Elsevier

Foot and Ankle Surgery

Volume 25, Issue 5, October 2019, Pages 684-690
Foot and Ankle Surgery

A meta-analysis of comparative clinical studies of isolated osteotomy versus osteotomy with lateral soft tissue release in treating hallux valgus

https://doi.org/10.1016/j.fas.2018.08.009Get rights and content

Highlights

  • The soft tissue release in treating hallux valgus (HV) is reported controversial.

  • The transection of the lateral sesamoido-metatarsal ligament seems beneficial.

  • The benefit was found for HV angle mainly, and for M1–M2 angle.

  • An added adductor hallucis transection is probably beneficial in severe HV.

Abstract

Background

Contradictory results have been reported in the literature over the beneficial effect of the lateral soft tissue release (LSTR) when associated to an osteotomy for the treatment of hallux valgus (HV).

Materials and methods

Six comparative studies totalizing 425 patients (549 feet) were computed and comparing two groups: one group of patients having osteotomy alone and the other group having osteotomy with LSTR.

Results

Subgroup analysis in relation to the type of LSTR yielded significant better HVA correction (P < 0.0001) in favor of those reporting the release of the lateral sesamoido-metatarsal ligament (LSML). A moderate significance (P = 0.03) of the inter-metatarsal angle (IMA) difference was found in favor of LSTR.

Conclusions

There could be a beneficial effect of transecting LSML in all cases of HV deformity, and a probable efficacy of an added adductor hallucis tendon transection when the deformity is moderate to severe.

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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