Abstract
Background
Moderate to severe hallux valgus deformities are traditionally managed with proximal chevron osteotomy (PCO) due to its ability to correct significant angular deviations. However, distal chevron osteotomy (DCO), either alone or in combination with other interventions, has demonstrated promising radiological outcomes. This meta-analysis is the first to compare PCO and DCO in the treatment of moderate to severe hallux valgus.
Methods
Four studies, including 294 cases, compared PCO and DCO. Primary outcomes were Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA). Secondary outcomes included AOFAS scores and postoperative complications.
Results
No significant differences were observed between PCO and DCO for HVA (P = 0.41) or IMA (P = 0.10). Similarly, AOFAS scores showed no statistical difference (P = 0.23).
Conclusion
Based on data from non-randomized studies, this meta-analysis found no significant clinical and radiological differences between PCO and DCO for moderate to severe hallux valgus. These findings suggest that DCO can be reliably used as an alternative to PCO, but further high-quality, randomized trials are needed to confirm long-term efficacy. Both techniques have low complication rates. The rehabilitation protocols across all studies included similar early mobilization and K-wire removal timing, but differences in weight-bearing, footwear, and post-operative exercise regimens highlight variability.
1
Introduction
Hallux valgus is a prevalent foot deformity that significantly impacts both self-reported function and quality of life, primarily due to chronic pain and impaired mobility. This condition is characterized by a combined deformity at the first metatarsophalangeal joint (MTPJ), resulting in lateral deviation of the great toe and medial deviation of the first metatarsal bone. The prevalence of hallux valgus varies globally, with particularly high rates in Asia and Oceania. It predominantly affects females and becomes more common with advancing age, particularly in individuals over 60 years old .
When conservative treatments fail, surgical intervention is often recommended, particularly for patients with persistent pain or difficulty with footwear. The choice of surgical technique is based on the severity of the deformity, which is typically assessed using radiological measurements, such as the HVA and the IMA.
For moderate to severe cases of hallux valgus, PCO is often indicated, as it allows for greater correction of the deformity. Among the various proximal osteotomy techniques, the PCO is commonly employed. In contrast, DCO is generally recommended for mild to moderate cases of hallux valgus , . However, recent studies , have explored the use of distal chevron osteotomy as a viable option for more severe deformities. The DCO either alone or in combination with other interventions, has demonstrated improved radiological outcomes and offers several advantages , .
Although several studies have demonstrated that the radiological and clinical outcomes of open DCO for moderate-to-severe hallux valgus are comparable to those of open PCO, it remains unclear whether these results can be replicated using a minimally invasive approach. Minimally invasive surgery (MIS), which has represented a significant advancement in orthopedic procedures since the late 1990s, has gained popularity in hallux valgus correction due to its potential advantages over open techniques, such as reduced operative time, smaller incisions, and faster postoperative recovery. The adoption of burrs for osteotomy enables corrections to be performed through small incisions rather than through open approaches, contributing to the widespread use of the term “minimally invasive” within orthopedic communities. However, this term refers not to a specific technique but to the use of specialized tools that can be applied across various surgical methods. Over time, three generations of MIS techniques have been developed. The first generation was introduced by Isham, which consists of an intra-articular osteotomy performed with burrs without fixation. The percutaneous distal osteotomy (PDO) technique is considered a second-level minimally invasive surgery because it is an extra-articular osteotomy, performed with a burr. It requires flexible fixation of the osteotomy to the metatarsal diaphysis. The third generation brought forth minimally invasive chevron and akin (MICA), which incorporated percutaneous osteotomies fixed with compression screws.
The objective of this study is to compare the outcomes of PCO vs DCO in patients with severe hallux valgus, with a focus on the reduction of the HVA and IMA, improvement in AOFAS scores, and associated complications.
2
Methods
2.1
Search strategy
A comprehensive electronic search was conducted using PubMed, SAGE Journal, Science Direct, and Google Scholar for studies published between 2009 and 2024. Additional relevant publications were identified from reference lists of included studies and prior systematic reviews. The search terms used were: (“Proximal Chevron Osteotomy” OR “Distal Chevron Osteotomy”) AND “Severe Hallux Valgus Deformity” AND (“Hallux Valgus Angle” OR “Intermetatarsal Angle”) AND “AOFAS Score”.
2.2
Eligibility criteria
Inclusion Criteria
-
1.
Patients diagnosed with moderate (HVA 20°–40°, IMA 11°–16°), or severe (HVA > 40°, IMA > 16°) hallux valgus deformity
-
2.
Studies including both male and female participants
-
3.
Comparison between PCO and DCO
-
4.
Clinical outcomes reported as AOFAS scores
-
5.
Radiological outcomes including HVA and IMA
-
6.
Articles published in English
-
7.
Published within the last 15 years
Exclusion Criteria
-
1.
Studies on other types of osteotomies
-
2.
