SYSTEMATIC REVIEW

published: 21 March 2022

doi: 10.3389/fsurg.2022.843410

Minimally Invasive vs. Open Surgery

for Hallux Valgus: A Meta-Analysis
Linfeng Ji, Ketao Wang, Shenglong Ding, Chengyi Sun, Songmin Sun and Mingzhu Zhang*

Department of Ankle and Foot Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China

Purpose: In recent years, minimally invasive surgery (MIS) for hallux valgus has emerged
and gained popularity. To date, evidence on the benefits of MIS for hallux valgus is
still controversial. This updated meta-analysis aimed to comprehensively evaluate the
efficiency of MIS vs. open surgery for hallux valgus.
Methods: A systematic literature search of PubMed, Embase, and the Cochrane Library
was performed. Two independent reviewers conducted data extraction and analyzed
data with R software. Data were presented with risk ratio (RR) and standardized mean
difference (SMD) along with 95% confidence interval (CI).
Results: A total of 22 studies in which there were 790 ft treated with the MIS procedure
and 838 ft treated with an open procedure were included. The correction of sesamoid
position was better in the MIS group. The post-operative distal metatarsal articular angle
(DMAA) of the MIS group was lower. There was less pain at the early phase in the
MIS group. The MIS group had a shorter surgery time and shorter hospitalization time
Edited by: compared with the open group. Our meta-analysis revealed no statistically significant
Daniel López-López,
University of A Coruña, Spain difference in hallux valgus angle (HVA), first intermetatarsal angle (IMA), the first metatarsal
Reviewed by: shortening, the American Orthopedic Foot and Ankle Society (AOFAS) score, visual
Dong Jiang, analog scale (VAS) score at the final follow-up or complication rate (when all studies were
Peking University Third Hospital, China
considered). When taking into consideration only randomized controlled trial (RCT), the
Minwei Zhao,
Peking University Third Hospital, China AOFAS score was higher in the MIS group while HVA, IMA, DMAA, and complication rate
*Correspondence: remained no significance. Post-operative IMA of the MIS group was significantly lower
Mingzhu Zhang when only studies reporting the second-generation (2G) MIS were included. When just
michaelzhang120@hotmail.com
studies adopting the third-generation (3G) MIS were included, the HVA and DMAA were
Specialty section: lower in the MIS group.
This article was submitted to
Orthopedic Surgery,
Conclusion: The MIS procedures were more effective than open surgeries in the
a section of the journal treatment of hallux valgus. Moreover, the MIS group achieved better radiologic and clinical
Frontiers in Surgery
outcomes compared with the open group.
Received: 25 December 2021
Accepted: 21 February 2022 Keywords: minimally invasive, percutaneous, hallux valgus, bunion, osteotomy
Published: 21 March 2022
Citation:
Ji L, Wang K, Ding S, Sun C, Sun S
INTRODUCTION
and Zhang M (2022) Minimally
Invasive vs. Open Surgery for Hallux Hallux valgus is a common forefoot disorder involving a lateral deviation of the hallux and medial
Valgus: A Meta-Analysis. deviation of the first metatarsal (1). Hallux valgus is often associated with first metatarsophalangeal
Front. Surg. 9:843410. joint osteoarthritis, and it has been linked to notable health problems, such as disability, a greater
doi: 10.3389/fsurg.2022.843410 risk of falling, impaired balance, and lesser quality of daily life (2). Symptomatic hallux valgus is

