Comparison of the outcomes of current surgical algorithms in hallux valgus

Introduction

Background

Hallux valgus (HV) is common, affecting 19% of the population and up to 36% of people over 65 years (1). Half of them develop symptomatic HV, and surgery might become necessary (2). There is no consensus on the classification of HV, and its therapeutic algorithm can be challenging. Surgery included open, minimally invasive and percutaneous techniques. Several techniques have been described, such as distal, shaft, or proximal metatarsal osteotomies, Akin osteotomy, Lapidus fusion, and hallux joint fusion (3). The degree of deformity, the shape and size of the metatarsal and phalangeal deviation and the extent of degenerative changes in the first metatarsophalangeal (MTP) joint are taken into account in the decision on which surgical technique should be used (4).

Rationale and knowledge gap

To date, few therapeutic algorithms for the management of HV have been published: those proposed by the American Orthopedic Foot & Ankle Society (AOFAS) (5), the European Foot & Ankle Society (EFAS), and the Chinese Consensus (4). AOFAS and EFAS algorithms analyze scientific evidence available on the effectiveness and the safety of different techniques according to the National Institute for Health and Clinical Excellence (NICE), providing a tool which indicates the most appropriate minimally invasive percutaneous technique. The AOFAS algorithm considers the possible presence of arthrosis and the congruence of the joint; in the case of an incongruent joint, the surgical decision is further guided by the radiographic values. The Foot and Ankle Working Committee of the Chinese Association of Orthopaedic Surgeons, following a debate among experts during the second Oriental Conference of Orthopaedic Surgeons in April 2015, provided a “Consensus on the Operative Correction of Hallux Valgus”. Chinese algorithm considers clinical parameters, such as symptoms and physical signs, radiographic measures, and the presence of arthrosis. In 2016, Fraissler et al. published another treatment algorithm for HV based on the degree of the deformity, congruency of the first MTP joint, and potential degenerative changes (3). However, the management of HV still lacks standardization (3). Different approaches and techniques can be used based on the severity of the deformity and no specific surgical procedure has been shown to achieve better results than others (6).

Objective

The aim of this study was to compare the radiological outcomes of current algorithms in patients who underwent surgical treatment for isolated HV. A clearer understanding of the effectiveness of surgical treatment of HV may be of interest to patients, clinicians, researchers and policy makers in the orthopedic field. We present this article in accordance with the STROBE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-11/rc).

Methods

Participants

A retrospective study was conducted on 120 consecutive patients who underwent different kinds of surgical treatment for isolated HV between February 2013 and September 2021. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Magna Graecia University of Catanzaro (protocol code 07/18, 15.05.2018). Informed consent was obtained from all participants included in the study. The inclusion criteria were (I) symptomatic HV; (II) age of more than 18 years; and (III) unsuccessful previous conservative treatment with orthotic devices to reduce symptoms in patients who initially refused or postponed surgical treatment. The exclusion criteria were (I) rheumatoid arthritis; (II) failed previous HV surgery; (III) severe osteopenia according to Jhamaria’s grade I and II calcaneus index (7,8); (IV) peripheral arterial disease and neurological disorders; and (V) concomitant surgical procedures on the lesser metatarsals. For seven patients, there were no postoperative data available since they were absent at the one-month outpatient check-up. Therefore, 113 of 120 patients (94.2%) were evaluated.

Operative procedures were performed by two senior authors, each with over 20 years of experience in foot surgery (O.G., B.I.). A single pre-operative intravenous dose of cefazolin, spinal anesthesia and a pneumatic tourniquet were used in all patients. Different surgical techniques were used based on surgeon preference and HV severity: Akin osteotomy, Scarf osteotomy, Reverdin-Green osteotomy, Lapidus procedure, and MTP arthrodesis. A corrective bandage was applied postoperatively. A hind-foot weight-bearing shoe was used to allow the weight-bearing on the day after surgery. A weekly change of the corrective dressing was recommended. One month postoperatively, patients underwent a radiographic control and were allowed to wear comfortable shoes. We analyzed pre- and postoperative radiographic measurements at one-month follow-up. Data from perioperative and postoperative complications were collected.

Radiographic evaluation

Pre- and postoperatively at one-month follow-up, weight-bearing dorsoplantar and lateral radiographs were performed. The one-month follow-up was used because it represents the time of clinical and radiographic control normally used to define bone healing after HV surgery. In fact, after this one-month control, in the absence of complications, the patient was allowed to wear normal footwear and return to normal daily activities. Angular measurements included the HV angle (HVA), intermetatarsal angle (IMA), hallux valgus interphalangeal angle (HVI), and distal metatarsal articular angle (DMAA) (Figure 1); these measurements were conducted according to the indications highlighted in the Ad Hoc Committee of the American Orthopaedic Foot & Ankle Society recommendations (9).