Studies not focused on moderate to severe hallux valgus deformity
-
3.
Studies involving pediatric patients or non-hallux valgus conditions
2.3
Data collection and analysis
Data were extracted using the Cochrane Collaboration’s Data Extraction Template to compare study characteristics, methods, participants, interventions, and outcomes. For studies with the same outcome measures, mean differences (MD) with 95 % confidence intervals (CI) were calculated. Statistical analysis was performed using RevMan Version 5.3 software, with a P-value of < 0.05 considered statistically significant.
2.4
Risk of bias assessment
The risk of bias was assessed following the Cochrane Handbook methodology, evaluating 7 key domains: (1) random sequence generation, (2) allocation concealment, (3) blinding of participants and personnel, (4) blinding of outcome assessors, (5) incomplete outcome data, (6) selective reporting, and (7) other biases. Each study was independently assessed, and the risk of bias was classified as “low,” “unclear,” or “high” based on available study information. A summary of the assessment is presented in Fig. 1
PRISMA Flow diagram outlining study search methods and selection.
3
Results
3.1
Search results
Table 1 shows the study selection process. Of 854 articles identified, 258 were duplicates, 206 were outside the publication date range, and 128 were excluded for other reasons such as lack of full-text availability, inadequate outcome reporting, and low methodological quality. After eligibility screening, 258 of the remaining 262 studies were excluded, leaving four studies included in the analysis. Risk of bias assessments for these studies are shown in Figs. 2 and 3 .
Table 1
Comparison of inclusion and exclusion criteria.
| Studies | Inclusion Criteria | Exclusion Criteria |
|---|---|---|
| Choi et al. (2021) |
|
|
| Lee et al. (2015) |
|
|
| Park HW et al. (2013) |
|
|
| Park HS et al. (2020) |
|
|
Risk of bias graph of each included study.
Risk of bias summary presented as percentages across all included studies.
3.2
Comparison of methodologies
The four studies included in this analysis each defined specific inclusion and exclusion criteria for the surgical management of hallux valgus, highlighting both commonalities and differences can be found in Table 1 .
3.3
Comparison of intervention
Figs. 4 to 7 illustrate the various techniques used for proximal and distal chevron osteotomies, both through traditional and minimally invasive approaches.
Flow diagram illustrating the sequence of steps in the study conducted by Choi et al. (2021). MIS: Minimally Invasive Surgery.
Flow diagram illustrating the sequence of steps in the study conducted by Lee et al. (2015).
Flow diagram illustrating the sequence of steps in the study conducted by Park HW et al. (2013).
Flow diagram illustrating the sequence of steps in the study conducted by Park HS et al. (2020).
3.4
Effects of Intervention
Four clinical studies demonstrated that both proximal and distal chevron osteotomies, whether performed through open or minimally invasive techniques and often combined with soft tissue release, significantly improved hallux valgus deformities. Notably, DCO and MIS-PCMO provided superior correction of radiological parameters, with modified DCO offering added advantages of simplicity, low complication rates, and high patient satisfaction.
The HVA and IMA were assessed to compare the outcomes between PCO and DCO. The analysis of HVA revealed no statistically significant difference between the two techniques, with a p-value of 0.41 are presented in Table 2 and Fig. 8 . The mean difference in HVA between PCO and DCO was −1.14. Similarly, the evaluation of IMA also showed no significant difference, with a p-value of 0.10. see in Table 3 and Fig. 9 . The mean difference in IMA between the two osteotomy methods was −1.13.
Table 2
Effect estimates and CI of HVA.
| Postoperative | ||||||||
|---|---|---|---|---|---|---|---|---|
| PCO | DCO | MD | ||||||
| Mean | SD | Total | Mean | SD | Total | Weight | IV, Random, 95 % CI | |
| Choi 2021 | 12.3 | 7.5 | 22 | 17.5 | 7.6 | 26 | 19.4 % | −5.20 [−9.48, −0.92] |
| Lee 2015 | 13.3 | 5.8 | 43 | 11.3 | 5.6 | 42 | 28.6 % | 2.00 [−0.42, 4.42] |
| Park HW (2013) | 12.2 | 6.9 | 56 | 12.9 | 7.3 | 54 | 27.4 % | −0.70 [−3.36, 1.96] |
| Park HS (2020) | 13.8 | 5.8 | 25 | 15.9 | 5.8 | 26 | 24.6 % | −2.10 [−5.28, 1.08] |
| Subtotal | 146 | 148 | 100.0 % | −1.14 [−3.87, 1.59] | ||||
| Heterogeneity: Tau 2 = 5.25; Chi2 = 9.70, df = 3 (P = 0.02); I 2 = 69 % Test for overall effect: Z = 0.82 (p = 0.41) | ||||||||
| Total (95 % CI) | 146 | 148 | 100.0 % | −1.14 [−3.87, 1.59] | ||||
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