Effectiveness of Surgery For Adults With Hallux Valgus

S YS T E M AT I C R E V I E W
Effectiveness of surgery for adults with hallux valgus

deformity: a systematic review
Jitka Klugarova 1 Victoria Hood 2 Fiona Bath-Hextall 2 Miloslav Klugar 1
Jana Mareckova 1 Zuzana Kelnarova 1
1
The Czech Republic (Middle European) Centre for Evidence-Based Healthcare: a Joanna Briggs Institute Centre of Excellence, 2The Nottingham
Centre for Evidence-Based Healthcare: a Joanna Briggs Institute Centre of Excellence
EXECUTIVE SUMMARY
Background
Hallux valgus (HV) is a common foot deformity. In severe stages of this condition, surgery is often necessary.
Currently, there is no systematic review comparing the effectiveness of surgery over conservative treatment.
Objectives
The objective of this review was to establish the effectiveness of surgery compared to conservatory management for
adults with HV.
Inclusion criteria
Types of participants
The current review included adults (18 years or over) with HV deformity, excluding adults with neurological problems
causing foot deformities, for example, cerebral palsy, neuropathy, stroke and multiple sclerosis.
Types of interventions
The review included any type of HV surgery compared to no surgery, conservative treatment or different types of HV
surgeries.
Outcomes
The primary outcome was gait measurement, and secondary outcomes included quality of life, patient satisfaction,
pain assessed using any validated assessment tool and adverse events.
Types of studies
The review included randomized controlled trials.
Search strategy
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized
in 16 databases without language and date limitations.
Methodological quality
Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion
in the review using standardized critical appraisal instruments developed by the Joanna Briggs Institute (JBI).
Data extraction
Data were extracted from papers included in the review using the standardized data extraction tool developed by
the JBI.
Data synthesis
Quantitative data were, where possible, pooled in statistical meta-analysis using RevMan5 (Copenhagen: The Nordic
Cochrane Centre, Cochrane). Effect sizes expressed as risk ratio (for categorical data) and mean differences (MD) or
standardized MD (for continuous data) and their 95% confidence intervals were calculated for analysis. Where
statistical pooling was not possible, the findings have been presented in narrative form.
Results Searching identified 2412 citations. After removal of duplicates, paper retrieval and critical appraisal,
25 studies were included in the review. The included trials were of medium-to-poor quality.
Correspondence: Jitka Klugarova, jitka.klugarova@gmail.com

There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2017-003422
JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 1671
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

SYSTEMATIC REVIEW J. Klugarova et al.
Twenty-four trials compared the effectiveness of different types of surgeries. Meta-analysis revealed no difference in
level of pain between distal chevron-type osteotomy and other surgical procedures (standard mean difference [SMD]
0.02, 95% confidence interval [CI] 0.24 to 0.28). One single trial reported that distal chevron osteotomy is more
effective than Lindgren osteotomy in terms of walking speed (MD 0.24, 95% CI 0.43 to 0.05).
One medium quality trial assessed the effectiveness of HV surgery compared to conservative or no treatment. This
trial showed that surgery, specifically distal chevron osteotomy of the first metatarsal, is a more effective procedure
for pain compared to conservative treatment (MD 15.00, 95% CI 22.79 to 7.21) and also no treatment in the
first year (MD 18.00, 95% CI 25.62 to 10.38).
Conclusion
The current systematic review showed that differences between various types of surgical procedures, specifically
osteotomies of the first metatarsal on clinical outcomes, are minimal. There is evidence from one study, that surgery,
specifically distal chevron osteotomy of the first metatarsal is a more effective procedure than conservative or no
treatment in reducing pain in the first year following surgery. However, this systematic review has identified that
there is a lack of high-quality studies comparing similar types of HV treatments that assess the same outcomes.
Keywords Conservative treatment; gait; hallux valgus; pain; quality of life; surgery
JBI Database System Rev Implement Rep 2017; 15(6):1671–1710.
Summary of findings
Distal chevron type osteotomy compared to other surgical procedures for adults with hallux valgus
Patient or population: adults with hallux valgus
Setting: Karolinska University Hospital
Intervention: distal chevron type osteotomy
Comparison: other surgical procedures
Outcome Relative Anticipated absolute effects (95% CI) Quality What happens
№ of participants effect
(studies) (95% CI)
Without distal With distal chevron type Difference
chevron type osteotomy
osteotomy
Gait measures - The mean gait The mean gait measures

(walking speed) in measures (walking (walking speed) in medium- MD 0.1 HIGH
Patients after
medium-term speed) at medium- term follow-up in the fewer
distal chevron
follow-up term follow-up was intervention group was 0.1 (0.24 fewer
osteotomy
№ of participants: 0 fewer (0.24 fewer to 0.04 to 0.04
walked faster.
22 more) more)
(1 RCT)
Gait measures - The mean gait The mean gait measures

(walking speed) in measures (walking (walking speed) in long-term MD 0.24 HIGH
Patients after
long-term follow- speed) at long-term follow-up in the intervention fewer
distal chevron
up follow-up was 0 group was 0.24 fewer (0.43 (0.43 fewer
osteotomy
№ of participants: fewer to 0.05 fewer) to 0.05
walked faster.
22 fewer)
(1 RCT)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; MD: Mean difference
GRADE Working Group grades of evidence

High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Surgery compared to conservative treatment for adults with hallux valgus

Setting: 4 general community hospitals in Finland
Intervention: surgery
Comparison: conservative treatment
№ of effect
participants (95% CI)
Without With surgery Difference
(studies)
surgery
Level of pain in - The mean level The mean level of pain in

long-term of pain in long- long-term follow-up in the MODERATE Level of pain was
MD 15 fewer
follow-up term follow-up intervention group was 15 lower after surgery
(22.79 fewer
№ of was 0 fewer (22.79 fewer to 7.21 compared to
to 7.21
participants: fewer) conservative
fewer)
140 treatment.
(1 RCT)
Level of pain in - The mean level The mean level of pain in

medium-term of pain in medium-term follow-up in MODERATE Level of pain was
MD 10 fewer
follow-up medium-term the intervention group was lower after surgery
(18.29 fewer
№ of follow-up was 0 10 fewer (18.29 fewer to compared to
to 1.71
participants: 1.71 fewer) conservative
fewer)
140 treatment.
(1 RCT)
Quality of life in - The mean The mean quality of life in

medium-term quality of life in medium-term follow-up in HIGH
follow-up medium-term the intervention group was 0 MD 0
№ of follow-up was 0 (2.29 fewer to 2.29 more) (2.29 fewer No difference
participants: to 2.29 more)
140
(1 RCT)
Quality of life in - The mean The mean quality of life in

long-term quality of life in long-term follow-up in the HIGH
MD 0.2
follow-up long-term intervention group was 0.2
fewer
№ of follow-up was 0 fewer (2.39 fewer to 1.99 No difference
(2.39 fewer
participants: more)
to 1.99 more)
140
(1 RCT)

Surgery compared to no treatment for adults with hallux valgus
Setting: 4 general community hospitals in Finland
Intervention: surgery
Comparison: no treatment
№ of effect
participants (95% CI)
Without With surgery Difference
(studies)
surgery
Pain – long- - The mean pain The mean pain – long-term in

term – long-term was the intervention group was 18 MD 18 fewer MODERATE Level of pain was
№ of 0 fewer (25.62 fewer to 10.38 (25.62 fewer lower after surgery
participants: fewer) to 10.38 compared to no
140 fewer) treatment.
(1 RCT)
Pain – - The mean pain The mean pain – medium-

medium-term – medium-term term in the intervention group MD 19 fewer MODERATE Level of pain was
№ of was 0 was 19 fewer (27.14 fewer to (27.14 fewer lower after surgery
participants: 10.86 fewer) to 10.86 compared to no
140 fewer) treatment.
(1 RCT)
Quality of life – - The mean The mean quality of life –

medium-term quality of life – medium-term in the HIGH
MD 1.5 fewer
№ of medium-term intervention group was 1.5
(4.07 fewer to No difference
participants: was 0 fewer (4.07 fewer to 1.07
1.07 more)
140 more)
(1 RCT)
Quality of life – - The mean The mean quality of life –

long-term quality of life – long-term in the intervention HIGH
MD 0.7 fewer
№ of long-term was 0 group was 0.7 fewer (2.96
(2.96 fewer to No difference
participants: fewer to 1.56 more)
1.56 more)
140
(1 RCT)

Background (FFI). du Plessis et al.6 tested the effect of a modified

allux valgus (HV) is a complex progressive structured protocol of manual and manipulative
H triplanar forefoot deformity, characterized by
a valgus deviation of the big toe, a metatarsus primus
therapy (the Brantingham protocol) on HV-related
pain (visual analog scale), FFI and range of hallux
varus and a medial prominence on its head. It devel- dorsiflexion (goniometry) compared to orthotic
ops gradually due to an interaction of biomechanical therapy using a night splint. They did not find any
factors, structural anomalies, systemic diseases, her- significant differences between these two interven-
editary predispositions and wearing of inappropriate tions after three weeks in patients with mild-to-
footwear.1 moderate HV. Bayar et al.7 reported that eight weeks
Hallux valgus is a common foot deformity. One of taping of the first ray and forefoot combined with
published systematic review with meta-analysis foot exercise decreased HVA (goniometry), foot pain
reported the wide variation in prevalence of HV, (visual analog scale) and improved walking ability
confirming higher prevalence of HV in woman and (the walking ability scale) by at least one grade in HV
older adults. Nix et al.2 found that HV deformity patients. Radovic and Shah8 demonstrated that use
effects on average 23% of adults aged 18–65 years of botulinum toxin A injection reduced the hallux
and 35.7% of older adults aged over 65 years.3 abducto valgus deformity clinically and radio-
People with HV usually complain about pain, graphically as well as pain in a 43-year-old woman
difficulties during walking and problems with foot- who presented with a chief complaint of bilateral
wear. A systematic review by Nix et al.2 found that bunion pain.
there were biomechanical changes in the gait of In severe stages of this condition, surgery is often
patients with HV. These included reduced peak of used. The aim of HV surgery is either to correct
dorsiflexion and rear foot supination during termi- the bony or soft tissues or both tissues.9 Surgical
nal stance. In older patients with HV, they described procedures for HV include simple bunionectomy,
a less stable gait pattern with reduced velocity and various soft tissue procedures, metatarsal and
stride length during walking on irregular surfaces. phalangeal osteotomies, resection arthroplasty and
Over the past 80 years, HV problems have been metatarsophalangeal arthrodesis.10 Bunionectomy is
dealt primarily by surgeons specialized in orthope- a simple procedure based on shaving off the medial
dics. In the available literature more than 130 sur- prominence on the medial side of the first MTPJ.
gical procedures have been described, correcting the Arthroplasty is a combination of bunionectomy and
axis of the first ray.4 The type of surgical procedure removal of part of the proximal phalanx; this pro-
depends on a severity of the deformity. One of the cedure is indicated in severe stages of HV and leaves
most commonly used diagnostic methods is radio- a flexible joint, but shorter first ray. Arthrodesis is a
logical assessment measuring HV angle (HVA) and more radical procedure than arthroplasty and is
1–2 intermetarsal angle (IMA): mild (HVA up to based on excision of the head of first MTPJ and
198, IMA up to 138); moderate (HVA 20 to 408, IMA fusion of the operated segment. Osteotomy of the
14 to 208); and severe (HVA > 408, IMA > 208).4 first metatarsus includes proximal and distal pro-
Although the most effective therapy is generally cedures. Distal osteotomy, for example, Chevron
prevention, in clinical practice many patients with osteotomy, is indicated in patients with mild HV
foot disorders visit a healthcare professional at a and proximal osteotomy, such as scarf osteotomy, in
more advanced stage of their problem. severe stages of HV deformity. Soft technique pro-
In mild stages of HV, conservative treatment is cedures often complement the bony pro-
recommended, and this usually involves the use of cedures.9,11,12
different types of orthoses, for example, night splints, In most cases, the effectiveness of HV treatment is
or taping. Another option is physical therapy, includ- verified using radiological examination (HVA and
ing manual therapy, mobilization, foot exercises, 1,2-intermetatarsal angle), visual analog scale
sensomotoric training, thermotherapy, hydrotherapy (pain), assessment scoring system developed by the
and ultrasound therapy. A pilot study done by Bran- American Orthopaedic Foot and Ankle Society
tingham et al.5 showed that progressive mobilization (AOFAS) (pain, satisfaction, range of movement),
of the first metatarsophalangeal joint (MTPJ) had FFI, etc.9 Stokes et al.13 did the first experimental
positive effects on pain and Foot Function Index study evaluating the effect of HV surgery using

