Abstract
Introduction
Hallux valgus (bunions) are prominent and often inflamed metatarsal heads and overlying bursae. They are associated with valgus deviation of the great toe which moves towards the second toe. Hallux valgus is found in at least 2% of children aged 9 to 10 years, and almost half of adults, with greater prevalence in women.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of conservative treatments for hallux valgus (bunions)? What are the effects of osteotomy for hallux valgus (bunions)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 15 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: chevron osteotomy plus adductor tenotomy; distal metatarsal osteotomy; minimally invasive surgery (percutaneous distal metatarsal osteotomy, SERI [Simple, Effective, Rapid, Inexpensive] distal metatarsal osteotomy); phalangeal (Akin) osteotomy plus distal chevron osteotomy; proximal osteotomy; night splints; and orthoses (including antipronatory orthoses in children).
Key Points
Hallux valgus (bunions) are prominent and often inflamed metatarsal heads and overlying bursae, which cause pain and problems with walking and wearing normal shoes.
Hallux valgus (where the great toe moves towards the second toe) is found in at least 2% of children aged 9 to 10 years and almost half of adults, with greater prevalence in women.
We don't know what role footwear plays in the development of hallux valgus.
We don't know whether night splints or orthoses (in adults or children) prevent deterioration of hallux valgus (bunions).
Distal chevron osteotomy may be more effective than orthoses or no treatment at reducing pain and improving function. However, we found insufficient evidence comparing its effectiveness with scarf osteotomy and other types of distal or proximal osteotomies.
We don't know whether minimally invasive surgery (percutaneous distal metatarsal osteotomy, SERI [Simple, Effective, Rapid, Inexpensive] distal metatarsal osteotomy) is beneficial in improving outcomes compared with non-minimally invasive types of osteotomy as we found insufficient evidence.
We don't know whether other surgical procedures such as phalangeal (Akin) osteotomy or proximal osteotomy are beneficial in improving outcomes.
About this condition
Definition
Hallux valgus is a deformity of the great toe, whereby the hallux (great toe) moves towards the second toe, overlying it in severe cases. This abduction (movement away from the midline of the body) is usually accompanied by some rotation of the toe so that the nail is facing the midline of the body (valgus rotation). With the deformity, the metatarsal head becomes more prominent, and the metatarsal is said to be in an adducted position as it moves towards the midline of the body. Radiological criteria for hallux valgus vary, but a commonly accepted criterion is to measure the angle formed between the metatarsal and the abducted hallux. This is called the metatarsophalangeal joint angle (also known as the hallux valgus angle, and hallux abductus angle), and it is considered abnormal when it is greater than 14.5°. Bunion is the lay term used to describe a prominent and often inflamed metatarsal head and overlying bursa. Symptoms include pain, limitation in walking, and problems with wearing normal shoes.
Incidence/ Prevalence
The prevalence of hallux valgus varies in different populations. In a study of 6000 UK school children aged 9 to 10 years, 2.5% had clinical evidence of hallux valgus, and 2% met both clinical and radiological criteria for hallux valgus. An earlier study found hallux valgus in 48% of adults. Differences in prevalence may result from different methods of measurement, varying age groups, or different diagnostic criteria (e.g., older studies generally used a metatarsal joint angle of >10° as a diagnostic criteria, but more recent studies have used a threshold of >15°).
Aetiology/ Risk factors
Nearly all population studies have found that hallux valgus is more common in women. Footwear may contribute to the deformity, but studies comparing people who wear shoes with those who do not have found contradictory results. Hypermobility of the first ray and excessive foot pronation are associated with hallux valgus.
Prognosis
Prognosis seems uncertain. While progression of deformity and symptoms is rapid in some people, others remain asymptomatic. One study found that hallux valgus is often unilateral initially, but usually progresses to bilateral deformity.
Aims of intervention
To reduce symptoms and deformity, with minimum adverse effects.
Outcomes
Pain; improvement in joint angle (hallux valgus angle [also known as hallux abductus angle, and metatarsophalangeal joint angle]; intermetatarsal joint angle); functional assessment; range of movement or motion of the first metatarsophalangeal joint (the total range of both dorsiflexion and plantar flexion); general satisfaction, including satisfaction with appearance (cosmetic); need for special footwear (requirement for specialist or extra-width footwear); mobility (proportion of people with mobility problems); healing (including time to healing); transfer lesions; time taken to return to normal activities; and adverse effects of treatment (including incidence of complications such as infection, re-operation, non-union, avascular necrosis).
