Foot and Ankle Surgery 22 (2016) 248–253

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Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Percutaneous hallux valgus treatment: Unilaterally or bilaterally

Paulo Carvalho a,b,*, G. Viana a, M. Flora a, P. Emanuel a, P. Diniz c
a
Department of Orthopaedics and Trauma, Santana Hospital, Lisbon, Portugal 1- Chief of Foot & Ankle Surgery Department, Santana Hospital,
Lisbon, Portugal
b
Chief of Foot & Ankle Surgery Department, Santana Hospital, Lisbon, Portugal
c
Resident

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Currently there is no consensus regarding the use of bilateral simultaneous percutaneous
Received 8 February 2013 surgery for Hallux valgus treatment. Although the technique described in M. Prado’s book, recommends
Received in revised form 10 October 2015 operating only one foot at a time there are no published studies confirming it. The aim of this study was
Accepted 6 November 2015
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
Keywords: Hallux valgus correction.
Hallux valgus
Material/Methods: We did a retrospective single centre evaluation of 93 feet (61 patients) with Hallux
Percutaneous foot surgery
Bilateral or unilateral
valgus operated percutaneously. 29 patients were operated unilaterally (group I) and 32 bilaterally
Minimally invasive simultaneously (group II) between 2005 and 2009. The Metatarsophalangeal angle (MPA),
Reverdin-Isham osteotomy 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.
ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction comparing the outcomes of simultaneous bilateral versus unilat-

Minimally invasive hallux valgus techniques include arthros-
copy, percutaneous and mini- incision osteotomies. The percuta-
neous surgery is a minimally invasive technique that consists of
performing osteotomies, exostosectomies and soft tissues release
through mini-incisions (1–3 mm long), under intra-operative
fluoroscopy (Fig. 1), using a mini-blade and specific power rotatory
burrs. [1–4]. The stabilization is done with screws and/or with the
dressing and taping.
The technique described in M. De Prado’s book [1] recommends
operating only one foot at a time. Currently, there is no consensus
regarding the use of bilateral simultaneous percutaneous surgery
for the Hallux valgus correction. Limited research is available
* Corresponding author at: Az das Galhardas, 17, Torre C, 78[3_TD$IF]A, 1600-[1_TD$IF]097 Lisboa,
Portugal, Tel.: +351 912707484.
E-mail address: carvalho.paulo1@gmail.com (P. Carvalho).
eral foot surgery [5,6]. Furthermore, there are no published studies
evaluating this issue concerning percutaneous surgery.
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.
2. Material and methods
We retrospectively evaluated 93 feet, in 61 patients, operated
between December 2005 and March 2009 using percutaneous
surgery for mild to moderate Hallux valgus treatment. The patients
were operated in the same Hospital, 29 patients (group I)
unilaterally and 32 patients (group II) bilaterally at the same
surgical time, by three surgeons from the same foot and ankle unit.
All patients had symptomatic Hallux valgus with no response

