Correction of lesser toe deformities: Minimally invasive versus open surgery – A prospective randomized study

Correction of lesser toe deformities: Minimally invasive versus open surgery – A prospective randomized study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Correction of lesser toe deformities: Minimally invasive versus open surgery – A prospective randomized study Benjamin Dr. med. Weigang, Angelina Dr. med. Garkisch, Angela Dr. med. Simon, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6682347/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose This study aimed to compare soft and hard outcome measures after minimally invasive (MIS) versus open surgical treatment (OS) of lesser toe deformities. We hypothesized that minimally invasive treatment would be associated with fewer complications alongside comparable subjective and objective results. Methods A prospective randomized controlled study was designed. 100 patients were included and randomized into two groups. The patients were evaluated clinically, functionally and radiologically prior to surgery and in a follow up of 1.5 years, resp. Additionally, they were asked about their personal satisfaction via patient-reported outcome measures. Results As anticipated, we found significantly more wound complications including infections in the open surgery group (p = 0.029). K-wire issues were distributed equally between the groups but differed in their clinical appearance (p = 0.03). Hospital stay was significantly reduced in the MIS group (p = 0.004). Only 7 out of the finally examined 95 patients were dissatisfied with their long-term results equally distributed between both groups (4 MIS vs. 3 OS, p = 0.914). The clinical and radiological corrections of the lesser toes were comparably good in both groups, but the open surgery group showed significantly more non-unions (p = 0.0013). The functional evaluation via FFI-D (Foot Function Index Germany), a validated reliable and internationally used standardized questionnaire to assess the correlation between foot deformity and function, also demonstrated a relevant improvement of all patients’ abilities postoperatively without any difference between the two technical approaches (p = 0.460). Conclusion Lesser toe surgery is a low-risk treatment with good overall results. Minimally invasive surgery offers equivalent clinical outcomes with lower risk of complications in soft tissue and bone healing. Level of evidence Level 1 prospective randomized controlled study. TRN DKRS00034137, 25.04.2024 Lesser toe deformities minimally invasive surgery open surgery safety outcome hammer toe claw toe Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. INTRODUCTION Lesser toe deformities are common and have been treated in multiple ways for decades. Different surgical techniques, including open and minimally invasive methods, have been developed over the time to accomplish the main goal of lesser toe surgery: creating a physiological and functional positioning of the treated ray while maintaining stability, flexibility and mobility of the lesser toe to achieve a pain free and powerful gait. So far, not many data have been presented regarding a comparison between the established open surgical and the growing minimally invasive treatment of lesser toe deformities [ 1 ], [ 2 ], [ 3 ], [ 4 ]. Therefore, we present a randomized controlled study with an adequate number of patients treated in a single center with a medium follow up of 18 months. The primary aim was to evaluate the safety of these two surgical techniques, i.e. open vs. minimum-invasive surgery. Secondary aims were to determine the personal satisfaction of the patients in both study groups, as well as the corresponding clinical, functional and radiological outcomes. We hypothesized that the minimally invasive treatment would be associated with fewer complications than in the open technique alongside comparable subjective and objective results. 2. METHODS In our prospective randomized, monocentric, clinical trial, approved by the local Ethics Committee (registration A 2020 − 0247), we recruited a total of 100 patients of all sexes over 18 years of age who had visited our outpatient unit with solitary or combined lesser toe deformities. Consent to join the study was a precondition. Patients with mental inabilities to act compliantly were excluded. Additional planned simultaneous procedures at the foot did not lead to exclusion. Inclusion into the study was performed by a senior physician. An unrestricted randomized allocation was performed by the patients themselves via manually drawing of a sealed opaque envelope out of a box. 50 patients were assigned to the minimally invasive treatment (MIS), while the other 50 patients built the group for an open surgical intervention (OS). The two groups were comparable demographically (Table 1 ). Surgeries were performed from December 2020 until April 2023. Based on our observation that the results after lesser toe surgery already reach a steady state after 12 to 18 months, we decided to perform the follow-up examinations after 1.5 years. All stages of the trial took place in the Department of Foot and Ankle Surgery of the corresponding author. CONSORT reporting guidelines were used to meet the scientific requirements of a prospective randomized clinical trial [ 5 ]. Table 1 Demographic data of the two groups minimally invasive surgery (MIS) open surgery (OS) Test statistics p value Number of Patients 47 48 Age (y) 60.6 ± 9.2 62.9 ± 11.5 U = − 0.931 0.352 Gender n % n % χ² = 0.407 0.524 Female 36 76.6 34 70.8 Male 11 23.4 14 29.2 Weight (kg) 79.0 ± 18.6 77.0 ± 10.2 U = − 0.443 0.658 Height (cm) 168.7 ± 10.5 168.8 ± 10.5 U = − 0.194 0.846 Follow-up (days) 474.9 ± 179.3 535.3 ± 153.8 U = − 1.098 0.272 Type of Lesser toe deformity (n) 47 48 U = − 2.192 0.169 Hammer toe Patients (n) 42 34 Claw toe Patients (n) 4 13 Mallet toe Patients (n) 1 1 Metatarsal Procedures 0 1 U = − 0.847 0.724 Significance at p < 0.05 Mean ± Standard deviation U: Mann Whitney U, χ²: Chi-square 2.1 Surgical techniques Minimally invasive correction was achieved by percutaneous release of the plantar capsule of the proximal interphalangeal joint and disintegration of the short flexor in combination with a percutaneous plantarizing closing wedge osteotomy of the suprabasal proximal phalanx with optional release of the metatarsophalangeal joint and a dorsal closing wedge osteotomy of the middle phalanx, if necessary. Retention was secured by a 1.4 mm retrograde longitudinal K-wire transfixion into the base of the proximal phalanx. In case of metatarsalgia additional distal minimally invasive metatarsal osteotomy (DMMO) was optional. Open surgical correction was mostly performed using z-split of the long extensor tendon for planned lengthening, balanced release of the metatarsophalangeal joint, v-shaped arthrodesis of the proximal interphalangeal joint with longitudinal K-wire transfixion into the metatarsal bone and, if necessary, subcapital elevating osteotomy of the metatarsal with screw fixation. Both groups received K-wire transfixion for all types of deformities. 2.2 Patient follow-up Preoperatively, baseline information was gathered such as demographics, health conditions, history of foot treatments, mechanical issues in footwear, type of deformity and risk factors in case report forms. Functional status was determined by foot function index Germany (FFI-D) 23-items questionnaire with known test reliability and validity [ 6 ]. Final scoring was achieved by summation of each patient’s statements reaching from 1 to 9 per item. Standard radiography was performed prior to the intervention, postoperatively at the ward and during the follow-up examination after 18 months. After the operation the patients were evaluated by compliance and clinical course. Any complications were documented, e.g. ischemia, prolonged wound healing, surgical site infection, K-wire issues or deep vein thrombosis. Patients were asked about their personal satisfaction regarding the surgical results, their readiness to hypothetically repeat the procedure and their will to recommend the treatment to other patients or family members via patient related outcome measurement questionnaire. Furthermore, clinical evaluation of the lesser toe correction in all 3 dimensions was performed. The clinical und radiological control 18 months after surgery was focused on long-term complications, such as scaring, strictures, arthrofibrosis, neuropathic pain or dysesthesia, recurrent deformity, non-union or instability. Function and satisfaction questionnaires were also completed during the final follow-up examination. 2.3 Statistical analysis Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 29.0.2.0 (IBM Corp., Armonk NY, released 2023). Primarily, data were analyzed using descriptive statistics displaying mean, median and standard deviation. Variables were tested regarding normal distribution with Kolmogorov test or Shapiro-Wilk test. If normal distribution was missing nonparametric tests were applied. Significance tests on independent ordinal variables were performed using the Mann Whitney-U test. Associations between categorial variables were investigated using Pearsons’s Chi-squared test (cross tables). Dependent ordinal variables were evaluated using the Wilcoxon test. The significance level was set at p < 0.05. 3. RESULTS The preoperative demographic characteristics are given in Table 1 . Out of the original 100 patients (50 in each group) 95 participants were reevaluated at the 18 months follow-up. 5 patients could not be included in the follow-up due to household move, serious health issues and even one case of decease not related to surgery. 47 patients received minimally invasive surgery and 48 patients had open surgery. Lesser toe deformities varied in these groups, showing more claw toes in the OS group (p = 0.0.28). 11 of these persons could only be reevaluated by telephone or email (PROM-questionnaires). Clinical and radiological assessment was not possible for these individuals. Complete data sets were available for 84 individuals. Both study groups did not differ demographically or in follow-up period (p > 0.05). The majority of the patients were female. At the final follow-up, overall patient satisfaction (Table 2 ) was high (88.4% satisfied and 4.2% indecisive) without any significant difference between the two surgical techniques (p = 0.914). Functional outcome (FFI-D) as shown in Table 3 was comparable in both cohorts (p > 0.05). The number of painful days and total FFI-D-scores improved significantly for both competing technical approaches in comparison of pre- and postoperative values. (p < 0.001). Table 4 shows the clinical evaluation at the final follow-up regarding three-dimensional correction of the lesser toe deformities and existence of persistent shoe conflict. Both minimally invasive and open surgeries allowed for a good overall correction rate with only 4 toes in 4 out of 84 patients having recurrent deformities. Misalignments were equally distributed to the MIS (2 toes in 2 patients) and OS group (2 toes in 2 patients) displaying no significant clinical difference (p = 0.833). The radiological outcome of both groups is shown in Table 5 . 18 months postoperatively in the MIS group a 100% osseous consolidation rate could be observed, while in the OS group 36 out of 44 patients (58 of 66 toes) had complete bony healing. 2 patients (2 toes) showed partial osseous consolidation (p = 0.029). 