate were similar in both groups.

Different MIS techniques were included in the analysis (Bosch, SERI/Krammer, mini scarf, percutaneous Chevron +Akin)

Toepfer A, Strässle M. (2022) 3rd generation MICA with the "K-wires-first technique" - a step-by-step instruction and preliminary results. BMC Musculoskelet Disord. 18;23(1):66.

Case series

N=50 consecutive MICAs in 47 patients were performed with the K-wires-first technique.

12 months follow-up.

There was one intraoperative conversion to an open surgical bunion correction corresponding to a 2% conversion rate respectively (1/50). On 3 feet (2 patients), removal of the Chevron screws was performed after 7, 9, and 12 months due to prominent and disturbing screw heads at the level of the medial cortex, accounting for a revision rate of 6% (3/50). The IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°, demonstrating MICA's high potential for correction.

Modified MICA technique

Toepfer A, Strassle M. (2022) The percutaneous learning curve of 3rd generation minimally-invasive Chevron and Akin osteotomy (MICA). Foot and Ankle Surgery 28 1389–1398.

Case series

N= first 50 consecutive MICA procedures with the "K-wires-First technique".

Although the learning curve of 3rd generation MICA is flat and requires specific training and intensive practice, the rate of complications is not elevated compared to other percutaneous hallux valgus techniques. The learning curve showed a continuous improvement regarding surgery time and use of fluoroscopy. After 40 procedures, the surgery time consistently dropped under 45 min and required less than 100 fluoro-shots. The modified surgical technique may help reduce Chevron screw mal-positioning when using large C-arm fluoroscopy for this procedure.

Learning curve

Studies reporting similar outcomes included in table 2.

Trnka HJ, Krenn S and Schuh R. (2013) Minimally invasive hallux valgus surgery: a critical review of the evidence. Int Orthop 37(9): 1731- 1735.

Systematic review

N=21 papers (1750 patients).

The majority of papers are level IV 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.

Different MIS techniques were included in the analysis.

Trnka HJ, (2021) Percutaneous, MIS and open hallux valgus surgery. EFORT Open Rev;6:432-438.

Review

Review distinguishes the first, second and third generation minimal incision surgery techniques and reports that minimally invasive and percutaneous hallux valgus correction lead to similar clinical and radiological results as the open chevron or SCARF osteotomies. Third generation minimally invasive Chevron osteotomies present similar clinical and radiological outcomes. Training is vital to avoid unnecessary complications and to minimize the surgeon's learning curve.

Review

Vernois J, Redfern DJ.(2016) Percutaneous surgery for severe hallux valgus. Foot Ankle Clin; 21:479–493.

Case series

N=100 feet treated with a percutaneous Chevron osteotomy.

Radiological analysis revealed a correction of the intermetatarsal angle from 14.5° to 5.5° at the last follow-up. The mean hallux valgus angle was corrected from 33.7° preoperatively to 7.3° at the last follow-up. Patient-reported satisfaction rate was 95% good/excellent results.

Higher level evidence included in table 2.

Yousaf A, Saleem J, Al-Hilfi L et al. (2023) Third‑Generation Minimally Invasive Chevron Akin Osteotomy for Hallux Valgus: Three‑Year Outcomes. Indian Journal of Orthopaedics. 57:1105–1111

Cohort study

N=33 patients underwent third-generation MICA surgery.

Follow-up 3 years.

Third-generation MICA demonstrates promising patient satisfaction scores post-operatively, and we have shown these improvements are sustained over a minimum three-year follow-up period.

Higher quality studies included in table 2.