biomechanical analysis of gait. During the last after surgery), medium-term ( six months and
30 years, many other researchers have used different <one year after surgery), and long-term ( one year
types of motion analysis software to evaluate the after surgery).
impact of HV surgery on dynamic and kinematic
parameters of gait.13-17 Types of studies
Many primary studies have evaluated the effects The review included randomized controlled trials
of surgical treatment for HV; however, to date there (RCTs) only.
is no systematic review that has studied the effect of
HV surgery or conservative management on gait, Search strategy
pain or function. The search strategy aimed to find both published and
The current review was conducted according to unpublished studies. A three-step search strategy
an a priori published protocol.18 was utilized in this review. This was followed by
the title, abstract and index terms of each article
Objectives being analyzed.
The objective of this review was to establish the An initial limited search of MEDLINE, Embase
effectiveness of surgery compared to conservatory and CINAHL used keywords, such as ‘‘hallux val-
management for adults with HV. gus,’’ ‘‘bunion,’’ ‘‘surgery’’.
A second search using all identified keywords and
Inclusion criteria index terms was undertaken in the following data-
Types of participants bases:
The current review included adults (18 years or over) MEDLINE (Ovid MEDLINE 1946 to current)
with HV deformity, excluding adults with neuro- CINAHL (CINAHL Plus with Full Text 1935 to
logical problems causing foot deformities, for current)
example, cerebral palsy, neuropathy, stroke, multiple Embase (1974 to current)
sclerosis. Trip database
Nursing@Ovid
Types of intervention(s)/phenomena of interest Web of Science
The review included any type of HV surgery com- Cochrane CENTRAL
pared to no surgery, conservative management (e.g. PEDro.
physical therapy, kinesio taping, orthosis, etc.) and The search for unpublished studies included
or different types of surgery. Google Scholar, ClinicalTrials.gov, The Grey Liter-
ature Report, Current Controlled Trials, COS Con-
Outcomes ference Papers Index, Scirus, ProQuest Dissertation
The primary outcome measure was gait measures and Theses.
(e.g. kinematic gait analysis, dynamic gait analysis Third, the reference list of all identified reports
etc.), assessed by any validated assessment tool (such and articles was searched for additional studies.
as biomechanical movement analysis etc.). Studies published in all languages were con-
The secondary outcomes included the following: sidered for inclusion in this review if they contained
Quality of life: assessed by any validated assess- an abstract written in English.
ment tool (such as SF-36, etc.) Studies published at any date were considered for
Patient satisfaction using any validated assess- inclusion in this review. Databases were searched
ment tool (such as COPM, MODEMS, from their inception to July 2014.
CGCAHPS or NRC Picker patient satisfaction Initial keywords used were as follows:
tool, etc.) hallux valgus OR halux valgus OR hallux abduc-
Pain using any validated pain assessment tool tovalgus OR halux abductovalgus OR bunion
(such as the visual analogue scale [VAS], Verbal OR great toe deformit OR big toe deformit OR
Rating Scale, McGill Pain Questionnaire, etc.) foot deformit OR forefoot deformit OR foot
Adverse events. problem
All the above outcomes could be measured at the surg OR operat OR osteotom OR arthrodes
following time points: short-term ( < six months OR arthroplas

The full search strategy is provided in Appendix I. Conference Papers Index, 12 in ClinicalTrials.gov,
0 in Grey Literature Report, 0 in Current Con-
Method of the review trolled Trials, 83 in Scirus and 50 in Google
Papers selected for retrieval were assessed for eligi- Scholar.
bility by two independent reviewers (JK and VH) There were 767 duplicates identified and removed
prior to assessment of methodological validity using citation management software (EndNote X7;
and inclusion in the review using the standardized Clarivate Analytics, formerly the IP & Science
critical appraisal instrument from the Joanna Briggs business of Thomson Reuters). The primary and
Institute Meta-analysis of Statistics Assessment secondary reviewers independently retrieved 62
and Review Instrument (JBI-MAStARI) for RCTs potentially relevant papers (from the initial 1645
(Appendix II). No disagreements regarding the papers) according to the inclusion criteria by title
quality appraisal occurred between reviewers (JK and abstract screening. During the second stage of
and VH). paper retrieval according to full text, another non-
relevant 37 papers were excluded.
Data extraction Twenty-five papers were finally included in this
Data were extracted from papers included in the systematic review (Figure 1). Details of the included
review using the standardized data extraction tool studies are provided in Appendix IV.
from JBI-MAStARI (Appendix III). The data extrac-
ted included specific details about the interventions, Methodological quality
populations, study methods and outcomes of signifi- Twenty-five studies were appraised for methodo-
cance to the review question and specific objectives. logical quality (Table 1). No studies were excluded
from the review based on the findings of the meth-
Data synthesis odological assessment. The quality of the studies was
Quantitative data were, where possible, pooled in variable ranging from a score of one point20 to eight
statistical meta-analysis using RevMan5 (Copenha- points.21 Randomization was performed using an
gen: The Nordic Cochrane Centre, Cochrane). Effect appropriate method in 15 studies.17,21-34 However,
sizes expressed as risk ratio (for categorical data) and in six of these studies,17,23,25-27,29 allocation con-
mean difference (MD) or standardized mean differ- cealment was unclear, creating a potential source for
ence (SMD) (for continuous data) and their 95% selection bias. In a further eight studies,20,35-41 the
confidence intervals were calculated for analysis. method of randomization was not clearly stated, and
Standardized mean difference was used in cases of two studies42,43 used a system of odd and even
different scales assessing the same outcome. The numbers on the waiting list that would not be
Mantel-Hanzel random effect model was used for considered to be true randomization. These two
the meta-analysis, since the results were clinically studies were still included in the review as bias
and statistically heterogeneous. Heterogeneity was was reduced by this system being administered by
assessed statistically using the standard Chi-square an independent study coordinator. No studies per-
test (significance level: 0.1) and I-squared test, with a formed any blinding of participants due to the need
value of I2 50% indicating significant heterogen- for informed consent regarding surgical procedures.
eity. Where statistical pooling was not possible, the Only three studies stated the use of blinded asses-
findings have been presented in narrative form sors,36,38,40 20 studies17,20-27,29-32,34,35,37,39,41-43
including figures to aid in data presentation where lacked detail regarding blinding of assessors, and
appropriate. two did not undertake blinding.28,33 The general
lack of blinding across the studies included in the
Results review must be considered when interpreting the
Description of studies findings due to the risk of bias.
Following the three-step search, 2412 citations In the majority of studies, the participants were
were found: 175 in Medline, 226 in Embase, 35 similar at baseline. Baseline characteristics were not
in CINAHL, 496 in Web of Science, 119 in PEDro, reported in seven studies.26,27,30,32,34,36,41 In four
20 in NursingOvid, 365 in the Cochrane Library, studies,35,37-39 there were differences in the baseline
350 in Trip database, 420 in ProQuest, 61 in COS characteristics of subjects. For Basile et al.,35 there

Citaons idenﬁed through systemac

Idenﬁcaon
searching (n =2412)
Duplicate citaons removed

(n = 767)
Titles and abstracts screened Arcles excluded (n = 1583)

(n = 1645)
Screening
Full-text arcles assessed for

Arcles excluded (n = 37)
eligibility according to inclusion
criteria
(n = 62)
Studies included in crical

Eligibility
appraisal (n = 25)
Studies included in meta

Included
analysis and narrave synthesis

(n = 25)
Figure 1: Study selection and inclusion process19
was a five-year age difference between groups, slightly higher pain scores and greater levels of
although there was similar severity of HV. Easley disability in the proximal metatarsal osteotomy
et al.37 also reported an older population and more group compared to the distal osteotomy group pre-
bilateral procedures in the crescentic group versus operatively. Lechler et al.39 noted a significant differ-
the chevron osteotomy. Chuckpaiwong38 reported ence between groups for AOFAS score and HVA. To

account for this, they undertook a matched group also level of pain.17,32,34 The authors of four
analysis to control for degree of severity of HV. studies17,22,31,34 with missing data were contacted;
For the majority of studies (n ¼ 24), outcomes however, none of them responded. Therefore, it was
were measured in the same way across groups, and not possible to include these in the meta-analysis.
appropriate statistical tests were stated in the Three studies applied an intention to treat
methodologies. In several studies, statistical change analysis,21,29,33 and 16 studies did not adequately
was stated for a given outcome variable; however, report the outcomes of subjects who dropped out.
means and standard deviations were not provided This is a weakness in the reporting for the majority of
to support this in the case of quality of life17,31 and the studies.
Table 1: Assessment of methodological quality
Reference Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Overall

35
Basile et al. U N U N U N N Y U Y 2
22
Calder et al. Y N Y N/A U Y Y Y U Y 6
36
Capasso et al. U N U N Y U Y Y Y Y 5
38
Chuckpaiwong U N Y N/A Y N U Y Y Y 5
23
Deenik et al. Y N U N U Y U Y N Y 4
37
Easley et al. U N U N U N N Y Y Y 3
21
Faber et al. Y N Y Y U Y Y Y Y Y 8
24
Faber et al. Y N Y N U Y Y Y Y Y 7
Giannini et al.25 Y N U N/A U Y Y Y N Y 5
Klosok et al.26 Y N U N U U N N N Y 2
39
Lechler et al. U N U N U N U Y Y Y 3
27
Lee et al. Y N U N/A U U N Y Y Y 4
42
Park et al. N N Y N U Y Y Y Y Y 6
43
Park et al. N N U N U Y U Y Y Y 4
28
Pentikäinen et al. Y N Y N N Y Y Y N Y 6
40
Prior et al. U N U N/A Y Y U Y N Y 4
29
Radwan and Mansour Y N U Y U Y Y Y Y Y 7
20
Resch et al. U N U N U U N Y N N 1
41
Resch et al. U N U N U U N Y N Y 2
30
Resch et al. Y N Y N U Y N Y N Y 5
17
Saro et al. Y N U N U Y Y Y Y Y 6
31
Saro et al. Y N Y N U Y Y Y Y Y 7
32
Tonbul et al. Y N Y N/A U U N Y Y Y 5
33
Torkki et al. Y N Y Y N Y Y Y Y Y 8
34
Windhagen et al. Y N Y N U U Y Y Y Y 6
% 60 0 44 16 12 52 48 96 60 96
Y, yes, N, no; U, unclear; N/A, not applicable.

