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Is Minimal Incision First Ray Surgery A Viable Option?

PointTed Lai, DPM, FACFAS

Citing factors such as improved cosmesis, less soft tissue disruption, stable fixation and improved postoperative pain scores, this author contends that minimal incision first ray surgery is an excellent option in the properly selected patient. 

By Ted C. Lai, DPM, AACFAS

Over 100 different procedures have been described in the literature for correcting hallux valgus deformities. However, many of these procedures have fallen out of favor as techniques have evolved. Currently, the most common procedures involve correction via a distal metatarsal osteotomy due to the ease of use, reproducibility and predictable postoperative course. However, these procedures do have inherent drawbacks and complications. About 15 percent of patients who have open hallux valgus correction experience complications, including severe early postoperative pain, swelling, joint stiffness, delayed wound healing, infection and slow recovery.1,2 Many of these complications may be due to the dissection required to obtain correction of the deformity. 

Minimally invasive surgery (MIS) has become a flourishing topic of interest in foot and ankle surgery recently with an astounding focus on hallux valgus correction. Utilization of minimally invasive incisions have been correlated with less pain, less postoperative edema, better cosmesis and faster recovery.3-7 Accordingly, MIS has been on the forefront of addressing the well-known associated issues with traditional hallux valgus correction. 

Although it appears that MIS hallux valgus correction is the newest innovation to come to foot and ankle surgery, surgeons have been performing this surgery for several decades.8 However, over the years, the podiatric profession has seen a transformation and evolution from first-generation MIS bunionectomies (utilizing a closing wedge osteotomy with no fixation) and second-generation procedures (using a transverse osteotomy with axial Kirschner wire fixation) to  the current third-generation procedures that utilize a percutaneous chevron osteotomy with screw fixation. As the technique of MIS has evolved, researchers have noted successful outcomes.4-7

What The Literature Reveals About MIS Hallux Valgus Correction

As more studies have been published, MIS hallux valgus correction has shown equivalent functional outcomes in comparison to traditional open procedures. 

In a case series of 40 consecutive patients undergoing MIS chevron and Akin osteotomies, Holme and colleagues noted improvement of American Orthopaedic Foot and Ankle Society (AOFAS) scores from 48 to 93 with 70 percent excellent and 30 percent good outcomes as reported by patients.4 The study authors also cited improved intermetatarsal angles from an average of 13.2 degrees preoperatively to 6.7 degrees postoperatively, and noted no reoccurrence of deformity. Kaufmann and team reported similar outcomes with their randomized control trial comparing MIS chevron osteotomy and open chevron osteotomy.7 They found similar results in both groups with regard to pain via the visual analog scale (VAS), AOFAS forefoot scores and radiographic outcomes. However, a significant difference did exist with respect to higher patient satisfaction at 12 weeks postoperatively within the MIS group.7

Along with similar functional and radiographic outcomes recognized between MIS and traditional hallux valgus correction, a major difference in the literature is early postoperative pain. With the smaller incision and less dissection, researchers have reported significantly less postoperative pain and edema in MIS hallux valgus correction.5,6

In a prospective randomized study involving 50 patients that compared percutaneous chevron and Akin osteotomy to open scarf and Akin osteotomy, Lee and coworkers noted similar radiographic outcomes, similar patient satisfaction rates and no serious complications in either group.5 They did note that the percutaneous chevron-Akin osteotomy group had significantly lower pain as per the visual analogue scale from day one to week six in comparison to the scarf -Akin osteotomy group.

Lai and team compared percutaneous chevron-Akin osteotomies and scarf-Akin osteotomies in 58 feet, and displayed similar results with regard to radiographic and clinical outcomes.6 They did note that the percutaneous group experienced less pain postoperatively. They also noted no significant complications with the percutaneous group in comparison to the open group, which had three wound complications that required formal intervention. 

