Abstract
Background
Minimally invasive surgery (MIS) chevron osteotomy has emerged as an alternative to the traditional open chevron (OC) osteotomy for hallux valgus correction, aiming to achieve similar deformity correction with reduced soft-tissue trauma and faster recovery. However, the relative clinical and radiographic outcomes of these techniques remain debated.
Methods
A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. PubMed, EMBASE, and Cochrane databases were searched through June 2025 for randomized controlled trials (RCTs) and cohort studies comparing MIS and OC osteotomies in patients with hallux valgus. Only studies explicitly describing a percutaneous, burr-based V-shaped Chevron osteotomy were included. Primary outcomes included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Visual Analog Scale (VAS) pain scores, radiographic parameters: hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) and complication rates. Random-effects meta-analyses were performed, with subgroup analyses at early (≤6 months), mid-term (6–12 months), and long-term (>12 months) follow-ups.
Results
Six studies (3 RCTs, 1 prospective, 2 retrospective) comprising 342 patients (352 feet) were included. MIS chevron osteotomy demonstrated no significant differences compared with OC in postoperative AOFAS, VAS scores, HVA correction, or DMAA correction at any follow-up. Early postoperative VAS scores favored MIS, while postoperative and corrected IMA values at selected time points favoured open Chevron. However, all differences were small in magnitude and unlikely to be clinically meaningful. Complication rates were comparable between the techniques (OR 2.10, 95 % CI 0.82–5.40, p = 0.12, I 2 =23 %).
Conclusion
This systematic review and meta-analysis demonstrate that MIS Chevron osteotomy provides clinical and radiological outcomes comparable to those of open Chevron osteotomy. Differences in pain scores, angular correction, and complication rates were small and not clinically meaningful. These findings suggest that MIS Chevron is a safe and effective alternative to open Chevron osteotomy.
1
Introduction
Hallux valgus is a common foot deformity, characterized by progressive lateral deviation of the hallux and medial deviation of the first metatarsal that can lead to pain, difficulty with footwear, and reduced quality of life. Radiographically, hallux valgus is identified by an increased hallux valgus angle (HVA) and intermetatarsal angle (IMA). Surgical correction is often indicated when conservative measures such as orthotics and footwear modifications fail , with a distal chevron osteotomy being one of the most widely performed techniques due to its predictable correction of mild to moderate deformities and favorable outcomes ,, . The Chevron osteotomy involves a V-shaped distal osteotomy of the first metatarsal that allows for lateral translation of the metatarsal head, thereby correcting the IMA and is often performed alongside soft tissue realignment and resection of the medial eminence , . Traditionally, the open approach (OC) osteotomy has been performed, as it provides direct visualization at the cost of greater soft tissue dissection and potentially longer recovery time. Minimally invasive surgical (MIS) techniques have become more popular as alternatives to open procedures. The proposed benefits of MIS chevron osteotomy are that equivalent angular correction can be achieved while minimizing soft tissue trauma, thereby conferring faster recovery, reduced postoperative pain, and improved cosmesis , . Concerns have emerged regarding the ability to achieve similar radiographic corrections, notably the HVA, IMA, and the distal metatarsal articular angle (DMAA), as well as technical difficulties associated with limited visualization and potential incomplete correction . Despite several studies comparing MIS and OC osteotomy techniques, the results have been equivocal ,,,,,,, . Previous reviews have frequently pooled data across various open and MIS procedures and across various time points , , making it challenging to isolate outcomes specific to chevron osteotomy with regards to short term, midterm, and long term follow-up.
The aim of this systematic review and meta-analysis was to compare the MIS and OC osteotomies in terms of clinical outcomes, radiological correction, and complication rates, while evaluating the durability of these results across short term, mid-term, and long-term follow-up periods.
2
Methods
The present systematic review has been conducted and authored according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline . Our patient, intervention, comparison, and outcome (PICO) were defined as follows: patients: patients with hallux valgus undergoing Chevron osteotomy; intervention: minimally invasive Chevron osteotomy; comparison: open Chevron osteotomy; and outcome: pain, function, and radiological scores (primary outcomes) in the short term, midterm, or long term, and complication rates (secondary outcomes).