6 patients from the OS cohort presented a manifest non-union (6 toes) with no such case in the MIS group (p = 0.013). Anatomic axial correction was achieved in both groups (p = 0.145) with 2 cases of insufficient correction in each cohort. Complications of both cohorts are given in Table 6 . Wire complications differed significantly in both groups (p = 0.03) with 4 wire migrations in the MIS patients and 3 wire deformations in the OS patients. Impaired wound healing (p = 0.029) and wound infection rates (p = 0.023) were significantly higher in the OS group. No toes were lost due to ischemic complications. Table 2 Safety of the surgical techniques in lesser toe surgery Complications minimally invasive surgery (MIS) open surgery (OS) Test statistics p value intraoperatively 0 0 * * Incompliance 7 8 χ² = 0.056 0,813 Type of wire complications 4 migrations 3 bendings χ² = 7.036 0.030 Wire bending 0 3 χ² = 3.033 0.082 Wire migration 4 0 χ² = 4.265 0.039 Toe ischemia 0 1 χ² = 0.990 0,320 Toe necrosis 0 0 * * Toe loss 0 0 * * Impaired wound healing 1 7 χ² = 4.777 0,029 Wound infection 0 5 χ² = 5.168 0.023 Osteomyelitis 0 0 * * Neuropathic pain syndrome 3 3 χ² = 0.001 0.979 Arthrofibrosis MTP-joint 2 2 χ² = 0.000 0.983 Keloid or stricture 0 2 χ² = 1.906 0,167 Thromboembolism 0 0 * * Significance at p < 0.05 U: Mann Whitney U, *: incalculable Table 3 Patient satisfaction 18 month postoperatively minimally invasive surgery (MIS) open surgery (OS) Test statistics p value Satisfaction (yes/indecisive/no) 41/2/4 43/2/3 χ² = 0.180 0.914 Will to repeat the procedure (yes/indecisive/no) 42/1/4 40/2/6 χ² = 0.772 0.680 Recommendation to patients (yes/indecisive/no) 42/1/4 41/2/5 χ² = 0.446 0.800 Recommendation to family (yes/indecisive/no) 42/1/4 41/2/5 χ² = 0.446 0.800 Significance at p < 0.05 χ²: Chi square Table 4 FFI-D preoperatively and follow-up minimally invasive surgery (MIS) Mean ± SD (CI) open surgery (OS) Mean ± SD (CI) Test statistics p value Number of painful days the past week - preoperatively 4.5 ± 2.5 (3.7–5.3) 4.9 ± 2.5 (4.1–5.6) U = − 1.046 0.296 Number of painful days the past week - postoperatively 1.0 ± 2.1 (0.3–1.7) 1.5 ± 2.7 (0.6–2.3) U = − 0.826 0.409 Mean reduction painful days ∆ = 3.5 ∆ = 3.4 U = − 0.095 0.924 Test statistics W = -5.290 W = -5.261 p value p < 0.001 p < 0.001 FFI-D points preoperatively 88.4 ± 25.0 (74.9–91.9) 86.1 ± 27.7 (74.1–95.1) U = − 0.547 0.584 FFI-D points postoperatively 28.9 ± 12.5 (24.7–33.1) 37.9 ± 26.4 (29.4–46.4) U = − 0.740 0.460 Mean reduction FFI-D points ∆ = 59.5 ∆ = 48.2 U = − 0.834 0.404 Test statistics W = − 5.874 W = − 5.918 p value p < 0.001 p < 0.001 Significance at p < 0.05 W: Wilcoxon test, U: Mann Whitney U test SD: Standard deviation, CI: Confidence interval, ∆: mean difference Table 5 Clinical outcome minimally invasive surgery (MIS) open surgery (OS) Test statistics p value Number of patients 40 44 Clinical axis correction (complete/satisfactory/inadequate) 30 / 8 / 2 30[ 1 ] / 11[ 1 ] / 2 χ² = 0.366 0.833 Persistent shoe conflict 3 4 χ² = 0.132 0.716 Significance at p < 0.05 χ²: Chi-square [ ]: one patient with different results in two corrected lesser toes Table 6 Radiological follow-up of the surgical techniques in lesser toe surgery 18 month postoperatively minimally invasive surgery (MIS) open surgery (OS) Test statistics p value insufficient axis correction 2 2 χ² = 3.862 0.145 good dp alignment 35 36 tolerable dp alignment 3 6 inadequate dp alignment 2 2 good dp alignment 29 33 lateral deviation 8 8 medial and lateral deviation (multiple rays) 0 1 medial deviation 3 2 inadequate ml alignment 2 2 complete osseous consolidation 40 36 χ² = 7.111 0.029 partial osseous consolidation 0 2 χ² = 7.111 0.029 Non union 0 6 χ² = 6.165 0.013 Significance at p < 0.05 χ²: Chi square, dp: dorsoplantar, ml: mediolateral 4. DISCUSSION To the best of our knowledge, this is the first randomized clinical trial to compare the minimally invasive and open surgical approach for lesser toe corrections with an adequate sample size and a mean follow-up of 18 months. Our main results demonstrate comparable subjective, functional and clinical patient outcomes for lesser toe corrections with the OS and MIS technique while proving a significantly lower risk for soft tissue and bone healing complications in the MIS group. The distribution of sex and age with almost 74% of females and a mean age of 63.2 years corresponded to previous studies. The comparative study of Yassin et al from 2017 included 352 patients with hammer toe deformities [ 2 ]. 55.9% of the patients were female and the mean age was 52.8 years. Open surgery was performed as resection arthroplasty of the proximal interphalangeal joint with K-wire fixation (265 patients with 454 toes). MIS surgery was performed using tendon release, percutaneous diaphyseal osteotomy of the middle and proximal phalanx with tape dressing for 3 weeks (87 patients with 221 toes). In conclusion OS using resection arthroplasty was not comparable to the arthrodesis approach of our study. MIS only differed in postoperative fixation regime using no K-wire and preferring Coban tape instead. The retrospective comparative study of Mateen et al from 2021 included 41 patients [ 1 ]. The MIS group consisted of 54 feet and 124 toes (71% females). Their surgical technique included soft tissue release, percutaneously burr denuding of all cartilage in the proximal interphalangeal joint and retrograde insertion of a 2.5 mm cannulated screw for arthrodesis fixation. This approach fundamentally differs from the MIS in our study. Open surgery was performed in 14 feet (22 toes) with extensor tendon lengthening, head resection of the proximal phalanx and release of the metatarsophalangeal joint using K-wire fixation (75% females). Except for the arthrodesis concept in our study this method used similar surgical steps. Mean age in the MIS group was 56 ± 15 years and 54 ± 14 years in the OS group. In 2017 Thomas et al. retrospectively examined 30 patients receiving distal minimally invasive metatarsal osteotomy (DMMO) for chronic metatarsalgia and MIS correction of lesser toe deformities using tendon release (Flexor digitorum longus) and percutaneous diaphyseal osteotomy of the middle and proximal phalanx with postoperative tape dressing (87% females, mean age 58 years). This surgical treatment was comparable to our MIS group, but we used K-wire fixation in all cases. Therefore, outcome comparison is limited. In the control group 30 patients received Weil osteotomy with screw fixation for chronic metatarsalgia (80% females, mean age 59 years) [ 4 ]. A similar study was conducted in 2016 by Yeo et al. where 20 patients had DMMO without any fixation (40 toes, 92.3% females) and 13 patients (22 toes, 70% female) were treated with Weil osteotomy with screw fixation for metatarsalgia [ 3 ]. The mean ages were 55.0 ± 13.0 years (DMMO) and 63.8 ± 8.0 years (Weil), resp.. This study also used different surgical procedures and provided limited information for the outcome after OS and MIS lesser toe surgery, only. Overall patient satisfaction with more than 92% was high in our study. Regardless of the surgical technique only 7 out of 95 patients reported dissatisfaction with their results after the 18 months period. Furthermore, 89% of the patients expressed their will to undergo the procedure again, if necessary. More than 90% would have given a corresponding recommendation to other patients or even family members. These findings did not differ between the two study groups (p > 0.05). Further analysis of the dissatisfying cases could reveal the main clinical issues to improve the patient experience. Yeo et al. used the RAND-36-score to measure the health based quality of life in their comparative study [ 3 ]. This score measures functioning and pain, but also social and psychological well-being, so the comparability with our study, in addition to the surgical differences, is limited. After a 6 months follow-up the Weil group achieved a significantly better mean score (92 points) than the DMMO group (78 points), which the authors justified by the prolonged swelling caused by MIS. These results differed from our satisfaction findings 18 months following surgery. Yassin et al. reported similar patient satisfaction rates for the open and percutaneous group in their comparative hammer toe study from 2017, but did not quantify this statement [ 2 ]. Mateen and Thomas did not make any statement about patient satisfaction [ 1 ], [ 4 ]. Coughlin et al. reported an 84% satisfaction rate in their non-comparative study regarding OS of 118 hammer toes with resection arthroplasty of the proximal interphalangeal joint [ 7 ]. O’Kane in 2005 found a 93% satisfaction rate after resection arthroplasty for hammer toe deviation in 75 treated patients [ 8 ]. Lehmann and Smith examined patient satisfaction after open correction of 137 hammer toe deformities using the peg-in-hole technique. Limited and full satisfaction was reported in 85% of the cases [ 9 ]. Cicchinelli et al. in their study about 25 patients with intramedullary fixation devices after open hammer toe correction reported full satisfaction in 84% of the cases and limited satisfaction in the remaining 16% [ 10 ]. These results were confirmed by Harmer et al in 2017 who registered less complaints after OS for hammer toes in 38 patients for 92.8% of the cases [ 11 ]. To the best of our knowledge, data regarding subjective results after MIS correction for lesser toe deformities could not be found, but the patient satisfaction rates after toe correction in general seem to be high. This has been confirmed in our study for both surgical techniques. Using patient related outcome measurements (PROM) is a common method to evaluate postoperative results. Because of the given reliability and validity we decided to use the FFI score [ 6 ]. Other scores such as the forefoot score of the American Orthopedic Foot and Ankle Society (AOFAS) [ 12 ], the EFAS score [ 13 ] or the Manchester Oxford Foot Questionnaire (MOXFQ) [ 14 ] are being used widely in international studies. Out of the four known mentioned comparative studies regarding lesser toe surgery or metatarsalgia only Yeo et al. used AOFAS and RAND 36 scores [ 15 ] to evaluate their functional results [ 3 ]. They found a significant improvement over time, but no difference between the two surgical techniques (postoperative p = 0.831) which goes along with our findings. Other studies investigating clinical results after OS of the lesser toes also found good to excellent values in their follow-up [ 7 ], [ 11 ], [ 16 ], [ 17 ]. This could be confirmed for MIS correspondingly [ 18 ], [ 19 ], [ 20 ], [ 21 ], [ 22 ]. In conclusion, both surgical techniques for lesser toe correction seem to deliver the desired functional results even though these scores are not fully comparable. In our study 80 out of the 84 patients had a good to excellent axis correction (95.2%). Two patients of the MIS group and two patients of the OS group showed recurrent deformities in the follow-up (p = 0.883), even though there were more claw toe deformities in the OS group preoperatively. Persistent shoe conflicts (Table 4 ) and scar strictures or cases of arthrofibrosis (Table 6 ) also were very rare and showed no difference between the two cohorts (p > 0.05), so we conclude, that both techniques are capable of achieving favourable and comparable clinical results. We used K-wire fixation for maintaining the correction in both groups, exclusively. Yassin et al. found recurrent deformities in 6.2% of the cases and an indication for revision surgery in 2.6% of them [ 2 ]. Mateen et al documented 4 cases of recurrent deviations in the MIS group with no such case in the OS group. Because of the small sample size this difference was not statistically significant [ 1 ]. Yeo et al. found a much better postoperative mobility for the metatarsal phalangeal joint in comparison to the Weil osteotomy (p = 0.043), which is most likely due to the extraarticular location of the osteotomy [ 3 ]. For the open lesser toe surgery Kramer et al. found recurrent deformities in 5.6% of their 2,698 treated hammer toes. In 3.5% of the cases this led to revision surgery [ 23 ]. Other studies even found rates up to 17% for persistent lesser toe deformities after open surgery [ 7 ], [ 8 ], [ 24 ], [ 25 ]. MIS also showed good clinical results with recurrence rates from 0 to 3.7% in our literature review [ 18 ], [ 22 ], [ 26 ], [ 27 ]. All in all, both surgical techniques seem to deliver good clinical results in lesser toe correction, most likely dependent on the experience of the surgeon. Data regarding shoe conflicts, and persistent scar strictures or arthrofibrosis could not be found in the literature. In the radiological control after 18 months more than 92% of the corrected toes did show successful osseous healing and anatomic alignment. Both cohorts featured two manifest recurrent deformities each (p = 0.593) in the follow-up. Thus, total recurrence rate was 4.8%, which is in accordance with the studies mentioned above. A statistically significant difference between the two study groups was found in the bone healing process. 