There are also emerging insights on correction of hallux valgus being three- dimensional as opposed to the traditional two-dimensional transverse plane correction concept. Studies have emphasized correction in the frontal plane by derotating the first metatarsal.9 Researchers have demonstrated that MIS hallux valgus repair affects correction of the intermetatarsal angle, the hallux valgus angle as well as correction in all three planes including the frontal plane. In a three-dimensional CT scan analysis of the first metatarsal in MIS distal metatarsal osteotomy, Seki and colleagues obtained 10.2 degrees of supination.10 They were able to quantitatively demonstrate that surgeons can obtain rotational correction with utilization of the MIS technique.

Reviewing The Advantages Of MIS Hallux Valgus Correction Over Traditional Correction

Minimally invasive hallux valgus correction involves utilizing small incisions on the medial aspect of the first metatarsal that usually range from four to six millimeters. The dissection is subperiosteal at the dorsal aspect of the first metatarsal. The lateral and plantar capsule are not traumatized or violated. Accordingly, there is no disruption of the plantar lateral vasculature. As we have learned from multiple cadaveric studies, the first metatarsal’s vascularity arises from the extraosseous supply from the first dorsal and plantar metatarsal arteries, the intraosseous blood supply from the nutrient artery, the periosteal vessels at the attachment of the MPJ capsule and capsular vessels that penetrate the metatarsal head.11  

One can preserve all of this with minimally invasive incisions in comparison to the traditional open procedures requiring extensive dissection. Avascular necrosis (AVN) of open distal metatarsal osteotomies is not a frequently reported complication. Nonetheless, aggressive dissection in an open procedure can lead to disruption of the capsule and vascularity, which in turn could lead to the development of avascular necrosis. 

Wilkinson and colleagues presented postoperative magnetic resonance imaging (MRI), which displayed avascular necrosis formation in 50 percent of patients who had Austin bunionectomies.12 On the contrary, Minokawa and team evaluated MIS distal metatarsal osteotomy vascularity by utilizing laser doppler flowmetry pre- and postoperatively.13 They found no change in both blood flow as well as systolic blood pressure to the metatarsal head. They were able to conclude that minimally invasive distal first metatarsal osteotomy has minimal effect on blood flow or the chance of development of avascular necrosis.13

Lack of disruption to the capsule also may lead to less postoperative edema, less joint stiffness and a faster recovery. For traditional open correction, surgeons can gain access to the first metatarsophalangeal joint with a capsulotomy, which may result in arthrofibrosis and scarring. Joint stiffness is common with traditional hallux valgus surgery and has been associated with poor patient satisfaction.14 Jones and coworkers reported that an average of 23 degrees of decreased motion of the first metatarsophalangeal joint following open hallux valgus correction can occur.15

Along with the consequences of capsular disruption, another complication that is associated with open correction is hallux varus development. Through my review of literature pertaining to MIS, there have been no reports of hallux varus following MIS hallux valgus correction. This may be due to the fact that MIS techniques do not involve altering the soft tissue structure to correct for capsular imbalance. More specifically, MIS does not involve aggressive medial capsulorrhaphy, excessive lateral release or staking of the medial metatarsal head, which are the usual culprits in the development of hallux varus. 

The MIS osteotomy is similar to many open procedures as they are both in a “V” or “L” configuration at the distal metatarsal. Performing this through percutaneous incisions is possible with a specialized power rotary burr, which is designed to perform at 6,000 rpm to prevent thermal necrosis or soft tissue damage. One can dial in lateral translation of the osteotomy to achieve appropriate correction and fixation of the deformity. In third-generation MIS hallux valgus correction, fixation has evolved from the use of axial pin fixation to the use of specifically designed headless cannulated screws that span the metatarsal shaft and osteotomy. Surgeons can create significant structural stability as well as compression with this fixation construct, further facilitating faster healing and recovery. 

Another advantage MIS provides is the idea of being able to address first ray pathology in patients in whom concern for incisional healing may be problematic. One may possibly utilize minimally invasive first ray correction in patients that are more prone to wound healing issues. Patients with controlled diabetes, rheumatological disorders, collagen disorders, tobacco use, a history of painful or keloid scarring, or any other patient who may have issues for incision site healing from traditional open first ray surgery could significantly benefit from MIS correction. Of course, appropriate patient selection is vital to successful outcomes and MIS does not enable you to perform corrective surgery in patients for which it is contraindicated. 

