Introduction:. The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital. Material and methods:. This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola. It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months. Results:. The average MOXFQ score was 26. Average improvement in the visual analogue pain score was 3.5. VAS deteriorated in three patients' whose pain got worse after surgery. Among these three, two had a further procedure on their toes. All of the patients experience prolonged forefoot swelling for at least 3 months. Discussion:. The most common complication after intra-articular ostetomy of the metatarsal head is stiffness of the metatarsophalangeal joint. We believe that using minimally invasive surgery with an extra-articular osteotomy, reduces the soft tissue injury to the joint, and therefore the amount of post-operative stiffness. In our cohort of patients, DMMO is associated with good patient satisfaction and low complication rates in the vast majority of cases

Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy. We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management. She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved. This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation. A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score. The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions. This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals. We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others. The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained. One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal

Aims. Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR. Methods. We conducted a retrospective review of 108 consecutive implants in 76 patients, between January 2005 and December 2016, with a minimum follow-up of two years. The mean age of the patients at the time of surgery was 61.6 years (42 to 84). There were 104 females and four males. Clinical, radiological, patient reported outcome measures (PROMS) data, a visual analogue score (VAS) for pain, and satisfaction scores were collected. Results. The survivorship at a mean follow-up of 5.3 years (2.1 to 14.1) was 97.2%. The mean Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) scores improved from 78.1 to 11.0, and VAS scores for pain from 7/10 to 1.3/10. The rate of satisfaction was 90.6%. Three implants (2.8%) required revision; one for infection, one-month postoperatively, and two for stem breakage at 10.4 and 13.3 years postoperatively. There was a 1.9% reoperation rate other than revision, 23.1% of patients developed a minor complication, and 21.1% of patients had non-progressive and asymptomatic cysts on radiological review. Conclusion. We report a 97.2% survivorship at a mean follow-up of 5.3 years with this implant. We did not find progressive osteolysis, as has been previously reported. These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage HR. Cite this article: Bone Joint J 2020;102-B(2):220–226

Introduction. Second ray problems are common, especially chronic MTP joint dislocation, and intractable metatarsalgia caused by a relatively long second ray we describe a new extra-articular technique that allows considerable shortening. Patients. We retrospectively reviewed 19 patients who underwent this type of osteotomy between 2006 and 2008. Mean age at operation was 62 years (43-78). All patients were. The indications for the operation were either MTP joint dislocation, or metatarsalgia caused by a relatively long metatarsal. This in turn was usually due to length lost on the first ray. Functional outcome was evaluated using the Manchester-Oxford foot and ankle score (MOXF), which is a validated outcome measure, the score being from zero to 64. A low numerical score indicates a good outcome. It assesses three main domains, walking, pain and social interaction. Range of motion, patient satisfaction and complication rates were also recorded. All patients had AP and lateral weight bearing radiographs. Results. At an average follow up of 20 months (5 -42) the mean total MOXF score was 17 (SD16). The metric scores for pain was15, walking 20 and social 15. Radiographically all patients showed sound bone. The majority of patients (16 of 19) reported that they are either ‘better’ or ‘much better’ following surgery, in terms of pain, function and quality of life. No patient developed transfer or recurrent metatarsalgia. No significant MTP joint stiffness was seen, and none of our patients developed osteonecrosis of the metatarsal head. Conclusion. Our new technique allows a planned, controlled shortening of the metatarsal with a stable fixation. The ‘long oblique’ osteotomy heals well, and is extra-articular. This avoids the joint stiffness which can follow the Weil osteotomy. We believe this technique makes a useful contribution to the surgical treatment of metatarsalgia and chronic MTP joint sublu