2.1
Search strategy
On June 2025, the following search terms were used: (((chevron) or (distal and metatarsal)) and osteotomy) and (minimally invasive or percutaneous or open or transarticular). The inclusion criteria were as follows: 1) any human clinical trials comparing open vs minimally invasive Chevron procedures for hallux valgus and evaluated outcomes, 2) published in peer-reviewed journals, 3) written in English. Exclusion criteria were as follows: 1) less than 10 patients, 2) less than 2 months follow-up, 3) case reports, 4) cadaver or animal studies, 5) systematic reviews. Two independent reviewers (EL, AT) screened the titles, abstracts, and full text articles to ensure the criteria were applied to all searched studies. This paper’s senior author (JGK) was consulted to arbitrate any disagreements that arose.
2.2
Assessment of level of evidence and methodological quality
The level of evidence (LOE) was evaluated using the criteria published by The Journal of Bone & Joint Surgery . The Cochrane Risk of Bias tool second edition (RoB2) and Risk Of Bias In Non-randomized Studies (ROBINS) tool was used to assess the risk of bias amongst the included trials , . Two reviewers (EL, AT) independently assessed risk of bias for all included studies. All domains of RoB2 were assessed: randomization process, deviations from the intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain was judged to have low, some concerns, or high risk of bias, and an overall risk of bias judgment was made for each trial guided by the RoB2 tool. All domains of the ROBINS-I tool were assessed, including confounding, participant selection, intervention classification, deviations from intended interventions, missing data, outcome measurement, and selective reporting. Each study received an overall judgment of low, moderate, serious, or critical risk of bias. If any discrepancy existed, the senior author (JGK) was consulted and evaluated the available data, and a consensus was reached.
2.3
Data extraction and evaluation
Two independent reviewers (EL, AT) independently extracted and assessed the data from each individual study. The key characteristics of each article were extracted and inserted into spreadsheets in Microsoft Excel to facilitate analysis and presentation. For missing data, attempts were made to contact the original investigators for included studies published less than 10 years ago. For the presentation of results, outcomes were divided into short-term (≤6 months), mid-term (>6 months to ≤12 months), and long-term (>12 months) follow-up. When sufficient data existed, short-term follow-up was subdivided into early short-term (2–6 weeks) and late short-term (3–6 months). All early follow-up points were converted to weeks, and all late short-term and mid-term follow-up points to months for consistency and easier analysis. Interventions reported in fewer than three studies were summarized in the supplementary results table and were not included in the main analysis. When three or more studies provided data for an outcome at comparable follow-up intervals (e.g., 2–6 weeks, 8–12 weeks, or 4–6 months), pairwise meta-analyses were performed. Raw mean differences (MDs) with their accompanying 95 % CIs were calculated and used in the tests for each comparison of subjective outcomes, such as American Orthopaedic Foot and Ankle Society (AOFAS), Visual Analogue Scale (VAS) for pain, Manchester–Oxford Foot Questionnaire (MOXFQ), and for radiological outcomes such as Hallux Valgus Angle (HVA), Intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). When multiple publications reported the same cohort at different time points, only the data from the relevant follow-up interval were used to avoid duplication. To improve clarity and ensure a direct comparison between open and minimally invasive Chevron osteotomies, we refined our inclusion criteria to require explicit descriptions of a percutaneous, burr-based V-shaped Chevron osteotomy. MIS studies that used non-Chevron osteotomies or did not provide sufficient operative details were excluded from MIS cohort.