In Conclusion

My practice guidelines are patient- and deformity-dependent. I reserve the use of the MIS approach for hallux valgus deformities with mild to moderate increases in intermetatarsal angles and use the Lapidus procedure for severe intermetatarsal angles. In my practice, I also employ an MIS approach for hallux limitus deformities with good success. Each surgeon has his or her own preferences and guidelines for the use of MIS bunion correction. However, these guidelines have provided me with successful outcomes in performing such correction. With MIS bunion correction, there have been outcomes of less pain, resulting in less opioid consumption, less postoperative edema, faster recovery, decreased impact on range of motion and superior cosmesis.3-7

Hallux valgus deformity correction is constantly evolving to address the many different issues associated with treating this pathology. There is no single procedure that is the “correct” procedure for treatment of hallux valgus. The correct procedure depends on the patient and deformity as well as the procedure that is best executed by the surgeon in order to obtain the appropriate correction and overall patient satisfaction. With that being said, I believe from both the recent literature as well as from my own experience that MIS is not only a viable option but an exceptional option for first ray surgery.  n

Dr. Lai is a fellowship-trained foot and ankle surgeon with Shore Orthopaedic University Associates in Somers Point, New Jersey. He is an Associate of the American College of Foot and Ankle Surgeons. 

CounterpointJ.P. McAleer, DPM, FACFAS

Contending that minimal incision first ray surgery can result in incomplete correction and new bone deformity, and worsen both the anatomic and mechanical axis alignment of the first ray, this author advocates instead for restoring ray alignment in all three planes.

By J.P. McAleer, DPM, FACFAS

Minimal incision or minimally invasive surgery (MIS) are common terms used to describe the modification of traditional distal ray osteotomies and other surgical approaches to hallux valgus reduction through percutaneous and mini-open incisions. First performed by Gernet in 1836, this style of technique is currently making a dramatic resurgence with modern surgeons advocating the approach for mild, moderate and severe first ray misalignment. 

The popularity of MIS has some authors advocating the procedures for an intermetatarsal angle of up to 20 degrees with aggressive lateral surgical displacement of the distal metatarsal segment up to 90 percent.1 These techniques push anatomic boundaries, resulting in a mismatch of the anatomic and mechanical axes of the first ray, and severe permanent metatarsal disfigurement.2 The metatarsal head is left to heal teetering on a small proximal metatarsal bone segment. This surgically induced bone position would be considered completely unacceptable if one were repairing a traumatically induced fracture. 

These techniques create new and unpredictable compound deformities and fail to properly address the altered position of the first metatarsal at both the first tarsometatarsal joint (TMT) and MPJ. The new center of rotation of angulation (CORA) at the osteotomized metatarsal segment is synergistically influenced by the triplane instability and motion of the first ray at the first tarsometatarsal joint, cuneiform 1-2 (C1-2) and naviculocuneiform joints.3 The coupling of these altered axes can lead to unpredictable outcomes due to the complicated geometry, mechanics and vector forces at play. Additionally, the resultant iatrogenic malunited osseous translational deformity will likely prove extremely challenging for those surgeons who are left with the task of correcting the failures associated with these procedures in the future. 

What The Literature Reveals About Osteotomies And Triplanar Correction

Despite widespread use, osteotomies have been shown to be less effective in truly correcting the deformity than our traditional teaching would indicate. 

Some would say that osteotomy is an ineffectual and temporary method of relative hallux valgus reduction. Long-term outcome studies show a 30 percent radiographic recurrence rate (RRR) with the scarf procedure at 10 years, a 65 percent RRR following proximal opening wedge osteotomy at 2.4 years,  a 73 percent RRR after a distal chevron procedure at eight years along with  73 percent RRR and 78 percent RRR after scarf and chevron osteotomies respectively at 14 years.4-7 

In a recent retrospective study of scarf-Akin procedures on 71 feet, Tenenbaum and colleagues also showed the effectiveness of hallux valgus surgery to address foot width was very limited.8 Approximately one-half of the cohort showed a clinical decrease in soft tissue width but there was only a two percent decrease in patients who had the most significant preoperative foot widening clinically and radiographically. The remainder of the study population were found to have either an increase in foot width or failed to have any improvement at all following the aforementioned surgery.

