Key messages
– Surgery may result in an improvement in pain, and a slight improvement in function and satisfaction with treatment compared with no treatment or non-surgical treatment. However, complications of surgery, such as wound infection, or hardware irritation requiring additional surgery, need to be balanced against its benefits in pain and function improvement.
What is hallux valgus?
Hallux valgus is a bony lump that forms on the inside of the feet (known as bunions). The exact cause is unknown but it is aggravated by constant pressure on the front of the foot, such as with ill-fitting shoes and high-heeled shoes. Hallux valgus leads to poor balance and increased risk of falling. Patients may have difficulty fitting into standard shoes, and have pain on the bottom of the foot and big toe, and pain caused by breakdown of the joint. All of these are worse when weight-bearing (i.e. when standing).
People with hallux valgus want a painless foot when wearing conventional shoes; improvements in swelling, joint pain and size of the bunion; improved walking; less restriction of sports activities; less use of walking aids or splints/braces; improved cosmetic appearance and freedom from medications.
How is hallux valgus treated?
Treatments include non-surgical options such as splints, braces or taping and surgical procedures involving one cut (simple surgery) or two or more cuts (complex surgery) to the bone to align it back to its previous or expected position.
What did we want to find out?
We wanted to find out if surgery was better than no treatment or non-surgical treatments to improve pain, function, quality of life and whether the person considered the treatment successful.
We also wanted to find out if surgery was associated with any unwanted effects or the need for another operation (treatment failure).
What did we do?
We searched for studies that compared surgery versus no treatment or non-surgical treatment or different types of surgery in adults. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 25 studies with 1597 adults aged 16 to 80 years. There were more women than men. Participants were monitored for an average of 20 months (ranging from five to 84 months). We found no studies comparing surgery versus placebo (a pretend treatment). One study compared surgery with no treatment and with non-surgical treatment, and 24 studies compared different types of surgery to each other.
Main results
Here, we limited reporting to the main comparison, surgery versus no treatment (1 study, 140 participants).
The study measured pain on a 0- to 100-point scale where lower scores mean less pain. At 12 months after surgery, pain may have reduced compared to no treatment (by 18 points).
– People who had no treatment rated their pain as 39 points.
– People who had surgery rated their pain as 21 points.
The study measured function on a 0- to 100-point scale where higher scores mean better function. At 12 months after surgery, function may have increased slightly compared to no treatment (by 9 points).
– People who received no treatment rated their function as 66 points.
– People who had surgery rated their function as 75 points.
The study measured quality of life on a 0- to 100-point scale where higher scores mean better quality of life. At 12 months after surgery, there may be little to no difference in quality of life between groups.
– People who received no treatment rated their quality of life as 93 points.
– People who had surgery rated their quality of life as 93 points.
The study measured satisfaction with treatment on a 0- to 100-point scale where higher scores mean better satisfaction. At 12 months after surgery, satisfaction may have slightly increased compared to no treatment (by 19 points).
– People who received no treatment rated their satisfaction as 61 points.
– People who had surgery rated their satisfaction as 80 points.
We are uncertain about the effects on unwanted effects or need for another operation between groups.
What are the limitations of the evidence?
All 25 studies had weaknesses that could have affected the reliability of their results. Generally, the studies had poor methods and low numbers of participants.
How up to date is the evidence?
The evidence is up to date to 20 April 2023.
There were no trials comparing surgery to placebo or sham. Surgery may result in a clinically important reduction in pain when compared to no treatment or non-surgical treatment. Surgery may also result in a slight increase in function and participant global assessment of treatment success compared to no treatment or non-surgical treatment. There may be little to no difference in quality of life between surgery and no treatment or non-surgical treatment. We are uncertain about the effect of surgery on reoperation (treatment failure), adverse events or serious adverse events, when compared to no treatment or non-surgical treatment.
