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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 96-106

Analysis of different osteotomies used in hallux valgus: A systematic review

1 Department of Orthopedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Orthopaedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA; Department of Orthopedic Surgery, College of Medicine, Ain Shams University, Cairo, Egypt
3 Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA

Date of Submission31-Aug-2020
Date of Decision24-Sep-2020
Date of Acceptance24-Oct-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Prof. Yasser Elbatrawy
Department of Orthopedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-3719.305859

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Background: A variety of metatarsal (MT) osteotomies have been described for the treatment of hallux valgus (HV) deformity. Many of these techniques were abandoned throughout the years. Because no one procedure has shown to be capable of correcting all types of HV deformities, clinicians have adopted treatment algorithms. Objective: This work aims to review different methods of, as well as indications and contraindications for osteotomies to treat HV in the literature, and provide cumulative data about the intermediate to long-term management of HV. Patients and Methods: An online search was performed using the Medline database on PubMed, Google Scholar, and Science Direct from 2000 to 2019. All English language published studies describing osteotomies in HV were identified and analyzed. Results: Twenty-eight studies were identified from 2000 to 2019. Seventeen of the studies (60.7%) were prospective, whereas 5 studies (17.9%) were retrospective. The most common procedure used were Chevron (10 studies), followed by Reverdin (4 studies), Bosch (4 studies), Magnan (3 studies), Akin (2 studies), and Scarf osteotomy (2 studies). Simple, effective, rapid, inexpensive (SERI), distal linear MT osteotomy, reverse L-shape osteotomy, subcapital osteotomy combined with lateral soft-tissue release, and modified Mitchel were represented by 1 study each. Conclusion: The management of HV involves several procedures. The choice of each patient's procedure depends on the degree and reducibility of deformity, the digital formula used, presence or absence of symptoms from lateral rays. It also depends on the training of the surgeon and the learning curve in his career. Interest in percutaneous surgery has been increasing for both patients and surgeons. The most commonly used procedures were Chevron in 10 studies. Complications occurred in 82.1% of studies, and only 5 (17.9%) had no complications. These studies used SERI, Chevron, Reverdin in one study and Akin in two studies. Chevron was the most commonly used procedure with less complications.

Keywords: Akin osteotomy, Bosch, chevron osteotomy, distal linear metatarsal osteotomy, hallux valgus, Magnan, modified Mitchel, Reverdin, Reverdin osteotomy, reverse L-shape osteotomy, scarf osteotomy, subcapital osteotomy

How to cite this article:
Elgoyoushi SM, Omar MA, Dabash S, Thabet AM, Elbatrawy Y. Analysis of different osteotomies used in hallux valgus: A systematic review. J Limb Lengthen Reconstr 2020;6:96-106

How to cite this URL:
Elgoyoushi SM, Omar MA, Dabash S, Thabet AM, Elbatrawy Y. Analysis of different osteotomies used in hallux valgus: A systematic review. J Limb Lengthen Reconstr [serial online] 2020 [cited 2021 Jun 19];6:96-106. Available from: https://www.jlimblengthrecon.org/text.asp?2020/6/2/96/305859

  Introduction Top

Hallux valgus (HV) is a lateral deviation of the great toe and medial displacement of the head of the first metatarsal (MT), causing a pseudo-exostosis of the medial eminence. A higher prevalence of this painful deformity is present with increasing age and in females. HV is classified as mild, moderate, and severe according to the radiological measurement of the HV angle (HVA) and the intermetatarsal angle (IMA). An HVA >15° and an IMA >9° is considered pathological.[1]

Distal MT osteotomies have been used in mild or moderate deformities with an IMA up to 20.[2] A vast number of techniques with variations in approach, osteotomy design, and fixation technique have been described.[3]

Most surgical techniques are associated with good outcomes. Still, there is neither consensus about the best management nor a clear advantage of any method over others found in the literature.[4]

More than 150 procedures have been described for conventional surgical treatment of HV. Surgical correction has been performed using many techniques that are often conceptually very different. Therefore, the surgical option is not unique, and the variety of choices has been dictated by the diversity of causal factors and the surgeon's personal preference.[5]

This study aimed to review results of different osteotomies for HV and provide cumulative data about the intermediate to long-term management of HV.