Weber made note of how unrecognized transverse plane instability alone at the level of the midfoot can contribute to the failure of procedures involving first metatarsal osteotomies.9 Multiple authors have also found that feet with hallux valgus deformities had significantly greater mobility of the C1-2 joint in comparison to normal feet and it may be possible to further improve the surgical outcomes through arthrodesis.10-13 Therefore, MIS osteotomy alone will not address this issue.

In 2013, Dayton and colleagues published data describing the frontal plane as the “third plane of deformity,” having found a consistent valgus rotation and everted position of the first metatarsal in patients with hallux valgus.14 This concept has been echoed and supported throughout the peer-reviewed literature.15-19 Failure to address sesamoid subluxation and metatarsal rotation results in a 10-time and 12-time risk of hallux valgus recurrence respectively.20,21 Conversely, a study by Ray and coworkers showed a recurrence rate of 3.2 percent in their cohort undergoing hallux valgus triplane correction with tarsometatarsal arthrodesis over a 13.5-month period.22

MIS-based procedures cannot and do not fully correct all three planes at the anatomic apex as they are limited by the same geometric constraints as other traditional two-dimensional open osteotomies. The limitation of smaller incisions compounded by soft tissue interference may also further hinder the ability to address the deformity appropriately. This is best depicted in a prospective study by Kadakia, Smerek and Myerson, who evaluated radiographic outcomes of percutaneous metatarsal osteotomies.23 This study was abandoned three months after its initiation due to a high number of early postoperative complications. They found a 38 percent rate of recurrent hallux valgus, a 69 percent incidence of dorsal malunion and a near immediate loss of deformity correction when removing K-wire fixation from a MIS osteotomy. 

Even proponents of these techniques have reported issues with metatarsal malalignment such as the data reported by Magnan and colleagues showing 12 percent dorsal displacement and 49 percent plantar translation and angulation.1 Enan and colleagues also reported a 55.6 percent rate of dorsal or plantar malalignment using MIS techniques.24

What You Should Know About Other Potential Complications Of MIS

Other known complications of first ray MIS techniques include: 

• mechanical and thermal injuries producing iatrogenic nerve injury; 

• soft tissue necrosis and bone necrosis associated with high-speed burr use; 

• infections due to prolonged exposed K-wire placement;

• distal metatarsal segment displacement due to osteotomy instability and poor fixation resulting in malunion or nonunion;

• metatarsal shortening and overaggressive bone resection; 

• avascular necrosis of the metatarsal head due to disruption of blood supply; 

• deformity recurrence due to lack of complete correction;

• heterotopic bone formation; and

• first MPJ stiffness and epidermal inclusion cysts due to driving epithelial cells underneath the dermis with the instrumentation.25-27 

In their original paper, Markowski and team also reported a decrease of first MPJ range of motion in 31 percent of patients after a percutaneous neck osteotomy.28 

Other concerns with this technique arise due to the lack of restoration of first ray mechanics. Patients may complain of lesser metatarsal pain due to an overload of the lateral metatarsal parabola, which is associated with reduced first metatarsal head purchase upon weightbearing. First metatarsal osteotomies typically fail to improve this weightbearing imbalance due to the remaining inherent instability of the first tarsometarsal joint in patients with hallux valgus. 

Minimal incision techniques, such as the Reverdin-Isham osteotomy, promote a plantar pressure pattern in the foot that may significantly increase lesser metatarsal head pressure and do not promote or increase the mean pressure registered under the first metatarsal head and hallux.29 This is a significant problem in patients with chronic hallux valgus, who have developed destabilization of the second MPJ due to plantar plate injury, who have associated neuromas or may have previously developed stress fractures of the lesser metatarsals. 