Methods
Clinical Evidence search and appraisal October 2013. The following databases were used to identify studies for this systematic review: Medline 1966 to October 2013, Embase 1980 to October 2013, and The Cochrane Database of Systematic Reviews 2013, Issue 9 (1966 to date of issue). Additional searches were carried out in the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment (HTA) Database. We also searched for retractions of studies included in the review. Titles and abstracts identified by the initial search, run by an information specialist, were first assessed against predefined criteria by an evidence scanner. Full texts for potentially relevant studies were then assessed against predefined criteria by an evidence analyst. Studies selected for inclusion were discussed with an expert contributor. All data relevant to the review were then extracted by an evidence analyst. Study design criteria for inclusion in this review were: published systematic reviews and RCTs, blinded or open-label trials, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum follow-up. We included RCTs and systematic reviews of RCTs, where harms of an included intervention were assessed, applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table.
GRADE Evaluation of interventions for Hallux valgus (bunions).
| Important outcomes | Functional assessment, General satisfaction, Healing, Improvement in joint angle, Mobility, Need for special footwear, Pain, Range of movement, Time to return to normal activities, Transfer lesions | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of conservative treatments for hallux valgus (bunions)? | |||||||||
| 1 (209) | Pain | Orthoses versus no treatment in adults | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results; consistency point deducted for different results at different endpoints |
| 1 (209) | Functional assessment | Orthoses versus no treatment in adults | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (209) | General satisfaction | Orthoses versus no treatment in adults | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for unclear outcome |
| 1 (209) | Time to return to normal activities | Orthoses versus no treatment in adults | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for unclear outcome |
| 1 (122) | Improvement in joint angle | Antipronatory orthoses versus no treatment in children | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for high loss to follow-up |
| What are the effects of osteotomy for hallux valgus (bunions)? | |||||||||
| 1 (209) | Pain | Distal chevron osteotomy versus no treatment | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (209) | Functional assessment | Distal chevron osteotomy versus no treatment | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (209) | General satisfaction | Distal chevron osteotomy versus no treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for unclear outcome |
| 1 (209) | Time to return to normal activities | Distal chevron osteotomy versus no treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for subjective outcome |
| 1 (209) | Pain | Distal chevron osteotomy versus orthoses | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (209) | Functional assessment | Distal chevron osteotomy versus orthoses | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (209) | General satisfaction | Distal chevron osteotomy versus orthoses | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for unclear outcome |
| 1 (209) | Time to return to normal activities | Distal chevron osteotomy versus orthoses | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for subjective outcome |
| 4 (361) | Improvement in joint angle | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results; consistency point deducted for conflicting results |
| 3 (316) | Functional assessment | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results; directness point deducted for no statistical comparison between groups in 1 RCT |
| 1 (51) | Need for special footwear | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for limited number of comparisons |
| 1 (96) | Range of movement | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and for incomplete reporting of results; directness point deducted for no statistical comparison between groups |
| 1 (96) | General satisfaction | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and for incomplete reporting of results; directness point deducted for no statistical comparison between groups |
| 1 (51) | Mobility | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for unclear subjective outcome |
| 1 (96) | Transfer lesions | Distal chevron osteotomy versus other types of distal osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and for incomplete reporting of results; directness point deducted for no statistical comparison between groups |
| 1 (53) | Pain | Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for restricted population |
| 1 (53) | Improvement in joint angle | Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for restricted population |
| 1 (53) | Functional assessment | Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for restricted population |
| 1 (53) | Range of movement | Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and short follow-up; directness point deducted for restricted population |
| 1 (53) | General satisfaction | Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for restricted population |
| 1 (20) | Improvement in joint angle | SERI (Simple, Effective, Rapid, Inexpensive) distal metatarsal osteotomy versus scarf osteotomy | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data; directness points deducted for no statistical analysis between groups and restricted population |
| 1 (20) | Functional assessment | SERI (Simple, Effective, Rapid, Inexpensive) distal metatarsal osteotomy versus scarf osteotomy | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data; directness points deducted for no statistical analysis between groups and restricted population |
| 1 (20) | Range of movement | SERI (Simple, Effective, Rapid, Inexpensive) distal metatarsal osteotomy versus scarf osteotomy | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data and uncertainty about measure of outcome; directness points deducted for no statistical analysis between groups and restricted population |
