Most procedures involving bone that exist for hallux valgus correction may be divided in two major subgroups: proximal osteotomies and distal osteotomies.¹ Historically, proximal osteotomies were used for correction of major deformities where the 1-2 intermetatarsal angle (IMA) is greater than 15 to 20 degrees, while distal metatarsal osteotomies have been indicated in cases of mild to moderate deformity with an IMA as large as 15 to 20 degrees.¹ The versatility and reliability of the distal osteotomies has led to a wider application of these procedures. Distal osteotomies are capable of correcting all the altered parameters typical of hallux valgus, such as hallux valgus angle (HVA), IMA, distal metatarsal articular angle (DMAA), and to derotate the metatarsal head in order to address the pronation of the hallux, or to reduce concomitant stiffness by shortening the first metatarsal.^{2, 3, 4, 5, 6, 7, 8, 9, 10}

Current trends for distal osteotomies are to perform them through smaller operative wounds, with less tissue damage and shorter operative times; all to achieve more rapid recovery.^{2, 11}

Less invasive techniques were pioneered by New, who in 1983 described a percutaneous technique for the correction of hallux valgus (personal communication). This technique was popularized by Bösch¹² by using an osteotomy similar to Hohmann’s,¹³ but with single Kirschner wire (K-wire) fixation as previously described by Lamprecht and Kramer.¹⁴ This percutaneous technique led to a substantial decrease in surgical trauma, since no soft tissue procedure is required. Aspects considered disadvantages of the procedure include the need for a C-arm, since direct visualization is not obtained as well as the use of a power burr, which inevitably produces a slight shortening of the metatarsal, due to the thickness of the tool. Nevertheless these have been used with satisfactory results.¹¹

The minimally invasive hallux valgus correction SERI (Simple Effective Rapid Inexpensive)² is not a new technique because it uses an osteotomy and a stabilization method already described. The transverse osteotomy is made immediately proximal to the metatarsal head, as described by Hohmann,¹³ Wilson,¹⁵ and Magerl.¹⁴ This is performed through a small incision that need to be no larger than 1 cm, as suggested by Kramer¹⁶ and by Bösch.¹² There is no need for a tangential resection of the prominence or open lateral release, since manual stretching of the abductor tendon is usually sufficient to obtain HV angle correction. Obviation of these steps substantially reduces the amount of time necessary to perform it. Its high efficacy derives from the unique combined characteristics of simplicity, versatility, and good stability of the construct all while being minimally invasive.^{2, 17} Finally it is inexpensive due to the reduced surgical time and simple fixation device used (single K-wire).

The preoperative plan includes acquiring a complete history of the patient, and a physical and radiographic examination. The severity of the prominent medial eminence and the hallux valgus deformity should be evaluated by pushing the metatarsal head laterally with one hand and simultaneously the great toe medially with the other hand. Stability of the metatarsophalangeal and cuneometatarsal joints must be assessed. Combined rotational deformity of the great toe or callosities under the external metatarsal heads must be considered, as well as any associated deformities of the lesser toes.

A standard radiographic examination, including anteroposterior and lateral weight-bearing views of the forefoot, allows the assessment of the arthritis and congruency of the joint; measurement of the HVA, IMA, and DMAA. Therefore, planning of the operation is performed in terms of the obliquity of the bone cut, the
extent of the medial-lateral or dorsal-plantar dislocation of the metatarsal head and the correction of the DMAA (Fig. 23-1A-C).

The patient is positioned on a radiolucent operating table in the supine position. Intraoperative imaging in two projections should be obtainable in particular during the period the technique is being adopted. With experience, the use of fluoroscopy is unnecessary.

The operation is usually performed under local or block anesthesia using ropivacaine 7.5 mg per mL. An Esmarch bandage or tourniquet may be optionally used at the ankle level.

Normally, when the deformity is manually reducible, a lateral soft tissue release is not needed because release of tension is achieved with the lateral offset of the metatarsal head itself. If the deformity is not reducible, a manual stretching of the adductor hallucis is performed, gently easing the big toe into a varus position. Otherwise, especially in younger patients, the detachment of the adductor hallucis tendon may be obtained through a percutaneous tenotomy by sliding the scalpel adjacent to the lateral side of the metatarsal head toward the base of the proximal phalanx.