A meta-analysis of comparative clinical studies of isolated osteotomy versus osteotomy with lateral soft tissue release in treating hallux valgus
Introduction
Hallux valgus (HV) is one of the most common deformities of the foot. The deformity combines a lateral deviation of the great toe and a medial deviation of the first metatarsal bone [1]. More than a hundred techniques were described for surgical correction [2]. The array of bone procedures includes proximal and distal metatarsal osteotomies, proximal phalanx osteotomy and arthrodesis of the first metatarso-cuneiform joint. The HV deformity also induces a medial displacement of the first metatarsal head in relation to the sesamoids; it has been demonstrated that the amount of displacement highly correlates with the severity of the HV [3]. Soft tissue procedures, named lateral soft tissue release (LSTR), have been proposed to release the soft tissue structures that are thought to be incriminated in the HV deviation and to bring the sesamoids beneath the metatarsal head. The combination of soft tissue procedures and osteotomies is believed to better reduce hallucal sesamoids in their anatomical position and to maintain a long-term correction [4], [5].
Distal osteotomies, such as the Chevron and Scarf, are very common in treating HV. The reported variants of these osteotomies mainly attempted to confer better stability with fewer complications. However, the lateral translation of the metatarsal head offered by such osteotomies is thought by many to yield a suboptimal HV angle correction [6], [7]. On the other hand, under the label of LSTR, the soft tissue structures involved in the release vary widely between authors. While some authors consider the tenotomy of the phalangeal conjoint tendon of the adductor hallucis (AddH) as a sufficient procedure for an optimal release [8], three other structures are commonly transected when performing LSTR: the lateral capsule of the first metatarso-phalangeal joint (MTPJ), the sesamoid suspensory ligament or lateral sesamoid metatarsal ligament (LSML), and the transverse metatarsal ligament (TML) (Fig. 1). One or more of these three structures could be combined to the AddH tenotomy when performing the LSTR. It is generally accepted that if lateral release is not performed the risk of recurrence is increased [9], [10]. However, its efficacy in reducing the hallux valgus deformity is not well known. Several authors have identified that incomplete postoperative reduction of the sesamoids is a potential risk factor for recurrence after proximal metatarsal osteotomy [11], [12], [13]. When combined to a Chevron, the benefit of the LSTR has been questioned by some reports [14], [15], [16] while others demonstarted significant better correction and long-term results [6], [7]. Augoyard et al. [16] demonstrated that more than 50% of their patients who presented with a severe preoperative hallux valgus deformity (HVA >30° or IMA >9°) were not reduced after full release.
Woo et al. [17] stated that although there were significantly improved clinical and radiologic outcomes after surgery, the LSTR procedure did not result in medial shift or reduction of the sesamoid position. Lamo-Espinosa et al. [18] suggested that dislocation of the sesamoid complex is actually caused by displacement of the first metatarsal. They concluded that the scarf–akin osteotomy adequately restores the sesamoid apparatus beneath the first metatarsal head without direct plantar-lateral soft tissue release.
Such contradictory results over the role of LSTR in the correction of HV deformity are source of confusion. The literature lacks an evidence synthesis over the benefit of a LSTR and on which structure(s), if any, should be transected in order to restore the axis of the big toe.
Therefore, the aim of this meta-analysis (MA) is to quantify and compare the effect size of HV correction in patients having an osteotomy versus those having LSTR combined to the osteotomy. It also investigates which of the lateral structures has an impact on HV correction.