Characteristics of included studies (non-chevron type) osteotomy with other surgical

Twenty-five trials included in this systematic review procedures. Chuckpaiwong38 included 125 patients
were divided into six categories according to com- and compared distal and proximal metatarsal
pared interventions: distal chevron osteotomy (and osteotomy. Faber et al.21 included 87 patients and
chevron-type osteotomy) versus other surgical pro- compared distal Hoffman osteotomy and Lapidus
cedure; distal osteotomy (non-chevron) versus other arthrodesis of the first tarsometatarsal joint
surgical procedures; proximal osteotomy versus combined with a soft-tissue procedure of the
other surgical procedures; adaptation of approach first MTPJ. Faber et al.24 is the same study as a
versus original operation; new methods of fixation previous one21 done in a 10 years follow-up.
versus traditional methods; surgery versus conserva- Giannini et al.25 included 20 patients and com-
tive treatment; surgery versus no treatment. pared distal scarf osteotomy and distal metatarsal
osteotomy, termed SERI (Simple, Effective, Rapid,
Distal chevron osteotomy (and chevron-type Inexpensive).
osteotomy) versus other surgical procedure One trial38 dealt with quality of life and three
Nine trials17,23,26,29,31,35,39,41,42 involving 649 trials21,24,38 with level of pain using validated tools.
patients with HV deformity assessed the effective- Two trials21,25 assessed the complication rate.
ness of distal chevron-type osteotomy compared to
other surgical procedures (Appendix V). Basile Proximal osteotomy versus other surgical
et al.35 included 32 patients and compared distal procedures
chevron-Akin osteotomy and Akin osteotomy with One study37 compared the effectiveness of proximal
distal soft tissue release. Deenik et al.23 included 120 osteotomy with other surgical procedures. Easley
patients and compared distal chevron and scarf et al.37 included 75 patients and compared proximal
osteotomy. Klosok et al.26 included 51 patients chevron osteotomy and proximal crescentic osteot-
and compared distal chevron and Wilson osteotomy. omy in terms of level of pain using a validated tool
Lechler et al.39 included 72 patients and compared and complication rate.
isolated distal chevron osteotomy and chevron-Akin
double osteotomy. Park et al.42 included 120 Adaptation of approach versus original
patients and compared distal chevron osteotomy operation
and proximal chevron osteotomy. Radwan and Four studies20,30,36,43 involving 280 patients com-
Mansour29 included 53 patients and compared distal pared the effectiveness of the surgeon’s adaptation of
chevron osteotomy and percutaneous distal meta- the original surgical approach. Capasso et al.36
tarsal osteotomy. Resch et al.41 included 79 patients included 35 patients and compared the adaptation
and compared distal chevron osteotomy and prox- of Keller-Lelievre arthroplasty (modified by detach-
imal osteotomy. Saro et al.17 included 22 patients ing the extensor hallucis brevis tendon from the
and compared distal chevron osteotomy and Lindg- proximal phalanx, and reattaching it to the
ren osteotomy. Saro et al.31 included 100 patients medial sesamoid) and the original Keller-Lelievre
and compared distal chevron osteotomy and arthroplasty. Park et al.43 included 120 patients
Lindgren osteotomy. and compared first the web-space approach and
One trial17 dealt with our primary outcome transarticular approach in the case of distal soft-
gait measures, specifically plantar pressure distri- tissue procedures combined with a distal chevron
bution and walking speed. Two trials17,31 assessed osteotomy. Resch et al.20 included 38 patients and
the quality of life and five trials17,29,31,39,42 the compared an adaptation of chevron osteotomy
level of pain using validated tools. Nine (combined with adductor tenotomy) and original
trials17,23,26,29,31,35,39,41,42 evaluated the compli- chevron osteotomy. Resch et al.30 included 87
cation rate after HV surgery. patients and compared an adaptation of chevron
osteotomy (combined with adductor tenotomy)
Distal osteotomy (non-chevron) versus other and original chevron osteotomy.
surgical procedures One trial43 was dealing with level of pain using
Four studies21,24,25,38 involving 232 patients with validated tools. Four studies20,30,36,43 assessed the
HV deformity compared the effectiveness of distal complication rate.

New methods of fixation versus traditional Primary outcome

method Gait measures: No study included comparison of
Six trials22,27,28,32,34,40 involving 262 patients com- gait performance at short-term follow-up.
pared the effectiveness of a new method of fixation One study17 included comparison of gait per-
with a traditional method of fixation. Calder et al.22 formance at medium-term and long-term follow-up.
included 30 patients and compared Mitchell’s Saro et al.17 found no significant difference in
osteotomy with screw fixation versus suture fix- walking speed between the chevron osteotomy group
ation. Lee et al.27 included 65 patients compared and Lindgren osteotomy group in the medium-term
proximal chevron osteotomy with transverse Kirsch- (MD 0.10, 95% confidence interval [CI] 0.24 to
ner wire fixation versus no fixation. Pentikäinen 0.04); however, from a long-term point of view there
et al.28 included 100 patients and compared distal was a significant difference between these two surgi-
chevron osteotomy with internal fixation versus cal groups in walking speed in favor of the chevron
no fixation. Prior et al.40 included 28 patients and osteotomy (MD 0.24, 95% CI 0.43 to 0.05)
compared Mitchell’s metatarsal osteotomy with (Appendix V). There were no significant differences
absorbable polydioixanone pins versus standard between the two operated groups in any pressure
fixation methods. Tonbul et al.32 included 13 distribution parameter under the foot in both the
patients and compared crescentic distal metatarsal medium-term and long-term follow-up.
osteotomy with two cross K-wires versus compres-
sive screw. Windhagen et al.34 included 26 patients Secondary outcomes
and compared chevron osteotomy with bio- Quality of life: No study included comparison of
degradable magnesium-based screw versus titanium quality of life at the short-term follow-up.
screw. One study17 included comparison of quality of
Four studies22,27,32,34 were dealing with level of life at medium-term follow-up.
pain using validated tools. Six trials22,27,28,32,34,40 Two studies17,31 included comparison of quality
assessed the complication rate. of life at long-term follow-up.
Saro et al.17 found no significant difference in
Surgery versus conservative treatment quality of life using the SF-36 between the chevron
One trial33 involving 209 patients compared the osteotomy group and Lindgren osteotomy group in
effectiveness of surgical and conservative treatment. the medium-term and long-term follow-up. Saro
Torkki et al.33 assessed the effectiveness of distal et al.31 also described no significant difference in
chevron osteotomy compared to conservative treat- quality of life using EuroQol between the chevron
ment (specifically orthosis) in terms of quality of life osteotomy group and Lindgren osteotomy group in
and pain using validated tools and also complication the long-term follow-up. Because of missing data in
rate. both studies, it was not possible to calculate MD or
SMD and 95% CI.
Surgery versus no treatment
One trial33 involving 209 patients compared the Patient satisfaction: No trial assessed patient satis-
effectiveness of surgical and no treatment. Torkki faction using a validated tool.
et al.33 assessed the effectiveness of distal chevron
osteotomy compared to no treatment (specifically Pain: No trial assessed level of pain using a validated
watchful waiting) in terms of quality of life and tool at short-term and medium-term follow-up.
pain using validated tools and also complication Five studies17,29,31,39,42 included assessment of
rate. pain using a validated instrument at long-term fol-
low-up.
Findings of the review Lechler et al.39 found no significant difference in
Distal chevron osteotomy (and chevron-type the level of pain using the VAS between isolated
osteotomy) versus other surgical procedure distal chevron osteotomy and chevron-Akin double
Nine trials17,23,26,29,31,35,39,41,42 compared the effec- osteotomy (SMD 0.16, 95% CI 0.64 to 0.33).
tiveness of distal chevron-type osteotomy with other Park et al.42 reported no significant difference in the
surgical procedures. level of pain using the AOFAS score between distal

chevron osteotomy and proximal chevron osteot- 74.94) and Saro et al.31 (RR 1.02, 95% CI 0.07 to
omy (SMD 0.13, 95% CI 0.50 to 0.24). Radwan 15.85). Saro et al.17 found no complication after
and Mansour29 observed no significant difference in surgery in both groups. Only one study reported
the level of pain using the AOFAS score between higher complication rates in proximal closing wedge
distal chevron osteotomy and percutaneous distal osteotomy compared to a distal chevron osteotomy
metatarsal osteotomy (SMD 0.48, 95% CI 0.02 to group – Resch et al.41 (RR 0.08 95% CI 0.01 to 0.58).
0.97). Saro et al.17 described no significant difference It was not possible to perform any meta-analysis;
in the level of pain using the VAS between distal even nine trials17,23,26,29,31,35,39,41,42 assessed the
chevron osteotomy and Lindgren osteotomy; how- same outcome, because these trials compared differ-
ever in the paper, there were missing data, so SMD ent type of surgical procedures (Figure 3).
and 95% CI could not be calculated. Saro et al.31
also found no significant difference in the level of Distal osteotomy (non-chevron) versus other
pain using the AOFAS score between distal chevron surgical procedures
osteotomy and Lindgren osteotomy (SMD 0.00, Four studies21,24,25,38 compared the effectiveness of
95% CI 0.24 to 0.28). distal (non-chevron type) osteotomy with other
Four studies29,31,39,42 were included in a meta- surgical procedures.
analysis that showed no significant difference in level
of pain between distal chevron osteotomy and other Primary outcome
surgical procedures (SMD 0.02, 95% CI 0.24 to Gait measures: No trial considered this outcome.
0.28) (Figure 2). One study17 was not included in the
Secondary outcomes
meta-analysis because of missing data.
Quality of life: No study included comparison of
Adverse events (complications): Nine quality of life at short-term and medium-term fol-
trials17,23,26,29,31,35,39,41,42 reported complication low-up.
rates between distal chevron-type osteotomy and Only one study38 included a comparison of qual-
other surgical procedures. Only two studies with ity of life at long-term follow-up. Chuckpaiwong38
this comparison performed any pre planned analysis found no significant difference in the physical com-
to determine the difference in complication rates – ponent of quality of life using the SF-12 between
Park et al.42 and Radwan and Mansour.29 Both distal and proximal metatarsal osteotomy (MD
found no difference in the number of complications 1.68, 95% CI 0.39 to 3.75); however, there was
between the distal chevron osteotomy and other a significant difference in mental component of
surgical procedure (RR ¼ 1.24, 95% CI 0.40 to quality of life in favor of the control group (proximal
3.84; RR 1.87, 95% CI 0.63 to 5.55). In all other metatarsal osteotomy) (MD 3.30, 95% CI 1.29 to
studies, the data for complications were extracted 5.31) (Appendix V).
from the presented results. There was no evidence of
Patient satisfaction: No trial assessed patient satis-
difference in complication rates for distal chevron-
faction using a validated tool.
type osteotomies and alternative procedures in a
further five studies – Basile et al.35 (RR 2.6, 95% Pain: No trial assessed level of pain using a validated
CI 0.27 to 24.78), Deenik et al.23 (RR 0.61, 95% CI tool at short-term and medium-term follow-up.
0.28 to 1.31), Klosok et al.26 (RR 0.99, 95% CI 0.58 Two trials21,38 included comparison of pain
to 1.70), Lechler et al.39 (RR 4.02, 95% CI 0.22, using validated tools between distal osteotomies
Figure 2: Forest plot of distal chevron osteotomy versus other surgical procedures on level of pain at
long-term follow-up (CI: confidence interval, SD: standard deviation, OT: osteotomy)