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

usually treated with surgeries such as chevron osteotomy, (1) unpublished data; (2) case series, case reports, reviews, and
Lapidus procedure, and scarf osteotomy (3–7). There are over proceedings of meetings; (3) biomechanical research; and (4) no
150 open surgical procedures for hallux valgus, but none of available data describing OMs mentioned earlier.
them have been proven to be better than others. In recent
years, minimally invasive surgery (MIS) has become popular Data Extraction and Quality Assessment
for hallux valgus because of its shorter operation time, smaller Duplicates were initially excluded using Endnote Version X9.
scar, and shorter recovery time compared with open surgeries. Two investigators independently screened titles and abstracts
So far, three generations of minimally invasive techniques of the remaining studies. Then, full texts of the remaining
have been developed. The first generation was the Reverdin– studies were reviewed for eligibility according to the inclusion
Isham technique (8), which used angular medial closed wedge and exclusion criteria. Two independent reviewers performed
osteotomy without osteosynthesis. The second generation (2G) data extraction from the included studies. The following data
was the Bösch osteotomy (9), which was a modification were extracted: the time of publication, country, study design,
of Hohmann osteotomy. Temporary internal fixation with sample size, patients’ age, technique, the duration of follow-up,
Kirschner wires were used after distal transverse osteotomy. The HVA, IMA, AOFAS, and complications. Two authors used the
third generation (3G) was minimally invasive chevron and akin Cochrane Handbook for Systematic Reviews of Interventions
(MICA) (10), which used percutaneous osteotomies and was 5.2.0. (20) to assess the methodological quality and risk
fixed with compression screws. of bias of randomized controlled trials (RCTs), while the
Recently, two meta-analyses (11, 12) have been carried out methodological qualities and risk of bias of non-RCTs were
to determine the effects of MIS vs. open surgery, showing no evaluated by the methodological index for non-randomized
significant difference in radiological outcomes and functional studies (MINORS) (21). MINORS score > 14 was set as the
scores. However, relatively a few outcome measures (OMs) had level of inclusion. Disagreements were resolved by a discussion
been included in Singh’s meta-analysis (11). Lu et al. conducted to reach a consensus.
a meta-analysis in which most of the included studies were
of low or moderate quality (12). In the last 3 years, several Statistical Analysis
new studies (13–18) performed a comparison between MIS and The data analysis was performed with Review Manager (Version
open surgery for hallux valgus have reported. Therefore, we 5.3; The Cochrane Collaboration, Oxford, UK) and the statistical
conducted this updated meta-analysis and included more OMs software R 4.0.3 with the meta package. For dichotomous
to comprehensively evaluate the efficacy of MIS vs. open surgery data, the risk ratio (RR) along with 95% confidence intervals
for hallux valgus. (CIs) was calculated. For continuous data, standardized mean
difference (SMD) with 95% CIs was calculated. p < 0.05
MATERIALS AND METHODS indicated a statistical significance. I 2 -test was used to evaluate
the heterogeneity between studies. When I 2 > 50% and p < 0.10,
This meta-analysis was conducted in accordance with the the heterogeneity was significant, and a random effect model was
preferred reporting items for systematic reviews and meta- used. Otherwise, a fixed-effects model was applied in the meta-
analyses (PRISMA) statement (19) and the Cochrane Handbook analysis. Subgroup meta-analysis was conducted according to
guidelines (20). study design (RCT or non-RCT) and technique (2G or 3G MIS).
The publication bias was assessed by the Egger’ test.
Search Strategy
A systematic literature search of Pubmed, Embase, and RESULTS
the Cochrane Library was performed from January 1, 1980
to October 1, 2021, using the following item: (“Hallux Characteristics of the Included Studies
Abductovalgus” OR “Hallux valgus” OR “Bunion”) AND As presented in Figure 1, a total of 537 articles were identified
(“Percutaneous” OR “Bosch” OR “minimally invasive after the primary literature search. After the removal of
surgery” OR “minimally invasive” OR “Bösch” OR “SERI” duplicates, 276 articles remained. During the screening of titles
OR “simple, effective, rapid, inexpensive” OR “minimally and abstracts of the remaining studies, 150 irrelevant articles
invasive chevron-Akin” OR “percutaneous chevron-Akin”), and 81 articles without a comparison group were excluded,
without a language filter. and a total of 45 articles remained. Then, full-text reviewing
according to inclusion and exclusion criteria was conducted. A
Inclusion and Exclusion Criteria total of 23 articles (including 18 case series, 3 reviews, and 2
All studies included in this meta-analysis need to meet the biomechanical studies) were eliminated. Eventually, 22 studies
following criteria: (1) comparative studies reporting comparisons were included in this meta-analysis, in which 790 ft were treated
of MIS vs. open surgery for hallux valgus; (2) patients with hallux with MIS procedure and 838 ft with the open procedure. The
valgus; (3) at least a 6-month follow-up; and (4) OMs including characteristics of the included studies are depicted in Table 1.
at least one of the following: hallux valgus angle (HVA), first Follow-up times were highly variable, ranging from 6 months
intermetatarsal angle (IMA), the American Orthopedic Foot and to 7 years. Among the included studies, 8 studies (15, 17, 24,
Ankle Society (AOFAS) score, visual analog scale (VAS) score, 26, 28, 29, 31, 35) were RCTs, 2 studies (4, 14) were prospective
operating time, and complications. The exclusion criteria were: comparative studies, and 12 studies (5, 13, 16, 18, 22, 23, 25,

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

FIGURE 1 | Flow diagram of the study selection process.

