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. 2024 Apr 14;16(6):1473–1479. doi: 10.1111/os.14056

A Joy‐Stick Assistant Three‐Dimensional Modified Technique of Minimally Invasive Surgery for Mild or Moderate Hallux Valgus

Xiang Geng 1, Zhaolin Teng 1, Li Chen 1, Chao Zhang 1, Jiazhang Huang 1, Xu Wang 1,✉, Xin Ma 1
PMCID: PMC11144513  PMID: 38616159

Abstract

Background

Minimally invasive surgery (MIS) such as minimally invasive chevron osteotomy and Akin osteotomy (MICA) has become popular in the treatment of hallux valgus. However, how to correct three‐dimensional deformities in hallux valgus effectively and simply in MICA is still difficult. Special equipment is required in MICA as has been reported before. It is meaningful and necessary to reduce the reliance on special equipment in MICA.

Methods

From January 2021 to July 2022, patients with mild or moderate hallux valgus were treated with a joy‐stick assistant three‐dimensional modified technique (Joy‐stick 3D technique) of MIS. VAS, AOFAS Hallux MTP‐IP scores, hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were measured pre‐ and postoperatively at the last follow‐up of at least 6 months. Scores and radiologic angles were compared using paired sample t‐test.

Results

A total of 36 cases were included. HVA, IMA, and DMAA were (22.3 ± 6.1)°, (14.0 ± 3.2)°, and (8.9 ± 3.2)° preoperatively, and decreased to (7.0 ± 1.8)°, (3.7 ± 1.0)°, and (3.3 ± 1.1)° postoperatively. VAS decreased from 4.3 ± 1.7 to 0.7 ± 0.7. AOFAS Hallux MTP‐IP scores improved from 68.6 ± 7.6 to 92.9 ± 6.1. Comparing mild and moderate cases, though HVA, IMA, and DMAA were significantly different preoperatively, the angles became statistically similar after surgery.

Conclusions

A joy‐stick assistant three‐dimensional modified technique is proposed to control the three‐dimensional position of the metatarsal head and to reduce dependence on special tools. Mild and moderate hallux valgus deformities are effectively corrected using Joy‐stick 3D technique.

Keywords: Forefoot Disorders, Hallux valgus, MICA, Minimally Invasive Surgery, Operative Technique

The paper describes a joy‐stick assistant three‐dimensional modified technique of minimally invasive surgery for hallux valgus. The series of X‐rays shows the surgical procedure and unique reduction of hallux valgus using towel forceps.

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Introduction

Hallux valgus (HV) is the most common forefoot deformity in old people, especially in women, and usually causes forefoot pain and limited mobility. The etiology remains unclear and previous studies have shown possible reasons: the degeneration of soft tissues, unbalance of muscles, and structural factors including various radiographic angles, metatarsal length, metatarsal head shape, sesamoid position, and so on. 1 , 2 , 3

For symptomatic HV, surgery is always the main solution after failed orthosis wearing. Over 150 procedures have been described for surgical treatment of HV. 4 In recent years, minimally invasive surgery (MIS) has become more and more popular due to aesthetics as well as shorter operative and recovery time. 5 Reverdin‐Isham procedure was the first generation of MIS for HV, and then was replaced by the second generation, represented by Bösch osteotomy and Magnan procedure. So far, the third generation of MIS including percutaneous double osteotomy and minimally invasive chevron osteotomy and Akin osteotomy (MICA) have been widespread in the minimally invasive treatment for HV. 5 Compared to open surgery, some studies believe that MIS can achieve equal and even better radiologic and clinical outcomes. 6 , 7 , 8 When MICA was applied in severe HV deformities, clinical and radiologic assessment showed significant improvement, but it was accompanied by more complications, such as hardware discomfort and recurrence. 9 Though the outcome is less satisfactory in severe HV deformities, MIS has been proved to be effective in mild and moderate deformities. 8 , 10

