Surgical interventions for treating hallux valgus and bunions

Background:
Hallux valgus (lateral angulation of the great toe towards the lesser toes, commonly known as bunions) presents in 23% to 35% of the population. This condition leads to poor balance and increases the risk of falling, adding to the difficulty in fitting into shoes and pain. Conservative (non‐surgical) interventions treating pain rather than curing deformity are usually first‐line treatments. When surgery is indicated, the overall best surgical procedure is an ever‐evolving topic of discussion.

Objectives:
To assess the benefits and harms of different types of surgery compared with placebo or sham surgery, no treatment, non‐surgical treatments and other surgical interventions for adults with hallux valgus.

Search methods:
We searched CENTRAL, MEDLINE, Embase and trial registries to 20 April 2023. We did not apply any language or publication restrictions.

Selection criteria:
We included randomised controlled trials evaluating surgical interventions for treating hallux valgus compared to placebo surgery or sham surgery, no treatment, non‐surgical treatment or other surgical interventions. The major outcomes were pain, function, quality of life, participant global assessment of treatment success, reoperation (treatment failure), adverse events and serious adverse events.

Data collection and analysis:
Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE.

Main results:
We included 25 studies involving 1597 participants with hallux valgus. All studies included adults and most were women. One study compared surgery (V‐shaped osteotomy) with no treatment and with non‐surgical treatment. Fifteen studies compared different surgical techniques, including a V‐shaped osteotomy (Chevron osteotomy), to other types of osteotomy. Nine studies compared different simple osteotomy techniques to each other or to a mid‐shaft Z‐shaped osteotomy (Scarf osteotomy).

Most trials were susceptible to bias: in particular, selection (80%), performance (88%), detection (96%) and selective reporting (64%) biases.

Surgery versus no treatment

Surgery may result in a clinically important reduction in pain. At 12 months, mean pain was 39 points (0 to 100 visual analogue scale, 100 = worst pain) in the no treatment group and 21 points in the surgery group (mean difference (MD) −18.00, 95% confidence interval (CI) −26.14 to −9.86; 1 study, 140 participants; low‐certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.

Surgery may result in a slight increase in function. At 12 months, mean function was 66 points (0 to 100 American Orthopedics Foot and Ankle Scale (AOFAS), 100 = best function) in the no treatment group and 75 points in the surgery group (MD 9.00, 95% CI 5.16 to 12.84; 1 study, 140 participants; low‐certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.

Surgery may result in little to no difference in quality of life. At 12 months, mean quality of life (0 to 100 on 15‐dimension scale, 100 = higher quality of life) was 93 points in both groups (MD 0, 95% CI −2.12 to 2.12; 1 study, 140 participants; low‐certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.

Surgery may result in a slight increase in participant global assessment of treatment success. At 12 months, mean participant global assessment of treatment success was 61 points (0 to 100 visual analogue scale, 100 = completely satisfied) in the no treatment group and 80 points in the surgery group (MD 19.00, 95% CI 8.11 to 29.89; 1 study, 140 participants; low‐certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.

Surgery may have little effect on reoperation (relative effect was not estimable), adverse events (risk ratio (RR) 8.75, 95% CI 0.48 to 159.53; 1 study, 140 participants; very low‐certainty evidence), and serious adverse events (relative effect was not estimable), but we are uncertain.

Surgery versus non‐surgical treatment

Surgery may result in a clinically important reduction in pain; a slight increase in function and participant global assessment of treatment success; and little to no difference in quality of life (1 study, 140 participants; low‐certainty evidence). We are uncertain about the effect on reoperation, adverse events and serious adverse events (1 study, 140 participants; very low‐certainty evidence).

Complex versus simple osteotomies

Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies (7 studies, 414 participants; moderate‐certainty evidence). Complex osteotomies may increase reoperation (7 studies, 461 participants; low‐certainty evidence), and may result in little to no difference in participant global assessment of treatment success (8 studies, 462 participants; low‐certainty evidence) and serious adverse events (12 studies; data not pooled; low‐certainty evidence). We are uncertain about the effect of complex osteotomies on function and adverse events (very low‐certainty evidence). No study reported quality of life.

Authors' conclusions:
There were no trials comparing surgery to placebo or sham. Surgery may result in a clinically important reduction in pain when compared to no treatment or non‐surgical treatment. Surgery may also result in a slight increase in function and participant global assessment of treatment success compared to no treatment or non‐surgical treatment. There may be little to no difference in quality of life between surgery and no treatment or non‐surgical treatment. We are uncertain about the effect of surgery on reoperation (treatment failure), adverse events or serious adverse events, when compared to no treatment or non‐surgical treatment.

Complex and simple osteotomies demonstrated similar results for pain. Complex osteotomies may increase reoperation (treatment failure) and may result in little to no difference in participant global assessment of treatment success and serious adverse events compared to simple osteotomies. We are uncertain about the effect of complex osteotomies on function, quality of life and adverse events.