Figure 3: Forest plot of distal chevron osteotomy versus other surgical procedures on adverse events
(non-chevron) and other surgical procedures at long- It was not possible to perform any meta-analysis,
term follow-up; while one trial of them was done in as only two trials21,38 assessed the same outcome;
two long-term follow-ups – two years21 and 10 however, these trials compared completely different
years.24 Chuckpaiwong38 reported a significant surgical procedures (distal versus proximal metatar-
difference in level of pain using the VAS between sal osteotomy21 and distal Hoffman osteotomy ver-
distal and proximal metatarsal osteotomy in favor of sus Lapidus arthrodesis of the first tarsometatarsal
distal metatarsal osteotomy (MD 2.20, 95% CI joint combined with a soft-tissue procedure of the
2.81 to 1.59). Faber et al.21 found no significant first MTPJ38) (Appendix V).
difference in level of pain using the VAS between
distal Hoffman osteotomy and Lapidus arthrodesis Adverse events (complications): Two studies24,25
of the first tarsometatarsal joint combined with a reported complication rates between distal osteoto-
soft-tissue procedure of the first MTPJ at the two mies and other surgical procedures. Faber et al.24
years follow-up (MD 0.25, 95% CI 0.58 to 1.08). found no difference in complication rates between a
Faber et al.24 reported no significant difference Hohmann Distal Osteotomy compared to a Lapidus
between distal Hoffman osteotomy and Lapidus procedure (RR 1.30, 95% CI 0.87 to 1.94). In Gian-
arthrodesis of the first tarsometatarsal joint com- nini et al.,25 there was no evidence of difference in
bined with a soft-tissue procedure of the first MTPJ complications between a distal scarf osteotomy and
at the 10 years follow-up. SERI (RR 7.0, 95% CI 0.38 to 127.32) (Figure 4).
Figure 4: Forest plot of distal (non-chevron) osteotomy versus other surgical procedures on adverse
events

Proximal osteotomy versus other surgical Secondary outcomes

procedures Quality of life: No trial considered this outcome.
One study37 compared the effectiveness of proximal
Patient satisfaction: No trial assessed patient satis-
osteotomy with other surgical procedures.
faction using a validated tool.
Primary outcome Pain: No trial assessed level of pain using a validated
Gait measures: This outcome was not measured. tool at short-term and medium-term follow-up.
One study43 assessed level of pain using a validated
Secondary outcomes tool at long-term follow-up. Park et al.43 found no
Quality of life: This outcome was not measured. significant difference in level of pain using the AOFAS
score between first web-space approach and trans-
Patient satisfaction: The trial did not assess patient
articular approach in the case of distal soft-tissue
satisfaction using a validated tool.
procedures combined with a distal chevron osteotomy
Pain: The trial did not assess level of pain using (MD 0.50, 95% CI 1.96 to 0.96) (Appendix V).
a validated tool at short-term and medium-term
Adverse events (complications): Four stud-
follow-up.
ies20,30,36,43 reported on complications. None
One study37 assessed level of pain using a vali-
reported any effect on complication rates with an
dated tool at long-term follow-up. Easley et al.37
adaptation to the original operation – Capasso
reported no significant difference in rate of pain
et al.36 (RR 1.50, 95% CI 0.29 to 7.78),
using the AOFAS scoring system between proximal
Park et al.43 (RR 0.81, 95% CI 0.26 to 2.50) and
chevron osteotomy and proximal crescentic osteot-
Resch et al.30 (RR 1.88, 95% CI 0.44 to 7.98). Resch
omy (MD and 95% CI could not be calculated
et al.20 reported no complications in either group
because of missing SD).
(Figure 5).
Adverse events (complications): One study measured
this outcome37. In Easley et al.,37 there was no New methods of fixation versus traditional
evidence of difference in rates of complications method
between proximal chevron osteotomy and proximal Six trials22,27,28,32,34,40 compared the effectiveness of
crescentic osteotomy (RR 1.23, 95% CI 0.50 to a new method of fixation with a traditional method
2.99) (Appendix V). of fixation.
Adaptation of approach versus original operation Primary outcome

Four studies 20,30,36,43
compared the effectiveness of Gait measures: No trial considered this outcome.
surgeon’s adaptation of surgical approach with
Secondary outcomes
original surgical approach.
Quality of life: No trial considered this outcome.
Primary outcome Patient satisfaction: No trial assessed patient satis-
Gait measures: No trial considered this outcome. faction using a validated tool.
Figure 5: Forest plot of surgeon’s adaptation of surgical approach versus original surgical approach on
adverse events

Figure 6: Forest plot of new methods of fixation versus traditional method on level of pain in long-term
follow-up
Pain: Two trials22,34 assessed level of pain using It was not possible to perform any meta-analysis,
validated tools at short-term follow-up. Calder as only two studies22,27 assessed the same outcome;
et al.22 found no significant difference in level of however, these trials compared different types of
pain using the Forefoot Scoring System (FFSS) score surgical procedures (Mitchell’s osteotomy22 and
between screw fixation and suture fixation in the crescentic distal metatarsal osteotomy27) (Figure 6).
case of Mitchell’s osteotomy (MD 0.00, 95% CI
4.17 to 4.17) (Appendix V). Windhagen et al.34 Adverse events (complications): Six stud-
described no significant difference in level of pain ies22,27,28,32,34,40 reported complications. There
using the VAS between biodegradable magnesium- was no effect in rate of complications with differ-
based screw and titanium screw in the case of chev- ences in fixation method – Calder et al.22 (RR 4.0,
ron osteotomy. MD and 95% CI could not be 95% CI 0.50 to 31.74), Lee et al.27 (RR 1.07, 95%
calculated due to missing data. CI 0.23 to 5.02), Prior et al.40 (RR 1.08, 95% CI
Two trials22,34 assessed level of pain using vali- 0.78 to 1.50), Tonbul et al.32 (RR 1.00, 95% CI 0.07
dated tools at medium-term follow-up. Calder to 13.37), Windhagen et al.34 (RR 2.00, 95% CI
et al.22 found no significant difference in level of 0.21 to 19.23) and Pentikäinen et al.28 who reported
pain using the FFSS score between screw fixation and no complications in either group (Figure 7).
suture fixation in the case of Mitchell’s osteotomy
(MD 2.70, 95% CI 1.34 to 6.74) (Appendix V). Surgery versus conservative treatment
Windhagen et al.34 described no significant differ- One trial33compared the effectiveness of surgical
ence in level of pain using the VAS between and conservative treatment.
biodegradable magnesium-based screw and titanium
screw in the case of chevron osteotomy. MD and Primary outcome
95% CI could not be calculated due to missing Gait measures: No trial considered this outcome.
data.
Three trials22,27,32 assessed level of pain using Secondary outcomes
validated tools at long-term follow-up. Calder Quality of life: No trial assessed quality of life using
et al.22 found no significant difference in level of a validated tool at short-term follow-up.
pain using the FFSS score between screw fixation and One trial33 assessed quality of life using 15-D at
suture fixation in the case of Mitchell’s osteotomy medium-term follow-up. Torkki et al.33 found no
(SMD 0.00, 95% CI 0.72 to 0.72). Lee et al.27 significant difference between surgical and conser-
reported no significant difference in level of pain vative treatment (MD 0.00, 95% CI 2.29 to 2.29)
using the AOFAS score between transverse Kirsch- (Appendix V).
ner wire fixation versus no fixation in the case of One trial33 assessed quality of life using 15-D at
proximal chevron osteotomy (SMD 0.09, 95% CI long-term follow-up. Torkki et al.33 found no sig-
0.51 to 0.034). Tonbul et al.32 described no significant difference between surgical and conservative
nificant difference in level of pain using the VAS treatment (MD 0.20, 95% CI 2.39 to 1.99)
between two cross K-wires versus compressive screw (Appendix V).
in the case of crescentic distal metatarsal osteotomy.
SMD and 95% CI could not be calculated due to Patient satisfaction: No trial assessed patient satis-
missing standard deviations. faction using a validated tool.

Figure 7: Forest plot of new methods of fixation versus traditional method on adverse events
Pain: No trial assessed level of pain using a validated Patient satisfaction: No trial assessed patient satis-
tool at short-term follow-up. faction using a validated tool.
One trial33 assessed level of pain using the VAS at
Pain: No trial assessed level of pain using a validated
medium-term follow-up. Torkki et al.33 found a
tool at short-term follow-up.
significant difference between surgical and conser-
vative treatment in favor of surgical treatment (MD
medium-term follow-up. Torkki et al.33 found a
10.00, 95% CI 18.29 to 1.71) (Appendix V).
significant difference between surgical and no treat-
ment in favor of surgical treatment (MD 19.00,
long-term follow-up. Torkki et al.33 found a signifi-
95% CI 27.61 to 10.39) (Appendix V).
cant difference between surgical and conservative
treatment in favor of surgical treatment (MD
long-term follow-up. Torkki et al.33 found a signifi-
15.00, 95% CI 22.79 to 7.21) (Appendix V).
cant difference between surgical and no treatment in
Adverse events (complications): No trial considered favor of surgical treatment (MD 18.00, 95% CI
this outcome. 25.62 to 10.38) (Appendix V).
Surgery versus no treatment Adverse events (complications): No data given for