However, it takes more time for surgeons to master MIS techniques to correct deformities of HV safely and effectively. 11 It has been reported that the dorsomedial cutaneous nerve is most vulnerable in MIS for HV, surgeons need to have deep anatomical knowledge and meticulous surgical techniques to avoid neurovascular injury. 12 , 13 Moreover, how to correct multi‐directional deformities in HV in MICA remains difficult because of previous osteotomy design, limited operating space and instruments. The so‐called fourth generation of MIS has been raised to cover the shortage of MICA. 14 In addition, many special tools are invited and applied in MIS: micromotorized Lindermann bone cutter, 15 Internal Hallux Fixator, 16 bio‐absorbable pins, 17 and navigational device such as Pecaplasty and Prostep MICA SOLO. Therefore, how to accurately correct and maintain the three‐dimensional position of the metatarsal head during the operation requires further solution.

The purposes of this study are as follows: (i) to propose a modified novel technique for three‐dimensional correction of HV while reducing the dependence on special tools in MIS; (ii) to prove the effectiveness and safety of the technique by mid‐term follow‐up.

Methods

Details of Patients

Patients were included in this retrospective study between January 2021 and July 2022 when they met the following inclusion criteria: (1) surgery needs due to HV‐related complaints; (2) HV deformity was mild or moderate according to HV angle (HVA) measured by foot weight‐bearing anteroposterior (AP) X‐rays. Mild: 15° ≤ HVA < 20°; Moderate: 20° ≤ HVA≤40° 18 ; (3) follow‐up time is not less than 6 months.

The exclusion criteria were patients with: (1) recurrent operation; (2) history of foot trauma or surgery; (3) generalized joint laxity; (4) rheumatic diseases, foot neuropathy, vascular insufficiency or other diseases involving foot.

A total of 36 cases were included in this study. The average follow‐up time was 8.8 ± 2.3 months and the longest and shortest follow‐up time were 15 months and 6 months, respectively. The HVA, intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were (22.3 ± 6.1)°, (14.0 ± 3.2)°, and (8.9 ± 3.2)° before surgery (Table 1). There were 22 mild and 14 moderate HV cases in this study. The HVA, IMA, and DMAA were significantly different in mild and moderate cases preoperatively (Table 2). Ethical approval for this study was obtained from Ethical Review Committee of Huashan Hospital of Fudan University (Approval number 2020–053).

Table 1.

Comparison between preoperative and postoperative scores and radiologic angles in 36 hallux valgus cases.

Time HVA° IMA° DMAA° VAS AOFAS Hallux MTP‐IP score
Preoperative 22.3 ± 6.1 14.0 ± 3.2 8.9 ± 3.2 4.3 ± 1.7 68.6 ± 7.6
Postoperative 7.0 ± 1.8 3.7 ± 1.0 3.3 ± 1.1 0.7 ± 0.7 92.9 ± 6.1
P <0.001 <0.001 <0.001 <0.001 <0.001
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Abbreviations: DMAA, distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle; MTP‐IP, metatarsophalangeal‐interphalangeal; VAS, visual analogue scale.

Table 2.

Comparison of scores and radiologic angles between mild and moderate cases before and after surgery.

HV Grading HVA° IMA° DMAA° VAS AOFAS Hallux MTP‐IP score
Pre‐ Post‐ Pre‐ Post‐ Pre‐ Post‐ Pre‐ Post‐ Post‐ Post‐
Mild 18.0 ± 1.4 6.7 ± 1.7 12.2 ± 1.5 3.6 ± 0.9 6.9 ± 1.5 2.7 ± 0.7 4.3 ± 1.7 0.6 ± 0.7 71.3 ± 6.2 93.3 ± 6.4
Moderate 29.1 ± 4.0 7.4 ± 1.8 16.9 ± 3.2 4.0 ± 1.3 12.1 ± 2.7 4.3 ± 0.9 4.4 ± 1.7 0.8 ± 0.7 64.3 ± 7.8 92.3 ± 5.7
p <0.001 0.969 0.008 0.112 0.001 0.396 0.985 0.532 0.447 0.845
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Abbreviations: DMAA, distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle; MTP‐IP, metatarsophalangeal‐interphalangeal; VAS, visual analogue scale.