One should not ignore proximal medial column functional instability as an etiology of hallux valgus as metatarsal osteotomies will not correct this pathological feature nor improve stability or resistance to recurrence. Traditional methods of hallux valgus reduction that fail to address unrecognized intercuneiform diastasis can result in an additive effect on the intermetatarsal angle (IMA) 1-2 and the magnitude of the deformity.13 

In a 2016 CT cadaveric model study evaluating the influence of the peroneus longus tendon on the foot under axial loading, Dullaert and colleagues raised concerns about persistent frontal plane rotational deformity and instability of the first metatarsal following hallux valgus correction without first tarsometatarsal arthrodesis.30 The striking finding when reviewing radiographs after MIS and other osteotomy repair is that the true intermetatarsal angle of the proximal first metatarsal is often much larger as it is forced open due to the abnormal segmental alignment and the persistence of the tarsometatarsal and intercuneiform functional instability. 

Final Thoughts

Conceptually, the MIS philosophy and tenets sound appealing as they dangle the promise of suitable surgical outcomes through a minimalistic approach, which should logically produce a rapid recovery with an early return to function. However, MIS results in an incomplete hallux valgus correction, creates a new level of bone deformity and makes the anatomic and mechanical axis alignment of the first ray worse. This coupled with a lack of direct anatomic visualization increases the risk of post-procedure complications. Magnan and team described MIS techniques as complex and upper-level with a rather long learning curve due to reduced surgical fields, difficult landmarks and the need for exact anatomic knowledge.1

Surgical correction of hallux valgus should be practical and reproducible. Why are we taking a straight metatarsal and making it crooked via an MIS or open osteotomy? Should we not be looking to realign the metatarsal at the tarsometatarsal and MPJ? Restoration of anatomic alignment in three dimensions seems to be a more logically sound approach regardless of incisional length. We should strive do what is best for our patients rather than what they perceive as a convenient lunch-hour surgery. We as surgeons need to shepherd them through the minefield of immediate gratification as their desire should not be allowed to interfere with appropriate procedure selection and sound biomechanical restoration.

Dr. McAleer is a shareholder partner with the Jefferson City Medical Group in Jefferson City, MO. He is on staff at SSM Health St. Mary’s Hospital in St. Louis and serves as the Vice Chief of Staff at the Jefferson City Medical Group (JCMG) Surgical Center. He is a Diplomate of the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons. 

Dr. McAleer has disclosed that he is a medical device consultant for Treace Medical Concepts, Inc., and a physician educator for Arthrex. Dr. McAleer would like to thank Paul Dayton, DPM, FACFAS for reviewing this article.

Features
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By Ted C. Lai, DPM, AACFAS and J.P. McAleer, DPM, FACFAS
References

Point

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Counterpoint

1. Magnan, B, Bondi M, Mezzari S, Bonetti I, Samaila E. Minimally invasive surgery of the forefoot: current concept review. Int J Clin Med. 2013;4(6):11-19.

2. Dayton PD, Feilmeier M, Lenz R. Clinical and surgical implications of first ray triplane deformity. In: Dayton PD, ed. Evidence-Based Bunion Surgery: A Critical Examination of Current and Emerging Concepts and Techniques. Switzerland: Springer International;2018:chapter 6. 

3. Roukis TS, Scherer PR, Anderson CF. Position of the first ray and motion of the first metatarsophalangeal joint. J Am Podiatr Med Assoc. 1996;86(11):538-546.

4. Bock P, Kluger R, Kristen KH, Mittlböck M, Schuh R, Trnka HJ.. The Scarf osteotomy with minimally  invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J Bone Joint Surg Am. 2015;97(15):1238-1245.

5. Iyer S, Demetracopoulos CA, Sofka CM, Ellis SJ. High rate of recurrence following proximal medial opening wedge osteotomy for correction of moderate hallux valgus. Foot Ankle Int. 2015;36(7):756-763.

6. Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Preoperative radiological factors correlated to long-term recurrence of hallux valgus following distal Chevron osteotomy. Foot Ankle Int. 2014;35(12):1262-1267. 

7. Jeuken RM, Schotanus MG, Kort NP, Deenik A, Jong B, Hendrickx RP. Long-term follow-up of a randomized controlled trial comparing Scarf to Chevron osteotomy in hallux valgus correction. Foot Ankle Int. 2016;37(7):687-695.

