Abstract
The effects of the introduction of minimally invasive surgical techniques have been reported in many fields of surgery and subspecialties, including urology, general surgery, surgical oncology, and gynecology; however, the effect that introducing minimally invasive hallux valgus surgery into an institution has on surgical volumes is unknown. In 2019, a single podiatric surgeon in our institution began using a minimally invasive surgical approach to bunion correction, while colleagues continued using an open approach, which afforded the opportunity to compare over time not only trends in minimally invasive versus open surgical volumes, but also those in surgical volumes of the surgeon using a minimally invasive approach with those of colleagues using an open approach . We therefore conducted a retrospective observational trend analysis evaluating 919 hallux valgus surgeries performed by 8 podiatric surgeons from 01/2015 through 12/2024. The surgeon who employed a minimally invasive correction technique had a statistically significant increase in rate of hallux valgus surgeries performed, while surgeons using an open approach overall had a decrease in rate of hallux valgus surgeries performed over the time period. During the study period, the volume of minimally invasive hallux valgus surgeries performed over time also increased. Future investigations are warranted to determine whether these trends can be applied to other types of foot and ankle surgery and to better understand what implications this suggests for shaping foot and ankle surgeon education/training, predicting healthcare costs related to these procedures, and ultimately providing superior patient outcomes.
Introduction
The bunion, termed hallux valgus or hallux abducto-valgus (HAV), is a common deformity of the lower extremity. It was recently reported that the global incidence of HAV is approximately 19%. Others report an incidence of about 23% in adults aged 65 years and younger. Women and people over the age of 60 years have a higher prevalence of HAV than do men and people younger than 60 years. , Patients often are prompted to seek care for painful medial prominence and/or first metatarsophalangeal joint pain, which may be associated with a callus, bursa, or even ulcer formation and difficulty wearing closed shoe-gear with a tight or constricting toe box. Conservative treatment consists of shoe modifications, orthotics, splinting, dry needling, and oral, topical, or injectable corticosteroids. Surgical correction is often required for patients who have progressive pain, deformity, and decreased quality of life and whose condition does not respond to conservative treatment.
Over 150 surgical procedures for HAV correction have been described. Over the past decade, percutaneous and minimally invasive surgical (MIS) approaches to HAV correction have increased in popularity among patients, foot and ankle surgeons, and industry. Although MIS HAV surgery has been performed since the early 1990s, modern-day minimally invasive instrumentation, specifically MIS burrs, were first approved for use in the United States by the US Food and Drug Administration in 2019. Since that time, ongoing innovation and research have provided a better understanding of MIS HAV procedures and have resulted in greater reproducibility for achieving optimal outcomes. The foot and ankle surgeon community has progressed through a generational evolution of MIS HAV surgery with changes in the shape of the osteotomy and advancements in deformity correction technique, as well as improved fixation to stabilize these corrections.
Although several generations of MIS HAV procedures have been described, most MIS foot surgeons currently use a fourth-generation MIS HAV technique, which consists of an extra-articular transverse osteotomy performed at the distal metaphysis of the first metatarsal. This provides for three-dimensional correction, and two screws provide bi-cortical rigid fixation. Ongoing research efforts continue to analyze and compare outcomes of open, MIS, and percutaneous HAV surgery, with many studies focusing on either a modified Lapidus approach or a distal first metatarsal osteotomy. Prior investigation into nationwide surgical trends for bunionectomies in Medicare beneficiaries between 2013 and 2022 demonstrated an increase in the number of Lapidus procedures.
The effects of the introduction of MIS techniques have been reported in some fields of surgery and subspecialties, such as urology, general surgery, surgical oncology, and gynecology. ,,, However, to date no studies have reported the effects of the introduction of MIS techniques for surgical bunion correction on case volumes over time. The purpose of this study was to perform a trend analysis of surgical bunion correction volumes among multiple podiatric surgeons from a single institution after a single surgeon began using MIS HAV surgical correction techniques. We hypothesized that the introduction of MIS HAV surgical volumes would increase case volume for the single MIS surgeon. We also predicted an overall decrease in HAV surgical volumes for all other surgeons using an open approach.
Methods
An observational retrospective trend analysis study was approved by the Gundersen Research Institute- Institutional Review Board. Using CPT codes 28292, 28295, 28296, 28297, 28298, 28299, and 28899, the electronic health record (EHR) system was queried to identify all patients who had undergone bunion-corrective surgery at Gundersen Health, La Crosse, Wisconsin from 01/2015 to 12/2024. No orthopedic foot and ankle specialists did elective foot surgery at our institution during the study period; thus, only doctors of podiatric medicine were included in the study. From the EHR we captured the date of procedure, the surgeon’s name, and the procedure description. No patient demographics, medical history, or surgical outcomes were obtained. All data were kept within password-protected servers and transmitted using secure and encrypted communication methods. The data were then manually reviewed by a single author (LS) to remove duplicate data and non-bunion corrective procedures, including isolated Akin osteotomies and first metatarsophalangeal joint arthrodesis, among others. Case volumes of surgeons using an open approach (Open Surgeons) were compared with those of the surgeon using an MIS approach (MIS Surgeon) to identify trends over time.
Statistical analysis
Cochran-Armitage test for trend in proportions over time was performed. This test was used to assess whether there was a linear trend in proportions across ordered categories or groups. All analysis was completed using the statistical software program R. (R Core Team, 2024. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria. < https://www.R-project.org/ >). A level of 0.05 was used throughout for assessing statistical significance.
Results
A total of 919 bunion corrective procedures were performed by 8 podiatric surgeons from 01/2015 through 12/2024. Of these procedures, 205 (22.3%) were performed with minimally invasive techniques, while the remaining 714 (77.7%) were open surgical procedures ( Table ).
Table
Case volumes by surgery type and by surgeon type (MIS vs Open) (N = 919)
| Characteristic | Overall N = 919 | 2015 n = 107 | 2016 n = 91 | 2017 n = 93 | 2018 n = 88 | 2019 n = 68 | 2020 n = 62 |
2021
n = 88 |
2022
n = 107 |
2023
n = 107 |
2024
n = 108 |
p -value | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Surgery type | |||||||||||||
| MIS | 205 (22) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 2 (2.9) | 10 (16) | 19 (22) | 38 (36) | 58 (54) | 78 (72) | p < 0.001 | |
| Open | 714 (78) | 107 (100) | 91 (100) | 93 (100) | 88 (100) | 66 (97) | 52 (84) | 69 (78) | 69 (64) | 49 (46) | 30 (28) | ||
| Surgeon type | |||||||||||||
| MIS | 261 (28) | 17 (16) | 8 (8.8) | 10 11 | 9 10 | 9 13 | 12 (19) | 20 (23) | 38 (36) | 60 (56) | 78 (72) | p < 0.001 | |
| Open | 658 (72) | 90 (84) | 83 (91) | 83 (89) | 79 (90) | 59 (87) | 50 (81) | 68 (77) | 69 (64) | 47 (44) | 30 (28) | ||
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