Figure 1 Pre- and postoperative X-ray examination of a bilateral symmetric hallux valgus case. Surgical techniques used were a medial closing wedge osteotomy of the proximal phalanx fixed with a staple (Akin osteotomy), and a distal metatarsal osteotomy fixed with two screws (Scarf osteotomy).

HVA has been described as the parameter that correlates best with the clinical classification of severity by the Manchester scale (10). The HVA values were used to categorize the severity of HV as follows: normal (<15°), mild (16–20°), moderate (21–39°), and severe (>40°) (11). HVI, formed by the diaphysis axes of the proximal and distal phalanges of the big toe, was considered normal with values between 0 and 10°. An increase of the HVI of greater than 10° define interphalangeal HV. Joint congruency at the first MTP joint was categorized as “congruent” (not subluxed) or “noncongruent” (subluxed) if the lateral border of the articular surface of the proximal phalanx was displaced outside the lateral border of the articular head surface of the first metatarsal (12). A four-grade scale was used to grade sesamoid subluxation based on the lateral displacement of the tibial sesamoid bone in relation to a reference line passing through the center of the diaphysis of the first metatarsal (13,14). Specifically, grade 0 meant a normal position, grade 1 meant a displacement of less than 50%, grade 2 meant a displacement of more than 50%, and grade 3 meant a complete displacement of the tibial sesamoid bone beyond the reference line. Osteoarthritis (OA) at the first MTP joint was categorized as “present” or “absent” based on the previously described radiographic criteria by Menz et al. in their atlas and scoring system considering the presence of osteophytes and joint space narrowing from either the dorsoplantar or lateral view (10).

Surgical treatment algorithms

The AOFAS algorithm considers the possible presence of arthrosis and the congruence of the joint; in the case of an incongruent joint, the surgical decision is further guided by the values of the HVA and the IMA (5). Chinese algorithm considers clinical parameters, such as symptoms and physical signs (4); these data are then integrated with the radiographic measures of the values of HVA, IMA, DMAA, the position of the sesamoids, and the possible presence of OA at the first MTP joint and surgical treatments are based on the level of severity of the deformity. The algorithm proposed by Fraissler et al., based on the choice of surgical treatment by evaluating the congruence and OA at the first MTP joint. In the case of a congruent MTP joint, the HV interphalangeal angle (HVI) is further investigated; in the case of incongruent joints, HVA and IMA are considered, and soft tissue procedures are also indicated (3). Patients were retrospectively categorized based on whether their pre-operative condition and performed surgery matched the criteria of each algorithm.

Statistical analysis

All data were collected prospectively, measured and reported with an accuracy of one decimal place. The mean, standard deviation and range were given for the continuous variables and the number and percentage for the categorical variables. Demographic characteristics of included cases were reported; the pre-operative and post-operative values of HVA, IMA, HVI, and DMAA and the sesamoid position were also calculated. The Kolmogorov‒Smirnov normality test was used to assess the distribution of the numeric samples. Parametric tests were adopted according to this preliminary analysis; to evaluate the significance of differences between preoperative and postoperative continuous variables (i.e., values of HVA, IMA, DMAA) a two-tailed Paired-Sample Student t-test was used. To evaluate the differences between preoperative and postoperative values of categorical dependent variables (i.e., presence of OA and joint congruence), a McNemar test was used. To compare the differences between preoperative and postoperative values of categorical dependent variables in 4x2 contingency tables (i.e., sesamoid position and HV severity), a Bowker test was used. Patients were also divided into three groups: Group A, patients whose treatment meets the criteria defined in the AOFAS algorithm; Group B, patients whose treatment meets the criteria defined in the algorithm by Fraissler et al.; and Group C, patients whose treatment meets the criteria defined in the Chinese algorithm. The sample size, the observed effect size, and an α-value of 0.05 were considered to calculate the post hoc power; a value greater than 80% was considered appropriate (15). IBM SPSS Statistics software (version 26; IBM Corp., Armonk, NY, USA) and G*Power (version 3.1.9.2; Institut fur Experimentelle Psychologie, Heinrich Heine Universität, Düsseldorf, Germany) were used to construct the database and perform statistical analysis. A P value of less than 0.05 was considered significant; according to the Bonferroni correction, the statistical significance only for the Bowker test was set at a P value <0.002 when 4×2 contingency tables with three degrees of freedom were reported.