33
One trial compared the effectiveness of surgical this outcome.
and no treatment. Discussion
Primary outcome Twenty-five RCTs17,20-43 were included in this sys-
Gait measures: No trial considered this outcome. tematic review. Most of them17,20-35,37-43 dealt with
the effectiveness of different types of osteotomy of
Secondary outcomes the first metatarsal in patients with HV; only one36
Quality of life: No trial assessed quality of life using assessed the effectiveness of arthrodesis of the first
a validated tool at short-term follow-up. MTPJ. Only one trial33 compared the effectiveness
One trial33 assessed quality of life using 15-D at of surgical treatment with conservative and no treat-
medium-term follow-up. Torkki et al.33 found no ment, the rest of the trials17,20-32,34-43 compared
significant difference between surgical and no treat- different type of surgical approaches.
ment (MD 1.50, 95% CI 4.07 to 1.07) The current systematic review was focused on the
(Appendix V). effectiveness of HV surgery on clinical outcomes
One trial33 assessed quality of life using 15-D at such as gait performance, quality of life, pain and
long-term follow-up. Torkki et al.33 found no signifi- complication rate as opposed to other systematic
cant difference between surgical and no treatment reviews that deal primarily with angle parameters
(MD 0.70, 95% CI 2.96 to 1.56) (Appendix V). using x-ray (e.g. HVA or 1,2 intermetatarsal

angle).44-47 Only one trial17 measured the primary magnesium-based screw and titanium screw in the
outcome of gait measures, specifically dynamic case of chevron osteotomy.34
parameters of the gait cycle using plantography.
Four trials17,31,33,38 assessed the influence of HV Effectiveness in the medium term
surgery on quality of life using validated instru- Four trials17,22,33,34 compared the effectiveness of
ments (SF-36, SF-12, EuroQol, 15-D). Nineteen various types of surgery at medium-term follow-up
trials17,21,22,24,26,27,29,31-40,42,43 dealt with level (less than one year). There was no significant differ-
of pain after HV surgery; however, only 15 ence between the different surgical procedures on gait
trials17,21,22,24,27,29,31-34,37-39,42,43 used validated performance and quality of life (chevron versus
instruments (VAS scale, AOFAS score, FFSS score). Lindgren osteotomy17) and level of pain (screw fix-
Although 11 trials20-22,27,30,32,33,35,40,42,43 assessed ation versus suture fixation in the case of Mitchell’s
patient satisfaction with HV surgery, none of them osteotomy,22 magnesium-based screw versus tita-
used validated instrument that was an essential item nium screw in the case of chevron osteotomy34). Only
for meeting the inclusion criteria of this review. All one trial33 compared the effectiveness of HV surgery
trials (except one38) included complication rates. with conservative and no treatment at medium-term
However, complications were inconsistently follow-up and found that surgery was more effective
reported between studies. There were few studies compared to conservative treatment and no treatment
that defined what postoperative complications in terms of level of pain; however, the differences in
would be considered as42,43 or performed any com- quality of life were not significant. This was a well
parison of these between groups.29,42,43 The com- conducted RCT, but more studies are required in
plications also varied in severity, from mild wound order to support these findings.
infection to recurrence of the HV requiring
additional surgical intervention. The percentage of Effectiveness in the long-term
patients having complications ranged from 0% Twenty-four trials17,20-33,35-43 (from 25 included to
to 2.4% depending on the study and what was this systematic review) assessed the effectiveness
defined as a complication. None of the comparisons of HV at long-term follow-up (equal or more than
demonstrated any effect on complication rates one year).
suggesting that these were comparable across most
surgeries and adaptations. The only comparison that Distal chevron osteotomy (and chevron-type
demonstrated an effect was that proximal closing osteotomy) versus other surgical procedure at
wedge osteotomy was found to result in greater long-term follow-up
complications than distal chevron osteotomy in a Nine trials17,23,26,29,31,35,39,41,42 assessed the effec-
single study, with low methodological quality.41 tiveness of distal chevron-type osteotomy compared
Due to the poor level of reporting and poor meth- to other surgical procedures. We were able to
odological quality, it is not possible to make perform only one meta-analysis including four stud-
recommendations regarding HV surgery related to ies29,31,39,42 that showed no significant difference in
complication rates. level of pain between chevron-type osteotomy and
other surgical procedures. For all other outcomes such
Effectiveness in the short term as gait performance, quality of life, and patient satis-
Only two trials22,34 from 25 studies included in this faction, it was not possible to undertake meta-analysis
systematic review assessed the effectiveness of because of lack of studies dealing with this outcome or
surgery in patients with HV compared to conserva- missing data or high heterogeneity. We found that
tive treatment or no treatment or other type of patients after distal chevron osteotomy walked faster
surgical procedure at short-term follow-up (less than compared to patients following Lindgren osteotomy.
six months after surgery), specifically comparison of However, there was no significant difference between
different types of fixation in the case of surgical these two groups in other parameters of gait cycle such
procedure (new versus traditional). There was no as pressure distribution parameter. Resch, Stenstrom,
significant difference in level of pain between screw Jonsson and Reynisson41 reported higher compli-
fixation and suture fixation in the case of Mitchell’s cation rates in proximal closing wedge osteotomy
osteotomy 22 and also between biodegradable compared to a distal chevron osteotomy group. There

were no other differences between distal chevron-type in level of pain in favor of distal metatarsal osteot-
procedures compared to other surgical procedure omy and in the mental component of quality of life in
in gait measures, quality of life,17,31 level of proximal metatarsal osteotomy; however, there was
pain17,29,31,39,42 or complications.17,23,26,29,31,35,39,42 no significant difference in the physical component
All nine trials17,23,26,29,31,35,39,41,42 compared dis- of quality of life. There were no other differences
tal chevron osteotomy with other types of osteotomy between distal (non chevron type) osteotomy and
of the first metatarsal that belong to the same group other surgical procedures in gait measures, quality of
of surgical procedures. Six trials26,29,35,39,41,42 life, level of pain or complications. However, in
assessed the effectiveness of distal osteotomies of the case of this comparison, there was a lack of
the first metatarsal such as chevron versus chevron studies assessing the same outcomes, and all included
modification35,39 or chevron versus different type of studies were considered as medium methodological
distal osteotomy.26,29,41,42 Three trials23,41,43 com- quality (scoring 5 to 8 points from a maximum of
pared distal chevron osteotomy with proximal 10 points). Subsequently, it is not possible to draw
osteotomy. No differences between two different any conclusions.
surgical procedures within the osteotomies of the
first metatarsal were probably caused by similarity Proximal osteotomy versus other surgical
of compared surgical approaches, except walking procedures at long-term follow-up
speed17 and incidence of complications41 in favor of Only one study37 compared the effectiveness of prox-
distal chevron osteotomy. However, the results of imal osteotomy with other surgical procedures (prox-
Saro et al.17 could be influenced by the small and imal chevron osteotomy and proximal crescentic
unequal sizes of surgical groups (14 and 8), and those osteotomy). There was no difference in level of pain
of Resch et al.41 were of very poor quality (scoring and complication rate between these two types of
2 points from a total of 10 points). Five proximal metatarsal osteotomy probably because of
trials23,26,35,39,41 were considered poor quality similarity in compared surgical procedures. However,
(scoring 2 to 4 points from a total of 10 points), conclusions should not be based on one trial, especi-
and four trials17,29,31,42 were considered medium ally since this study was of poor quality (scoring 3
quality (scoring 6 to 7 points from a total of points from a total of 10 points). The randomization
10 points). Randomization was not performed pro- process was not clearly reported, and the groups’
perly in one trial,42 and in three trials,35,39,41 the type characteristics and treatment were not identical.
of randomization was not clear. In two trials,35,39
baseline characteristics of the groups were not similar, Adaptation of approach versus original
and in three trials,26,35,41 the groups were not treated operation at long-term follow-up
identically. These issues could bias the results. Four studies20,30,36,43 assessed the effectiveness of
surgeon’s adaptation of a surgical approach versus
Distal osteotomy (non-chevron) versus other the original surgical approach. Three20,30,43 com-
surgical procedures at long-term follow-up pared surgeon’s adaptation of chevron osteotomy
Four studies21,24,25,38 compared the effectiveness of with its original version. One36 compared adap-
distal (non-chevron type) osteotomy with other sur- tation of Keller-Lelievre arthroplasty with its
gical procedures. It was not possible to undertake original version. It was not possible to perform
meta-analysis as only two trials21,38 assessed the meta-analysis because of lack of studies assessing
same outcome, and these trials compared completely the same outcome and high heterogeneity. There was
different surgical procedures (distal versus proximal no difference in level of pain and complication rate
metatarsal osteotomy21 and distal Hoffman osteot- between surgeon’s adaptation of surgical approach
omy versus Lapidus arthrodesis of the first tarsome- versus original surgical approach, either in the
tatarsal joint combined with a soft tissue procedure case of Keller-Lelievre arthroplasty36 nor chevron
of the first MTPJ38). Therefore, the results have been osteotomy.20,30,43 The methodological quality was
described narratively because of high heterogeneity poor in two trials (scoring 1 and 4 points from a total
and lack of studies assessing the same outcomes. of 10 points) and medium in two trials (scoring 5
Chuckpaiwong38 reported a significant difference points from a total of 10 points). The randomization
between distal and proximal metatarsal osteotomy process was only performed properly in one trial,30

two trials30,43 had the same characteristics of the quality (scoring 8 points from a total of 10 points).
groups, and in one trial36 where the groups were So, it seems that in the first year after treatment, the
clearly treated identically. Therefore, it seems that surgical treatment was more effective than orthosis.
the difference between surgeon’s adaptation and the However, the difference was more excessive in
original version of one surgical procedure was not medium-term follow-up and decreased at the one
sufficiently strong to influence level of pain or com- year follow-up. More trials are needed before con-
plication rate. However, because of not enough data clusions can be drawn.
and low methodological quality, it is not possible to
draw any strong conclusions. Surgery versus no treatment at long-term
follow-up
New methods of fixation versus traditional Only one trial33 compared the effectiveness of
method at long-term follow-up surgery and no treatment, specifically waiting, in
Six trials22,27,28,32,34,40 compared the effectiveness of patients with HV. There was no difference between
a new method of fixation with the traditional method surgical and no treatment in quality of life. However,
of fixation. All of them compared the effectiveness of Torkki et al.33 reported a significant difference in
different type of fixation in osteotomy of the first level of pain between surgical and no treatment in
metatarsal: two of them Mitchell’s osteotomy,22,40 favor of surgery at the one year follow-up. This RCT
three of them distal or proximal chevron osteot- was rated as medium quality (scoring 8 points from a
omy27,28,34 and one crescentic distal metatarsal total of 10 points). The difference in level of pain
osteotomy.32 It was not possible to perform any between surgical and no treatment was more exces-
meta-analysis due to lack of studies assessing the same sive than that between surgical and conservative
outcome. However, three trials22,27,34 showed no treatment (see above). However, more trials are
difference in level of pain between different fixation needed before conclusions can be drawn.
methods in osteotomy of the first metatarsal. Five
trials22,27,32,34,40 showed no difference in compli- Conclusion
cation rate between different fixation methods in Our systematic review showed that differences
osteotomy of the first metatarsal. No other relevant between various types of surgical procedures,
outcomes, such as gait measure, quality of life or specifically osteotomy of the first metatarsal on
patient satisfaction, were assessed in any trial using clinical outcomes, are minimal. There is also evi-
a validated instrument. Two trials27,40 were of poor dence from one study that surgery, specifically distal
quality (scoring 4 points from a total of 10 points), chevron osteotomy of the first metatarsal, is a more
and four trials22,28,32,34 were of medium quality (scor- effective procedure than conservative or no treat-
ing 5 to 6 points from a total of 10 points). However, ment in level of pain during the first year. However,
in one trial40 the randomization process was not clear, this systematic review has identified that there is a
in three trials,27,32,34 it was unclear if the groups had lack of high-quality studies comparing similar types
the same characteristics and in two trials27,32 the of HV treatment. Selection of outcome measures is
groups were not treated the same way. This could inconsistent, and few trials have compared the same
result in bias in the results. It seems that the differences two surgical procedures. It is therefore not possible
between fixation methods in the case of osteotomy of to recommend one type of treatment over another.
the first metatarsal did not affect the clinical outcomes
such as level of pain and complication rate. Implications for practice
Based on meta-analysis, there was no significant
Surgery versus conservative treatment at difference in level of pain between distal chevron-
long-term follow-up type osteotomy and other surgical proce-
Only one trial33 compared the effectiveness of sur- dures,29,31,39,42 and also between different fixation
gical and conservative treatment in patients with methods in osteotomy of the first metatarsal22,27,34
HV. There was no difference between surgical and (Grade B). Two single trials of low and medium
conservative treatment in quality of life.33 However, quality reported that chevron osteotomy was more
Torkki et al.33 found a significant difference in level effective than Lindgren osteotomy on walking
of pain in favor of surgery. This RCT was of medium speed17 and proximal closing wedge osteotomy in