  Patients and Methods Top

Study selection

A search was conducted using the Medline database on PubMed, Google Scholar, and Science Direct for studies describing osteotomies for HV published from 2000 to 2019. Abstracts were screened for inclusion and exclusion criteria; articles that passed this initial screen were reviewed in their entirety. If there was a question of study qualification, a second reviewer assessed the article and consensus were reached. After performing a critical exclusion process, the number of eligible studies included for final synthesis considered was 28. Most of the studies were prospective: 17 studies (60.7%) followed by retrospective in 5 studies (17.9%)

Primary MEDLINE search for keywords HV; Chevron osteotomy; Akin osteotomy; Scarf osteotomy; Reverdin osteotomy; Distal linear MT osteotomy; Magnan; Bosch; Reverdin; reverse L-shape osteotomy; subcapital osteotomy; Modified Mitchel, Systematic review.

Data extraction

Data were independently extracted by two reviewers and crosschecked.

Statistical considerations

Outcomes from included trials were combined using the systematic review manager software and manually screened for eligibility to be included. A Preferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart was produced based on the search results and the inclusion/exclusion criteria [Figure 1].
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analysis

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To facilitate the assessment of possible risk of bias for each study, information was collected using the Cochrane collaboration tool.

After pooling of the collected data from the desired search studies, the relative risk of each of the intended outcome measures of interest was calculated and compared between each of the two main methods of osteotomies in HV.

Evidence of publication bias was sought using the funnel plot method

Studies included in meta-analysis were tested for heterogeneity of the estimates using the following tests:

  1. Cochran Q Chi-square test
  2. I-squared (I2) index.

Finding that all our outcomes showed heterogeneity, so we used the random-effects method.

In addition, examining publication bias for all our outcomes was assessed by reviewing Funnel plots revealing the absence of publication bias as the studies were distributed symmetrically about the combined effect size.

A funnel plot is a simple scatter plot of the intervention effect estimates from individual studies against some measure of each study's size or precision [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14].
Figure 2: Funnel plot for the complication

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Figure 3: Funnel plot for the recurrence

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Figure 4: Funnel plot for the chevron procedure

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Figure 5: Funnel plot for the Reverdin

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Figure 6: Funnel plot for the Bosch

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Figure 7: Funnel plot for the Magnan

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Figure 8: Funnel plot for the akin

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Figure 9: Funnel plot for the scarf osteototomy

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Figure 10: Funnel plot for the distal linear metatarsal osteotomy

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Figure 11: Funnel plot for the simple, effective, rapid, inexpensive

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Figure 12: Funnel plot for the reverse L-shape osteotomy

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Figure 13: Funnel plot for the subcapital osteotomy combined with lateral soft tissue release

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Figure 14: Funnel plot for the modified Mitchell

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Literature search database on PubMed showed 473 studies.

Primary screening

Three hundred and eighty-two studies were excluded due to language other than English language and other topics not related to search goals.

Secondary screening

Ninety-one were full-text articles assessed for eligibility. Sixty-three articles were excluded due to lack of functional outcome and case reports. Twenty-eight studies were included in the qualitative synthesis.

Tertiary screening

Full-text review of the 28 studies was done.

Areas of interest

Primary outcomes of interest were a range of motion, pain relief, and X-ray findings. The preoperative patients' complaints were loss of range of motion, pain over prominence at metatarsophalangeal (MTP) joint, compression of digital nerve causing symptoms, difficulty with shoe wear due to medial eminence, as well as cosmetic deformity [Figure 1].

Inclusion criteria

  1. Levels of evidence I to IV in one or more of the three primary outcomes of interest
  2. Human examinations and treatment
  3. Included measures of functional and clinical outcomes
  4. Article type: clinical trial, comparative study, or case study
  5. English or articles translated into English.

Exclusion criteria

  1. Non-English papers
  2. Non-human trials
  3. Articles with no clinical data
  4. Duplicated articles for the same authors unless with longer follow-up studies.