Surgical Procedure

Positioning and Preoperative Preparation

Patients under general anesthesia laid supine on an operation table, with a tourniquet placed on the root of the thigh. The foot is placed outside the operating table and on the C‐arm machine. Sterilize the operation side and protect C‐arm machine with a sterile sheath.

Channel Establishment for Metatarsal Screw

The entry point is 1 cm distal to the first metatarsocuneiform joint and 1 cm medial to the extensor hallucis longus tendon. Avoid the sentinel vein and dorsomedial cutaneous nerve when inserting the K‐wire. The K‐wire points to the direction between the I‐II metatarsal heads on AP view and is parallel to the first metatarsal on lateral view (Figure 1). The distal exit point is located 1 cm proximal to the metatarsal head–neck junction. Drill the channel for the cannulated screw along the K‐wire. The second K‐wire was inserted parallel to the first K‐wire and about 1 cm distal (depending on the diameter of the cannulated screw and the length of the first metatarsal). Pull out the K‐wires after drilling along it for cannulated screw.

Figure 1.

Figure 1

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The lateral view (A) and AP view (B) of guide pin for proximal screw channel. Channel was drilled along the K‐wire (C). The second K‐wire was inserted parallel to the first and about 1 cm ahead (D).

Distal Metatarsal Osteotomy

The osteotomy site is located at the metatarsal head–neck junction confirmed by C‐arm. Release the plantar and dorsal soft tissues with the nerve stripper. A Chevron osteotomy is performed with fissure bur. The orientation of the bur is designed preoperatively according to the characteristics of 3D deformities of HV and the length of the first metatarsal. Rinse continuously during osteotomy to cool down (Figure 2).

Figure 2.

Figure 2

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Locate the osteotomy site at the metatarsal head–neck junction, perform Chevron osteotomy with fissure bur, and rinse continuously during osteotomy.

Reduction of HV

A 1.2 mm K‐wire serving as a joy‐stick was transversely inserted into the metatarsal head slightly on the dorsal side (Figure 3). The surgeon clutched the proximal metatarsal shaft with towel forceps with one hand and controlled the metatarsal head through the K‐wire with the other hand. Move the metatarsal head to the lateral side and supinate the metatarsal head to reduce the sesamoids at the same time. Make the metatarsal head moderately varus to correct DMAA. Control the dorsal/plantar flexion of the metatarsal head to reconstruct the transverse arch. Thus, three‐dimensional reduction of HV can be completed. The lateral displacement was determined through AP view. The position of the sesamoids and DMAA in AP view were used to identify the rotation of metatarsal head in coronal and transverse plane (Figure 3). The displacement of metatarsal head in sagittal side was confirmed in lateral view (Figure 4).

Figure 3.

Figure 3

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A K‐wire was transversely inserted into the metatarsal head. The surgeon clutched the proximal metatarsal shaft with towel forceps and controlled the metatarsal head with the transverse K‐wire. The position of the metatarsal head was confirmed by fluroscopy.

Figure 4.

Figure 4

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Confirm the positions of wires on anteroposterior (AP) (A) and lateral (B) view. Insert screws along the wires (C).

Fixation

The surgeon controlled the towel forceps and the joy‐stick, and the assistant put the screw guide wires back in the channels. The AP and lateral position of the wires were confirmed by C‐arm again. Insert screws of suitable length and diameter along the guide wires (Figure 4).

Akin Osteotomy and Soft Tissue Release

Whether to perform Akin osteotomy was decided by surgeon according to the residual deformity after the osteotomy and reduction of metatarsal. Use a small lateral incision to release the lateral capsule, adductor pollicis tendon, and lateral suspensory ligament of sesamoid. 19 Tighten the medial capsule through the osteotomy incision. Finally, confirm shape and internal fixations again with C‐arm (Figure 5).