complication rate41 (Grade B). There were no other 6. du Plessis M, Zipfel B, Brantingham JW, Parkin-Smith GF,
differences among various type of surgical pro- Birdsey P, Globe G, et al. Manual and manipulative therapy
cedures, specifically osteotomy of the first metatarsal compared to night splint for symptomatic hallux abducto
in 25 trials and arthrodesis of the first MTPJ in one valgus: an exploratory randomised clinical trial. Foot
2011;21(2):71–8.
trial on gait measures, quality of life, pain or com-
7. Bayar B, Erel S, Simsek IE, Sümer E, Bayar K. The effects of
plications (Grade B).
taping and foot exercises on patients with hallux valgus: a
Based on one medium-quality single trial,33 we preliminary study. Turk J Med Sci 2011;3(41):403–9.
conclude that surgery, specifically distal chevron 8. Radovic PA, Shah E. Nonsurgical treatment for hallux
osteotomy of the first metatarsal, is a more effective abducto valgus with botulinum toxin A. J Am Podiatr
procedure in level of pain than conservative or no Med Assoc 2008;98(1):61–5.
treatment during first year (Grade B). 9. Ferrari J, Higgins JP, Prior TD. WITHDRAWN: interventions for
treating hallux valgus (abductovalgus) and bunions.
Implications for research Cochrane Database Syst Rev 2009;(2):CD000964.
In the current literature, there are limited high-qual- 10. Bascarevic Z, Vukasinovic ZS, Bascarevic VD, Stevanovic VB,
ity RCTs assessing the effectiveness of surgery in Spasovski DV, Janicic RR. Hallux valgus. Acta Chir Iugosl
patients with HV on clinical outcomes, specifically 2011;58(3):107–11.
gait measures, quality of life, level of pain and 11. Dungl P. Ortopedie. Praha: Grada; 2005.
patient satisfaction using validated tools. Although 12. Wulker N, Mittag F. The treatment of hallux valgus. Dtsch
there are several trials assessing complications after Arztebl Int 2012;109(49):857–67; quiz 68.
13. Stokes IA, Hutton WC, Stott JR, Lowe LW. Forces under the
different types of HV surgery, their inconsistency in
hallux valgus foot before and after surgery. Clin Orthop
reporting makes comparison between studies very
Relat Res 1979;142(142):64–72.
difficult. It would be recommended for future studies 14. Bryant AR, Tinley P, Cole JH. Plantar pressure and radio-
that clear definitions are stated as to what a post- graphic changes to the forefoot after the Austin bunion-
operative complication is. There is a need for trials to ectomy. J Am Podiatr Med Assoc 2005;95(4):357–65.
investigate surgical management with conservative 15. Milani TL, Retzlaff S. Analysis of pressure distribution for the
and no treatments. evaluation of gait in patients with hallux valgus surgery.
Z Orthop Ihre Grenzgeb 1995;133(4):341–6.
Acknowledgements 16. Nyska M, Liberson A, McCabe C, Linge K, Klenerman L.
Plantar foot pressure distribution in patients with hallux
The current review was supported by a grant from
valgus treated by distal soft tissue procedure and proximal
European Social Funds ‘‘Support of Human Resour-
metatarsal osteotomy. Foot Ankle Surg 1998;4(1):35–41.
ces in Science and Research in Non-medical Health- 17. Saro C, Andren B, Fellander-Tsai L, Lindgren U, Arndt A.
care at the Faculty of Health Sciences at Palacký Plantar pressure distribution and pain after distal osteot-
University Olomouc’’ (CZ.1.07/2.3.00/20.0163) omy for hallux valgus. A prospective study of 22 patients
and RVO (61989592). with 12-month follow-up. Foot 2007;17(2):84–93.
18. Klugarova J, Hood V, Bath-Hextall F, Klugar M, Mareckova J,
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4. Robinson AH, Limbers JP. Modern concepts in the treatment 21. Faber FW,Mulder PG,Verhaar JA.Roleoffirstray hypermobility
of hallux valgus. J Bone Joint Surg Br 2005;87(8):1038–45. in the outcome of the Hohmann and the Lapidus procedure.
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pilot study of the efficacy of a conservative chiropractic and one feet. J Bone Joint Surg Am 2004;86-A(3):486–95.
protocol using graded mobilization, manipulation and ice 22. Calder JD, Hollingdale JP, Pearse MF. Screw versus suture
in the treatment of symptomatic hallux abductovalgus fixation of Mitchell’s osteotomy. A prospective, randomised
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23. Deenik A, van Mameren H, de Visser E, de Waal Malefijt M, 35. Basile A, Battaglia A, Campi A. Comparison of chevron-Akin
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with eight- to 11-year follow-up involving 101 feet. Bone Relat Res 1994;308:43–9.
Joint J 2013;95-B(9):1222–6. 37. Easley ME, Kiebzak GM, Davis WH, Anderson RB. Prospec-
25. Giannini S, Cavallo M, Faldini C, Luciani D, Vannini F. The SERI tive, randomized comparison of proximal crescentic and
distal metatarsal osteotomy and scarf osteotomy provide proximal chevron osteotomies for correction of hallux
similar correction of hallux valgus foot and ankle. Clin valgus deformity. Foot Ankle Int 1996;17(6):307–16.
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without transverse Kirschner wire fixation. Foot Ankle Int tive matched group analysis. Arch Orthop Trauma Surg
2008;29(11):1101–6. 2012;132(1):9–13.
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dressing choice of distal chevron osteotomy: randomized tarsal osteotomy: comparing standard fixation methods with
control trial. Foot Ankle Int 2012;33(5):420–3. absorbable polydioixanone pins. Foot 1997;7(3):121–5.
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31. Saro C, Andrén B, Wildemyr Z, Felländer-Tsai L. Outcome 43. Park YB, Lee KB, Kim SK, Seon JK, Lee JY. Comparison of
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Appendix I: Search strategy

1. MEDLINE (Database[s]: Ovid MEDLINE[R])
No. Searches Results

1 expHallux Valgus/or hal#ux valgus.mp. 2766
2 bunion.mp. 597
3 hallux abductovalgus.mp. 23
4 Halux abductovalgus.mp. 0

5 Foot deform .mp. 6459

6 Forefoot deform .mp. 115

7 expMetatarsophalangeal Joint/or big toe deform .mp. 2049

8 expFoot Diseases/or foot problem .mp. 10,814
9 HV.mp. 2948
10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 23,612

11 surg .mp. 1454,320

12 operat .mp. 734,585

13 osteotom .mp. 30,423

14 arthroplast .mp. 46,611

15 expArthrodesis/or arthrodes .mp. 10,719
16 11 or 12 or 13 or 14 or 15 1887,367
17 10 and 16 7199
18 Limit: Therapy (best balance of sensitivity and specificity) 175

2. CINAHL with full text

1 All fields: hallux valgus OR halux valgus 889
2 All fields: hallux abductovalgus OR halux abductovalgus 25

3 All fields: bunion 329
4 All fields: HV OR HAV 424

5 All fileds: hallux deformit OR foot deformit or forefoot deformit 1466

6 All fields: foot problem or foot disease 835

7 All fields: great toe deformit OR big toe deformit 13
8 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 3276

9 All fields: surg 211,049

10 All fields: operat 62,812

11 All fields: osteotom 3742

12 All fields: arthrodes 1848

13 All fields: arthroplast 13,124
14 10 OR 11 OR 12 OR 13 OR 14 247,065
15 9 AND 15 1556
16 All Fileds: RCt 2277

17 All Fields: randomi 78,450

18 All fields: control trial 49,363

19 All fields: clinical trial 98,502

20 All fields: random assign 38,633

21 All fields: random allocat 3355

22 All fields: control group 40,080

23 All fields: comparison group 6012

24 All fields: treat group 18,693

25 All fields: wait list 3911

26 All fields:wait -list 3980

27 All fields: control condition 3941

28 All fields: quasi-ex 6621

29 All fields: quasiex 231

30 All fields: control N3 intervention 5264

31 All fields: control N3 treat ) 7726
32 16–31 (OR) 46,498
33 32 AND 15 35

3. Embase


2 bunion .mp. 878
4 Haluxabductovalgus.mp. 0

5 Foot deform .mp. 2038
6 Forefoot deform.mp. 167

7 expMetatarsophalangeal Joint/or big toe deform /or great toe deform .mp. 3475
8 expFoot Diseases/or foot problem.mp. 1585
9 HV or HAV.mp. 9632
10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 19,586

11 surg .mp. 2308,766
12 Operat.mp. 1042,612

13 Osteotom .mp. 38,919

14 Arthroplast .mp. 60,094

15 expArthrodesis/or arthrodes .mp. 15,584
16 11 or 12 or 13 or 14 or 15 2899,158
17 10 and 16 6127
18 Pt OR Wt: clinical trial 105,404
19 Pt OR Wt: randomized controlled trial 41,387
20 Pt OR Wt: randomization 22,306
21 Pt OR Wt: Single blind procedure 19
22 Pt OR Wt: Double blind procedure 229
23 Pt OR Wt: Crossover procedure 38
24 Pt OR Wt: placebo OR placebo$ 206,196
25 Pt OR Wt: Randomi?ed controlled trial 54,815
26 Pt OR Wt: RCT 13,542
27 Pt OR Wt: Random allocation 1366
28 Pt OR Wt: Randomly allocated 20,572
29 Pt OR Wt: Allocated randomly 1973
30 Wt: (allocated adj2 random) 23,540
31 Wt: Single blind$ 14,625
32 Wt: Double blind$ 150,139
33 Wt: ((treble or triple) adj (blind$) 375
34 Pt OR Wt: Prospective study 127,106
35 18–34 (OR) 554,600
36 35 AND 17 226

4. Trip database

1 All fiels: hallux valgus OR hal#ux valgus 447
2 All fields: hallux abductovalgus or halux abductovalgus 43
3 All fields: bunion 237

4 All fields: hallux deformit 2

5 All fields: great toe deformit or big toe deformit 2

6 All fields: foot deformit or forefoot deformit 4

7 All fields: foot problem or foot disease 9773
8 All fields: HV or HAV 2662

9 All fields: surg 377,619

10 All fields: operat 1771

11 All fields: osteotom 3656

12 All fields: arthrodes 1759

13 All fields: arthroplast 15,022
14 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 12,587
15 9 or 10 or 11 or 12 or 13 or 382,905
16 14 AND 15 6716
17 16 AND (((randomizedcontrolled trial[Publication Type]) OR ((randomi- 350
zed[TI] OR randomised[TI] OR placebo[ti]) OR (controlled[TI] OR
trial[Ti])))

5. Nursing Ovid


2 bunion .mp. 71
4 Haluxabductovalgus.mp. 0
5 Foot deform.mp. 321

6 Forefoot deformity/or forefoot deform .mp. 14
7 expMetatarsophalangeal Joint/or big toe deform/or great toe deform.mp. 272
8 expFoot Diseases/or foot problem.mp. 624
9 HV or HAV.mp. 103
10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 1407
11 surg.mp. 47,492