Results

Baseline characteristics of included patients and comparison between preoperative and postoperative values are shown in Table 1. The final sample consisted of 113 cases, female patients were 104 (92%), with an average age of 57±12.4 (range, 19–83) years. Different surgical techniques were used: 30 isolated distal metatarsal osteotomies (Scarf osteotomy), one isolated osteotomy of the proximal phalanx (Akin osteotomy), and 72 combined Scarf with Akin procedures; five percutaneous distal metatarsal osteotomies (Reverdin-Green osteotomy), four first tarsometatarsal (TMT) arthrodesis (Lapidus procedure), and one MTP arthrodesis (Figure 1). All the post-operative HVA, IMA, HVI, and DMAA values significantly improved compared to preoperative values (all P<0.001). The severity of HV significantly decreased in all stratifications (all P<0.001). Joint congruency improved after treatment (P<0.001). Preoperatively, the sesamoid position was graded as 3 in 63% of the cases, while postoperatively, most patients were graded as 0 or 1 (73% of the cases). No cases of complications and recurrence of HV were reported.

Group A

Group A included 101 patients whose treatment met the criteria defined in the AOFAS algorithm (Table 2). HVA, IMA, HVI and DMAA values significantly improved from preoperative to postoperative evaluations (all P<0.001). Preoperatively, the sesamoid position was graded as 3 in 61% of the cases, while postoperatively, most of the patients were graded as 0 or 1 (76% of the cases).

According to HV severity, patients who showed a preoperative mild HV achieved physiological values in 71% of cases; 29% of cases improved their preoperative condition, although remaining in the mild range. Patients who showed a preoperative moderate HV improved to a mild condition in 34% of cases, to physiological values in 51% of cases, while in 15% of cases, remained in the moderate range despite a reduction of the analyzed angles. Patients with a preoperative severe HV improved in physiological values in 9% of cases, mild HV in 26%, and moderate HV in 65% of cases.

Group B

Group B included 75 patients whose treatment met the criteria defined in the algorithm by Fraissler et al. (Table 3). HVA, IMA, HVI and DMAA values significantly improved from preoperative to postoperative evaluations (all P<0.001). Preoperatively, the sesamoid position was graded as 3 in 69% of the cases, while postoperatively, most patients were graded as 0 or 1 (68% of the cases).

According to HV severity, patients who showed a preoperative mild HV achieved physiological values in 100% of cases. Patients who showed a preoperative moderate HV improved to a mild condition in 38% of cases and to physiological values in 38% of cases, while in 24% of cases, they remained in the moderate range despite a reduction of the analyzed angles. Patients with a preoperative severe HV improved in physiological values in 18% of cases, mild HV in 23%, and moderate HV in 59% of cases.

Group C

Group C included 107 patients whose treatment met the criteria defined in the Chinese Consensus algorithm (Table 4). HVA, IMA, HVI and DMAA values significantly improved from preoperative to postoperative evaluations (all P<0.001). Preoperatively, the sesamoid position was graded as 3 in 63% of the cases, while postoperatively, most patients were graded as 0 or 1 (73% of the cases).

According to HV severity, patients who showed a preoperative mild HV achieved physiological values in 83% of cases; 17% of cases improved their preoperative condition, although remaining in the mild range. Patients who showed a preoperative moderate HV improved to a mild condition in 34% of cases, to physiological values in 51% of cases, while in 15% of cases, remained in the moderate range despite a reduction of the analyzed angles. Patients with a preoperative severe HV improved in physiological values in 19% of cases, mild HV in 21%, and moderate HV in 60% of cases.

Discussion

Key findings

The most important finding from this study was that a statistically significant improvement in HVA, IMA, HVI and DMAA values was observed in all patients who underwent surgical treatment for isolated HV. Even though surgical algorithms showed different designs and factors to consider, radiographic improvements were noted in all groups analyzed.

Explanations of findings

Algorithms by AOFAS and Fraissler et al. evaluated whether the first MTP joint was congruent or arthritic. AOFAS algorithm, in this step, also distinguished patients with a high risk of ulceration in whom mini-invasive surgery is the recommended surgical treatment (5). Brogan and colleagues (16) reported on a cohort study investigating the minimally invasive versus the open technique. The authors reported no difference between the groups in terms of clinical and radiographic postoperative scores. According to the AOFAS algorithm, Akin osteotomy was recommended if the first MTP joint was congruent. If the first MTP joint was incongruent, distal soft-tissue procedures were recommended, combined with Chevron or Scarf or Modified Lapidus procedures according to the IMA and HVA severity. In the current study, Scarf osteotomy was the most common procedure performed; this type of osteotomy was introduced by Burutaran in 1976 and later popularised by Barouk (17). Several studies confirmed satisfactory results with Scarf osteotomy, which remains a popular option due to its reliability and versatility in the treatment of various deformities (18-20). One study comparing chevron osteotomy in combination with lateral release to chevron osteotomy in isolation found that although radiographic correction was significantly better in the combined group, patient satisfaction was similar (21). The algorithm by Fraissler et al. shows that fusion of the first MTP joint should be considered if the joint was arthritic. Pydah et al. (22) examined 69 cases that underwent primary fusion of the first MTP joint, demonstrating not only correction of the HVA and IMA but also improvement of the sesamoid position on X-ray examination.