http://dx.doi.org/10.1016/j.fas.2015.11.002
1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
[(Fig._1)TD$IG]
P. Carvalho et al. / Foot and Ankle Surgery 22 (2016) 248–253
Fig. 1. Procedure done under fluoroscopy.
toconservative treatment and there had been no previous
surgeries in any group. The criterion for operating one foot or
both was based on the existence of symptoms only one foot or
both, respectively and has been used since we started performing
the technique.
Both groups were similar in age and gender distribution. The
mean age was 61.5 (50–81 years) for group I and 58.7 (30–86
years) for group II. The gender distribution was 0 male (0%) and
29 females (100%) in group I and 2 male (6.2%) and 30 females
(93.8%) in group II. Some cases were operated percutaneously on
other pathologies at the same surgical time namely claw toes and/
or metatarsalgia – 8 cases (27.6%) in group I and 19 cases (29.7%) in
group II.
2.1. Surgical procedure
All patients were operated according to M. De Prado’s
algorithm, which has not been validated in the literature [1]. There
are 3 procedures that we have always performed: a distal
exostosectomy of the first metatarsal (M1) (Fig. 2), a Hallux
proximal phalanx (P1) Akin osteotomy [7] and a lateral soft tissue
release which includes an adductor hallucis tenotomy (Fig. 3). In
patients with distal metatarsal articular angle (DMAA) above 88
[8,9] a Reverdin-Isham osteotomy (Fig. 2, Fig. 4) was associated
[1,2,10,11] which was done after the exostectomy. The Akin and
Reverdin-Isham osteotomies have never been fixed. The patients
with an intermetarsal angle (IMA) of 168 or more were excluded of
this study because in this cases a proximal M1 osteotomy was
performed, always fixed with one or two screws [1,3]. We have
[(Fig._2)TD$IG]
249
Fig. 2. Exostosectomy and Reverdin-Isham osteotomy.
used standard percutaneous surgery material, specifically a
64 beaver mini-blade, an angulated rasp and a cylindrical 2 mm
Shannon1[2_TD$IF] burr for the osteotomies and a conical 4.1 mm Wedge1
burr (Fig. 5) for the exostosectomies, with an electrical microdrill
(Fig. 6), under fluoroscopy. After the surgery, the dressing was
made with gauzes, bandages and taping with a slight over-
correction, preventing hallux dorsiflexion (Fig. 7). The dressings
were changed between the 10th and 12th postoperative day and at
that time the stitches were removed and an orthotic toe spreader
(Fig. 8) was then put on to be used for 4 more weeks. The patients
used a flat sole full weight-bearing shoe (Fig. 9). A medial support
insole was also used during the first 6 to 8 weeks on flat feet
patients to avoid valgus of the forefoot, thus preventing
malalignment of the P1 osteotomy.
In patients with concomitant claw toe deformity, percutaneous
correction was done using a distal metaphyseal P1 osteotomy and
flexor and/or extensor tenotomies, ‘‘a la carte’’ according to the
deformity. In rare cases of distal claw deformity a P2 osteotomy
was performed. No implants were used. The stabilization was
made with the surgical dressing that was done in the same fashion
as for the hallux valgus correction. Adhesive taping was used for
3 to 4 weeks after removal of stitches in order to maintain the
alignment. Regarding patients complaining of metatarsalgia,
percutaneous oblique osteotomies in the distal metaphysis of
the second, third and fourth metatarsals were performed. No
fixation was made
[(Fig._3)TD$IG]
250 P. Carvalho et al. / Foot and Ankle Surgery 22 (2016) 248–253

Fig. 3. (a) Hallux valgus (b) Post-operative of distal exostosectomy of the first metatarsal, Hallux first phalanx Akin osteotomy and lateral soft tissue release.

2.2. Clinical evaluation capacity (maximum of 45 points) and Hallux realignment

The clinical evaluation was made by two independent
elements who did not take part on the surgical interventions.
The Hallux-Metatarsal-Interphalangical score from the Ameri-
can Orthopaedic Foot and Ankle Society (AOFAS) was used. This
score grades from 0 to 100, and focus on subjective and objective
criteria, such as pain (maximum of 40 points), functional
[(Fig._4)TD$IG]
(maximum of 15 points). Another evaluated issue was the
patients’ degree of satisfaction rated as very satisfied, satisfied
and not satisfied. All the complications were registered. A
recurrence of the deformity was established when the meta-
tarso-phalangeal angle (MPA) was superior to 208. Stiffness was
established when the global mobility of the metatarso-phalan-
geal (MTP) joint was inferior to 458.

Fig. 4. (a) Hallux valgus (b) Post-operative of Reverdin-Isham osteotomy.

[(Fig._5)TD$IG] [(Fig._7)TD$IG]
P. Carvalho et al. / Foot and Ankle Surgery 22 (2016) 248–253 251

Fig. 5. Shannon1 2,0 and Wedge1 4,1 burrs.

2.3. Radiological evaluation

The DMAA, MPA and the IMA were measured on the pre-
operative and on the last post-operative full weight-bearing x-rays.
[12]

2.4. Statistics

The statistical analysis of the results was based on the Student’s

t-test. It was evaluated whether there were statistically significant
differences between the two groups, regarding the correction of
the DMAA, MPA and IMA, the AOFAS score and the patientś degree
of satisfaction. For statistical relevance a 5% level (p < 0.05) was
chosen.