6 of the 44 OS patients radiographically developed a non-union while none of the MIS patients had a bone healing complication. This might be due to the location and the portion of the osteotomy. The osteotomy is articular-sided and with complete separation in the OS cohort, whereas in the MIS group one cortex generally stays intact at the junction of the diaphysis to the metaphysis. Vascular supply might also play a vital role in this context which is assumed to be better preserved in the MIS technique. Mateen et al. found comparable periods for bone healing in their MIS and OS groups (p = 0.065) [ 1 ]. Yeo et al. documented a 100% consolidation rate for all of their patients [ 3 ]. Other studies regarding open lesser toe surgery found fusion rates from 81 to 100% [ 7 ], [ 9 ], [ 16 ], [ 25 ]. Minimally invasive lesser toe surgery generally led to full bony consolidation with non-unions in isolated cases, only as reported by others [ 18 ], [ 20 ], [ 22 ], [ 26 ]. These data suggest that MIS can provide adequate axis correction and comparable with OS at a lower risk for bone healing complications. 15 of the 95 patients were labelled as incompliant postoperatively. This led to four wire migrations in the MIS group and three wire deformations in the OS group which was seen as a significant difference between the two groups (p = 0.03). This might be caused by the positioning of the wire during the different procedures. Open surgery used a wire fixation within the metatarsal bone, while with the MIS procedure wires were placed in the basal phalanx, only. Overall wire complications were seen in 7.4% of the cases. Mateen et al had 4% unexpected screw removals in their minimally invasive cohort, but no wire issues in their open surgical cohort [ 1 ]. Yassin et al. reported 5.5% wire migrations in their OS group. In the MIS group taping was used for fixation, so no wire problems could occur [ 2 ]. A large retrospective study with 2017 open surgical treatments of lesser toe deformities was conducted by McKenzie et al. They found 1.14% non-infection based wire migrations in all cases [ 28 ]. All in all, implant migration seems to be an infrequent phenomenon with specific risks for every implant. Another notable complication is ischemia. We only had one case with postoperative ischemia in the OS group, which could be fixed by reducing the toe length on the wire. Not a single toe was lost due to postoperative ischemic problems. Yassin et al. reported 0.5% ischemic complications resulting in toe amputation in 0.25% of the cases [ 2 ]. 0.6% of the 1,000 hammer toes that were corrected in OS from the retrospective study of Kramer et al. suffered from ischemia and 0.4% of the cases ended in toe amputation [ 23 ]. Consistent with our findings these complications are rare. A parameter of paramount importance for the success of lesser toe surgery is soft tissue healing because complications in this field can lead to severe consequences like surgical site infections. In our study 7 patients with OS (7.4%) developed impaired and prolonged soft tissue healing which resulted in 5 superficial wound infections (5.3%). The MIS group contained one such case without consecutive deep infection, only. In conclusion, a clear advantage for MIS regarding soft tissue healing (p = 0.029) and wound infection (p = 0.023) can be derived even though higher temperature might occur due to the intraoperative use of high-speed rotating instruments with the potential of a heat necrosis. In analogy with our data Yassin et al. found 7% of wound complications and 4% of wound infections in the OS group, but surprisingly high 20% with compromised soft tissue healing and 2.3% surgical site infections in the MIS group [ 2 ]. Mateen et al reported 0.8% wound complications in the MIS group and 4.6% for OS without any case of deep infection[ 1 ]. Other non-comparative studies showed infection rates from 0.3 to 4.9% for OS of lesser toe deformities [ 23 ], [ 28 ] and rates from 0 to 13% infections for MIS [ 24 ], [ 26 ], [ 27 ]. These rates vary for various reasons including the individual expertise. Maidmann et al. described that comorbidities such as diabetes mellitus, chronic obstructive lung disease and osteoporosis could considerably increase the risk for wound infections in lesser toe surgery by up to 4 times [ 29 ]. In our study, we found 3 patients in each cohort having neuropathic pain after 18 months follow-up (p = 0.2). Richmann et al. saw single cases of long-lasting local hypesthesia, peroneal nerve neuritis or persistent local pain syndrome in their study including 99 patients with OS [ 30 ]. Other studies investigating the results after MIS for hammer toe deformities could not identify any neuropathic complications [ 26 ], [ 27 ]. All in all, both procedures under discussion appear to be reliable and safe. The main limitations of this study are seen in the monocentric design and possible surgical bias regarding clinical and radiological evaluation, the relatively short mean follow-up duration of 18 months. The known weaknesses of the FFI scoring system such as missing documentation of joint mobility and stability or the evaluation of toe positioning and footwear are to mention even though this score has been one of the most frequently used assessment instruments in foot an ankle surgery until today [ 31 ]. Additionally, only 20 out of the 95 patients had solitary lesser toe corrections. 75 patients had undergone additional forefoot procedures simultaneously which might have affected the results. Multicentric studies with larger patient cohorts and longer follow-up periods are to be conducted to confirm our findings. Moreover, other validated scoring systems, such as the EFAS score could be used to reach a broader audience and present better comparability. For the radiological outcome evaluation using computed tomography would be the most delicate tool, even though in clinical routine this is not the standard in surgery of the lesser toes. 5. CONCLUSION Both MIS and OS techniques for correction of lesser toe deformities were found to be safe and reliable procedures with high patient satisfaction rates. Clinical, radiological and functional outcome were comparable for both study groups. MIS appeared to have a significantly better risk profile regarding soft tissue and bone healing than OS. This may lead to a clinical preference in favor of the MIS technique, but OS for hammer and claw toes is widespread and MIS is not available everywhere. The final decision lies in the hand of the experienced surgeon on the basis of his personal expertise and should be made individually for every patient. Declarations ACKNOWLEDGEMENTS This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. DECLARATION OF COMPETING INTERESTS The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. REGISTRATION www.drks.de Number: 00034137 References S. Mateen, S. Raja, D. J. Casciato, und N. A. Siddiqui, „Minimally Invasive Versus Open Hammertoe Correction: A Retrospective Comparative Study.“, J. Foot Ankle Surg. Off. Publ. Am. Coll. Foot Ankle Surg. , Bd. 63, Nr. 2, S. 156–160, Apr. 2024, doi: 10.1053/j.jfas.2023.09.014. M. Yassin, A. Garti, E. Heller, und D. Robinson, „Hammertoe Correction With K-Wire Fixation Compared With Percutaneous Correction.“, Foot Ankle Spec. , Bd. 10, Nr. 5, Art. Nr. 5, Okt. 2017, doi: 10.1177/1938640016681069. N. E. M. Yeo, B. Loh, J. Y. Chen, A. K. S. Yew, und S. Y. Ng, „Comparison of early outcome of Weil osteotomy and distal metatarsal mini-invasive osteotomy for lesser toe metatarsalgia.“, J. Orthop. Surg. Hong Kong , Bd. 24, Nr. 3, S. 350–353, Dez. 2016, doi: 10.1177/1602400315. M. Thomas und M. Jordan, „Minimal-invasive Korrektur von Deformitäten der Kleinzehen und Behandlung der Metatarsalgie“, Oper. Orthop. Traumatol. , Bd. 30, Nr. 3, S. 171–183, Juni 2018, doi: 10.1007/s00064-018-0548-6. K. F. Schulz, D. G. Altman, und D. Moher, „CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials.“, Open Med. Peer-Rev. Indep. Open-Access J. , Bd. 4, Nr. 1, S. e60-68, 2010. F. D. Naal, F. M. Impellizzeri, M. Huber, und P. F. Rippstein, „Cross-cultural adaptation and validation of the Foot Function Index for use in German-speaking patients with foot complaints.“, Foot Ankle Int. , Bd. 29, Nr. 12, Art. Nr. 12, Dez. 2008, doi: 10.3113/FAI.2008.1222. M. J. Coughlin, J. Dorris, und E. Polk, „Operative repair of the fixed hammertoe deformity.“, Foot Ankle Int. , Bd. 21, Nr. 2, Art. Nr. 2, Feb. 2000, doi: 10.1177/107110070002100202. C. O’Kane und T. Kilmartin, „Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases.“, Foot Ankle Int. , Bd. 26, Nr. 4, Art. Nr. 4, Apr. 2005, doi: 10.1177/107110070502600408. D. E. Lehman und R. W. Smith, „Treatment of symptomatic hammertoe with a proximal interphalangeal joint arthrodesis.“, Foot Ankle Int. , Bd. 16, Nr. 9, S. 535–541, Sep. 1995, doi: 10.1177/107110079501600904. L. D. Cicchinelli, J. Štalc, M. Richter, und S. Miller, „Prospective, Multicenter, Clinical and Radiographic Evaluation of a Biointegrative, Fiber-Reinforced Implant for Proximal Interphalangeal Joint Arthrodesis.“, Foot Ankle Orthop. , Bd. 5, Nr. 4, S. 2473011420966311, Okt. 2020, doi: 10.1177/2473011420966311. J. L. Harmer, A. Wilkinson, und A. J. Maher, „A Midterm Review of Lesser Toe Arthrodesis With an Intramedullary Implant.“, Foot Ankle Spec. , Bd. 10, Nr. 5, S. 458–464, Okt. 2017, doi: 10.1177/1938640017704943. C. C. Tan, A. A. Sayampanathan, Y. H. Kwan, W. Yeo, I. Singh Rikhraj, und N. E. M. Yeo, „Validity and Reliability of the American Orthopaedic Foot and Ankle Society Score for the English-Literate Singapore Population With Hallux Valgus.“, Foot Ankle Spec. , Bd. 17, Nr. 4, S. 329–335, Aug. 2024, doi: 10.1177/19386400221079490. M. Richter, „EFAS Score validated in 13 languages with more than 3 billion total speakers.“, Foot Ankle Surg. Off. J. Eur. Soc. Foot Ankle Surg. , Bd. 29, Nr. 3, S. 179, Apr. 2023, doi: 10.1016/j.fas.2023.02.009. J. Dawson u. a. , „The MOXFQ patient-reported questionnaire: assessment of data quality, reliability and validity in relation to foot and ankle surgery.“, Foot Edinb. Scotl. , Bd. 21, Nr. 2, S. 92–102, Juni 2011, doi: 10.1016/j.foot.2011.02.002. R. D. Hays, C. D. Sherbourne, und R. M. Mazel, „The RAND 36-Item Health Survey 1.0.“, Health Econ. , Bd. 2, Nr. 3, S. 217–227, Okt. 1993, doi: 10.1002/hec.4730020305. R. Caterini, P. Farsetti, U. Tarantino, V. Potenza, und E. Ippolito, „Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity.“, Foot Ankle Int. , Bd. 25, Nr. 4, S. 256–261, Apr. 2004, doi: 10.1177/107110070402500411. J. C. Schrier, N. L. Keijsers, G. A. Matricali, J. W. K. Louwerens, und C. C. P. M. Verheyen, „Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized Clinical Trial.“, Foot Ankle Int. , Bd. 37, Nr. 6, Art. Nr. 6, Juni 2016, doi: 10.1177/1071100716629776. B. Molenaers, J. Vanlommel, und P. Deprez, „Percutaneous hardware free corrective osteotomy for bunionnette deformity.“, Acta Orthop. Belg. , Bd. 83, Nr. 2, S. 284–291, Juni 2017. L. Ramírez-Andrés, E. Nieto-García, E. Nieto-González, N. López-Ejeda, und J. Ferrer-Torregrosa, „Effectiveness of minimally invasive surgery using incomplete phalangeal osteotomy for symptomatic curly toe of adults with a trapezoidal phalanx: An observational study.“, Front. Surg. , Bd. 9, S. 965238, 2022, doi: 10.3389/fsurg.2022.965238. G. F. Ferreira, T. F. Dos Santos, D. Oksman, und M. V. Pereira Filho, „Percutaneous Oblique Distal Osteotomy of the Fifth Metatarsal for Bunionette Correction.