_applied_  
_sciences_  
_Review_  
**Minimally Invasive Metatarsal Osteotomies (MIMOs) for the Treatment of Plantar Diabetic Forefoot Ulcers (PDFUs):**  
**A Systematic Review and Meta-Analysis with Meta-Regressions**  
**[PERSON] 1,*\(\copyright\), [PERSON] 1,2,*\(\copyright\), [PERSON] 1, [PERSON] 3,4, [PERSON] 1,5, [PERSON] 1 and [PERSON] 1\(\copyright\)**  
1 Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padova, 35129 Padova, Italy, [EMAIL_ADDRESS] (A.C.J.; [EMAIL_ADDRESS] (P.N.); [EMAIL_ADDRESS] (F.M.); [EMAIL_ADDRESS] (P.R.).
2 Musculoskeletal Patindogy and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padova, 35129 Padova, Italy
3 Department of Mathematics and Statistics, Laboratory for Industrial and Applied Mathematics (LIAM), York University, Toronto, ON MJ 1P3, Canada; [EMAIL_ADDRESS]
4 Leeds Institute of rheumatic and Musculoskeletal Medicalicine (LIRMM), University of Leeds, Leeds LS7 4 SA, UK
5 Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35128 Padova, Italy
*Correspondence: [EMAIL_ADDRESS] (C.B.); [EMAIL_ADDRESS] (E.B.); Tel.: +39-049-821-3329 (E.B.)  
**Abstract: Plantar Diabetic Foot Ulcers (PDFUs) are frequent injuries affecting and heavily limiting the quality of life in diabetic patients. PDFUs can be treated both conservatively (with a high recurrence rate) or surgically (with a high rate of complication). Recently, minimally invasive surgery (MIS), performed by small incisions, has been increasingly applied on diabetic feet due to their encouraging outcomes and low complication rate. This systematic review with meta-analysis and meta-regression aims to evaluate for the first time the effectiveness of minimally invasive metatarsal osteectomies (MIMOs) in treating PDFUs and reducing their recurrence rate. A literature search of PubMed/MEDLINE, ISI/Web of Science and Scopus databases was carried out with the keywords \"(metatarsal osteotom*) OR (metatarsal AND osteotom*) AND diabetic* AND (feet OR foot OR forefoot) AND ulcer\", covering the period from 1980 until June 2021 following PRISMA guidelines. The JBI critical appraisal tool was used for Quality Assessment. Healing rate/time, infection rate, recurrence rate, non-union rate and complication rate were evaluated. When possible, these values were pooled and expressed in effect size (ES), and their 95% confidence interval (CI) was computed. Meta-regression analysis (both uni- and multivariate) was conducted. Eight studies were included in the review, including 189 patients. The healing rate of these studies ranged between 55.1 and 100%, infection rate from 3.3 to 31.8%, recurrence rate from 0.0% and 13.6% and non-union rate from 4.5-30.0%. Overall complication rate was reported in three studies and ranged from 44.9 to 68.2%. Meta-analysis of the various rates revealed an overall healing rate of 91.9% (range from 74.9 to 97.8%), infection rate of 10.9% (4.2-25.2%), recurrence rate 7.2% (3.6-14.2%), non-union rate 16.9% (10.2-26.7%) and finally, the complication rate was computed at 53.2%. Satisfactory short- to medium-term clinical and radiographic results were reported by the studies included in this review, supporting that MIMOs represent an effective surgical approach to treat PDFUs. However, poor quality in the methodology of some studies and the lack of long-term data were reported. Therefore, randomized controlled trials, prospective studies and long-term follow-up studies are needed.  
**Keywords:** diabetes; diabetic ulcers; foot; foot ulcer; meta-analysis; metatarsal bone; metatarasalgia; minimally invasive surgery; osteotomy; systematic review