3. Results
Fig. 7. Dressing made with gauzes, bandages and taping with a slight
overcorrection, preventing hallux dorsiflexion.
The mean follow-up was 24.0 months (6–43) in group I, and
28.0 months (4–42) in group II. The average postoperative AOFAS Only minor complications were found. Hallux dysesthesias
score was 86.8 (29–100); 82.9 (29–100) in group I and 88.6 (40– were present in 1 case (3.4%) in group I and in 2 cases (3.1%) in
100) in group II (p > 0,05) (Table 1). 90.3% of the cases were group II. Stiffness was found in 2 cases (6.9%) in group I and in
satisfied or very satisfied – 90.6% in group I, and 89.7% in group II 1 case (1.6%) in group II. The recurrence of deformity was found on
(p > 0.05). (Table 1).
[(Fig._8)TD$IG] 9.4% and 10.3% respectively in group I and group II.
Radiological evaluation showed a significant correction of all
the three angles, similar in both groups There was no statistically
significant difference (p > 0,05) in the mean correction of MPA
(13.28 in group I and 14.88 in group II), DMAA (7.58 in group I and 88
in group II), and IMA (0.78 about in group I and 1.08 in group II)
(Table 2).

[(Fig._6)TD$IG]

Fig. 6. Handpiece. Fig. 8. Orthotic toe spreader.

[(Fig._9)TD$IG]
252 P. Carvalho et al. / Foot and Ankle Surgery 22 (2016) 248–253

Table 2
Metatarso-phalangeal angle (MPA), Intermetatarsal angle (IMA) and Distal
metatarsal articular angle (DMAA).

MPA Preoperative Postoperative Correction

Group I 32.5 19.4 13.2

Group II 34.1 19.2 14.8
p 0.43
Significance ns
IMA Preoperative Postoperative Correction
Group I 14.3 13.6 0.7
Group II 13.4 12.4 1.0
p 0.23
Significance ns
DMAA Preoperative Postoperative Correction
Group I 13.5 6.0 7.5
Group II 16.1 8.1 8.0
p 0.53
Significance ns

Fig. 9. Flat sole post-operative shoe. ns-non significant (p > 0.05).

We did not find any infection, pseudarthroses, Hallux varus or pathologies (Very satisfied and Satisfied – 92.9%, average AOFAS –
significant loss of reduction namely dorsal tilt of the metatarsal 85.2).
head. We didn’t find statistic significant differences between the
outcomes of patients who were operated only to one foot and those
4. Discussion operated on both feet simultaneously. The AOFAS score, the overall
satisfaction rate, the complications rate and the MPA, DMAA and IMA
Many studies have evaluated bilateral versus unilateral surgery correction were similar in both groups. These results are moreover, in
in large joints, but limited research is available comparing the agreement with other mini-incision techniques where bilateral
outcomes of bilateral foot surgery versus unilateral foot surgery surgery has already been described, with good results [13–15].
[5,6]. There are some articles about mini-incision distal osteo- The surgeries were performed by three surgeons, fact that may
tomies of M1, namely the Bosch technique [13] and the Magnan have introduced some bias. This study has only 2 years of follow-
osteotomy [14,15], advocating good results with bilateral surgery. up which could be insufficient to confirm the global results but is
However there is no consensus regarding simultaneous bilateral enough for the current study. It also shows the typical weaknesses
correction of mild to moderate Hallux valgus through distal of the retrospective studies. Prospective surveys are needed to
percutaneous surgery according to the M. De Prado algorithm. The confirm these outcomes.
original technique recommends operating only one foot at a time
[1], which seems to be the general opinion among most of the 5. Conclusion
surgeons performing it. However after reviewing the published
literature, the authors found no studies that assessed this specific The similar results obtained on both groups suggest that the
topic. simultaneous bilateral percutaneous surgery gives equivalent
The outcomes found in our study, namely the AOFAS score, the results to the unilateral, which has an important socioeconomic
patients’ satisfaction and the angles’ correction, were similar to impact since there is only one recovery time for both feet. Further
those found in other articles, either using percutaneous techniques research is needed.
[16–19] or open surgery [20–23].
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