Complex and simple osteotomies demonstrated similar results for pain. Complex osteotomies may increase reoperation (treatment failure) and may result in little to no difference in participant global assessment of treatment success and serious adverse events compared to simple osteotomies. We are uncertain about the effect of complex osteotomies on function, quality of life and adverse events.
Hallux valgus (lateral angulation of the great toe towards the lesser toes, commonly known as bunions) presents in 23% to 35% of the population. This condition leads to poor balance and increases the risk of falling, adding to the difficulty in fitting into shoes and pain. Conservative (non-surgical) interventions treating pain rather than curing deformity are usually first-line treatments. When surgery is indicated, the overall best surgical procedure is an ever-evolving topic of discussion.
To assess the benefits and harms of different types of surgery compared with placebo or sham surgery, no treatment, non-surgical treatments and other surgical interventions for adults with hallux valgus.
We searched CENTRAL, MEDLINE, Embase and trial registries to 20 April 2023. We did not apply any language or publication restrictions.
We included randomised controlled trials evaluating surgical interventions for treating hallux valgus compared to placebo surgery or sham surgery, no treatment, non-surgical treatment or other surgical interventions. The major outcomes were pain, function, quality of life, participant global assessment of treatment success, reoperation (treatment failure), adverse events and serious adverse events.
Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE.
We included 25 studies involving 1597 participants with hallux valgus. All studies included adults and most were women. One study compared surgery (V-shaped osteotomy) with no treatment and with non-surgical treatment. Fifteen studies compared different surgical techniques, including a V-shaped osteotomy (Chevron osteotomy), to other types of osteotomy. Nine studies compared different simple osteotomy techniques to each other or to a mid-shaft Z-shaped osteotomy (Scarf osteotomy).
Most trials were susceptible to bias: in particular, selection (80%), performance (88%), detection (96%) and selective reporting (64%) biases.
Surgery versus no treatment
Surgery may result in a clinically important reduction in pain. At 12 months, mean pain was 39 points (0 to 100 visual analogue scale, 100 = worst pain) in the no treatment group and 21 points in the surgery group (mean difference (MD) −18.00, 95% confidence interval (CI) −26.14 to −9.86; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.
Surgery may result in a slight increase in function. At 12 months, mean function was 66 points (0 to 100 American Orthopedics Foot and Ankle Scale (AOFAS), 100 = best function) in the no treatment group and 75 points in the surgery group (MD 9.00, 95% CI 5.16 to 12.84; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.
Surgery may result in little to no difference in quality of life. At 12 months, mean quality of life (0 to 100 on 15-dimension scale, 100 = higher quality of life) was 93 points in both groups (MD 0, 95% CI −2.12 to 2.12; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.
Surgery may result in a slight increase in participant global assessment of treatment success. At 12 months, mean participant global assessment of treatment success was 61 points (0 to 100 visual analogue scale, 100 = completely satisfied) in the no treatment group and 80 points in the surgery group (MD 19.00, 95% CI 8.11 to 29.89; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision.
Surgery may have little effect on reoperation (relative effect was not estimable), adverse events (risk ratio (RR) 8.75, 95% CI 0.48 to 159.53; 1 study, 140 participants; very low-certainty evidence), and serious adverse events (relative effect was not estimable), but we are uncertain.
Surgery versus non-surgical treatment
Surgery may result in a clinically important reduction in pain; a slight increase in function and participant global assessment of treatment success; and little to no difference in quality of life (1 study, 140 participants; low-certainty evidence). We are uncertain about the effect on reoperation, adverse events and serious adverse events (1 study, 140 participants; very low-certainty evidence).
Complex versus simple osteotomies
Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies (7 studies, 414 participants; moderate-certainty evidence). Complex osteotomies may increase reoperation (7 studies, 461 participants; low-certainty evidence), and may result in little to no difference in participant global assessment of treatment success (8 studies, 462 participants; low-certainty evidence) and serious adverse events (12 studies; data not pooled; low-certainty evidence). We are uncertain about the effect of complex osteotomies on function and adverse events (very low-certainty evidence). No study reported quality of life.