A comprehensive literature search was conducted in April 2025 and updated through 19 August 2025 across the following electronic databases: PubMed, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy used combinations of keywords and MeSH terms related to hallux rigidus and cheilectomy, including: “hallux rigidus”, “cheilectomy”, “open cheilectomy”, “minimally invasive”, “percutaneous”, and “first metatarsophalangeal joint”. Boolean operators and database-specific filters were applied to optimize sensitivity and specificity. Reference lists of included articles and relevant reviews were manually screened to identify additional studies.

Study selection was based on the Population–Intervention–Comparison–Outcomes (PICO) framework.

Population: Adults (≥18 years) with a diagnosis of hallux rigidus. Interventions: Open dorsal cheilectomy (traditional dorsal approach), Percutaneous or minimally invasive cheilectomy (with or without arthroscopic assistance).

Comparison: No direct comparison between open and MIS techniques within the same study was required; single-arm cohorts were eligible if they reported relevant outcomes.

Outcomes: At least one of the following: pain scores (e.g., VAS), patient-reported outcome measures (PROMS) including first MTPJ ROM (total ROM and/or dorsiflexion), complications, and reoperation rates.

All study designs were considered, including randomized controlled trials, prospective and retrospective cohort studies, and case series with more than 10 patients. Exclusion criteria were: case reports, technical notes without outcome data, biomechanical or cadaveric studies, expert opinion, non-English language articles, and studies lacking extractable outcome data.

After removal of duplicates, two reviewers independently screened titles and abstracts for relevance. Full texts of potentially eligible articles were retrieved and assessed against the inclusion criteria. Disagreements were resolved by consensus or, when necessary, by consultation with a senior reviewer.

A standardized data extraction form was used to collect the following information: author, year of publication, country, study design, sample size, number of feet, follow-up duration, patient demographics (age, sex), hallux rigidus grade when reported, details of the surgical technique (open vs MIS, adjunct procedures), outcome measures used (e.g., VAS and other validated PROMS), pre- and postoperative scores, ROM data, complications, and reoperations. Where necessary, corresponding authors were contacted for clarification of data.

The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. This instrument scores non-comparative studies on a 16-point scale and comparative studies on a 24-point scale, with higher scores indicating better methodological quality. Each item is scored 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). Two reviewers independently performed the MINORS assessment; disagreements were resolved by consensus. Levels of evidence were classified according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria.

The primary aim of the meta-analysis was to quantify the pre- to postoperative improvements following open and MIS cheilectomy, and to compare pooled outcomes between techniques. Outcomes of interest were: VAS pain scores, First MTPJ ROM (total ROM), First MTPJ dorsiflexion ROM and Reoperation rates. VAS pain was designated as the primary confirmatory outcome; all other outcomes are secondary/exploratory.

Because each included study reported results for only one surgical approach (open or MIS), direct within-study comparisons between techniques were not available. Therefore, pooled estimates were calculated separately for open and MIS cohorts, and between-technique differences were assessed using tests for subgroup differences. This indirect comparison approach inherently limits the strength of inferences regarding superiority. In the absence of within-study comparisons, baseline differences in patient populations (e.g., hallux rigidus grade, BMI, age, follow-up duration) between MIS and open cohorts cannot be controlled for, and the assumption of comparable populations cannot be verified.

Continuous outcomes were summarized as mean differences (MDs) with 95% confidence intervals (CIs) for pre- to postoperative change. When necessary, standard deviations were derived from other summary statistics (e.g., confidence intervals, p-values). Dichotomous outcomes (reoperation) were pooled as proportions with 95% CIs.

Random-effects models were used for all meta-analyses to account for anticipated clinical and methodological heterogeneity. Statistical heterogeneity was quantified using the I² statistic, with values >50% indicating substantial heterogeneity. Where possible, subgroup analyses compared open versus MIS techniques. All analyses were conducted using R (R Foundation for Statistical Computing, Vienna, Austria) and the meta/metafor packages. The certainty of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Results were interpreted in relation to published Minimal Clinically Important Difference (MCID) thresholds where available.