12 Operation/or operat .mp. 37,033
13 Osteotomy/or osteotom.mp. 499
14 Arthroplasty/or arthroplast.mp. 1715

15 expArthrodesis/or arthrodes .mp. 392
16 11 or 12 or 13 or 14 or 15 65,714
17 10 and 16 599
18 Pt OR Wt: clinical trial 15,475
19 Pt OR Wt: randomized controlled trial 15,521
20 Pt OR Wt: randomization 494
21 Pt OR Wt: Single blind procedure 2
22 Pt OR Wt: Double blind procedure 6
23 Pt OR Wt: Crossover procedure 1

24 Pt OR Wt: placebo OR placebo$ 4159
25 Pt OR Wt: Randomi?ed controlled trial 15,847
26 Pt OR Wt: RCT 560
27 Pt OR Wt: Random allocation 39
28 Pt OR Wt: Randomly allocated 649
29 Pt OR Wt: Allocated randomly 28

30 Wt: (allocated adj2 random ) 689
31 Wt: Single blind$ 468
32 Wt: Double blind$ 3030
33 Wt: ((treble or triple) adj (blind$) 12
35 Pt OR Wt: Prospective study 2930
36 18–35 (OR) 28,499
37 17 AND 36 20

6. Web of Science

1 Topic: hallux valgus OR hal?ux valgus 6066
2 Topic: hallux abductovalgus or halux abductovalgus 39
3 Topic: bunion 1082

4 Topic: hallux deformit 1781

5 Topic: great toe deformit or big toe deformit 498

6 Topic: foot deformit or forefoot deformit 17,568

7 Topic: foot problem or foot disease 17,568
8 Topic: HV or HAV 42,167

9 Topic: surg 4920,839

10 Topic: operat 7003,732

11 Topic: osteotom 68,824

12 Topic: arthrodes 26,303

13 Topic: arthroplast 131,150
14 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 164,013
15 9 or 10 or 11 or 12 or 13 11,083,515
16 14 AND 15 32,742
17 Topic: (clinical near trial or crossover or cross over) or

((single or doubl or trebl or tripl) near (blind or mask or
dummy)) or (singleblind or doubleblind or trebleblind or
tripleblind or placebo or random) 1516,990

18 Title: (clinical near trial or crossover or cross over) or
((single or doubl or trebl or tripl) near (blind or mask or
dummy)) or (singleblind or doubleblind or trebleblind or
tripleblind or placebo or random) 313,524
19 17 OR 18 1516,990
20 19 AND 16 565
31 Exclude document type: Review 496

7. Cochrane Library

1 Title, Ab, Key: hallux valgus OR hal?ux valgus 183
2 Title, Ab, Key: hallux abductovalgus or halux abductovalgus 2

3 Title, Ab, Key: bunion 46

4 Title, Ab, Key: hallux deformit 46

5 Title, Ab, Key: great toe deformit or big toe deformit 10

6 Title, Ab, Key: foot deformit or forefoot deformit 153

7 Title, Ab, Key: foot problem or foot disease 1316
8 Title, Ab, Key: HV or HAV 360

9 Title, Ab, Key: surg 87,661

10 Title, Ab, Key: operat 35,833

11 Title, Ab, Key: osteotom 790

12 Title, Ab, Key: arthrodes 190

13 Title, Ab, Key: arthroplast 4724
14 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 1942
15 9 or 10 or 11 or 12 or 13 103,910
16 14 AND 15 420
17 Limiter: trials 365
8. Pedro

1 Abstract and Title: hallux valgus 13
2 Abstract and Title: halux valgus 0
3 Abstract and Title: hallux abductovalgus 4
4 Abstract and Title: halux abductovalgus 0

5 Abstract and Title: bunion 4

6 Abstract and Title: hallux deformit 6

7 Abstract and Title: foot deformit 23

8 Abstract and Title: forefoot deformit 3

9 Abstract and Title: foot problem 41
10 Abstract and Title: foot disease 57

11 Abstract and Title: big toe deformit 1

12 Abstract and Title: great toe deformit 0

13 Abstract and Title: surg 2047

14 Abstract and Title: operat 922

15 Abstract and Title: osteotom 21

(Continued)

16 Abstract and Title: arthrodes 9

17 Abstract and Title: arthroplast 250

18 Abstract and Title: hallux valgus AND surg 6

19 Abstract and Title: hallux valgus AND operat 1

20 Abstract and Title: hallux valgus AND arthroplast 0

21 Abstract and Title: hallux valgus AND arthrodes 0

22 Abstract and Title: hallux valgus AND osteotom 1

23 Abstract and Title: bunion AND surg 3

24 Abstract and Title: bunion AND operat 0

25 Abstract and Title: bunion AND osteotom 1

26 Abstract and Title: bunion AND arthrodes 0

27 Abstract and Title: bunion AND arthroplast 0

28 Abstract and Title: hallux deformit AND surg 1

29 Abstract and Title: hallux deformit AND operat 0

30 Abstract and Title: hallux deformit AND osteotom 0

31 Abstract and Title: hallux deformit AND arthrodes 0

32 Abstract and Title: hallux valgus AND arthroplast 0

33 Abstract and Title: foot deformit AND surg 3

34 Abstract and Title: foot deformit AND operat 1

35 Abstract and Title: foot deformit AND osteotom 0

36 Abstract and Title: foot deformit AND arthrodes 0

37 Abstract and Title: foot deformit AND arthroplast 0

38 Abstract and Title: foot problem AND surg 9

39 Abstract and Title: foot problem AND operat 0

40 Abstract and Title: foot problem AND osteotom 1

41 Abstract and Title: foot problem AND arthroplast 0

42 Abstract and Title: foot problem AND arthrodes 0

43 Abstract and Title: foot disease AND surg 10

44 Abstract and Title: foot disease AND operat 5

45 Abstract and Title: foot disease AND osteotom 0

46 Abstract and Title: foot disease AND arthrodes 0

47 Abstract and Title: foot disease AND arthroplast 1
48 13 limiter Body part: foot or ankle 173
49 14 limiter Body part: foot or ankle 117
50 17 limiter body part: foot or ankle 13

9. Clinicaltrials.gov
Hallux valgus OR Hallux abductovalgus OR bunion OR hallux deformit OR forefoot deformit OR foot
deformit OR great toe deformit OR big toe deformitOR foot disease OR foot problem – 12 references
10. Greylit.org
Halle valgus OR Hallux abductovalgus OR bunion OR hallux deformit OR forefoot deformit OR foot
deformit OR great toe deformit OR big toe deformit OR foot disease OR foot problem – 0 references
11. Controlled-trials.com
Hallux vagus OR Hallux abductovalgus OR bunion OR hallux deformit OR forefoot deformit OR foot
deformit OR great toe deformit OR big toe deformitOR foot disease OR foot problem – 0 references
12. ProQuest COS

1 Hallux valgus 42
2 hallux abductovalgus 0
3 halux valgus or halux abductovalgus 1

4 bunion 12

5 hallux deformit 9

6 big toe deformit or great toe deformit 0

7 foot problem 37
8 foot disease 314

9 foot deformit or forefoot deformit 35

10 surg 86,816
11 operat 35,671

12 osteotom 557

13 arthrodes 138

14 arthroplast 2972
15 1–9 (OR) 433
16 10–14 (OR) 122,891
17 15 AND 16 61

13. ProQuest Dissertations and Theses

1 Hallux valgus 248
2 hallux abductovalgus 7
3 halux valgus or halux abductovalgus 7

4 bunion 868

5 hallux deformit 243

6 big toe deformit or great toe deformit 6137

7 foot problem 337,973
8 foot disease 164,870

9 foot deformit or forefoot deformit 16,531

10 surg 324,743

11 operat 1039,700

12 osteotom 1739

13 arthrodes 612

14 arthroplast 3489
15 1–9 (OR) 350,032
16 10–14 (OR) 1133,160
17 15 AND 16 420
14. Google Scholar

(Hallux valgus OR Hallux abductovalgus OR bunion OR hallux deformity OR great toe deformity OR
big toe deformity OR footdeformity OR foot disease OR foot problem) AND (surg oroperation OR
osteotomy OR arthrodesis OR arthroplasty) AND (random) – 50 references
15. Scirus
(Hallux valgus OR Hallux abductovalgus OR bunion OR hallux deformit OR forefoot deformit OR foot
deformit OR great toe deformit OR big toe deformit OR foot disease OR foot problem) AND (surg
oroperat OR osteotom OR arthroplast OR arthrodes) AND (placebo OR random OR kontrol group
OR comparison group OR trial)
Key OR Title ¼ 82 references

Appendix II: Appraisal instrument

MAStARI appraisal instrument

Appendix III: Data extraction instrument

MAStARI data extraction instrument


Appendix IV: Characteristics of included studies

Reference Methods Participants Intervention A Intervention B Notes
Basile et al.35 RCT 32 patients, Italy Distal chevron-Akin Akin osteotomy with dis- Inclusion criteria:
Sex: 29 female and 3 male osteotomy (10 patients/18 tal soft tissue release (13 mild
patients feet) patients/20 feet) HV deformity, age between 20
Age range: 20–55 years and 55 years;
Loss to follow up: 9 preoperative IMA of -<148;
HVA < 308; no prior
involvement of the hallux by
surgery, osteoarthritis
or inflammatory arthritis; a
minimum follow-up of 1 year
Calder RCT 30 patients, UK Mitchell’s osteotomy with Mitchell’s osteotomy Clinical evaluation was carrying
et al.22 Sex: 24 females, 6 males cortical screw and early with a suture and plaster by FFSS (forefoot scoring
Age range 19–68 years mobilization (13 women, 2 boot for six weeks (12 system)
Loss to men) screw with early women, 3 men)
follow-up: none weight bearing
Capasso RCT 35 patients with unilateral Modified Keller-Lelievre Original Keller-Lelievre Complication rate, Blinded asses-
et al.36 HV, Italy arthroplasty (by detaching arthroplasty sor
Sex: 34 females and 1 male the extensor hallucis brevis (17 patients: women)
Age range 55–76 years tendon from the proximal
Loss to follow up: 4 phalanx, and reattaching it
on the medial sesamoid)
(18 patients: 17 women, 1
men)
Chuckpai- RCT 125 patients with moderate- Distal metatarsal osteot- Proximal Metatarsal Patient with previous foot injury
wong38 to-severe HV omy osteotomy surgery or mild deformation
Sex: 12 men, 113 women) (75 patients/79 feet) (50 patients/52 feet) were excluded. Criteria for
Age range: 30–79 years severe HV: HVA >408 or IMA
Loss to follow-up: none >128
Deenik RCT 120 patients (141 feet) Scarf osteotomy (66 feet) Distal chervon osteotomy Classified as mild, moderate,
et al.23 Loss to follow-up: 5 (70 feet) severe according to IMA
Easley et al.37 RCT 75 patients (97 feet), USA Proximal chevron osteot- Proximal crescentic Pain (AOFAS score), compli-
Age range’’ 25–73 years omy (29 patients: 41 feet) osteotomy (37 patients: cations
Loss to follow up: 9 43 feet)
Faber et al.21 RCT 87 patients (101 feet) Distal Hoffman osteotomy Lapidus arthrodesis (51 68 feet with hypermobile feet,
Sex: 84 women, 3 men (50 feet) feet) 33 with nonhypermobile first
Age range: 16–63 years tarsometataral joint
Loss to follow-up: none Inclusion criteria: 15–65 years
Faber et al.24 RCT 87 patients (101 feet) Distal Hoffman osteotomy Lapidus arthrodesis (46 Same study as Faber, F. W. M.,
Sex: 84 women, 3 men (45 feet) feet) Mulder, P. G. H., Verhaar, J. A.
Age range: 16–63 years N., 2004 in 10 years follow-up
Loss to follow up: 10
Giannini RCT 20 patients (40 feet) with Distal Scarf osteotomy (20 Distal SERI osteotomy Randomization of feet
et al.25 bilateral HV feet – one foot in all (20 feet – one foot in all
Sex: women patients) patients)
Mean age: 53 11 years
Loss to follow-up: none
Klosok RCT 51 patients (87 feet) Distal chevron osteotomy Wilson osteotomy (26 Chevron group: Crepe bandage
et al.26 Sex: (44 women 7 men) (25 patients, 45 feet) patients, 42 feet) Wilson group: below-knee
Age range: 23–77 years plaster
Lechler RCT 72 patients with mild-to- Distal chevron osteotomy Chevron-Akin double All patients were given physical
et al.39 moderate HV (46 patients) osteotomy 26 patients examination, standardized ques-
Sex: 59 women, 13 men tionnaire.
Mean age: 52.3 years Matched groups: 26 vs. 26
Loss to follow up: unclear patients
Lee et al.27 RCT 65 patients (85 feet) with Proximal chevron osteot- Proximal chevron osteot- 9 patients in gr. 1 and 5 in gr. 2
moderate-to-severe HV omy (with a distal soft omy (with a distal soft- went bilateral procedure
Age range: 19 to 76 years tissue procedure) with tissue procedure) without
Loss to follow up: unclear transverse Kirschner wire fixation 33 patients 44
fixation 32 patients 41 feet feet
Park et al.42 RCT 130 patients (130 feet) Distal chevron osteotomy Distal chevron osteotomy All procedures were performed by
Sex: females (combined with distal soft- (combined with distal a single surgeon.
Age range: 19–72 years tissue procedures) – web- soft-tissue procedures) – The inclusion criteria were pain-
Loss to follow up: 8 space approach (60 feet) medial transarticular ful HV, difficulty in wearing
approach (62 feet) shoes, no history of previous HV
surgery, HVA 408 or a first-
second IMA 178