Introduction. Arthroplasty for treatment of end stage hallux rigidus is controversial. Arthrodesis remains the gold-standard, but this procedure is not without complications, with up to 10% non-union, 14% re-operation and 10% transfer metatarsalgia rates reported. The aim of this study was to analyse the outcome of the double-stemmed silastic implant (Wright-Medical) for end stage hallux rigidus. Method. We conducted a retrospective review of a consecutive series of 108 silastic 1. st. MTPJ implanted in our Unit (January 2005 – December 2016). Data was collected from our research databases, patient notes, PACS and PROMS. No patient was lost to follow-up. Results. Average age was 60.1 years (range 42–42 years; 104F; 4M). Results show a 98.1% survivorship at an average 5.1 years follow up (range 6 months-12 years). Average pre- and post-operative MOXFQ scores were 78.8/100 and 11.0/100 respectively and VAS scores improved from 7/10 to 1.3/10, with an average post-operative range of movement of 26.3°. Overall satisfaction rate was 90.6%. 2 patients (1.9%) required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years). There were 15 complications (13.9%) in the group, 5 lateral metatarsalgia, 7 patients stiffness and ongoing pain in the index joint occurred in 2.7%. There was a 20% incidence of radiological cyst formation or demarcation, but this was neither progressive, symptomatic, nor affected clinical outcome. Conclusions. The authors believe these results are superior to results of other published implants for hallux rigidus (BioPro and Cartiva). Additionally, these results do not confirm progressive osteolysis, previously reported for this implant in other series, as being a mechanism of failure. Finally, these results suggest the double stemmed silastic 1. st. MTPJ replacement provides a reliable alternative, with at least comparable outcomes, to that of fusion, for the treatment of end stage hallux rigidus

Introduction. Forefoot deformities are common in the rheumatoid population and lead to abnormal loading, plantar callosities and metatarsalgia. First MTP joint arthrodesis with lesser toe Stainsby procedures has become a popular method of reconstructing the rheumatoid forefoot but there is little data that reviews the clinical or biomechanical results of combining the two procedures. Materials & Methods. A prospective observational study was set up to review 10 rheumatoid patients (20 feet) undergoing bilateral first MTP joint arthrodesis via a medial approach with Stainsby procedures to all lesser toes via curved incisions with resection of two thirds of the proximal phalanx, repositioning of plantar fat pad, extensor to flexor interposition and temporary stabilisation with k wires. Clinical scoring and dynamic pedobarograph pressure measurements were taken pre operatively and at one year post surgery. Results. Nine female and one male patient with a mean age of 60.2 years were reviewed. Pre operatively there were 11 abnormal high pressure areas in 10 feet, reducing to 8 abnormal areas in 6 feet following surgery. Post operatively the mean pressure time integral increased under the first metatarsal and decreased under lesser metatarsals. Following surgery no patient suffered significantly from callosities or metatarsalgia and AOFAS scores improved. Conclusion. The post operative pressure time integrals suggest the medial weightbearing column is recreated with a reduction of abnormal pressures under the lesser metatarsal heads. These results show that first MTP joint arthrodesis with lesser toe Stainsby procedures reduces the number of abnormal high pressure areas under the forefoot and should be considered for deformity correction in the rheumatoid forefoot

Introduction. Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal. Methods. 36 lengthening scarf osteotomies were undertaken in 31 patients. Clinical (AOFAS and SF12 scores) and radiographic measures (IMA, HVA) were taken pre- and post-operatively. The maximum theoretical lengthening was 10mm, to prevent first MTP joint stiffness post-operatively. The actual lengthening was determined and measured intra-operatively. Results. There were 28 female and three male patients, with mean age at presentation 53.4 years. The mean follow-up was 3.9 years. Four cases were lost to follow-up. The mean first metatarsal lengthening achieved was 4.9mm (range 1–8mm). All of the osteotomies united without complication. The mean IMA reduction was 4.0° (p<0.001) and HVA 13.0° (p<0.001). The mean AOFAS score increase was 33.8 (p<0.001). There was no correlation between change in IMA and AOFAS score (r=−0.13) or between improvement in HVA and AOFAS score (r=−0.02). There was a positive trend but no correlation (r=0.28) between amount of metatarsal lengthening and change in AOFAS score. The inter- and intra-observer correlation was excellent. The SF12 physical sub-domains improved more than the mental sub-domains. Conclusion. We describe the largest series of lengthening scarf osteotomies for recurrent hallux valgus and symptomatic iatrogenic first brachymetatarsia. The significant improvement in both clinical and radiographical measures suggests the procedure is successful, with a low complication rate. Lengthening did not reduce the MTPJ range of movement. We hypothesise that restoring both the length and alignment enables greater weight-bearing under the first metatarsal head, reducing biomechanical transfer metatarsalgia

Aims

The Manchester-Oxford Foot Questionnaire (MOxFQ) is an anatomically specific patient-reported outcome measure (PROM) currently used to assess a wide variety of foot and ankle pathology. It consists of 16 items across three subscales measuring distinct but related traits: walking/standing ability, pain, and social interaction. It is the most used foot and ankle PROM in the UK. Initial MOxFQ validation involved analysis of 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual’s response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ.