27, 30, 32–34) were retrospective comparative studies. A total of et al. (25) performed a retrospective comparison between Bösch
10 studies (13, 17, 22–28, 32) reported on the 2G percutaneous and Ludloff osteotomies. Giannini et al. (26) conducted a RCT
hallux valgus surgery, in which 7 studies (13, 22–25, 28) involved to determine the efficiency of the SERI technique and scarf
Bösch osteotomy and 3 studies (17, 26, 27) involved a simple, an surgery. Poggio et al. (27) conducted a retrospective study to
effective, a rapid, and an inexpensive (SERI) technique. Roth et compare between the SERI technique and open scarf technique
al. (22) conducted a retrospective comparative study to compare for hallux valgus. Othman and Hegazy (28) performed a RCT to
between Bösch and Kramer osteotomies. Maffulli et al. (23) compare between Bösch surgery and open Chevron osteotomy.
performed a comparison between the Bösch technique and open Choi et al. (13) performed a retrospective comparison between
Scarf osteotomy. Radwan and Mansour (24) performed a RCT the Bösch technique and Chevron surgery. Palmanovich et
to compare between Bösch and Chevron osteotomies. Chiang al. (17) conducted a RCT to compare between the SERI and

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

TABLE 1 | Characteristics of the included studies.

References Country Design No. of feet Age (years) Technique used Follow-up (months)

MIS Open MIS Open MIS Open MIS Open

Roth et al. (22) Austria Retrospective 88 36 49 50 Bosch Kramer 17 17

Maffulli et al. (23) UK Retrospective 36 36 51.5 52.6 Bosch Scarf 25 25
Radwan and Mansour (24) Egypt RCT 29 31 32.7 35.7 Bosch Chevron 21.7 19.5
Chiang et al. (25) China Taiwan Retrospective 32 30 61.1 64.5 Bosch Ludloff 24 24
Giannini et al. (26) Italy RCT 20 20 53 53 SERI Scarf 84 84
Poggio et al. (27) Spain Retrospective 69 133 62.5 52.9 SERI Scarf 12 12
Brogan et al. (5) UK Retrospective 49 32 53 57 PECA Chevron 31 37
Othman and Hegazy (28) Egypt RCT 33 25 40.47 39.2 Bosch Chevron 49.36 51.56
Lee et al. (29) Australia RCT 25 25 52.6 53.4 PECA Scarf/Akin 6 6
Lai et al. (30) Singapore Retrospective 29 58 54.3 54.3 PECA Scarf/Akin 24 24
Kaufmann et al. (15) Austria RCT 25 22 52 44 MICA Chevron/Akin 9 9
Boksh et al. (4) UK Prospective 16 21 52.2 46 Mini-Scarf Scarf 28 28
Choi et al. (13) South Korea Retrospective 25 30 21.3 22.4 Bosch Chevron 19.9 20.5
Frigg et al. (14) Switzerland Prospective 48 50 48.04 48.23 MICA Scarf/Akin 24 24
Palmanovich et al. (17) Israel RCT 20 15 38.7 49.2 SERI Chevron 38.7 49.2
Lim et al. (16) Singapore Retrospective 52 52 48.7 52.3 MICA Scarf 48.7 52.3
Kaufmann et al. (15) Austria RCT 19 20 54 47 MICA Chevron/Akin 54 47
Schilde et al. (18) Germany Retrospective 124 86 56.8 57.1 MICA Scarf/Akin 56.8 57.1
Torrent et al. (31) Spain RCT 30 28 60.7 64.2 Mini-Scarf Scarf 21 21
Siddiqui et al. (32) USA Retrospective 31 30 43.2 50 Bosch Chevron 18.7 26.6
Guo et al. (33) China Retrospective 48 64 60.9 60.6 POO Chevron 24 24
Tay et al. (34) Singapore Retrospective 30 30 51.7 52.7 MICA Scarf/Akin 24 24

RCT, Randomized controlled trial; NO., Number; MIS, Minimally invasive surgery; SERI, Simple, Effective, Rapid, Inexpensive; PECA, Percutaneous Chevron-Akin; MICA, Minimally
invasive Chevron-Akin; POO, percutaneous oblique osteotomy.