Section snippets
Methods
A search strategy was developed using the following electronic databases: PubMed, Embase, SciELO, Cochrane, and Google Scholar from inception till the first of February 2018. Broad Boolean terms were used to locate the maximum number of relevant studies: (“hallux valgus” AND lateral AND release). The primary outcome is set to be the hallux valgus angle (HVA) correction. Secondary outcomes were defined as the inter-metatarsal angle (IMA) correction, the post-operative tibial sesamoid position,
Search results
The electronic search yielded 112 records. Ninety-nine abstracts were screened and 13 duplicates were removed. Full manuscripts of eleven potentially relevant papers were retrieved. Five papers were retained after applying the inclusion criteria. Reference checking yielded one additional relevant paper. In total, six papers comprising 425 patients (549 feet) were included in the meta-analysis (Fig. 2). Two papers used a sort of randomization while the other four were of retrospective
Discussion
The main finding of this meta-analysis is that LSML is found to be the most important element to be transected in order to obtain an optimal lateral release in mild and moderate HV. This MA could also explain the contradictory results reported in the literature over the role of the LTSR in the surgical management of hallux valgus deformity. When all studies are included in the analysis, no significance was found between LSTR and non-LSTR groups. However, subgroup analysis related to the HVA
Conclusion
This meta-analysis demonstrates a beneficial effect of lateral soft tissue release when associated to a distal osteotomy in correcting HV deformity. Lateral release reduces significantly the hallux valgus angle only when the lateral sesamoid metatarsal ligament is transected. It also concludes that the transection of other single lateral structures such as the adductor hallucis and the trans-metatarsal ligament are likely to have less corrective effect. These findings conclude that a lateral
Funding
None.
Conflict of interest
None.
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Cited by (11)
Effectiveness of hallux valgus surgery on improving health-related quality of life: A follow up study
2022, Foot and Ankle SurgeryCitation Excerpt :However, no consensus exists on the optimal surgical technique to correct this deformity [15,16] Thus, the surgical choice should be taken after considering the range of causal factors [17–19]. Open procedures are the most commonly used surgical techniques, including chevron's distal osteotomy and scarf diaphyseal osteotomy in the first metatarsal [20–22]. In the last years, the interest in minimally invasive surgery (MIS) has been growing due to its theoretical advantages including lower morbidity and less time required for recovery and rehabilitation [23].
The American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Hallux Valgus
2022, Journal of Foot and Ankle SurgeryHallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis
2022, Foot and Ankle SurgeryCitation Excerpt :Therefore, distal soft tissue/marginal bone procedures combined with as osteotomy performed in HV deformities associated with mild or moderate OA cannot be considered as supplementary surgeries but as indispensable procedures to restore the physiological function of the first MTPJ. Therefore, the additional procedures adopted for the treatment of the osteoarthritic articular components are addressed at a morphological and functional rebalancing of the first MTPJ and the first ray [18,32]. This avoids the recurrence of deformity caused by the failed reduction of the metatarsal head on the sesamoids, in fact, a "simple osteotomy" could lead to normalization of the IMA but would not restore the functional balance of the first ray.
Correction Power of Percutaneous Adductor Tendon Release (PATR) for the Treatment of Hallux Valgus: A Cadaveric Study
2021, Journal of Foot and Ankle SurgeryCitation Excerpt :While it is not exactly known which anatomical structures should be released, some authors recommend an isolated release (that means including a latero-plantar capsule release as well) of the adductor tendon (24,39). According to Yammine and Assi (9), there could be a beneficial effect of sectioning the suspensory ligament in all cases of HV deformity, added to an adductor hallucis tendon transection in a moderate-to-severe HV. The conjoined lateral tendon of the adductor hallucis and lateral head of the flexor hallucis brevis muscle plays an essential role on the deformity development.
Percutaneous Lateral Release in Hallux Valgus: Anatomic Basis and Indications
2020, Foot and Ankle ClinicsCitation Excerpt :The main indication for a lateral release is mild to severe HV. The combination of osteotomies and soft tissue procedures is thought to better reduce sesamoids in their anatomic position and to maintain a long-term correction when treating HV deformity.37–39 Despite this affirmation, several studies failed to describe accurately which structures are being released or must be detached as a soft tissue adjuvant treatment of HV.2,7–9
Evolution of Minimally Invasive Surgery in Hallux Valgus
2020, Foot and Ankle ClinicsCitation Excerpt :Yet, it is not clear which structures are being sectioned during the percutaneous lateral release.23,33,37 Further studies are needed to clearly define the correct indications (congruent vs incongruent metatarsophalangeal joint) and approaches needed (MIS vs open), among others.45–47 3G techniques reliably mimic the open chevron procedure with all its known virtues, but do not reproduce its disadvantages and complications.