Percutaneous Treatment of Hallux Valgus: What’s the Evidence? A Systematic Review

SLR - December 2017 - Kelly C. Parks

Podiatric Relevance: Hallux valgus is the quintessential pathology of podiatric medicine, and mastery of the various surgical approaches for the correction of the deformity should be in the repertoire of all podiatric surgeons. Minimally invasive and percutaneous procedures are growing in popularity for their proposed quicker healing times, reduced infections rates and reduced patient pain. However, to date, there is no consensus in the literature regarding the surgical management of hallux valgus percutaneously. Therefore, the purpose of this article was to review and analyze the available literature regarding percutaneous surgical management of hallux valgus and compare it to other minimally invasive techniques. 

Methods: A systematic review of Pubmed and Google Scholar was performed rendering 61 citations from only peer-reviewed journals obtained by two independent reviewers. Article exclusion criteria included non-English language papers, cadaveric or sawbone procedures, skeletally immature patients, isolated phalangeal or nondistal metatarsal osteotomies, presence of permanent fixation and articles with no clinical data. Methodologic quality of the included articles was assessed by the Modified Coleman Methodology Screen. Each study was evaluated for multiple factors, including follow-up period, surgical technique, operative time, clinical and radiological outcomes and complications.

Results: Of the 61 studies, four case series from 2005 to 2015 met inclusion criteria for a total of 464 surgeries. Two techniques were described, a distal linear transverse osteotomy with straight burr and a Reverdin-Isham distal osteotomy with straight burr. Follow-up ranged from a mean of five to 32.6 months. Final clinical subjective outcomes were assessed by AOFAS scores in all four articles with a mean of 90.61 at final follow-up. Three articles described postoperative radiologic parameters with mean postoperative measures of HVA 13.61º and IMA 8.36 º, and PASA 7.35 º. Complications in the Reverdin Ishaman procedure patients included CRPS, phalanx and metatarsal fractures, DVTs, MTPJ stiffness requiring arthrolysis and DASA overcorrections. Complications in the distal linear group included recurrence, numbness, ROM limitations, pin track infections and deep infection. Operating times were reported in two studies with a mean of 50.8 minutes. In regards to AOFAS scores and radiographic measures, percutaneous procedures were similar compared to other described minimally invasive techniques.

Conclusions: Percutaneous surgery has the theoretical advantage of reduced risks of nonunion, hematoma, stiffness due to scar tissue and soft-tissue damage. However, improper technique can lead to higher rate of complications and longer surgical times increasing costs, anesthesia risks and peri/postoperative complications. Additionally, the linear burr presents concern for thermal injury and increased bone loss with fragmentation into joint/capsular tissues, becoming a potential cause of stiffness. Fluoroscopy is also required for this technique, and radiation exposure is currently understudied in this practice, presenting an area for further exploration. Other limitations included lack of homogeneity in the study designs between included articles and lack of objective radiographic outcome parameters. Percutaneous procedures represent an interesting emerging technique, and in regards to patient satisfaction, pain and radiographic outcomes, it is comparable with other minimally invasive procedures. However, further reproducible, standardized studies are needed to better explore and optimize this technique.