Chevron technique. Siddiqui et al. (32) performed a retrospective Radiologic Outcomes

comparison between Bösch and Chevron surgery. Nine studies Hallux Valgus Angle
(5, 14–16, 18, 29, 30, 34, 35) reported on the 3G percutaneous A total of 21 studies reported post-operative HVA. When
hallux valgus surgery, including percutaneous chevron–akin evaluating all studies, the pooled SMD of HVA at the
(PECA) and MICA. Brogan et al. (5) performed a retrospective final follow-up was not significant between MIS and open
study to compare between the PECA and Chevron technique. groups (Figure 3A). When only studies reporting 3G MIS
Lee et al. (29) conducted a RCT to compare between the were included, the post-operative HVA was significantly lower
PECA and open scarf/akin technique. Lai et al. (30) performed in the MIS group (SMD: −0.4; 95% CI −0.68–0.13; p =
a retrospective comparison between the PECA and scarf/akin 0.004; I 2 = 69%;), but this significance was lost when
technique. Kaufmann et al. (35) conducted a RCT to compare comparing the just studies reporting 2G MIS (Table 3). Eight
between the MICA and chevron/akin technique. Frigg et al. RCTs evaluated HVA, which did not reach a statistical
(14) performed a prospective comparative study to compare significance (SMD: −0.08; 95% CI −0.50–0.34; p = 0.53;
between the MICA and scarf/akin technique. Lim et al. (16) I 2 = 76%; Table 3).
performed a retrospective comparison between MICA and scarf
surgery. Schilde et al. (18) conducted a retrospective comparative First Intermetatarsal Angle
study to compare between the MICA and scarf/akin technique. First intermetatarsal angle was assessed in 21 studies, and there
Tay et al. (34) performed a retrospective study to compare was no significant difference in the post-operative IMA between
between the MICA and scarf/akin surgery. Two studies (4, 31) these two groups (Figure 3B). Nine RCTs documented IMA
performed a comparison of the mini-scarf with open scarf post-operatively, which demonstrated no statistical significance
osteotomy. Guo et al. (33) conducted a retrospective comparative between MIS and open groups (SMD: −0.25; 95% CI −0.58–
study for a comparison of percutaneous oblique osteotomy 0.08; p = 0.14; I 2 = 63%; Table 3). 2G MIS was assessed in 9
(POO) with open chevron osteotomy. The methodological studies, which found that IMA was significantly lower in the
quality of RCTs is shown in Figure 2. The MINORS score MIS group (SMD: −0.28; 95% CI −0.57–0.01; p = 0.04; I 2 =
of comparative studies was 17.4 ± 2.0 (ranged from 15 64%; Table 3). However, the significance lost when comparing
to 21) (Table 2), which indicated a high quality of the the studies reporting 3G MIS (SMD: 0.01; 95% CI −0.30–0.31;
included studies. p = 0.96; I 2 = 75%; Table 3).

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

FIGURE 2 | Quality assessment for randomized controlled trials (RCTs). (A) Risk of bias summary and (B) risk of bias graph.

Distal Metatarsal Articular Angle Sesamoid Position Correction

A total of 10 studies provided a post-operative distal metatarsal A total of 4 studies (5, 13, 14, 25) reported the medial sesamoid
articular angle (DMAA). The post-operative DMAA was position as demonstrated by Hardy and Clapham (36). The
significantly lower in the MIS group compared with the open pooled results showed that there were more sesamoid position
group (SMD: −0.34; 95% CI −0.58–0.08; Z = −2.67; p = 0.007; changes in the MIS group compared with the open group
I 2 = 51%; Figure 3C). Three studies reported DMAA after 3G (SMD: 0.58; 95% CI 0.34–0.82; Z = 4.69; p < 0.001; I 2 = 24%;
MIS, in which the post-operative DMAA was significantly lower Figure 3E).
in the MIS group (SMD: −0.79; 95% CI −1.08 to −0.49; p <
0.01; I 2 = 35%; Table 3). Nevertheless, there was no significance
between the MIS and open group when just comparing the 3G
MIS studies (SMD: −0.14; 95% CI −0.38–0.11; p = 0.27; I 2 = Clinical Outcomes
0%; Table 3). AOFAS Score
The AOFAS score (37) was available in 17 studies, and no
significant difference between MIS and surgery groups was
The First Metatarsal Shortening observed (Figure 4A). Seven RCTs reported the AOFAS score,
Three studies assessed the first metatarsal shortening, in which and demonstrated a higher score in the MIS group (SMD: 0.45;
there were 98 ft treated with the MIS procedure and 84 ft treated 95% CI 0.03–0.87; p = 0.04; I 2 = 73%; Table 3). Subgroup meta-
with the open procedure. As shown in Figure 3D, the pooled analysis of techniques (2G or 3G MIS) found no significant
SMD was also not significant between these two groups. difference (Table 3).