2.4
Statistical analysis
All continuous variables are expressed as means ± standard deviations (SD). Pairwise meta-analyses, along with forest plots and heterogeneity assessments (χ² and I² statistics), were performed using Review Manager (RevMan) version 5 software. If only interquartile ranges (IQRs) were provided, SDs were estimated by dividing the IQR by 1.35. When only the median was available, it was assumed to approximate the mean. Pooled means were computed as the weighted average of means, using sample sizes as weights. Pooled SDs including those for differences between pre- and post-operative scores were derived using the following formula :
Pairwise meta-analyses were conducted to assess the differences in subjective outcomes, radiological outcomes, and risk of complications in the short term (early 2–6weeks, late 12 weeks to 6months, and overall short term ≤6 months), midterm (6–12 months), and long term (>12 months). Numerical data are only presented for statistically significant comparisons; those that were nonsignificant appear in forest plots in the supplemental materials . Due to the inclusion of fewer than 10 studies in each comparison, formal statistical tests for publication bias (e.g., Egger’s test) and funnel plot asymmetry were not performed, as these methods are underpowered. Instead, we qualitatively assessed the potential for publication bias by evaluating study characteristics and completeness of outcome reporting. Due to the anticipated heterogeneity across studies, the random effects model was used.
2.5
Results
The search generated 342 studies, and 6 studies ,,,,, met the inclusion and exclusion criteria ( Fig. 1 ). Table 1 shows the full study characteristics, and Table 2 shows the recorded study outcomes. The cohort comprised of 162 patients (168 feet) treated with open techniques and 180 patients (184 feet) treated with minimally invasive approaches. The weighted mean age was 52.2 ± 5.2 years for the open cohort and 51.8 ± 2.7 years for the minimally invasive cohort, with most participants being female. Based on the level of evidence (LOE), there were three randomized controlled trials (LOE I) ,, , two prospective cohort studies (LOE II) , , and four retrospective studies (LOE III) ,,, . Follow-up duration ranged from 6 weeks to 5 years, with most follow-up occurring at 6 weeks ,,, , 12 weeks or 3 months ,, , and 12 months ,,, . Long-term follow-up beyond 2 years was reported by four studies ,,, . Kaufmann et al. presented 9-month outcomes at latest follow-up , while Kaufmann et al. reported the 5-year follow-up of the same cohort . The risk of bias assessment using ROBINS-I and RoB 2 tools showed that most studies demonstrated a low risk of bias across key domains, particularly in outcome measurement and reporting ( Fig. 2 ) ,,,,, . However, Brogan et al. (2016)) displayed “some concerns” in domains such as participant selection and deviation from intended interventions . All randomized studies ,, scored well in randomization and allocation concealment. The overall judgment indicated that the majority of studies had either low risk or some concerns, with no studies rated as high risk.
PRISMA checklist.
Table 1
Study characteristics.
| Author(s) | LOE | Study Design | Patients/Feet (n) | Age (y) | M/F | Follow-up time |
|---|---|---|---|---|---|---|
| Open chevron osteotomy | ||||||
| Brogan et al. 2016 | 3 | rCS | 32/32 | 57 | 0/32 | 37mo |
| Kaufmann et al. 2018* | 1 | RCT | 19/22 | 44 | 3/19 | 6wk, 12wk, 9mo |
| Kaufmann et al. 2020* | 1 | RCT | 17/20 | 47 | 3/17 | 60mo |
| Dragosloveanu et al. 2022 | 1 | RCT | 26/26 | 55.3 | 2/24 | 6wk, 6mo, 12mo |
| Kim et al. 2024 | 3 | rCS | 33/33 | 54.7 | 1/32 | 12mo |
| Yoon et al. 2024 | 2 | pCS | 35/35 | 52.9 | 4/31 | 2wk, 6wk, 3mo, 6mo, 12mo |
| Minimally invasive | ||||||
| Brogan et al. 2016 | 3 | rCS | 49/49 | 53 | 3/46 | 31mo |
| Kaufmann et al. 2018* | 1 | RCT | 23/25 | 52 | 4/21 | 6wk, 12mo, 9mo |
| Kaufmann et al. 2020* | 1 | RCT | 17/19 | 54 | 3/19 | 60mo |
| Dragosloveanu et al. 2022 | 1 | RCT | 24/24 | 49.4 | 0/24 | 6wk, 6mo, 12mo |
| Kim et al. 2024 | 3 | rCS | 32/32 | 54.4 | 32/0 | 12mo |
| Yoon et al. 2024 | 2 | pCS | 35/35 | 53.6 | 9/26 | 2wk, 6wk, 3mo, 6mo, 12mo |
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