“, Foot Ankle Int. , Bd. 41, Nr. 7, S. 811–817, Juli 2020, doi: 10.1177/1071100720917906. S. Haque, R. Kakwani, C. Chadwick, M. B. Davies, und C. M. Blundell, „Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia.“, Foot Ankle Int. , Bd. 37, Nr. 1, S. 58–63, Jan. 2016, doi: 10.1177/1071100715598601. M. Lopez-Vigil, S. Suarez-Garnacho, V. Martín, C. Naranjo-Ruiz, und C. Rodriguez, „Evaluation of results after distal metatarsal osteotomy by minimal invasive surgery for the treatment of metatarsalgia: patient and anatomical pieces study.“, J. Orthop. Surg. , Bd. 14, Nr. 1, S. 121, Mai 2019, doi: 10.1186/s13018-019-1159-0. W. C. Kramer, M. Parman, und R. M. Marks, „Hammertoe correction with k-wire fixation.“, Foot Ankle Int. , Bd. 36, Nr. 5, Art. Nr. 5, Mai 2015, doi: 10.1177/1071100714568013. H. R. Martin und A. R. Kadakia, „Patient-Reported Outcome Measurement Information System Measures for Proximal Interphalangeal Joint Arthrodesis in Lesser Toe Deformities.“, Foot Ankle Spec. , S. 19386400231208518, Nov. 2023, doi: 10.1177/19386400231208518. O. W. 2nd Ohm, M. McDonell, und W. A. Vetter, „Digital arthrodesis: an alternate method for correction of hammer toe deformity.“, J. Foot Surg. , Bd. 29, Nr. 3, S. 207–211, Juni 1990. M. Gilheany, O. Baarini, und D. Samaras, „Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators.“, J. Foot Ankle Res. , Bd. 8, S. 17, 2015, doi: 10.1186/s13047-015-0073-x. S. Frey, M. Hélix-Giordanino, und B. Piclet-Legré, „Percutaneous correction of second toe proximal deformity: Proximal interphalangeal release, flexor digitorum brevis tenotomy and proximal phalanx osteotomy“, Orthop. Traumatol. Surg. Res. , Bd. 101, Nr. 6, S. 753–758, Okt. 2015, doi: 10.1016/j.otsr.2015.06.009. J. C. McKenzie u. a. , „Incidence and Risk Factors for Pin Site Infection of Exposed Kirschner Wires Following Elective Forefoot Surgery.“, Foot Ankle Int. , Bd. 40, Nr. 10, S. 1154–1159, Okt. 2019, doi: 10.1177/1071100719855339. S. D. Maidman u. a. , „Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population.“, Foot Ankle Orthop. , Bd. 5, Nr. 4, S. 2473011420946726, Okt. 2020, doi: 10.1177/2473011420946726. S. H. Richman, M. B. P. Siqueira, K. A. McCullough, und M. J. Berkowitz, „Correction of Hammertoe Deformity With Novel Intramedullary PIP Fusion Device Versus K-Wire Fixation.“, Foot Ankle Int. , Bd. 38, Nr. 2, Art. Nr. 2, Feb. 2017, doi: 10.1177/1071100716671883. E. Budiman-Mak, K. J. Conrad, J. Mazza, und R. M. Stuck, „A review of the foot function index and the foot function index - revised.“, J. Foot Ankle Res. , Bd. 6, Nr. 1, S. 5, Feb. 2013, doi: 10.1186/1757-1146-6-5. Additional Declarations No competing interests reported. Supplementary Files flowchartPaper.pdf Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 26 Jun, 2025 Reviews received at journal 26 Jun, 2025 Reviews received at journal 23 Jun, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers agreed at journal 10 Jun, 2025 Reviewers agreed at journal 09 Jun, 2025 Reviewers invited by journal 08 Jun, 2025 Editor assigned by journal 19 May, 2025 Submission checks completed at journal 19 May, 2025 First submitted to journal 16 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6682347","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":468368172,"identity":"f274ee07-9f5a-49b7-ad5d-ded475fa7fc2","order_by":0,"name":"Benjamin Dr. med. Weigang","email":"data:image/png;base64,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","orcid":"","institution":"Diakonie Klinikum Dietrich-Bonhoeffer Malchin","correspondingAuthor":true,"prefix":"","firstName":"Benjamin","middleName":"Dr. med.","lastName":"Weigang","suffix":""},{"id":468368173,"identity":"296f0685-6228-487a-ab66-e003c7ef02ee","order_by":1,"name":"Angelina Dr. med. Garkisch","email":"","orcid":"","institution":"Universitätsmedizin Rostock","correspondingAuthor":false,"prefix":"","firstName":"Angelina","middleName":"Dr. med.","lastName":"Garkisch","suffix":""},{"id":468368174,"identity":"9eac0dc1-b5d7-4328-aaea-0496ca49cd0e","order_by":2,"name":"Angela Dr. med. Simon","email":"","orcid":"","institution":"Diakonie Klinikum Dietrich-Bonhoeffer Malchin","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"Dr. med.","lastName":"Simon","suffix":""},{"id":468368175,"identity":"b0b42242-5516-4e28-af2d-9601beda5eb5","order_by":3,"name":"Thomas Prof. Dr. med. Mittlmeier","email":"","orcid":"","institution":"Universitätsmedizin Rostock","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Prof. Dr. med.","lastName":"Mittlmeier","suffix":""}],"badges":[],"createdAt":"2025-05-16 16:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6682347/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6682347/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-025-06114-1","type":"published","date":"2025-11-24T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84424045,"identity":"9f4d56d1-af2c-4550-8735-a453d66281b3","added_by":"auto","created_at":"2025-06-11 18:55:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":410802,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig1OSpreoperative.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/76ce470c141d27c8b05a699f.jpg"},{"id":84424549,"identity":"7dd06de6-8f9a-41b7-8603-6a996b2a0b33","added_by":"auto","created_at":"2025-06-11 19:11:22","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":862267,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig2OSpostoperative.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/f3fd28d4564dd3d1833e4576.jpg"},{"id":84423435,"identity":"8901be36-ad41-40cb-b34c-08ac3ce45f8a","added_by":"auto","created_at":"2025-06-11 18:47:22","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":786992,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig3OSFollowup.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/5a656d583bc22ffb57d586df.jpg"},{"id":84424197,"identity":"d6ffd54c-cd7b-4fc9-a7e1-ace182af414e","added_by":"auto","created_at":"2025-06-11 19:03:22","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":465663,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig4MISpreoperative.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/5e9cfe6728196f6f975e28cd.jpg"},{"id":84424051,"identity":"850f8307-49c4-4440-a805-4d8ea1b0450a","added_by":"auto","created_at":"2025-06-11 18:55:22","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":461996,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig5MISpostoperative.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/273313e910f699b658deeb4f.jpg"},{"id":84424053,"identity":"49ef4d44-6bd0-4941-9733-8fb8637330f8","added_by":"auto","created_at":"2025-06-11 18:55:22","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":601563,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Fig6MISFollowup.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/2e9d506969db5cdf7f8b8583.jpg"},{"id":97178747,"identity":"e88745a5-3e50-4ea0-aea5-5ae835bdf59d","added_by":"auto","created_at":"2025-12-01 16:13:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4486331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/48b9e519-e3cd-4396-a11b-372e46f1991c.pdf"},{"id":84423447,"identity":"cf63712e-b7aa-4b59-824e-eed7890b9358","added_by":"auto","created_at":"2025-06-11 18:47:22","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":315478,"visible":true,"origin":"","legend":"","description":"","filename":"flowchartPaper.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6682347/v1/fc827d43dbac5797c8c6572f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correction of lesser toe deformities: Minimally invasive versus open surgery – A prospective randomized study","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eLesser toe deformities are common and have been treated in multiple ways for decades. Different surgical techniques, including open and minimally invasive methods, have been developed over the time to accomplish the main goal of lesser toe surgery: creating a physiological and functional positioning of the treated ray while maintaining stability, flexibility and mobility of the lesser toe to achieve a pain free and powerful gait. So far, not many data have been presented regarding a comparison between the established open surgical and the growing minimally invasive treatment of lesser toe deformities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, we present a randomized controlled study with an adequate number of patients treated in a single center with a medium follow up of 18 months. The primary aim was to evaluate the safety of these two surgical techniques, i.e. open vs. minimum-invasive surgery. Secondary aims were to determine the personal satisfaction of the patients in both study groups, as well as the corresponding clinical, functional and radiological outcomes. We hypothesized that the minimally invasive treatment would be associated with fewer complications than in the open technique alongside comparable subjective and objective results.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003e In our prospective randomized, monocentric, clinical trial, approved by the local Ethics Committee (registration A 2020\u0026thinsp;\u0026minus;\u0026thinsp;0247), we recruited a total of 100 patients of all sexes over 18 years of age who had visited our outpatient unit with solitary or combined lesser toe deformities. Consent to join the study was a precondition. Patients with mental inabilities to act compliantly were excluded. Additional planned simultaneous procedures at the foot did not lead to exclusion. Inclusion into the study was performed by a senior physician. An unrestricted randomized allocation was performed by the patients themselves via manually drawing of a sealed opaque envelope out of a box. 50 patients were assigned to the minimally invasive treatment (MIS), while the other 50 patients built the group for an open surgical intervention (OS). The two groups were comparable demographically (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Surgeries were performed from December 2020 until April 2023. Based on our observation that the results after lesser toe surgery already reach a steady state after 12 to 18 months, we decided to perform the follow-up examinations after 1.5 years. All stages of the trial took place in the Department of Foot and Ankle Surgery of the corresponding author. CONSORT reporting guidelines were used to meet the scientific requirements of a prospective randomized clinical trial [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery (MIS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eopen surgery\u003c/p\u003e \u003cp\u003e(OS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.931\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 76.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 70.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 29.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.0\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.443\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.658\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e474.9\u0026thinsp;\u0026plusmn;\u0026thinsp;179.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e535.3\u0026thinsp;\u0026plusmn;\u0026thinsp;153.