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TABLE 2 | MINORS score for each study to assess methodological quality.

References Methodological items Total

1 2 3 4 5 6 7 8 9 10 11 12

Roth et al. (22) 2 0 1 2 0 2 2 0 2 2 1 1 15

Maffulli et al. (23) 2 1 1 1 1 2 1 0 2 2 1 2 16
Chiang et al. (25) 2 1 2 2 1 2 2 0 2 2 1 2 19
Poggio et al. (27) 2 2 2 2 0 2 1 0 2 2 2 2 19
Brogan et al. (5) 2 2 2 2 0 2 0 2 2 2 2 1 19
Lai et al. (30) 2 0 2 2 1 2 2 2 2 2 2 2 21
Boksh et al. (4) 2 2 2 1 1 2 2 0 1 2 2 1 18
Choi et al. (13) 2 1 2 2 0 1 0 0 1 2 2 2 15
Frigg et al. (14) 2 2 2 1 2 2 2 0 1 2 2 2 20
Schilde et al. (18) 2 1 1 1 1 1 1 0 1 2 2 2 15
Lim et al. (16) 2 0 1 2 0 1 2 0 2 2 2 2 16
Siddiqui et al. (32) 2 1 1 1 1 2 0 0 2 2 1 2 15
Guo et al. (33) 2 2 2 1 1 1 2 0 1 2 2 1 17
Tay et al. (34) 2 2 2 1 1 2 2 0 1 2 2 1 18

The final score comprises the results of 8 items or 12 items in cases of comparative studies: 1 A clearly stated aim; 2 Inclusion of consecutive patients; 3 Prospective collection of data;
4 Endpoints appropriate to the aim of the study; 5 Unbiased evaluation of the study endpoint; 6 Follow-up period appropriate to the aim of the study; 7 Loss to follow-up <5%; 8
Prospective calculation of the study size; 9 An adequate control group; 10 Contemporary groups; 11 Baseline equivalence of groups; 12 Adequate statistical analysis.

VAS Score −5.64; p < 0.001; I 2 = 90%), indicating the less duration
Eight studies were incorporated in the analysis of VAS score at the of surgery in the MIS group in comparison with the
final follow-up (38). The overall results indicated no significant open group.
difference between MIS and open groups (Figure 4B). Besides,
5 studies assessed the VAS score within post-operative 2 weeks. Length of Hospitalization
The pooled results showed that the MIS procedure was associated Two studies (16, 23) assessed the length of hospitalization,
with obviously less pain in the early post-operative phase (SMD: and the pooled results demonstrated that the MIS group was
−1.48; 95% CI −2.33–0.62; Z = −3.38; p < 0.001; I 2 = 92%; associated with a shorter length of hospitalization (SMD: −0.64;
Figure 4C). 95% CI −0.95 to −0.34; Z = −4.13; p < 0.001; I 2 = 62%;
Figure 5B).
Satisfaction Rate
A total of 7 studies documented the satisfaction rate. The pooled The Scar Length
results indicated that the satisfaction rate was remarkably higher Three studies (13, 14, 29) documented the scar length. The
in the MIS group (RR: 1.15; 95% CI: 1.05–1.27; Z = 3.09; p = pooled results indicated that the scar length was less in the MIS
0.002; I 2 = 0%; Figure 4D). group as compared to the open group (SMD: −6.70; 95% CI
−10.03 to −3.37; Z = −3.94; p < 0.001; I 2 = 97%; Figure 5C).
Complication Rate
There were some post-operative complications in MIS and open Publication Bias
surgery for hallux valgus, such as screw irritation, recurrence, The Egger’ test of HVA suggested that there was no obvious
and non-union. In total, 20 studies reported complication publication bias (p = 0.58).
rates. According to the pooled results, there was no difference
between MIS and open groups with respect to the complication
DISCUSSION
rate (Figure 4E). Subgroup analysis of study design (RCT or
non-RCT) and techniques (2G or 3G MIS) demonstrated no More than 150 open surgical procedures have been described for
significance difference in the complication rate between the two the treatment of hallux valgus (39). There was a trend toward
groups (Table 3). more minimally invasive surgery for hallux valgus, involving
the theoretical advantages of less soft tissue dissection, reduced
Secondary Outcomes surgical time, and a faster recovery time (3). In this meta-analysis,
Duration of Surgery MIS procedure showed better radiologic and clinical outcomes
The duration of surgery was available in 7 studies. compared with the open group.
Figure 5A showed that the pooled SMD was statistically Compared to the former meta-analysis conducted by Singh
significant (SMD: −2.81; 95% CI −3.55 to −2.07; Z = et al. (11), 13 new studies were included in this meta-analysis,