8. Tenenbaum SA, Herman A, Bruck N, Bariteau JT, Thein R, Coifman O.  Foot width changes following hallux valgus surgery. Foot Ankle Int. 2018;39(11) :1272–1277.

9. Weber AK, Hatch DJ, Jensen JL. Use of the first ray splay test to assess transverse plane instability before first metatarsocuneiform fusion. J Foot Ankle Surg. 2006;45(4):278-282.

10. Kimura T, Kubota M, Suzuki N, Hattori A, Marumo K. Comparison of intercuneiform 1-2 joint mobility between hallux valgus and normal feet using weightbearing computed tomography and 3-dimensional analysis. Foot Ankle Int. 2018;39(3):355-360.

11. Hansen ST Jr. Hallux valgus surgery. Morton and Lapidus were right! Clin Podiatr Med Surg. 1996;13(3):347-354. 

12. Roling BA, Christensen JC, Johnson CH. Biomechanics of the first ray. Part IV: the effect of selected medial column arthrodeses. A three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg. 2002;41(5):278-285.

13. Fleming JJ, Kwaadu KY, Brinkley JC, Ozuzu Y. Intraoperative evaluation of medial intercuneiform instability after Lapidus arthrodesis: intercuneiform hook test. J Foot Ankle Surg. 2015;54(3):464-472. 

14. Dayton PD, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux plane alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013;52(3):348-354.

15. Scranton PE Jr, Rutkowski R. Anatomic variations in the first ray: part II. Disorders of the sesamoids. Clin Orthop Relat Res. 1980;151:256-264. 

16. Talbot KD, Saltzman CL. Assessing sesamoid subluxation: how good is the AP radiograph? Foot Ankle Int. 1998;19(8):547–554.

17. Mortier JP, Bernard JL, Maestro M. Axial rotation of the first metatarsal head in a normal population and hallux valgus patients. Orthop Traumatol Surg Res. 2012;98(6):677-683. 

18. Dayton PD, Kauwe M, Feilmeier M. Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy. J Foot Ankle Surg. 2015;54(1):102-111.

19. Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee SY. A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. Foot Ankle Int. 2015;36(8):944–952.

20. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2009;91(7):1637-1645. 

21. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. The shape of the lateral edge of the first metatarsal head as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2007;89(10):2163-2172.

22. Ray JJ, Koay J, Dayton PD, Hatch DJ, Smith B, Santrock RD. Multicenter early radiographic outcomes of triplanar tarsometatarsal arthrodesis with early weightbearing. Foot Ankle Int. 2019;40(8):955-960.

23. Kadakia AR, Smerek JP, Myerson MS. Radiographic results after percutaneous distal metatarsal osteotomy for correction of hallux valgus deformity. Foot Ankle Int. 2007;28(3):355-360.

24. Enan A, Abo-Hegy M, Seif H. Early results of distal metatarsal osteotomy through minimally invasive approach for mild-to-moderate hallux valgus.  Acta Orthop Belg. 2010;76(4):526-535. 

25. Arauz JY. Treatment of minimally invasive hallux valgus surgery complications, techniques in foot and ankle surgery. Tech Foot Ankle Surg. 2017:16(1):11-19.

26. Solomon MG. Complications in minimal incision surgery. Clin Podiatr Med Surg. 1991 Jan;8(1):221-42.

27. Farrer AK, Forman WM, Boike AM. Epidermal inclusion cysts following minimal incision surgery. J Am Podiatr Med Assoc. 1992;82(10):537-541.

28. Markowski HP, Bosch P, Rannicher V. Surgical technique and preliminary results of percutaneous neck osteotomy of the first metatarsal for hallux valgus. Foot. 1991;2:93–98. 

29. Rodríguez-Reyes G, Lopez-Gavito E, Perez-Sanpablo AI, et al. Dynamic plantar pressure distribution after percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Rev Invest Clin. 2014;S1:79-84.

30. Dullaert K, Hagen J, Klos K, et al. Influence of the peroneus longus muscle on the foot under axial loading: a CT evaluated dynamic cadaveric model study. Clin Biomech. 2016;34:7-11.

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