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Lesser toe deformity (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHammer toe Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClaw toe Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMallet toe Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetatarsal Procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.724\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSignificance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eU: Mann Whitney U, χ\u0026sup2;: Chi-square\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Surgical techniques\u003c/h2\u003e \u003cp\u003eMinimally invasive correction was achieved by percutaneous release of the plantar capsule of the proximal interphalangeal joint and disintegration of the short flexor in combination with a percutaneous plantarizing closing wedge osteotomy of the suprabasal proximal phalanx with optional release of the metatarsophalangeal joint and a dorsal closing wedge osteotomy of the middle phalanx, if necessary. Retention was secured by a 1.4 mm retrograde longitudinal K-wire transfixion into the base of the proximal phalanx. In case of metatarsalgia additional distal minimally invasive metatarsal osteotomy (DMMO) was optional. Open surgical correction was mostly performed using z-split of the long extensor tendon for planned lengthening, balanced release of the metatarsophalangeal joint, v-shaped arthrodesis of the proximal interphalangeal joint with longitudinal K-wire transfixion into the metatarsal bone and, if necessary, subcapital elevating osteotomy of the metatarsal with screw fixation. Both groups received K-wire transfixion for all types of deformities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Patient follow-up\u003c/h2\u003e \u003cp\u003ePreoperatively, baseline information was gathered such as demographics, health conditions, history of foot treatments, mechanical issues in footwear, type of deformity and risk factors in case report forms. Functional status was determined by foot function index Germany (FFI-D) 23-items questionnaire with known test reliability and validity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Final scoring was achieved by summation of each patient\u0026rsquo;s statements reaching from 1 to 9 per item. Standard radiography was performed prior to the intervention, postoperatively at the ward and during the follow-up examination after 18 months. After the operation the patients were evaluated by compliance and clinical course. Any complications were documented, e.g. ischemia, prolonged wound healing, surgical site infection, K-wire issues or deep vein thrombosis. Patients were asked about their personal satisfaction regarding the surgical results, their readiness to hypothetically repeat the procedure and their will to recommend the treatment to other patients or family members via patient related outcome measurement questionnaire. Furthermore, clinical evaluation of the lesser toe correction in all 3 dimensions was performed. The clinical und radiological control 18 months after surgery was focused on long-term complications, such as scaring, strictures, arthrofibrosis, neuropathic pain or dysesthesia, recurrent deformity, non-union or instability. Function and satisfaction questionnaires were also completed during the final follow-up examination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics for Windows, Version 29.0.2.0 (IBM Corp., Armonk NY, released 2023). Primarily, data were analyzed using descriptive statistics displaying mean, median and standard deviation. Variables were tested regarding normal distribution with Kolmogorov test or Shapiro-Wilk test. If normal distribution was missing nonparametric tests were applied. Significance tests on independent ordinal variables were performed using the Mann Whitney-U test. Associations between categorial variables were investigated using Pearsons\u0026rsquo;s Chi-squared test (cross tables). Dependent ordinal variables were evaluated using the Wilcoxon test. The significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eThe preoperative demographic characteristics are given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Out of the original 100 patients (50 in each group) 95 participants were reevaluated at the 18 months follow-up. 5 patients could not be included in the follow-up due to household move, serious health issues and even one case of decease not related to surgery. 47 patients received minimally invasive surgery and 48 patients had open surgery. Lesser toe deformities varied in these groups, showing more claw toes in the OS group (p\u0026thinsp;=\u0026thinsp;0.0.28). 11 of these persons could only be reevaluated by telephone or email (PROM-questionnaires). Clinical and radiological assessment was not possible for these individuals. Complete data sets were available for 84 individuals. Both study groups did not differ demographically or in follow-up period (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The majority of the patients were female. At the final follow-up, overall patient satisfaction (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e2\u003c/span\u003e) was high (88.4% satisfied and 4.2% indecisive) without any significant difference between the two surgical techniques (p\u0026thinsp;=\u0026thinsp;0.914). Functional outcome (FFI-D) as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e was comparable in both cohorts (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The number of painful days and total FFI-D-scores improved significantly for both competing technical approaches in comparison of pre- and postoperative values. (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the clinical evaluation at the final follow-up regarding three-dimensional correction of the lesser toe deformities and existence of persistent shoe conflict. Both minimally invasive and open surgeries allowed for a good overall correction rate with only 4 toes in 4 out of 84 patients having recurrent deformities. Misalignments were equally distributed to the MIS (2 toes in 2 patients) and OS group (2 toes in 2 patients) displaying no significant clinical difference (p\u0026thinsp;=\u0026thinsp;0.833). The radiological outcome of both groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e. 18 months postoperatively in the MIS group a 100% osseous consolidation rate could be observed, while in the OS group 36 out of 44 patients (58 of 66 toes) had complete bony healing. 2 patients (2 toes) showed partial osseous consolidation (p\u0026thinsp;=\u0026thinsp;0.029). 6 patients from the OS cohort presented a manifest non-union (6 toes) with no such case in the MIS group (p\u0026thinsp;=\u0026thinsp;0.013). Anatomic axial correction was achieved in both groups (p\u0026thinsp;=\u0026thinsp;0.145) with 2 cases of insufficient correction in each cohort. Complications of both cohorts are given in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Wire complications differed significantly in both groups (p\u0026thinsp;=\u0026thinsp;0.03) with 4 wire migrations in the MIS patients and 3 wire deformations in the OS patients. Impaired wound healing (p\u0026thinsp;=\u0026thinsp;0.029) and wound infection rates (p\u0026thinsp;=\u0026thinsp;0.023) were significantly higher in the OS group. No toes were lost due to ischemic complications.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSafety of the surgical techniques in lesser toe surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery (MIS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eopen surgery (OS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eintraoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncompliance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,813\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of wire complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 migrations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 bendings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 7.036\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWire bending\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 3.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWire migration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 4.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToe ischemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToe necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToe loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpaired wound healing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 4.777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0,029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 5.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeuropathic pain syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.979\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthrofibrosis MTP-joint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeloid or stricture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 1.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThromboembolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSignificance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eU: Mann Whitney U, *: incalculable\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient satisfaction 18 month postoperatively\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery (MIS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eopen surgery (OS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction (yes/indecisive/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41/2/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43/2/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWill to repeat the procedure (yes/indecisive/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42/1/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40/2/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.772\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecommendation to patients (yes/indecisive/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42/1/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41/2/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecommendation to family (yes/indecisive/no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42/1/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41/2/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSignificance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eχ\u0026sup2;: Chi square\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFFI-D preoperatively and follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery (MIS)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eopen surgery (OS)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of painful days the past week - preoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 (3.7\u0026ndash;5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 (4.1\u0026ndash;5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of painful days the past week - postoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 (0.3\u0026ndash;1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 (0.6\u0026ndash;2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean reduction painful days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ = 3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e∆ = 3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.924\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eW = -5.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eW = -5.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFFI-D points preoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.4\u0026thinsp;\u0026plusmn;\u0026thinsp;25.0 (74.9\u0026ndash;91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.1\u0026thinsp;\u0026plusmn;\u0026thinsp;27.7 (74.1\u0026ndash;95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.584\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFFI-D points postoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5 (24.7\u0026ndash;33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.9\u0026thinsp;\u0026plusmn;\u0026thinsp;26.4 (29.4\u0026ndash;46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.460\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean reduction FFI-D points\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e∆ = 59.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e∆ = 48.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eU\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.834\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eW\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;5.