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

FIGURE 3 | Forest plots of radiologic outcomes. (A) HVA between the MIS and open groups; (B) IMA; (C) DMAA; (D) the first metatarsal shortening; and (E) the
medial sesamoid position correction. HVA, hallux valgus angle; MIS, minimally invasive surgery; IMA, first intermetatarsal angle; DMAA, distal metatarsal articular angle.

making it more comprehensive. Most of the included studies 2G MIS were included. The 2G MIS was Bösch osteotomy or
in the meta-analysis performed by Lu et al. (12) were of low the SERI technique, which adopted an axial wire to displace
or moderate quality, and limited OMs were assessed due to and maintain the metatarsal head in the initial few weeks (5).
incomplete information. Our meta-analysis included all new When just studies adopted 3G MIS were included, the HVA were
studies according to the inclusion and exclusion criteria and lower in the MIS group. Lai et al. (30) performed a comparison
pooled 12 OMs. between the PECA and open scarf/akin technique, showing a
Hallux valgus angle and IMA were the most common better HVA correction but a comparable IMA correction in the
radiologic OMs to evaluate hallux valgus because they have MIS group. The 3G MIS included MICA and PECA. PECA is a
been shown to determine the severity of hallux valgus. IMA modification from the MICA procedure as introduced by Vernois
correction was a marker to determine the corrective potential of and Redfern (10). The MICA technique adopted phalangeal
a metatarsal osteotomy (40). Singh et al. (11) pooled 8 studies osteotomy with burr, which had a direct impact on the correction
for HVA and IMA, showing no significant difference between of HVA (35). Lim et al. (16) also demonstrated lower post-
MIS and open groups. Our meta-analysis found no significant operative HVA in the MIS group, and they believed that it was
difference in HVA and IMA between the two groups when all 22 possibly owing to the use of toe alignment splint after the MICA
studies were included. Nevertheless, post-operative IMA of the procedure. DMAA is the angle between the perpendicular line
MIS group was significantly lower when only studies reporting to the distal metatarsal articular surface and the first metatarsal

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

TABLE 3 | Main results of subgroup meta-analysis.