Chinese algorithm evaluates symptoms and history, physical signs and radiographic measurements, reporting different surgical procedures based on HV severity and associated deformity (4). Liang et al. (23), who studied performance information and decision aids, showed that patients rely on the algorithm when they are convinced of its merits. Participants who were better informed about the algorithm through feedback and training were more likely to trust its recommendations. Each algorithm showed that the patient’s stratification on the level of severity of the HV is necessary to guide surgical decisions. According to Moscadini et al. (5), algorithms proposed by AOFAS and the EFAS are the most reliable (24). However, the methods referred to the Chinese Consensus are also accepted and recommended by many foot and ankle surgeons after decades of clinical practice (4).

Comparison with similar researches

Overall, the appearance and degree of deformity determine the surgical treatment strategies. Interestingly, Okuda et al. found that patients with a preoperative HVA of more than 40° had a higher risk of recurrence after Scarf osteotomy, while an HVA of less than 15° and an IMA of less than 10° were protective factors (25). The choice of an appropriate technique also depends on the potential degenerative changes of the first MTP joint, the size and shape of the metatarsal, and joint congruency. The role of joint incongruity in determining recurrent HV has been described by previous authors in both Scarf and distal chevron osteotomies (26,27). The role of hypermobility in the first TMT joint is controversial. Coughlin and Jones reported a proximal crescentic osteotomy of the first metatarsal in combination with distal soft tissue realignment for the treatment of moderate to severe subluxed HV deformities (28). Interestingly, the authors also reported that hypermobility of the first ray routinely and spontaneously reduced to average levels in the postoperative period without the need for arthrodesis of the first TMT joint, suggesting that stability of the first ray is a function of the alignment of the first ray and not an intrinsic property of the first TMT joint. A relationship between TMT mobility and the severity of HV was found by Manceron et al. Using a clinically easy to perform ultrasound test, the authors emphasised the importance of the sagittal dynamic component in HV. This supports the pathophysiologic mechanism of metatarsus primus varus (MPV): the condition of the ligaments around the TMT joint determines whether HV develops (29). Nevertheless, further high-quality prospective comparative studies are needed to answer the question of the role of instability of the first TMT joint.

Strengths and limitations

Several limitations must be considered when drawing conclusions from this study. The sample size in the present study was limited. Clinical scores assessing pain, joint function, bone quality, quality of life and mental status were not included (30,31). These factors could influence the decision for treatment, apart from the fact that they have already been associated with impaired functional recovery after various orthopedic procedures (32,33). Furthermore, we have not reported the data of patients who, despite having an indication for surgery, decided not to undergo the surgical procedure; these patients could represent a control group to compare the results of surgery, but this comparison was outside the objectives of the current study. Comorbidities, biomechanical and anatomical-pathological conditions and long-term clinical outcomes were not considered in this study. Indeed, we excluded cases with rheumatoid arthritis, severe osteopenia, and neurological disorders; these conditions may be present in other patients and may affect their postoperative outcome (34-36). Moreover, HV surgery is measured by a variety of parameters and not only by the postoperative radiographic improvement; in this context, pain reduction, increased functionality, satisfaction, and non-recurrence were not assessed in the current study. We also did not perform a direct comparison among algorithms, but we analyzed the different designs. However, reporting the results according to different HV treatment algorithms could be considered a strength of the study and could help surgeons choose the best surgical approach. Indeed, prior to the performance of the index surgery by the two surgeons involved in the study, none of the algorithms analyzed in the current study had been consulted or taken into rigorous consideration. The choice of the type of surgery to be performed was made by the surgeon based on his own experience as often happens in real clinical practice. Moreover, the use of validated, accurate, and standardized radiological assessments and the prospective nature of the data collection represent considerable strengths of the present study.

Conclusions

Satisfactory radiological results can be expected in patients who underwent surgical treatment for isolated HV. Even though treatment algorithms proposed in literature showed different designs and factors to consider, radiographic improvements were noted in all groups analyzed. Clinicians can use these findings to select the best treatment and inform patients about what they can expect after surgery.

Acknowledgments

The authors thank the Italian Orthopaedic Research Society (IORS). M.M. and G.G. are members of the IORS Executive Board.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-11/rc

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-11/dss

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-11/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-11/coif). M.M. serves as an unpaid editorial board member of AME Surgical Journal from December 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Magna Graecia University of Catanzaro (protocol code 07/18, 15.05.2018). Informed consent was obtained from all participants included in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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