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eW\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;5.918\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSignificance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eW: Wilcoxon test, U: Mann Whitney U test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSD: Standard deviation, CI: Confidence interval, ∆: mean difference\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcome\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery (MIS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eopen surgery\u003c/p\u003e \u003cp\u003e(OS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical axis correction\u003c/p\u003e \u003cp\u003e(complete/satisfactory/inadequate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 / 8 / 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] / 11[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] / 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent shoe conflict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 0.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSignificance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eχ\u0026sup2;: Chi-square\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e[ ]: one patient with different results in two corrected lesser toes\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiological follow-up of the surgical techniques in lesser toe surgery 18 month postoperatively\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery (MIS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eopen surgery (OS)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einsufficient axis correction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 3.862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egood dp alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etolerable dp alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einadequate dp alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egood dp alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elateral deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emedial and lateral deviation (multiple rays)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emedial deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003einadequate ml alignment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecomplete osseous consolidation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 7.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epartial osseous consolidation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 7.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon union\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; = 6.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSignificance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eχ\u0026sup2;: Chi square, dp: dorsoplantar, ml: mediolateral\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eTo the best of our knowledge, this is the first randomized clinical trial to compare the minimally invasive and open surgical approach for lesser toe corrections with an adequate sample size and a mean follow-up of 18 months. Our main results demonstrate comparable subjective, functional and clinical patient outcomes for lesser toe corrections with the OS and MIS technique while proving a significantly lower risk for soft tissue and bone healing complications in the MIS group.\u003c/p\u003e \u003cp\u003eThe distribution of sex and age with almost 74% of females and a mean age of 63.2 years corresponded to previous studies. The comparative study of Yassin et al from 2017 included 352 patients with hammer toe deformities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. 55.9% of the patients were female and the mean age was 52.8 years. Open surgery was performed as resection arthroplasty of the proximal interphalangeal joint with K-wire fixation (265 patients with 454 toes). MIS surgery was performed using tendon release, percutaneous diaphyseal osteotomy of the middle and proximal phalanx with tape dressing for 3 weeks (87 patients with 221 toes). In conclusion OS using resection arthroplasty was not comparable to the arthrodesis approach of our study. MIS only differed in postoperative fixation regime using no K-wire and preferring Coban tape instead. The retrospective comparative study of Mateen et al from 2021 included 41 patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The MIS group consisted of 54 feet and 124 toes (71% females). Their surgical technique included soft tissue release, percutaneously burr denuding of all cartilage in the proximal interphalangeal joint and retrograde insertion of a 2.5 mm cannulated screw for arthrodesis fixation. This approach fundamentally differs from the MIS in our study. Open surgery was performed in 14 feet (22 toes) with extensor tendon lengthening, head resection of the proximal phalanx and release of the metatarsophalangeal joint using K-wire fixation (75% females). Except for the arthrodesis concept in our study this method used similar surgical steps. Mean age in the MIS group was 56\u0026thinsp;\u0026plusmn;\u0026thinsp;15 years and 54\u0026thinsp;\u0026plusmn;\u0026thinsp;14 years in the OS group. In 2017 Thomas et al. retrospectively examined 30 patients receiving distal minimally invasive metatarsal osteotomy (DMMO) for chronic metatarsalgia and MIS correction of lesser toe deformities using tendon release (Flexor digitorum longus) and percutaneous diaphyseal osteotomy of the middle and proximal phalanx with postoperative tape dressing (87% females, mean age 58 years). This surgical treatment was comparable to our MIS group, but we used K-wire fixation in all cases. Therefore, outcome comparison is limited. In the control group 30 patients received Weil osteotomy with screw fixation for chronic metatarsalgia (80% females, mean age 59 years) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A similar study was conducted in 2016 by Yeo et al. where 20 patients had DMMO without any fixation (40 toes, 92.3% females) and 13 patients (22 toes, 70% female) were treated with Weil osteotomy with screw fixation for metatarsalgia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The mean ages were 55.0\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0 years (DMMO) and 63.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0 years (Weil), resp.. This study also used different surgical procedures and provided limited information for the outcome after OS and MIS lesser toe surgery, only.\u003c/p\u003e \u003cp\u003eOverall patient satisfaction with more than 92% was high in our study. Regardless of the surgical technique only 7 out of 95 patients reported dissatisfaction with their results after the 18 months period. Furthermore, 89% of the patients expressed their will to undergo the procedure again, if necessary. More than 90% would have given a corresponding recommendation to other patients or even family members. These findings did not differ between the two study groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Further analysis of the dissatisfying cases could reveal the main clinical issues to improve the patient experience. Yeo et al. used the RAND-36-score to measure the health based quality of life in their comparative study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This score measures functioning and pain, but also social and psychological well-being, so the comparability with our study, in addition to the surgical differences, is limited. After a 6 months follow-up the Weil group achieved a significantly better mean score (92 points) than the DMMO group (78 points), which the authors justified by the prolonged swelling caused by MIS. These results differed from our satisfaction findings 18 months following surgery. Yassin et al. reported similar patient satisfaction rates for the open and percutaneous group in their comparative hammer toe study from 2017, but did not quantify this statement [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Mateen and Thomas did not make any statement about patient satisfaction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Coughlin et al. reported an 84% satisfaction rate in their non-comparative study regarding OS of 118 hammer toes with resection arthroplasty of the proximal interphalangeal joint [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. O\u0026rsquo;Kane in 2005 found a 93% satisfaction rate after resection arthroplasty for hammer toe deviation in 75 treated patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Lehmann and Smith examined patient satisfaction after open correction of 137 hammer toe deformities using the peg-in-hole technique. Limited and full satisfaction was reported in 85% of the cases [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Cicchinelli et al. in their study about 25 patients with intramedullary fixation devices after open hammer toe correction reported full satisfaction in 84% of the cases and limited satisfaction in the remaining 16% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These results were confirmed by Harmer et al in 2017 who registered less complaints after OS for hammer toes in 38 patients for 92.8% of the cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To the best of our knowledge, data regarding subjective results after MIS correction for lesser toe deformities could not be found, but the patient satisfaction rates after toe correction in general seem to be high. This has been confirmed in our study for both surgical techniques.\u003c/p\u003e \u003cp\u003eUsing patient related outcome measurements (PROM) is a common method to evaluate postoperative results. Because of the given reliability and validity we decided to use the FFI score [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Other scores such as the forefoot score of the American Orthopedic Foot and Ankle Society (AOFAS) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the EFAS score [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] or the Manchester Oxford Foot Questionnaire (MOXFQ) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] are being used widely in international studies. Out of the four known mentioned comparative studies regarding lesser toe surgery or metatarsalgia only Yeo et al. used AOFAS and RAND 36 scores [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] to evaluate their functional results [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. They found a significant improvement over time, but no difference between the two surgical techniques (postoperative p\u0026thinsp;=\u0026thinsp;0.831) which goes along with our findings. Other studies investigating clinical results after OS of the lesser toes also found good to excellent values in their follow-up [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This could be confirmed for MIS correspondingly [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In conclusion, both surgical techniques for lesser toe correction seem to deliver the desired functional results even though these scores are not fully comparable.