Freiberg's Infraction; osteonecrosis of the metatarsal head, is the fourth most common intra-articular osteonecrosis in the body. Surgical intervention is usually reserved for late stage of the disease process (III-V) or failure of conservative management. We evaluated the outcomes of patients treated with primary Interpositional Arthroplasty technique using periosteum and fat for adequate surfacing and as a spacer for Freiberg's Disease. Twenty-three cases (21 patients) were performed from February 2009 – March 2016 (18 women, 5 men). Mean age at surgery was 51.1 years (range 19 – 70.5 years) with 91% affecting the second metatarsal. Twenty-one cases were primary and two cases were revision. Five cases were stage III, 10 were in stage IV and 8 were stage V. All patients underwent Interpositional Arthroplasty using periosteum and fat graft from affected metatarsal inserted as joint spacer and secured with sutures. Patients were followed up by postal questionnaires using two validated questionnaires; MOXFQ and AOFAS. Mean follow-up was 3.7 years (0.6 – 7.6 years). Paired two-tailed student t tests were used to assess clinical significance. The left and right foot was affected in 12 and 11 cases respectively. There were no postoperative infections, non-unions or transfer metatarsalgia. Surgery allowed 8 patients to wear normal footwear, 9 wearing fashion shoes, 5 wearing dress shoes and 5 patients returned to sporting activities. Mean pre-operative and post-operative VAS pain scores were 6.7 (range 4–10) and 3.2 (range 0–0) (p< 0.05). Mean peri-operative AOFAS scores were 43.8 (range 14–14) and 71.3 (range 10–10) (p< 0.05). Mean peri-operative MOXFQ scores were 62.9 (range 23–23) and 31.8 (range 0–0) (p< 0.05). We recommend our novel Interpositional Arthroplasty using periosteum and fat spacer for late stage Freiberg's disease as it can result in significant improvement in pain, prevents donor site morbidity and produces significant functional improvement and patient satisfaction

Aim. To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1. st. metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus. Methods. We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes. Results. 2 patients required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years 1 month). 5 patients reported lateral metatarsalgia, 2 patients reported neuropathic pain, 6 patients developed superficial infection which fully responded to oral antibiotics, and 1 patient developed interphalangeal joint pain. 2 patients died in the cohort. Pre-operative mean MOXFQ was 44, mean EQ5D Index was 0.564 and VAS was 6.97. At mean follow-up of 5.3 years, the mean MOXFQ was 12.7 (0–57), the mean EQ5D Index was 0.851 (−0.02–1) and the mean VAS was 1.67 (0–8). The mean range of motion was 35° (30° dorsiflexion and 5° plantarflexion). The overall satisfaction rate was 90.2%. The implant survival rate was 97.6%. Conclusions. The silastic big toe arthroplasty offers excellent clinical mid term survival and functional outcomes and could be considered as an attractive alternative to traditional fusion for end stage hallux rigidus

Aims

The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

One of the complications of hallux valgus surgery is shortening of the first metatarsal and this becomes particularly symptomatic in patients with a pre existing short metatarsal (Morton's foot or Greek foot). Initial treatment consists of appropriate insoles which incorporate not only relief of pain due to pressure metatarsalgia under the lesser metatarsal heads but also a Morton type extension under the big toe. Insoles with metatarsal relief are, however, not always well tolerated and surgery becomes necessary. The options are to shorten the lesser metatarsal heads or lengthen the previously shortened first metatarsal. Arthrodesis of the great toe metatarso-phalangeal joint can provide functional length to the first metatarsal. We have achieved good results in lengthening of the first metatarsal and believe that it is a safe option which avoids trauma to the lesser metatarso-phalangeal joints. The technique is presented and depends on whether there is a residual hallux valgus or whether the toe is well aligned. The operation should address the plane of the deformity and reverse the cause of the lengthening. Emphasis should however be placed in not getting the complication in the first instance and the incidence of the problematic short first metatarsal has significantly reduced since the decrease in popularity of the Wilson osteotomy