Figure 5.

Figure 5

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Positions of internal fixations and the shape of foot postoperatively.

Postoperative Protocol

The hallux was bandaged in a herringbone shape to maintain the position of the metatarsophalangeal join with small gauze placed between the hallux and second toe. On the second day after the operation, limited activities could be performed under forefoot decompression shoes. Sutures were removed at 14 days. Then rehabilitation exercises were suggested including active and passive exercise of toes three times a day. X‐ray was examined at 6 weeks. After confirming the healed bone, daily walking could be resumed.

Outcome Measures

Patients were instructed to follow up until at least 6 months after surgery. Patients were assessed using the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal‐Interphalangeal (AOFAS Hallux MTP‐IP) scores, as well as visual analogue scale (VAS), HVA, IMA, and DMAA were measured on AP X‐ray pre‐ and postoperatively at the last follow‐up examination (Figure 6).

Figure 6.

Figure 6

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Follow‐up data of another case at 6 months postoperatively.

Statistical Analysis

Statistical analysis was performed with SPSS (Version 23.0, SPSS Inc., USA). Scores and radiologic angles were compared using paired sample t‐test in pre‐ and postoperative comparisons. Independent t‐test was used in comparisons between mild and moderate cases. A p value less than 0.05 was considered statistically significant.

Results

Operation Time and Fluoroscopy Times

The operations usually ended within 30 to 50 min for each foot. During operation, 12 to 18 fluoroscopies were required.

Pre‐ and Postoperative Comparisons

The HVA, IMA, and DMAA were (22.3 ± 6.1)°, (14.0 ± 3.2)°, and (8.9 ± 3.2)° before surgery and decreased to (7.0 ± 1.8)°, (3.7 ± 1.0)°, and (3.3 ± 1.1)°, respectively, after surgery. VAS were 4.3 ± 1.7 before surgery and decreased to 0.7 ± 0.7 at the last follow‐up. AOFAS Hallux MTP‐IP scores were 68.6 ± 7.6 and improved to 92.9 ± 6.1 after surgery. Paired t‐test showed significances in HVA, IMA, DMAA, VAS, and AOFAS Hallux MTP‐IP scores pre‐ and postoperatively as shown in Table 1.

Comparisons between Mild and Moderate Cases

Though the HVA, IMA, and DMAA were different in mild and moderate cases preoperatively, there was no significant difference in the radiologic angles between mild and moderate deformities at the follow‐up of over 6 months (Table 2). VAS and AOFAS Hallux MTP‐IP scores were similar before and after surgery in two groups.

Discussion

In this retrospective study, patients with mild or moderate deformities of HV have benefited from the joy‐stick assistant three‐dimensional modified technique of MIS. The increased scores showed the improved function and remission of complaint, and the changes of measured angles proved the correction of HV.

Overview of Current MIS

The third generation of MIS for HV called MICA/PECA is now widespread. According to many retrospective and prospective studies, MICA is proven to be equivalently effective compared to open chevron or scarf osteotomy in the correction of mild and moderate HV deformities. 6 , 20 , 21 Even for severe HV, MICA can achieve good outcomes with few recurrences and complications. 22 , 23 MICA is also associated with earlier weightbearing and higher satisfaction.

Although MICA is accepted by doctors and patients, there are some obstacles to be overcome. First is that MICA requires a certain learning curve. 11 , 24 Second is how to accurately control the three‐dimensional position of the metatarsal head during the operation. Many surgeons actively improved the techniques and developed different special tools to assist the completion of the surgical process. 4

Advantages of Joy‐Stick 3D Technique and Soft Tissue Release

Thus, we developed Joy‐stick 3D technique to make MIS easier and quicker. No special equipment is required in our technique. The osteotomy line is located at metatarsal head–neck junction, outside the capsule of the first metatarsophalangeal joint, that not only ensures good lateral shift, but also increases the chances of healing of the cancellous bone surface. Additionally, the osteotomy line keeps the medial capsule intact allowing for good postoperative mobility. Surgeons can accurately and completely control the position of the metatarsal head: length, rotation, and plantar flexion, as well as the reduction of sesamoids and DMAA correction.