Index n RR SMD 95% CI P I2 % P for heterogeneity Model

HVA (RCT only) 8 NA −0.08 −0.50 ∼ 0.34 0.53 76 P < 0.01 REM
HVA (non-RCT only) 13 NA −0.2 −0.43 ∼ 0.03 0.03 63 P < 0.01 REM
HVA (2G MIS) 9 NA −0.08 −0.31 ∼ 0.15 0.51 46 0.06 FEM
HVA (3G MIS) 9 NA −0.4 −0.68 ∼ 0.13 P < 0.01 69 P < 0.01 REM
IMA (RCT only) 9 NA −0.25 −0.58 ∼ 0.08 0.14 63 P < 0.01 REM
IMA (non-RCT only) 13 NA −0.09 −0.33 ∼ 0.14 0.42 72 P < 0.01 REM
IMA (2G MIS) 9 NA −0.28 −0.57 ∼ 0.01 0.04 64 P < 0.01 REM
IMA (3G MIS) 9 NA 0.01 −0.30 ∼ 0.31 0.96 75 P < 0.01 REM
DMAA (RCT only) 5 NA −0.19 −0.46 ∼ 0.06 0.14 0 0.72 FEM
DMAA (non-RCT only) 5 NA −0.44 −0.87 ∼ 0.02 0.04 71 P < 0.01 REM
DMAA (2G MIS) 5 NA −0.14 −0.38 ∼ 0.11 0.27 0 0.71 FEM
DMAA (3G MIS) 3 NA −0.79 −1.08 ∼ −0.49 P < 0.01 35 0.21 FEM
AOFAS score (RCT only) 7 NA 0.45 0.03 ∼ 0.87 0.04 73 P < 0.01 REM
AOFAS score (non-RCT only) 10 NA 0.14 −0.25 ∼ 0.53 0.48 89 P < 0.01 REM
AOFAS score (2G MIS) 7 NA 0.37 −0.17 ∼ 0.90 0.18 88 P < 0.01 REM
AOFAS score (3G MIS) 8 NA 0.17 −0.22 ∼ 0.56 0.39 83 P < 0.01 REM
Complication rate (RCT only) 8 1.03 NA 0.68 ∼ 1.57 0.89 28 0.21 FEM
Complication rate (non-RCT only) 12 1.12 NA 0.70 ∼ 1.82 0.62 52 0.01 REM
Complication rate (2G MIS) 9 1.05 NA 0.55 ∼ 2.02 0.88 65 P < 0.01 REM
Complication rate (3G MIS) 9 1.07 NA 0.76 ∼ 1.51 0.71 0 0.47 FEM

N, number of included studies; RR, risk ratio; SMD, standardized mean difference; CI, confidence interval; RCT, randomized controlled trial; HVA, hallux valgus angle; 2G, second
generation; 3G, third generation; MIS, minimally invasive surgery; NA, not applicable; FEM, fixed effect model; REM, random effect model; IMA, first intermetatarsal angle; DMAA, distal
metatarsal articular angle; AOFAS, the American Orthopedic Foot and Ankle Society.

axis. A pathological joint line is associated with a significantly in the AOFAS score. Poggio et al. (27) reported that the open
increased recurrence rate (41), so it is essential to restore the scarf technique showed more increases in the AOFAS score than
DMAA. Brogan et al. (5) reported a trend toward a difference the Kramer technique (also known as the 2G MIS technique).
in DMAA in favor of the PECA group compared with the open Radwan and Mansour (24) and Lee et al. (29) reported a trend
chevron group, perhaps because of the effect of the wire causing a toward a better improvement in the AOFAS score in the MIS
slight varus displacement of the metatarsal head fragment. Frigg group. This meta-analysis pooled 17 studies and found no
et al. (14) performed a retrospective comparison of MICA with difference in the improvement of the AOFAS score between
open scarf-akin surgery for hallux valgus and reported a lower the two groups. When taking into consideration only RCTs,
DMAA in the MICA group. This meta-analysis pooled the data the AOFAS score was higher in the MIS group. The VAS score
from 10 studies reporting DMAA, indicating a lower DMAA in of the early post-operative phase was lower in the MIS group,
the MIS group. which reflected that the MIS surgery required a minor soft
The diameter of burrs used in MIS procedures is about tissue dissection (15). The VAS score at the final follow-up
2 mm, which may lead to shorter metatarsal compared with was not found to be significant, which was in accordance with
open techniques (5). The shortened first metatarsal will transfer Singh’s meta-analysis.
more load to the lateral metatarsal heads, which could cause Singh’s meta-analysis pooled 4 studies and found no
metatarsalgia (42). This meta-analysis indicated that MIS surgery significant difference in the satisfaction rate between MIS
do not cause more metatarsal shortening compared with and open groups. Lu’s meta-analysis pooled 3 studies and
open surgery. demonstrated a higher satisfaction level in the MIS group. Our
The change of the sesamoid position was better in the MIS meta-analysis included 7 studies, showing a higher satisfaction
group than in the open group, which perhaps was due to more rate in the MIS group. The high satisfaction rate in the MIS
use of image intensifier. Okuda et al. (43) pointed out that was possibly due to the cosmetic result of surgery. Choi et
insufficient sesamoid position correction was an important risk al. reported 2G MIS for young female patients, and believed
factor for hallux valgus recurrence, so the correction of the that the MIS technique could be considered for young female
sesamoid position was needed. patients who desire a less visible scar (13). The scar length
The AOFAS score (37) was to evaluate the functional outcome, was significantly shorter in the MIS group. Because of the
including pain (40 points), function (45 points), and alignment limited scar on the medial side, MIS is expected to result
(15 points). Singh et al. (11) conducted a meta-analysis to in fewer soft tissue complications, less stiffness, and a higher
demonstrate that the open group provided more improvement satisfaction rate.