Background. The Weil osteotomy is successful in the management of metatarsalgia and toe deformity. The aim is to achieve controlled shortening whilst avoiding plantarflexion. Recognised complications of the Weil osteotomy include a ‘floating toe’ in up to 20% or more of cases. Aim. Can modification of the Weil osteotomy avoid the metatarsal head plantarflexion and subsequent dorsal subluxation of the interosseous muscle that is implicated in the development of a ‘floating toe’. Methodology. The 2nd, 3rd and 4th rays were dissected out en bloc with all tendons attached from 6 pairs of fresh frozen cadavers. The ray was fixed to a board and the tendons physiologically balanced via low-friction pulleys and light weights. This model is highly sensitive to alterations in moment arm of the tendons. Once the MTP joint was balanced these weights were not altered. After standard release of the dorsal capsule a Maceira or ‘triple-cut’ osteotomy was performed. This osteotomy was developed in order to permit shortening without plantar flexion of the metatarsal head. The osteotomy was performed using a image intensifier in order to maintain uniformity of the osteotomy cut. The neck was shortened by removing a 2mm slice of bone made with parallel cuts. The ray was photographed and x-rayed pre and post ‘surgery’ and the relationships of the interosseous tendon andcentre of rotation of the metatarsal head, tendon balance and toe posture were recorded. Results. The Maceira osteotomy can avoid plantarflexion of the metatarsal head The line of pull of the interosseous tendon can maintains it's normal relationship with the centre of rotation of the metatarsal head. None of the toes developed dorsiflexion. In fact, plantarflexion at the MTP joint could be seen. PIP ‘fusion’ resulted in dorsiflexion at the MTP joint in some toes

Introduction. Freiberg's disease is an uncommon condition of anterior metatarsalgia that involves the head of metatarsals. Avascular necrosis of the metatarsal head is thought to arise during puberty. Treatment is usually conservative and operative treatment reserved for cases that do not respond to these measures. Materials and Methods. We retrospectively reviewed a consecutive series of ten patients who presented to our institution who did not respond to conservative methods. These patients were treated surgically with a previously undescribed operative technique involving microfracture of the metatarsal heads and reattachment of the cartilage flap. Results. Mean follow up was 49 post operative months (18–96). Mean pain score at rest and on mobilising was 2.1 (0–3) and 3.1 (0–5) respectively. At 6 months, all 10 patients had reported a satisfactory outcome and return to acceptable activity levels. Discussion. The aim of the treatment for late stage Freiberg's disease is to relieve pain and improve the mobility of the patient by restoring the metatarsophalangeal joint function. Other techniques described involve osteotomies or minimal resection of the base of the proximal phalanx and insertion of metallic spacers which are removed several weeks later. However none has shown to be significantly superior to another. All of our patients reported a significant reduction of pain in their feet and all were able to walk and run almost pain free. There were no reported cases of severe restriction of movement or fixed deformity of the toe. Conclusion. This technique involves a single operative procedure that encourages metatarsal head remodelling and restoration of the joint articular surface. It is advantageous as we have seen remodelling of the metatarsal heads without causing shortening or other anatomical abnormalities in the area

We performed distal chevron osteotomy of the second, third, or fourth metatarsal for painful plantar callosities in 19 non-rheumatoid patients (16 women, 3 men; 21 feet); their mean age was 59 years (32 to 85). The mean follow-up was four years (2 to 7). The overall results were good in 16 feet, fair in two, and poor in three, with four patients still having painful plantar callosities. There was union in all feet, but transfer metatarsalgia developed in three and three required an orthosis. Distal chevron osteotomy for intractable plantar callosities was successful both clinically and radiologically in most patients

