SLR - February 2023 - Preeti Kumrah, DPM
Title: Role of lateral soft tissue release in percutaneous hallux valgus surgery: a systematic review and meta-analysis of the literatureReference: Izzo, Antonio et al. Role of lateral soft tissue release in percutaneous hallux valgus surgery: a systematic review and meta-analysis of the literature. Archives of orthopaedic and trauma surgery. 2022 Nov 10
Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Preeti Kumrah, DPM
Residency Program: Ascension St. Vincent- Indianapolis
Podiatric Relevance: It has been long contested whether a lateral soft tissue release is necessary as part of percutaneous hallux valgus (HAV) surgery. As one of the most common foot disorders, surgical correction is indicated with the goal to realign the first ray and alleviate patient symptoms. When addressing a mild to moderate HAV, the percutaneous approach involves a distal metaphyseal / metaphyso-diaphyseal osteotomy of the first metatarsal head with the aim to shift the metatarsal head laterally. Derotation of the metatarsal in the coronal plane is to correct excessive pronation and the correction in the transverse plane is to restore the distal metaphyseal metatarsal angle. In terms of soft tissue, the tension of lateral structures (abductor tendon, joint capsule, lateral sesamoid suspensory ligament, and lateral collateral ligament), has been well described in literature as necessary to address to achieve proper alignment and reduction of recurrence.
Methods: The inclusion criteria for the systematic review included: studies reporting percutaneous HAV surgery in patients between 15-85 years old, clearly described lateral release technique, minimum follow up of 6 months, and pre and post operative weightbearing radiographs. Exclusion criteria were: open surgery, cases not reporting distal/diaphyseal osteotomies, proximal osteotomies, Lapidus, biomechanical studies, cadaveric studies, or animal cases. Data was collected addressing type of study, year of publication, level of evidence, type of procedure, additional procedures, length of follow up, clinical scores pre and post operative, pre and post operative radiographic angles, and post operative complications. The studies were separated into two groups, Group 1 with a lateral release and Group 2 without a lateral release.
Results: Of the 1833 studies, 16 were included, for a total of 1147 feet in 960 patients (594 feet in Group 1(G1) and 553 feet in Group 2 (G2)). The pre- (G1: 51.7 ± 10.6 and G2: 45.8 ± 1.7 points) and post-operative AOFAS scores (G1: 89.4 ± 4.3 and G2: 86.9 ± 3.2 points) and the pre- (HVA: G1: 29.7 ± 2.9 and G2: 44.1° ± 26.8°) (IMA: G1: 12.5 ± 4.2 and G2: 14.1° ± 2.6°) and post-operative radiological angles (HVA: G1: 12.1 ± 4.3 and G2: 12.3° ± 2.3°) (IMA: G1: 9.2 ± 2.2 and G2: 7.9° ± 1.3°) were not statistically significant in the two groups. It was noted that G1 was more likely to have an Akin osteotomy than G2 but was not noted to correlate with clinical or radiographic outcomes. An Akin was recommended in the case of residual interphalangeal valgus. At 21 month follow up, with a mean of 51 months, the rate of recurrence was 2% in both G1 and G2. The overall complication rate of G1 was 27% and G2 resulting in 25%, depicting that the difference between both groups was not statistically significant in close proximity.
Conclusions: The purpose of the systematic review was to assess whether the lateral soft tissue release reduces the risk of recurrence in HAV and whether the release increases the risk of complications and improves clinical/radiographic outcomes. The main finding through the present study was that the soft tissue release does not appear to influence recurrence rate through percutaneous HAV correction in a 4 year follow up. Comparing both groups, the number of complications is similar. Assessing the AOFAS scores, the clinical outcome and radiographic correction achieved with long term follow up did not differ. Authors of this systematic study hypothesized that the lateral release would lead to greater correction and greater complications, although not supported by the data. This study impacts general practices in HAV procedures moving forward by determining the value of lateral soft tissue release. Assessing the results, the authors conclude there is no significant increase in recurrence rate by performing the release, deeming the HAV without it as adequate and stable. Although the authors hypothosized that the recurrence rate should be higher in groups without the release, they recognize and hypothesize that percutaneous techniques may allow for a greater lateral shift and that realignment of the first ray may neutralize the valgus deforming force of the soft tissue. The authors recognize limitations of the study, including quality of studies analyzed, level of evidence, the description of the lateral release between studies, comparison of average values/clinical scores, and low follow up time frame. Although the article completed an appropriate analysis of comparing the two groups, the limitations they recognize heavily affect the validity and bias of the study. Describing the lateral release between studies is difficult, determining clinical values outside of an average, and long term follow up play a role in the efficacy of the conclusion. Further follow up with prospective comparative studies would be beneficial.