The follow‐up results of more than 6 months confirmed that the mild and moderate HV deformities were corrected and the scores were significantly improved, proving the effectiveness, safety, and feasibility of Joy‐stick 3D technique. In addition, we recommend soft tissue release in MIS for HV. 25 In HV deformity, the soft tissue is out of balance. Medial joint capsule of the metatarsophalangeal joint is pulled, resulting in a decrease in strength, while the structural contracture of the adductor hallucis muscle and its lateral combined tendon will lead to the development of HV. 26 The adduction and pronation of the first metatarsal head will lead to the displacement of the sesamoid complex and contracture of the sesamoid suspensory ligament. Therefore, soft tissue release will help reduction of the metatarsal‐sesamoid complex and decrease the risk of recurrence. 27 , 28 In MIS for HV, soft tissue release should be included as a routine part of treatment.

Comparisons in Terms of Operation Time and Angles

The operation time is 30–50 mins for each foot using the Joy‐stick 3D technique, which is obviously less than the average 58.7 mins reported in the literature. 29 After the surgeons reach the plateau phase of the learning curve, the time is usually between 40 and 50 mins as is reported. 29 The comparison confirms that the Joy‐stick 3D technique does not prolong the operation time. The simpler reduction after mastering the technique could help reduce the operation time. In terms of correcting the angles of HV, our results are not inferior to those reported before. 20 , 21 , 30

Surgical Tips

Preoperative examination of transverse arch is necessary. In the situation of collapsed transverse arch, the joy‐stick was suggested to be inserted slightly on the dorsal side so that the lateral and plantar displacement would be achieved together. The displacement would be adjusted precisely according to the fluoroscopy. The joy‐stick was inserted parallel to the metatarsal‐tarsal joint. After placing the joy‐stick perpendicular to the proximal part of first metatarsal, DMAA was corrected.

Limitations and Prospect of Clinical Application

Limitations of this study included a small sample size and no comparison with other surgical procedures. Joy‐stick 3D technique has not been used in patients with severe HV. A randomized control study should be carried out to compare this novel technique and traditional MICA not only in mild and moderate HV but also in severe HV. In addition, the follow‐up duration is not long enough to prove the long‐term efficacy of Joy‐stick 3D technique. Joy‐stick 3D technique has been proved to obtain good prognosis without requirement for special tools, which would help the further popularization of MIS for mild and moderate HV.

Conclusions

A joy‐stick assistant three‐dimensional modified technique is proposed for surgeons to control the 3D position of the metatarsal head, reduce the dependence on special tools. Joy‐stick 3D technique is effective in correcting mild and moderate HV deformities and improving prognosis according to our mid‐term follow‐up. We will make efforts to describe the learning curve as well as the long‐term radiological and functional outcomes of the technique in the future.

Conflict of Interest Statement

All authors declare no competing interests.

Ethics Statement

Ethical approval for this study was obtained from Ethical Review Committee of Huashan Hospital of Fudan University (Approval Number 2020‐053).

Authors Contribution

ZL Teng and X Geng contributed equally to the paper. ZL Teng and X Geng were responsible for follow‐up, statistics analysis, and paper writing; L Chen, C Zhang, and JZ Huang collected patients and contributed to the application of technique. X Wang proposed the modified technique and reviewed the paper. X Ma reviewed the paper and provided funding for the study.

Funding

The study was funded by National Natural Science Foundation of China (82172378), Ministry of Science and Technology of China (2022YFC2009501 & 2022YFC2009503), and Science and Technology Commission of Shanghai Municipality (21511102200).

Acknowledgements

None.

Xiang Geng and Zhaolin Teng contributed equally to this study.

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