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

FIGURE 4 | Forest plots of clinical outcomes. (A) SMD for the AOFAS score improvement between the MIS and open groups; (B) VAS score at the final follow-up; (C)
VAS score within post-operative 2 weeks; (D) satisfaction rate; and (E) complication rate. SMD, standardized mean difference; AOFAS, the American Orthopedic Foot
and Ankle Society; MIS, minimally invasive surgery; VAS, visual analog scale; postop, post-operative.

The duration of surgery and the length of hospitalization To our knowledge, this meta-analysis includes the largest
were shorter in the MIS group, possibly due to the limited number of studies (22 studies) evaluating the efficiency
exposure and steps involved in the MIS technique (23). The of MIS vs. open surgery for hallux valgus. There were
shorter length of hospitalization in the MIS group made some limitations in this meta-analysis. First, different surgical
the MIS procedure a beneficial choice for high-risk patients techniques were used in the MIS and open groups, involving
suffering recurrent ulceration (23). However, Lai et al. reported a high heterogeneity. Secondly, non-randomized controlled
that the fluoroscopy time was longer in the MIS group studies were included; therefore, the results of this study must
compared with the open group, involving higher radiation be interpreted with caution due to the natural defects of
exposures (30). retrospective studies. Larger sample multicenter randomized
Jowett et al. described a steep learning curve for MIS controlled studies are needed to further verify the results of
techniques. Jowett et al. made a comparison of a single surgeon this meta-analysis.
series and found a higher reoperation rate and a lower satisfaction
rate in the first 53 ft compared with the subsequent 53 ft CONCLUSION
(44). To minimize the learning curve, cadaveric training was
recommended for any surgeon considering performing MIS The MIS procedures were more effective than open surgery
surgery (30). in the treatment of hallux valgus. Moreover, the MIS group

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

FIGURE 5 | Forests plot of secondary outcomes between the MIS and open groups. (A) Duration of surgery; (B) length of hospitalization; (C) the scar length. MIS,
minimally invasive surgery.

achieved better radiologic and clinical outcomes compared with AUTHOR CONTRIBUTIONS
the open group. The 2G MIS demonstrated better corrective
power to IMA while the 3G MIS provided a stronger correction MZ designed this study. KW and SD conducted the
to HVA. The MIS procedures offered benefits mainly in the literature search and data extraction. SD and CS performed
early post-operative period, including a shorter surgery time, quality assessment of the included studies. LJ and SS
a more cosmetic scar, a higher satisfaction rate, and a faster performed a statistical analysis. LJ and KW wrote this
recovery time. These features of the MIS procedure make manuscript. All authors have read and approved this
it a better choice for young female patients who favor a final manuscript.
cosmetic scar and patients who are at high risk due to
recurrent ulceration.
FUNDING
DATA AVAILABILITY STATEMENT This work was supported by the Natural Science
Foundation of Beijing (Grant No. 7212020), Science
The original contributions presented in the and Technology Planning Project of Beijing Municipal
study are included in the article/supplementary Education Commission (Grant No. KM202110025013),
material, further inquiries can be directed to the and the Beijing Thousand Talents Project (Grant
corresponding author/s. No. 2020A43).

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Ji et al. Meta-Analysis of Hallux Valgus Treatment

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of hallux valgus. J Bone Joint Surg Br. (2005) 87:1038–45. absence of any commercial or financial relationships that could be construed as a
doi: 10.1302/0301-620X.87B8.16467 potential conflict of interest.
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BMC Musculoskelet Disord. (2008) 9:1–6. doi: 10.1186/1471-2474-9-70 and do not necessarily represent those of their affiliated organizations, or those of
41. Iyer S, Demetracopoulos CA, Sofka CM, Ellis SJ. High rate of
the publisher, the editors and the reviewers. Any product that may be evaluated in
recurrence following proximal medial opening wedge osteotomy for
this article, or claim that may be made by its manufacturer, is not guaranteed or
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doi: 10.1177/1071100715577195 endorsed by the publisher.
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incomplete reduction of the sesamoids as a risk factor for recurrence of publication in this journal is cited, in accordance with accepted academic practice.
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00796 terms.

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