| 1 (84) | Pain | Chevron osteotomy plus adductor tenotomy compared with chevron osteotomy alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short (unspecified) follow-up |
| 1 (84) | Improvement in joint angle | Chevron osteotomy plus adductor tenotomy compared with chevron osteotomy alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short (unspecified) follow-up |
| 1 (84) | Range of movement | Chevron osteotomy plus adductor tenotomy compared with chevron osteotomy alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short (unspecified) follow-up |
| 1 (84) | General satisfaction | Chevron osteotomy plus adductor tenotomy compared with chevron osteotomy alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short (unspecified) follow-up |
| 1 (84) | Need for special footwear | Chevron osteotomy plus adductor tenotomy compared with chevron osteotomy alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short (unspecified) follow-up |
| 1 (84) | Mobility | Chevron osteotomy plus adductor tenotomy compared with chevron osteotomy alone | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and short (unspecified) follow-up |
| 1 (52) | Pain | Phalangeal (Akin) osteotomy plus distal chevron osteotomy versus distal chevron osteotomy | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and weak methods |
| 1 (52) | Functional assessment | Phalangeal (Akin) osteotomy plus distal chevron osteotomy versus distal chevron osteotomy | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and weak methods |
| 1 (52) | Improvement in joint angle | Phalangeal (Akin) osteotomy plus distal chevron osteotomy versus distal chevron osteotomy | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and weak methods |
| 1 (52) | General satisfaction | Phalangeal (Akin) osteotomy plus distal chevron osteotomy versus distal chevron osteotomy | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and weak methods |
| 1 (23) | Improvement in joint angle | Phalangeal (Akin) osteotomy plus distal chevron osteotomy versus phalangeal (Akin) osteotomy plus distal soft-tissue reconstruction | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and for possibly being a subset of data from a larger RCT |
| 1 (23) | Range of movement | Phalangeal (Akin) osteotomy plus distal chevron osteotomy versus phalangeal (Akin) osteotomy plus distal soft-tissue reconstruction | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, unclear randomisation, and for possibly being a subset of data from a larger RCT |
| 1 (66) | Improvement in joint angle | Proximal chevron osteotomy versus other types of proximal osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for no longer-term follow-up |
| 1 (66) | Functional assessment | Proximal chevron osteotomy versus other types of proximal osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for no longer-term follow-up |
| 1 (66) | Healing | Proximal chevron osteotomy versus other types of proximal osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for no longer-term follow-up |
| 1 (66) | Transfer lesions | Proximal chevron osteotomy versus other types of proximal osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for no longer-term follow-up |
| 1 (68) | Pain | Proximal osteotomy versus distal chevron osteotomy | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (110) | Functional assessment | Proximal osteotomy versus distal chevron osteotomy | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data; directness point deducted for use of co-interventions |
| 2 (178) | Improvement in joint angle | Proximal osteotomy versus distal chevron osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for use of co-interventions |
| 2 (178) | General satisfaction | Proximal osteotomy versus distal chevron osteotomy | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results; directness point deducted for use of co-interventions |
| 1 (68) | Need for special footwear | Proximal osteotomy versus distal chevron osteotomy | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (68) | Mobility | Proximal osteotomy versus distal chevron osteotomy | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Glossary
- American Orthopaedic Foot and Ankle Scale (AOFAS)
The AOFAS is a series of validated scoring systems for different parts of the foot. For hallux valgus (bunions) studies, the metatarsophalangeal-interphalangeal score is used. The score includes three domains (pain, function, and alignment), which form a composite score of 100 points. Higher scores indicate better outcome.
- First ray
The first metatarsal and medial cuneiform function as a single unit called the first ray.
- Lindgren osteotomy
A modified Wilson's osteotomy involving a transverse cut in the distal metatarsal shaft, with the distal fragment being realigned laterally and slightly plantarly.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Percutaneous distal metatarsal osteotomy
A minimally invasive transverse osteotomy procedure performed through a 1–2 cm longitudinal medial incision, allowing for lateral displacement with or without slight plantar displacement of the metatarsal head. The metatarsal head can also be rotated in the axial plane to correct rotational deformity.
- SERI (Simple, Effective, Rapid, Inexpensive) osteotomy
A minimally invasive osteotomy technique performed through a small (approximately 1 cm) medial incision allowing direct visual control of the osteotomy procedure.
- Scarf osteotomy
A form of osteotomy in which a long Z-shaped cut is made in the metatarsal, with the bone fragments being fixed with screws after realignment.
- Transfer lesions
Areas of corns or callus that develop when the weight-bearing forces are transferred from one area of the foot to another.
- Very low-quality evidence
Any estimate of effect is very uncertain.
- Wilson's osteotomy
A form of osteotomy in which a double oblique cut is made in the distal portion of the metatarsal shaft and the metatarsal head is slid into a corrected position.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
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