Minimally invasive vs open surgery for hallux valgus: a meta-analysis

SLR - June 2022 - Justin Adame, DPM

Reference: Ji L, Wang K, Ding S, Sun C, Sun S, Zhang M. Minimally invasive vs open surgery for hallux valgus: a meta-analysis. Front Surg. 2022. Mar 21;9:843410.

Level of Evidence: I

Scientific Literature Review

Reviewed By: Justin Adame, DPM
Residency Program: McLaren Oakland Hospital (Pontiac, MI)

Podiatric Relevance: Hallux valgus (HV) is a progressive multiplanar deformity that often leads to pain with ambulation, gait abnormality, inability to fit in some footwear, and overall decreased quality of life. As the deformity progresses, HV is often accompanied by overlap of the adjacent digits, arthritic changes, and painful calluses at areas of pressure due to altered biomechanics. Multiple open and minimally invasive techniques have been described in the literature to address the degree of deformity. However, previous meta-analyses have found no significant difference in radiological outcomes or functional scores when comparing minimally invasive surgery (MIS) and open hallux valgus surgery. The purpose of this meta-analysis was to re-examine the literature concerning MIS versus open surgery for the treatment of hallux valgus with the inclusion of newer studies and more robust outcome measures.

Methods: A literature search was performed of PubMed, Embase, and Cochrane Library between the dates of 01/01/1980 and 10/01/2021. A variety of search terms were used including variations of hallux abductovalgus and minimally invasive surgery. Inclusion criteria included comparative studies of MIS versus open HV, at least 6-month follow up, and at least one of six outcome measures that included hallux valgus angle, first intermetatarsal angle, the American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analog score (VAS), operating time, and complications. Exclusion criteria omitted studies without outcome measures, biomechanical research, unpublished data and case series, reports, reviewed, or proceedings of meetings.  In the end, 22 studies met the inclusion criteria that varied from retrospective to randomized-controlled trials.  Each study compared one MIS procedure to one open procedure.  MIS HV procedures included Bösch, SERI (simple effective rapid inexpensive), PECA (percutaneous Chevron-Akin), MICA (minimally-invasive Chevron-Akin), and POO (percutaneous oblique osteotomy).  Open HV procedures included Kramer, Scarf, Chevron, Ludloff, Scarf-Akin, and Chevron-Akin.

Results: This meta-analysis came to show that there were better radiological outcomes and clinical outcomes for the MIS group versus the open group. More specifically, MIS showed greater reduction in intermetatarsal angle and hallux valgus angle, no significant difference in post-surgical metatarsal length, improved sesamoid position, lower VAS score early post-operative phase, higher patient satisfaction rate, significantly shorter scar length, decreased duration of surgery, and decreased time of hospitalization. While this most recent meta-analysis showed promising results for MIS versus open surgical hallux valgus correction, the greatest challenge of MIS is the learning curve in developing the proper skills and technique to adequately perform the procedure.

Conclusion: This meta-analysis compared MIS versus open hallux valgus surgery has shown improvement in techniques in recent years with more robust outcome measures is indicative of MIS bunion surgery being superior in regards to radiologic outcomes, clinical outcomes, and cosmetic appearance. One of the major hurdles when it comes to performing MIS bunion surgery is surgeon proficiency. Those wishing to improve their technique should spend an adequate amount of time with cadaveric limbs. Additionally, advances in hardware systems from medical device companies may help with performing MIS procedures and obtaining desirable outcomes.