The search strategy identified 1,339 records across databases and other sources. After the removal of 25 duplicates and 1,121 records for other reasons (e.g., clearly unrelated topics), 193 titles and abstracts were screened. Twenty-four full-text articles were assessed for eligibility. Seven were excluded due to language other than English (n = 1), insufficient or missing outcome data (n = 2), or use of non-comparable PROMS that precluded pooling (n = 4). Seventeen studies met the inclusion criteria and were included in the final qualitative and quantitative syntheses. ( Figure 1 )

PRISMA Flow Diagram . The diagram illustrates the stepwise process of patient identification, screening, and inclusion in the study.

Across the 17 studies, a total of 907 patients and 968 feet were analysed. MIS cheilectomy was performed in 431 feet and open cheilectomy in 537 feet. The mean age was approximately 51 years, and the reported male-to-female ratio (available in 11 studies) was approximately 1:2. Follow-up durations varied, with most studies reporting short- to mid-term outcomes. Open dorsal cheilectomy was performed via traditional or slightly modified dorsal approaches. MIS techniques included purely percutaneous cheilectomy, arthroscopy-assisted cheilectomy, and combined percutaneous cheilectomy with proximal phalanx osteotomy in selected series. ^,,,,,,, Hallux rigidus severity ranged from early to moderate grades; in several studies, advanced arthritis or severe deformity were excluded. ( Table 1 )

MINORS scores varied widely. Non-comparative series generally scored between 10 and 15/16, while comparative studies achieved up to 22/24. Many studies clearly stated their aims, included consecutive patients, and used appropriate endpoints, but few incorporated prospective sample size calculations or blinded outcome assessment. According to OCEBM criteria, most studies provided Level III or IV evidence (retrospective comparative or case series), with only a small number approaching Level II. ( Table 2 ).

Table 2

Methodological Quality of Included Studies Assessed Using the MINORS Criteria. This table presents the quality appraisal of all included studies based on the Methodological Index for Non-Randomized Studies (MINORS). Each study was evaluated across the standardized domains addressing study design, data collection, follow-up, and outcome assessment, with scores reflecting overall risk of bias. The assessment demonstrates variable methodological quality among the included literature and provides a structured framework for interpreting the strength and limitations of the pooled evidence.

Column1	Clearly stated aim	Inclusion of consecutive patients	Prospective data collection	Endpoints appropriate	Unbiased assessment of endpoints	Follow-up period appropriate	Loss to follow-up <5%	Prospective calculation of study size	Adequate control group	Contemporary groups	Baseline equivalence	Adequate statistical analyses	Total Score
GAUTHIER	2	2	2	2	1	2	2	1	0	0	0	0	14
COUGHLIN	2	2	2	2	1	2	1	0	0	0	0	0	12
EASLEY	2	2	1	2	2	2	1	0	0	0	0	0	12
GLENN	2	2	2	2	2	2	1	1	0	0	0	0	14
HARRISON	2	2	1	1	1	2	1	0	0	0	0	0	10
HICKEY	2	2	2	1	1	2	2	0	0	0	0	0	12
KOH	2	2	2	2	1	2	2	1	2	2	2	2	22
LEVAJ	2	2	1	1	1	2	2	0	0	0	0	0	11
LIN & MURPHY	2	2	2	2	1	2	2	0	0	0	0	0	13
DI NALLO	2	2	2	2	2	2	2	1	0	0	0	0	15
MULIER	2	2	2	2	2	2	2	0	0	0	0	0	14
NICOLOSI	2	2	2	2	2	2	1	0	0	0	0	0	13
PASTIDES	2	2	1	2	1	2	1	0	0	0	0	0	11
SIDON	2	2	2	2	1	2	2	0	0	0	0	0	13
SMITH	2	2	2	2	1	2	2	1	0	0	0	0	14
STEVENS	2	2	2	2	1	2	1	1	2	2	2	2	21
TEOH	2	2	2	2	1	2	1	0	0	0	0	0	12

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