Method. A questionnaire was given to delegates at the British Orthopaedic Foot & Ankle Society (BOFAS) annual scientific meeting 3rd–5th November 2010. A total of 75 questionnaires were included within the analysis. The questionnaire asked delegates for their most commonly performed procedure for a variety of common foot and ankle conditions. Results. Which procedure do you most commonly perform?. Hallux valgus mild;. Chevron 60.0%. Scarf 28.0%. Hallux Valgus Moderate;. Scarf 85.3%. Chevron 12.0%. Hallux Valgus Severe;. Scarf 65.3%. Basal Osteotomy 29.3%. 1st MTPJ OA Fusion;. crossed screws 54.7%. Plate 26.7%. Lesser toe Metatarsalgia;. Weil 48.6%. BRT 22.8%. Hammer second toe;. PIPJ Fusion 62.7%. Oxford Procedure 15%. Tib Post stage 1;. Debridement 60.0%. Conservative 24.0%. Tib Post stage 2;. FDL Transfer 76.0%. Calc. osteotomy 78.7%. Achilles tendon rupture. Open Repair 61.5%. Percutaneous 13.8%. In delegates' normal practice they would fuse an osteoarthritic ankle 90% and perform a Total Ankle replacement 10% of the time. The method of fusion is split 50/50 between arthroscopic and open. Regarding the anaesthetic used for forefoot surgery most are using GA + Regional Block (mean 60%) only occasionally using regional anaesthesia alone (mean 8%). Only 12.3% of delegates have tried minimally invasive [forefoot] surgery (MIS), 17.3% of delegates think they will do more MIS in the future. The practice of British orthopaedic foot and ankle surgeons is broadly in line with an evidence-based approach. Knowledge of current practice may help trainees make sense of the myriad foot and ankle operations described in the literature

Background. Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem. Methods. Between 2002 and 2009 our department performed 21, 1st MTPJ arthrodeses using a tri-cortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores which were collected prospectively. We analysed the following parameters: time to radiological, requirement for further surgery, lengthening of 1st ray and any post operative complications. Results. Patient Demographics – Male: Female = 4:16. Mean age – 58 years (38-78 years). Mean follow up – 35 months (4-94 months). Indication for surgery –. Failed arthroplasty 8. Failed fusion 9. Previous Keller's 1. Failed Scarfe Osteotomy 1. Avascular Necrosis 2. Total 21. Arthrodesis achieved – 18 patients (90%) at 4 months post surgery (2-12 months). Mean AOFAS – 45 pre op, 75 post op. Lengthening of 1st Ray achieved – 6 mm average (5mm – 10mm). Complications – 7 (35%). Major – 3 (15%) – 2 non s, 1 varus overcorrection. Minor – 4 (20%) – 2 superficial infection, 2 painful hardware. Conclusions. Using interposition arthrodesis for the salvage of 1st MTPJ surgery we can achieve in 90% of patients. However, the rate of complications is not low and hardware often causes irritation, requiring removal

Introduction. We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for hallux valgus correction. This technique adheres to the same principles as open surgical correction but is performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals. Methods. All patients undergoing minimally invasive hallux valgus correction between November 2009 and April 2010 were included in this study and were subject to prospective clinical and radiological review. Patients were scored using the Kitaoka score as well as radiological review and patient satisfaction survey. Surgery was performed under general anaesthetic and included distal soft tissue release, Chevron and Akin osteotomies, with the same indications as for open surgery. All osteotomies were internally fixed with cannulated compression screws. Results. 83 operations were performed on 70 patients (2 male 65 female, mean age 54 years (27-78)). The pre-operative mean HVA was 34° and IMA 14°. Post-operative mean HVA was 9° and IMA 9.5°. Kitaoka score improved significantly at 3-12 months follow-up. There were no delayed or non- s and no osteonecrosis. Six M1 osteotomies moved during the postoperative period (3 feet (2 patients) required further surgery + 3 incomplete corrections without need for further surgery) and the fixation technique was successfully modified to avoid this problem. Mild transfer metatarsalgia was observed in 4 patients. There were 2 superficial wound infections. Cutaneous nerve injuries were noted in 3 feet but none painful. No recurrent deformities observed to date. Overall, 65% patients very satisfied, 29% satisfied, 6% unsatisfied. Discussion. This study suggests that good results can be obtained in forefoot surgery with the MICA technique. We believe this technique may offer advantages for some patients in terms of reduced morbidity and cosmesis. A randomized study is in progress to compare open and minimally invasive techniques