Points of comparison

  1. Patient characteristics and the number of cases
  2. Type of surgical procedure and mean follow-up
  3. Patient-reported functional outcome
  4. Radiological outcomes
  5. Complications.

  Results Top

Twenty-eight studies were reviewed, with a total number of 2280 patients. Seventeen studies (60.7%) were prospective, while five studies (17.9%) were retrospective. The mean number of feet included was 81.3, with (range, 6.0–408). The mean age of the included patients was 51.2 years. The mean follow-up period among studies was 27.5 months. The degree of HV mentioned in most studies as an indication of surgery as 3 studies had moderate grade, 2 studies had severe grade, six had mild\moderate grade, four studies had moderate\severe grade and eight studies had mild\moderate\severe grade [Table 1].
Table 1: Demographic data of included studies

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Regarding functional outcomes; the mean AOFAS score pre-operation was 50.42, which increased post-operation to 90.11, HVA pre-operation was 32.67°, which decreased to 12.11, IMA pre-operation was 14.86°, which decreased post-operation to 7.81, distal metatarsal articular angle (DMAA) decreased from 12.75 pre operation to 6.83 post operation. Contraindications were arthrosis, hallux rigidus with MTP stiffness, feet with previous Keller-Brandes osteotomy, osteoarthritis, hypermobility of the first tarsometatarsal joint, and a short M1 was included.

Complications occurred in 82.1% of studies. Recurrence of HV was found in 42.9%. Infection occurred in 46.4%. Skin inflammation occurred in 21.4%. K-wire pull-out occurred in 3.6%. Nonunion was reported in 17.9%. Malunion occurred in 10.7%. Hallux varus was found in 10.7%. Complex regional pain syndrome (CRPS) occurred in 3.6%. Osteonecrosis was reported in 7.1%. Transfer metatarsalgia was found in 25%. Joint stiffness was reported in 25%. Fracture occurred in 10.7% [Table 2].
Table 2: Clinical and Radiological data of included studies

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The most common procedure used was Chevron (10 studies), followed by Reverdin (4 studies), Bosch (4 studies), Magnan (3 studies), Akin (2 studies), scarf osteotomy (2 studies), and simple, effective, rapid, inexpensive (SERI), distal linear metatarsal osteotomy (DLMO), reverse L-shape osteotomy, subcapital osteotomy (SCOT) combined with lateral soft-tissue release, and modified Mitchel (1 study each). In general, good correction of the HV deformity was found with improvement in the HVA, IMA, and DMAA. Clinical improvement by the AOFAS Ankle-Hindfoot Score was also found in the included studies.

The procedures that showed no complications in some studies was SERI, Chevron, Reverdin (one study), and Akin (two studies). DLMO showed higher number of complications in 63 cases in form of (recurrence in 22, skin inflammatory reaction in 5, nonunion in 18, osteonecrosis in 2, and transfer metatarsalgia in 16).

BOSCH showed 25 complications and a higher percentage of joint stiffness in 16 cases, Reverdin-Isham had 12 complications and higher incidence of fracture in 9 cases, Magnan showed 12 complications, mostly was malunion in 5 cases, SCOT combined with lateral soft-tissue release showed complications in 11 cases in the form of transfer metatarsalgia in 3 cases, 2 recurrence, skin inflammatory reactions in 2 cases, nonunion in 2 cases, fracture in 2 cases, AKIN showed 6 complications in the form of 5 cases with recurrence and 1 with stiffness.

Chevron osteotomy was used in 10 studies with fewer complications compared to other procedures. Studies with no complications used SERI, Chevron, Reverdin (one study), and Akin (two studies). Chevron was the most commonly used procedure with less complication. It is the recommended procedure for HV deformity based on these data. DLMO, Lateral soft-tissue release procedure and Bosch techniques resulted in greater rates of HV Recurrence and Joint Stiffness.

  Discussion Top

Chevron, AKIN and Reverdin-Isham were indicated mainly in moderate and severe HV, Scarf osteotomy, Bosch, SERI, SCOT were used either in mild\moderate\severe cases. Complications were reported in 82.1% of studies [Table 1], recurrence of HV was found in 42.9% of studies. The procedures with no complications in some studies was SERI, Chevron, Reverdin (one study), and Akin (two studies).