(Continued)
Reference Methods Participants Intervention A Intervention B Notes
Park et al.43 RCT 120 patients (120 feet) Proximal chevron osteot- Distal chevron osteotomy The inclusion criteria: painful
Sex: females omy (56 feet) (54 feet) HV, difficulty in wearing shoes,
Age range: 24–71 years no history of previous HV
Loss to follow up: 10 surgery, HVA 408 or a first-
second IMA 178
Pentikäinen RCT 100 patients (100 feet) Distal chevron osteotomy Distal chevron osteotomy The inclusion criteria: age 20–50
et al.28 Sex: 92 females, 8 males with internal fixation (50 without any fixation (50 years, HVA 50 and IMA 21
Age range: 21 to 50 years feet) feet) degree.
Loss to follow up: none The exclusion criteria – bunion
surgery
Prior et al.40 RCT 28 patients (39 feet), UK Mitchell’s metatarsal Mitchell’s metatarsal Patients with rheumatoid arthri-
Sex: 25 female, 3 males. osteotomy with standard osteotomy with absorb- tis excluded
Mean age: Vicryl group 38.8 Vicryl bone suture or K- able polydioxanone pins
years, polydioxanone group wire fixation stabilization (22 feet)
44.1 years (17 feet)
Radwan and RCT 53 patients (64 feet) with Percutaneous distal meta- Distal chevron osteotomy Exclusive criteria: rheumatic
Mansour29 mild-to-moderate sympto- tarsal osteotomy (31 feet) (33 feet) arthritis, failed of previous
matic HV surgery, severe deformity, joint
Mean age: percutaneous laxity, hypermobility of first
group 32.7, chevron group metatarso-cuneiform joint
35.7 years
Loss to follow up: unclear
Resch et al.20 RCT 38 patients (41 feet) Original chevron osteot- Adaptation of chevron One surgeon
Age range: 21–76 years omy (18 feet) osteotomy (combined
Loss to follow up: 2 with adductor tenotomy)
(21 feet)
Resch et al.41 RCT 79 patients, Sweden Proximal osteotomy (37 Distal chevron osteotomy No. of patients with rheumatoid
Age range: 16–78 years feet) (43 feet arthritis: not stated
Resch et al.30 RCT 87 patients; Sweden Adaptation of chevron Original chevron osteot- Average HVA 318
Age range: 15–74 years osteotomy (combined with omy (62 feet)
Loss to follow up: 3 adductor tenotomy (44
feet)
Saro et al.17 RCT 22 patients (22 feet) Lindgren osteotomy (14 Chevron osteotomy (8 The inclusion criteria: age 16–80
Sex: women feet) feet) years, HVA 20–448, IMA up to
Mean age: 49 years 208, DMAA up to 258.
Loss to follow up: none The exclusion criteria previous
HV surgery, diabetes, peripheral
vascular disease, peripheral neu-
ropathy or systemic systemic dis-
order, drug abuse, inability to
fill out the questionnaire
Saro et al.31 RCT 100 patients (100 feet) Lindgren osteotomy (44 Chevron osteotomy (46 The inclusion criteria: 16–80
Sex: 94 women, 6 men feet) feet) years, HVA 20–448, IMA up to
Mean age: 48 years 208, DMAA up to 258. The
Loss to follow up: 10 exclusion criteria previous HV
surgery
Tonbul RCT 13 patients mild-to-moderate Crescentic distal metatarsal Crescentic distal metatar- The inclusion criteria: 15–60
et al.32 HV (16 feet) osteotomy with two cross sal osteotomy with com- years, HVA 20 to 358, IMA up
Sex: 11 women, 2 men K-wires (8 feet) pressive screw (8 feet) to 148, a DMAA up to 258, no
Mean age: 36,5 years radiographic evidence of degen-
Loss to follow-up: none erative
metatarsophalangeal arthritis,
and persistent symptoms.
Blinded physical therapist
Torkki RCT 209 patients, Finland Distal chevron osteotomy Orthosis (69 No Exclusion criteria: previous HV
et al.33 Mean age: 48 years (71 feet) feet) therapy surgery or use of orthoses, preg-
Sex: 193 females, 16 males (waiting) nancy, age >60 years, HVA >35
Loss to follow-up: 2 (69 feet) degrees, IMA >15 degrees,
rheumatoid arthritis
Windhagen RCT 26 patients (26 feet) Chevron osteotomy with Chevron osteotomy with
et al.34 Sex: 24 women, 2 men biodegradable magnesium- titanium screw (13 feet)
Mean age: biodegradable based screw (13 feet)
group 57.2, titanium group
49.9 years
Loss to follow-up: none
DMAA, distal metatarsal articular angle; HV, hallux valgus; HVA, hallux valgus angle; IMA, 1–2 intermetatarsal angle.

Appendix V: Risk ratios for gait measure, quality of life and pain between surgical and
other type of treatment in patients with hallux valgus
Distal chevron osteotomy (and chevron-type osteotomy) versus other surgicalprocedure
Forest plot 1. Mean difference for walking speed between distal chevron osteotomies and Lindgren
osteotomy at medium-term follow-up.
Forest plot 2. Mean difference for walking speed between distal chevron osteotomies and Lindgren
osteotomy at long-term follow-up.
Distal osteotomy (non-chevron) versus other surgical procedures
Forest plot 3. Mean difference for physical component of quality of life between distal and proximal
metatarsal osteotomy at long-term follow-up.
Forest plot 4. Mean difference for mental component of quality of life between distal and proximal
metatarsal osteotomy in long-term follow-up.
Forest plot 5. Standardized mean difference for level of pain between distal osteotomy (non chevron) and
other surgical procedures at long-term follow-up.

Proximal osteotomy versus other surgical procedures
Forest plot 6. Risk ratio for adverse events between a proximal chevron osteotomy and proximal
crescentic osteotomy.
Adaptation of approach versus original operation
Forest plot 7. Mean difference for level of pain between first web-space approach and transarticular
approach in case of distal soft-tissue procedures combined with a distal chevron osteotomy at long-term
follow-up.
New methods of fixation versus traditional method
Forest plot 8. Mean difference for level of pain between screw fixation and suture fixation in case of
Mitchell’s osteotomy at short-term follow-up.
Forest plot 9. Mean difference for level of pain between screw fixation and suture fixation in case of
Mitchell’s osteotomy at medium-term follow-up.
Surgery versus conservative treatment
Forest plot 10. Mean difference for quality of life between surgical and conservative treatment at medium-
term follow-up.

Forest plot 11. Mean difference for quality of life between surgical and conservative treatment at long-term
follow-up.
Forest plot 12. Mean difference for level of pain between surgical and conservative treatment at medium-
term follow-up.
Forest plot 13. Mean difference for level of pain between surgical and conservative treatment at long-term
follow-up.
Surgery versus no treatment
Forest plot 14. Mean difference for quality of life between surgical and no treatment at medium-term follow-up.
Forest plot 15. Mean difference for quality of life between surgical and no treatment at long-term follow-up.
Forest plot 16. Mean difference for level-of pain between surgical and no treatment at medium-term follow-up.

Forest plot 17. Mean difference for level-of pain between surgical and no treatment at long-term follow-up.

Effectiveness of Surgery For Adults With Hallux Valgus

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Effectiveness of Surgery For Adults With Hallux Valgus

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S YS T E M AT I C R E V I E W

Effectiveness of surgery for adults with hallux valgus

Correspondence: Jitka Klugarova, jitka.klugarova@gmail.com

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Setting: Karolinska University Hospital

Intervention: distal chevron type osteotomy

Comparison: other surgical procedures

Gait measures - The mean gait The mean gait measures

Gait measures - The mean gait The mean gait measures

GRADE Working Group grades of evidence

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Surgery compared to conservative treatment for adults with hallux valgus

Setting: 4 general community hospitals in Finland

Comparison: conservative treatment

Level of pain in - The mean level The mean level of pain in

Level of pain in - The mean level The mean level of pain in

Quality of life in - The mean The mean quality of life in

Quality of life in - The mean The mean quality of life in

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Surgery compared to no treatment for adults with hallux valgus

Patient or population: adults with hallux valgus

Setting: 4 general community hospitals in Finland

Pain – long- - The mean pain The mean pain – long-term in

Pain – - The mean pain The mean pain – medium-

Quality of life – - The mean The mean quality of life –

Quality of life – - The mean The mean quality of life –

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Background (FFI). du Plessis et al.6 tested the effect of a modified

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Citaons idenﬁed through systemac

Duplicate citaons removed

Titles and abstracts screened Arcles excluded (n = 1583)

Full-text arcles assessed for

Studies included in crical

Studies included in meta

analysis and narrave synthesis

Figure 1: Study selection and inclusion process19

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Table 1: Assessment of methodological quality

Reference Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Overall

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Characteristics of included studies (non-chevron type) osteotomy with other surgical

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

New methods of fixation versus traditional Primary outcome

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Proximal osteotomy versus other surgical Secondary outcomes

Adaptation of approach versus original operation Primary outcome

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©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

Surgery versus no treatment Adverse events (complications): No data given for

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

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Appendix I: Search strategy

No. Searches Results

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17 Topic: (clinical near trial or crossover or cross over) or