\u003c/p\u003e \u003cp\u003eIn our study 80 out of the 84 patients had a good to excellent axis correction (95.2%). Two patients of the MIS group and two patients of the OS group showed recurrent deformities in the follow-up (p\u0026thinsp;=\u0026thinsp;0.883), even though there were more claw toe deformities in the OS group preoperatively. Persistent shoe conflicts (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and scar strictures or cases of arthrofibrosis (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e6\u003c/span\u003e) also were very rare and showed no difference between the two cohorts (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), so we conclude, that both techniques are capable of achieving favourable and comparable clinical results. We used K-wire fixation for maintaining the correction in both groups, exclusively. Yassin et al. found recurrent deformities in 6.2% of the cases and an indication for revision surgery in 2.6% of them [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Mateen et al documented 4 cases of recurrent deviations in the MIS group with no such case in the OS group. Because of the small sample size this difference was not statistically significant [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Yeo et al. found a much better postoperative mobility for the metatarsal phalangeal joint in comparison to the Weil osteotomy (p\u0026thinsp;=\u0026thinsp;0.043), which is most likely due to the extraarticular location of the osteotomy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For the open lesser toe surgery Kramer et al. found recurrent deformities in 5.6% of their 2,698 treated hammer toes. In 3.5% of the cases this led to revision surgery [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Other studies even found rates up to 17% for persistent lesser toe deformities after open surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. MIS also showed good clinical results with recurrence rates from 0 to 3.7% in our literature review [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. All in all, both surgical techniques seem to deliver good clinical results in lesser toe correction, most likely dependent on the experience of the surgeon. Data regarding shoe conflicts, and persistent scar strictures or arthrofibrosis could not be found in the literature.\u003c/p\u003e \u003cp\u003eIn the radiological control after 18 months more than 92% of the corrected toes did show successful osseous healing and anatomic alignment. Both cohorts featured two manifest recurrent deformities each (p\u0026thinsp;=\u0026thinsp;0.593) in the follow-up. Thus, total recurrence rate was 4.8%, which is in accordance with the studies mentioned above. A statistically significant difference between the two study groups was found in the bone healing process. 6 of the 44 OS patients radiographically developed a non-union while none of the MIS patients had a bone healing complication. This might be due to the location and the portion of the osteotomy. The osteotomy is articular-sided and with complete separation in the OS cohort, whereas in the MIS group one cortex generally stays intact at the junction of the diaphysis to the metaphysis. Vascular supply might also play a vital role in this context which is assumed to be better preserved in the MIS technique.\u003c/p\u003e \u003cp\u003eMateen et al. found comparable periods for bone healing in their MIS and OS groups (p\u0026thinsp;=\u0026thinsp;0.065) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Yeo et al. documented a 100% consolidation rate for all of their patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Other studies regarding open lesser toe surgery found fusion rates from 81 to 100% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Minimally invasive lesser toe surgery generally led to full bony consolidation with non-unions in isolated cases, only as reported by others [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These data suggest that MIS can provide adequate axis correction and comparable with OS at a lower risk for bone healing complications.\u003c/p\u003e \u003cp\u003e15 of the 95 patients were labelled as incompliant postoperatively. This led to four wire migrations in the MIS group and three wire deformations in the OS group which was seen as a significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.03). This might be caused by the positioning of the wire during the different procedures. Open surgery used a wire fixation within the metatarsal bone, while with the MIS procedure wires were placed in the basal phalanx, only. Overall wire complications were seen in 7.4% of the cases. Mateen et al had 4% unexpected screw removals in their minimally invasive cohort, but no wire issues in their open surgical cohort [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Yassin et al. reported 5.5% wire migrations in their OS group. In the MIS group taping was used for fixation, so no wire problems could occur [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A large retrospective study with 2017 open surgical treatments of lesser toe deformities was conducted by McKenzie et al. They found 1.14% non-infection based wire migrations in all cases [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. All in all, implant migration seems to be an infrequent phenomenon with specific risks for every implant. Another notable complication is ischemia. We only had one case with postoperative ischemia in the OS group, which could be fixed by reducing the toe length on the wire. Not a single toe was lost due to postoperative ischemic problems. Yassin et al. reported 0.5% ischemic complications resulting in toe amputation in 0.25% of the cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. 0.6% of the 1,000 hammer toes that were corrected in OS from the retrospective study of Kramer et al. suffered from ischemia and 0.4% of the cases ended in toe amputation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Consistent with our findings these complications are rare. A parameter of paramount importance for the success of lesser toe surgery is soft tissue healing because complications in this field can lead to severe consequences like surgical site infections. In our study 7 patients with OS (7.4%) developed impaired and prolonged soft tissue healing which resulted in 5 superficial wound infections (5.3%). The MIS group contained one such case without consecutive deep infection, only. In conclusion, a clear advantage for MIS regarding soft tissue healing (p\u0026thinsp;=\u0026thinsp;0.029) and wound infection (p\u0026thinsp;=\u0026thinsp;0.023) can be derived even though higher temperature might occur due to the intraoperative use of high-speed rotating instruments with the potential of a heat necrosis. In analogy with our data Yassin et al. found 7% of wound complications and 4% of wound infections in the OS group, but surprisingly high 20% with compromised soft tissue healing and 2.3% surgical site infections in the MIS group [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Mateen et al reported 0.8% wound complications in the MIS group and 4.6% for OS without any case of deep infection[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Other non-comparative studies showed infection rates from 0.3 to 4.9% for OS of lesser toe deformities [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and rates from 0 to 13% infections for MIS [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These rates vary for various reasons including the individual expertise. Maidmann et al. described that comorbidities such as diabetes mellitus, chronic obstructive lung disease and osteoporosis could considerably increase the risk for wound infections in lesser toe surgery by up to 4 times [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In our study, we found 3 patients in each cohort having neuropathic pain after 18 months follow-up (p\u0026thinsp;=\u0026thinsp;0.2). Richmann et al. saw single cases of long-lasting local hypesthesia, peroneal nerve neuritis or persistent local pain syndrome in their study including 99 patients with OS [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Other studies investigating the results after MIS for hammer toe deformities could not identify any neuropathic complications [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. All in all, both procedures under discussion appear to be reliable and safe.\u003c/p\u003e \u003cp\u003eThe main limitations of this study are seen in the monocentric design and possible surgical bias regarding clinical and radiological evaluation, the relatively short mean follow-up duration of 18 months. The known weaknesses of the FFI scoring system such as missing documentation of joint mobility and stability or the evaluation of toe positioning and footwear are to mention even though this score has been one of the most frequently used assessment instruments in foot an ankle surgery until today [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, only 20 out of the 95 patients had solitary lesser toe corrections. 75 patients had undergone additional forefoot procedures simultaneously which might have affected the results. Multicentric studies with larger patient cohorts and longer follow-up periods are to be conducted to confirm our findings. Moreover, other validated scoring systems, such as the EFAS score could be used to reach a broader audience and present better comparability. For the radiological outcome evaluation using computed tomography would be the most delicate tool, even though in clinical routine this is not the standard in surgery of the lesser toes.\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eBoth MIS and OS techniques for correction of lesser toe deformities were found to be safe and reliable procedures with high patient satisfaction rates. Clinical, radiological and functional outcome were comparable for both study groups. MIS appeared to have a significantly better risk profile regarding soft tissue and bone healing than OS. This may lead to a clinical preference in favor of the MIS technique, but OS for hammer and claw toes is widespread and MIS is not available everywhere. The final decision lies in the hand of the experienced surgeon on the basis of his personal expertise and should be made individually for every patient.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eACKNOWLEDGEMENTS\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eDECLARATION OF COMPETING INTERESTS\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003eREGISTRATION\u003c/p\u003e\n\u003cp\u003ewww.drks.de\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNumber: 00034137\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eS. Mateen, S. Raja, D. J. Casciato, und N. A. Siddiqui, \u0026bdquo;Minimally Invasive Versus Open Hammertoe Correction: A Retrospective Comparative Study.\u0026ldquo;, \u003cem\u003eJ. Foot Ankle Surg. Off. Publ. Am. Coll. Foot Ankle Surg.\u003c/em\u003e, Bd. 63, Nr. 2, S. 156\u0026ndash;160, Apr. 2024, doi: 10.1053/j.jfas.2023.09.014.\u003c/li\u003e\n\u003cli\u003eM. Yassin, A. Garti, E. Heller, und D. Robinson, \u0026bdquo;Hammertoe Correction With K-Wire Fixation Compared With Percutaneous Correction.\u0026ldquo;, \u003cem\u003eFoot Ankle Spec.\u003c/em\u003e, Bd. 10, Nr. 5, Art. Nr. 5, Okt. 2017, doi: 10.1177/1938640016681069.\u003c/li\u003e\n\u003cli\u003eN. E. M. Yeo, B. Loh, J. Y. Chen, A. K. S. Yew, und S. Y. Ng, \u0026bdquo;Comparison of early outcome of Weil osteotomy and distal metatarsal mini-invasive osteotomy for lesser toe metatarsalgia.\u0026ldquo;, \u003cem\u003eJ. Orthop. \u003c/em\u003e\u003cem\u003eSurg. Hong Kong\u003c/em\u003e, Bd. 24, Nr. 3, S. 350\u0026ndash;353, Dez. 2016, doi: 10.1177/1602400315.\u003c/li\u003e\n\u003cli\u003eM. Thomas und M. Jordan, \u0026bdquo;Minimal-invasive Korrektur von Deformit\u0026auml;ten der Kleinzehen und Behandlung der Metatarsalgie\u0026ldquo;, \u003cem\u003eOper. \u003c/em\u003e\u003cem\u003eOrthop. Traumatol.\u003c/em\u003e, Bd. 30, Nr. 3, S. 171\u0026ndash;183, Juni 2018, doi: 10.1007/s00064-018-0548-6.\u003c/li\u003e\n\u003cli\u003eK. F. Schulz, D. G. Altman, und D. Moher, \u0026bdquo;CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials.\u0026ldquo;, \u003cem\u003eOpen Med. Peer-Rev. Indep. Open-Access J.\u003c/em\u003e, Bd. 4, Nr. 1, S. e60-68, 2010.\u003c/li\u003e\n\u003cli\u003eF. D. Naal, F. M. Impellizzeri, M. Huber, und P. F. Rippstein, \u0026bdquo;Cross-cultural adaptation and validation of the Foot Function Index for use in German-speaking patients with foot complaints.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 29, Nr. 12, Art. Nr. 12, Dez. 2008, doi: 10.3113/FAI.2008.1222.\u003c/li\u003e\n\u003cli\u003eM. J. Coughlin, J. Dorris, und E. Polk, \u0026bdquo;Operative repair of the fixed hammertoe deformity.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 21, Nr. 2, Art. Nr. 2, Feb. 2000, doi: 10.1177/107110070002100202.