Effectiveness of surgery for adults with hallux valgus deformity: a systematic review
Authors: Klugarova Jitka , Hood Victoria , Bath-Hextall Fiona , Klugar Miloslav , Mareckova Jana , Kelnarova Zuzana 
Published: June 2017

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The search strategy aimed to find both published and unpublished studies.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.
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.