The most common procedure used in the included studies was Chevron in 10 studies followed by Reverdin in 4 studies, Pooled analysis of all studies revealed that rate was 27.328% with 95% (confidence interval [CI] 99.34–99.48). Reverdin rate was 7.475%, Bosch rate was 6.113%, Magnan rate was 4.050%, Akin rate was 2.774%, Scarf osteotomy rate was 2.261%, DLMO rate was 1.543%, SERI rate was 1.241%, reverse L-shape osteotomy rate was 1.389%, SCOT combined with lateral soft-tissue release rate was 1.382%, and modified Mitchell rate was 1.298%.

Conflicting reports were found regarding complications encountered after surgical correction of HV. Although some investigators reported no major complications with the procedure,[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] others described significant complications which was higher in Seki which used (DLMO) and Faour-Martin who used Bosch procedure. Recurrence of the deformity was found in 42.9% of studies with rate of 2.034% with 95% (CI 57.22–80.07).[7],[8],[10],[13],[16],[20],[21],[22],[23],[24],[25],[26],[27],[28] Seki using DLMO had the highest rate of recurrence among studies (40%) [Table 5].
Table 3: Distribution of included studies complications

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Table 4: Meta-analysis of Complications

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Table 5: Meta-analysis for Recurrence

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Joint stiffness was reported in 25% of studies.[16],[17],[20],[23],[28] The study by Faour-Martin used the Bosch procedure and showed the highest rate 44.4% of joint stiffness. Malunion was seen in 17.9% of studies.[17],[25],[21] Diaz Fernandez had the highest rate 55.5% of malunion using the reverdin procedure. Infections occurred in 46.4% of studies[14],[17],[18],[20],[21],[22],[23],[27],[29],[30],[31],[32],[33],[34] and the highest rates of infections 34.48% were found in two studies by Lucas y Hernandez which used percutaneous, extra-articular reverse-L chevron osteotomy and Curtin which used Scarf osteotomy without internal fixation for correction of HV.[14],[33]

Transfer metatarsalgia was found in 25% of studies,[7],[8],[10],[14],[17],[28],[30] with the highest rate 61.53% found in the study by Seki et al. Skin inflammatory reaction was reported in 21.4% of studies,[7],[10],[20],[21],[31],[32] with the highest rates 31% found in the study by Seki et al. Nonunion occurred in 17.9% of studies,[7],[10],[21],[24],[34] with the highest rates 72% were found in the study by Seki et al[Table 3].

DLMO, lateral soft-tissue release procedure, and the Bosch techniques resulted in HV recurrence and joint stiffness. The clinical outcome measures are of the fundamental importance. The retrospective evaluation of AOFAS Ankle-Hindfoot Score could lead to an overestimation of the improvement achieved.[35] Although AOFAS is the most widely used in research, the Manchester-Oxford Foot Questionnaire has recently been validated and has shown better responsiveness.[36]

Radiologic assessments should be reviewed with caution. The studies in this paper included measurements of the HVA and IMA; however, the (DMAA) was measured in only 14 of the 28 studies included in the present systematic review.[7],[8],[9],[10],[13],[16],[17],[20],[23],[24],[26],[28],[32],[34] This is likely due to its poor inter- and intra-observe reliability.[37],[38]

  Conclusion Top

The study provides a comprehensive overview of the current literature and demonstrates the variation in outcome and complication rates among different studies in literature. The most common used procedure in the treatment of HV deformity was Chevron in 10 studies. It was found to have the least intermediate to long-term complications..Hence, it is the recommended procedure and the osteotomy of choice.

Manchester-Oxford foot questionnaire is a validated assessment survey and should be included in the foot and ankle research papers as it gives better data.

Future research should include adequately sized randomized control trials (levels II and I), standardization of treatment protocols, and the use of validated tools for the measurement of clinical outcomes before percutaneous techniques for surgery of the first MT can be validated.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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