\u003c/li\u003e\n\u003cli\u003eC. O\u0026rsquo;Kane und T. Kilmartin, \u0026bdquo;Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 26, Nr. 4, Art. Nr. 4, Apr. 2005, doi: 10.1177/107110070502600408.\u003c/li\u003e\n\u003cli\u003eD. E. Lehman und R. W. Smith, \u0026bdquo;Treatment of symptomatic hammertoe with a proximal interphalangeal joint arthrodesis.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 16, Nr. 9, S. 535\u0026ndash;541, Sep. 1995, doi: 10.1177/107110079501600904.\u003c/li\u003e\n\u003cli\u003eL. D. Cicchinelli, J. \u0026Scaron;talc, M. Richter, und S. Miller, \u0026bdquo;Prospective, Multicenter, Clinical and Radiographic Evaluation of a Biointegrative, Fiber-Reinforced Implant for Proximal Interphalangeal Joint Arthrodesis.\u0026ldquo;, \u003cem\u003eFoot Ankle Orthop.\u003c/em\u003e, Bd. 5, Nr. 4, S. 2473011420966311, Okt. 2020, doi: 10.1177/2473011420966311.\u003c/li\u003e\n\u003cli\u003eJ. L. Harmer, A. Wilkinson, und A. J. Maher, \u0026bdquo;A Midterm Review of Lesser Toe Arthrodesis With an Intramedullary Implant.\u0026ldquo;, \u003cem\u003eFoot Ankle Spec.\u003c/em\u003e, Bd. 10, Nr. 5, S. 458\u0026ndash;464, Okt. 2017, doi: 10.1177/1938640017704943.\u003c/li\u003e\n\u003cli\u003eC. C. Tan, A. A. Sayampanathan, Y. H. Kwan, W. Yeo, I. Singh Rikhraj, und N. E. M. Yeo, \u0026bdquo;Validity and Reliability of the American Orthopaedic Foot and Ankle Society Score for the English-Literate Singapore Population With Hallux Valgus.\u0026ldquo;, \u003cem\u003eFoot Ankle Spec.\u003c/em\u003e, Bd. 17, Nr. 4, S. 329\u0026ndash;335, Aug. 2024, doi: 10.1177/19386400221079490.\u003c/li\u003e\n\u003cli\u003eM. Richter, \u0026bdquo;EFAS Score validated in 13 languages with more than 3 billion total speakers.\u0026ldquo;, \u003cem\u003eFoot Ankle Surg. Off. J. Eur. Soc. Foot Ankle Surg.\u003c/em\u003e, Bd. 29, Nr. 3, S. 179, Apr. 2023, doi: 10.1016/j.fas.2023.02.009.\u003c/li\u003e\n\u003cli\u003eJ. Dawson \u003cem\u003eu. a.\u003c/em\u003e, \u0026bdquo;The MOXFQ patient-reported questionnaire: assessment of data quality, reliability and validity in relation to foot and ankle surgery.\u0026ldquo;, \u003cem\u003eFoot Edinb. Scotl.\u003c/em\u003e, Bd. 21, Nr. 2, S. 92\u0026ndash;102, Juni 2011, doi: 10.1016/j.foot.2011.02.002.\u003c/li\u003e\n\u003cli\u003eR. D. Hays, C. D. Sherbourne, und R. M. Mazel, \u0026bdquo;The RAND 36-Item Health Survey 1.0.\u0026ldquo;, \u003cem\u003eHealth Econ.\u003c/em\u003e, Bd. 2, Nr. 3, S. 217\u0026ndash;227, Okt. 1993, doi: 10.1002/hec.4730020305.\u003c/li\u003e\n\u003cli\u003eR. Caterini, P. Farsetti, U. Tarantino, V. Potenza, und E. Ippolito, \u0026bdquo;Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 25, Nr. 4, S. 256\u0026ndash;261, Apr. 2004, doi: 10.1177/107110070402500411.\u003c/li\u003e\n\u003cli\u003eJ. C. Schrier, N. L. Keijsers, G. A. Matricali, J. W. K. Louwerens, und C. C. P. M. Verheyen, \u0026bdquo;Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized Clinical Trial.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 37, Nr. 6, Art. Nr. 6, Juni 2016, doi: 10.1177/1071100716629776.\u003c/li\u003e\n\u003cli\u003eB. Molenaers, J. Vanlommel, und P. Deprez, \u0026bdquo;Percutaneous hardware free corrective osteotomy for bunionnette deformity.\u0026ldquo;, \u003cem\u003eActa Orthop. Belg.\u003c/em\u003e, Bd. 83, Nr. 2, S. 284\u0026ndash;291, Juni 2017.\u003c/li\u003e\n\u003cli\u003eL. Ram\u0026iacute;rez-Andr\u0026eacute;s, E. Nieto-Garc\u0026iacute;a, E. Nieto-Gonz\u0026aacute;lez, N. L\u0026oacute;pez-Ejeda, und J. Ferrer-Torregrosa, \u0026bdquo;Effectiveness of minimally invasive surgery using incomplete phalangeal osteotomy for symptomatic curly toe of adults with a trapezoidal phalanx: An observational study.\u0026ldquo;, \u003cem\u003eFront. Surg.\u003c/em\u003e, Bd. 9, S. 965238, 2022, doi: 10.3389/fsurg.2022.965238.\u003c/li\u003e\n\u003cli\u003eG. F. Ferreira, T. F. Dos Santos, D. Oksman, und M. V. Pereira Filho, \u0026bdquo;Percutaneous Oblique Distal Osteotomy of the Fifth Metatarsal for Bunionette Correction.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 41, Nr. 7, S. 811\u0026ndash;817, Juli 2020, doi: 10.1177/1071100720917906.\u003c/li\u003e\n\u003cli\u003eS. Haque, R. Kakwani, C. Chadwick, M. B. Davies, und C. M. Blundell, \u0026bdquo;Outcome of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Lesser Toe Metatarsalgia.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 37, Nr. 1, S. 58\u0026ndash;63, Jan. 2016, doi: 10.1177/1071100715598601.\u003c/li\u003e\n\u003cli\u003eM. Lopez-Vigil, S. Suarez-Garnacho, V. Mart\u0026iacute;n, C. Naranjo-Ruiz, und C. Rodriguez, \u0026bdquo;Evaluation of results after distal metatarsal osteotomy by minimal invasive surgery for the treatment of metatarsalgia: patient and anatomical pieces study.\u0026ldquo;, \u003cem\u003eJ. Orthop. Surg.\u003c/em\u003e, Bd. 14, Nr. 1, S. 121, Mai 2019, doi: 10.1186/s13018-019-1159-0.\u003c/li\u003e\n\u003cli\u003eW. C. Kramer, M. Parman, und R. M. Marks, \u0026bdquo;Hammertoe correction with k-wire fixation.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 36, Nr. 5, Art. Nr. 5, Mai 2015, doi: 10.1177/1071100714568013.\u003c/li\u003e\n\u003cli\u003eH. R. Martin und A. R. Kadakia, \u0026bdquo;Patient-Reported Outcome Measurement Information System Measures for Proximal Interphalangeal Joint Arthrodesis in Lesser Toe Deformities.\u0026ldquo;, \u003cem\u003eFoot Ankle Spec.\u003c/em\u003e, S. 19386400231208518, Nov. 2023, doi: 10.1177/19386400231208518.\u003c/li\u003e\n\u003cli\u003eO. W. 2nd Ohm, M. McDonell, und W. A. Vetter, \u0026bdquo;Digital arthrodesis: an alternate method for correction of hammer toe deformity.\u0026ldquo;, \u003cem\u003eJ. Foot Surg.\u003c/em\u003e, Bd. 29, Nr. 3, S. 207\u0026ndash;211, Juni 1990.\u003c/li\u003e\n\u003cli\u003eM. Gilheany, O. Baarini, und D. Samaras, \u0026bdquo;Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators.\u0026ldquo;, \u003cem\u003eJ. Foot Ankle Res.\u003c/em\u003e, Bd. 8, S. 17, 2015, doi: 10.1186/s13047-015-0073-x.\u003c/li\u003e\n\u003cli\u003eS. Frey, M. H\u0026eacute;lix-Giordanino, und B. Piclet-Legr\u0026eacute;, \u0026bdquo;Percutaneous correction of second toe proximal deformity: Proximal interphalangeal release, flexor digitorum brevis tenotomy and proximal phalanx osteotomy\u0026ldquo;, \u003cem\u003eOrthop. Traumatol. Surg. Res.\u003c/em\u003e, Bd. 101, Nr. 6, S. 753\u0026ndash;758, Okt. 2015, doi: 10.1016/j.otsr.2015.06.009.\u003c/li\u003e\n\u003cli\u003eJ. C. McKenzie \u003cem\u003eu. a.\u003c/em\u003e, \u0026bdquo;Incidence and Risk Factors for Pin Site Infection of Exposed Kirschner Wires Following Elective Forefoot Surgery.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 40, Nr. 10, S. 1154\u0026ndash;1159, Okt. 2019, doi: 10.1177/1071100719855339.\u003c/li\u003e\n\u003cli\u003eS. D. Maidman \u003cem\u003eu. a.\u003c/em\u003e, \u0026bdquo;Comorbidities Associated With Poor Outcomes Following Operative Hammertoe Correction in a Geriatric Population.\u0026ldquo;, \u003cem\u003eFoot Ankle Orthop.\u003c/em\u003e, Bd. 5, Nr. 4, S. 2473011420946726, Okt. 2020, doi: 10.1177/2473011420946726.\u003c/li\u003e\n\u003cli\u003eS. H. Richman, M. B. P. Siqueira, K. A. McCullough, und M. J. Berkowitz, \u0026bdquo;Correction of Hammertoe Deformity With Novel Intramedullary PIP Fusion Device Versus K-Wire Fixation.\u0026ldquo;, \u003cem\u003eFoot Ankle Int.\u003c/em\u003e, Bd. 38, Nr. 2, Art. Nr. 2, Feb. 2017, doi: 10.1177/1071100716671883.\u003c/li\u003e\n\u003cli\u003eE. Budiman-Mak, K. J. Conrad, J. Mazza, und R. M. Stuck, \u0026bdquo;A review of the foot function index and the foot function index - revised.\u0026ldquo;, \u003cem\u003eJ. Foot Ankle Res.\u003c/em\u003e, Bd. 6, Nr. 1, S. 5, Feb. 2013, doi: 10.1186/1757-1146-6-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Lesser toe deformities, minimally invasive surgery, open surgery, safety, outcome, hammer toe, claw toe","lastPublishedDoi":"10.21203/rs.3.rs-6682347/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6682347/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to compare soft and hard outcome measures after minimally invasive (MIS) versus open surgical treatment (OS) of lesser toe deformities. We hypothesized that minimally invasive treatment would be associated with fewer complications alongside comparable subjective and objective results.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective randomized controlled study was designed. 100 patients were included and randomized into two groups. The patients were evaluated clinically, functionally and radiologically prior to surgery and in a follow up of 1.5 years, resp. Additionally, they were asked about their personal satisfaction via patient-reported outcome measures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAs anticipated, we found significantly more wound complications including infections in the open surgery group (p\u0026thinsp;=\u0026thinsp;0.029). K-wire issues were distributed equally between the groups but differed in their clinical appearance (p\u0026thinsp;=\u0026thinsp;0.03). Hospital stay was significantly reduced in the MIS group (p\u0026thinsp;=\u0026thinsp;0.004). Only 7 out of the finally examined 95 patients were dissatisfied with their long-term results equally distributed between both groups (4 MIS vs. 3 OS, p\u0026thinsp;=\u0026thinsp;0.914). The clinical and radiological corrections of the lesser toes were comparably good in both groups, but the open surgery group showed significantly more non-unions (p\u0026thinsp;=\u0026thinsp;0.0013). The functional evaluation via FFI-D (Foot Function Index Germany), a validated reliable and internationally used standardized questionnaire to assess the correlation between foot deformity and function, also demonstrated a relevant improvement of all patients\u0026rsquo; abilities postoperatively without any difference between the two technical approaches (p\u0026thinsp;=\u0026thinsp;0.460).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLesser toe surgery is a low-risk treatment with good overall results. Minimally invasive surgery offers equivalent clinical outcomes with lower risk of complications in soft tissue and bone healing.\u003c/p\u003e\u003ch2\u003eLevel of evidence\u003c/h2\u003e \u003cp\u003eLevel 1 prospective randomized controlled study. TRN DKRS00034137, 25.04.2024\u003c/p\u003e","manuscriptTitle":"Correction of lesser toe deformities: Minimally invasive versus open surgery – A prospective randomized study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-11 18:47:17","doi":"10.21203/rs.3.rs-6682347/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-26T18:32:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-26T08:11:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T14:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294245773247217110765535873495031625126","date":"2025-06-17T21:38:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16385539309573244554896663394636395159","date":"2025-06-10T05:20:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293375495147332868023855605985918311619","date":"2025-06-09T05:14:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-09T01:17:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-19T14:06:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T13:59:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-05-16T16:14:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3b6077bb-5f1a-40bc-b3d5-2a7409a1e996","owner":[],"postedDate":"June 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:05:59+00:00","versionOfRecord":{"articleIdentity":"rs-6682347","link":"https://doi.org/10.1007/s00402-025-06114-1","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2025-11-24 15:57:05","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-06-11 18:47:17","video":"","vorDoi":"10.1007/s00402-025-06114-1","vorDoiUrl":"https://doi.org/10.1007/s00402-025-06114-1","workflowStages":[]},"version":"v1","identity":"rs-6682347","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6682347","identity":"rs-6682347","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}