| OBJECTIVE:Evaluate the efficacy and safety of different first metatarsal osteotomies for correction of hallux valgus deformity, and provide podiatrists with the best evidence on which the clinical dicision-making could be made.[1]The study is divided into three parts, the first part is the comparison of the proximal Chevron osteotomy versus proximal Crescentic osteotomy for correction of moderate and severe hallux valgus. In the second part, we will compare the safety and efficacy of the distal Chevron osteotomy and proximal closed wedge osteotomy for correction of hallux valgus; the last part compare the efficacy and safety of the distal Chevron osteotomy versus Mitchell osteotomy for the mild and moderate hallux valgus.MATERIALS AND METHODS:Firstly, we formulate the search strategy and then search the literature on the first metatarsal osteotomy for the correction of hallux valgus in the database such as Medline, Embase, ScienceDirect, Pubmed, CNKI and so on. Select the literature strictly in accordance with the inclusion and exclusion criteria, evaluate the quallity of the included literature. Read the fulltext carefully and extract the data about the gender, age, follow-up time, hallux valgus angle (HVA), the 1/2 intermetatarsal angle (1/2 IMA), patient satisfaction, sesamoid reduction, metatarsal shortening, malunion, delayed union, internal fixation, healing time, transfer lesions, wound infection, metatarsophalangeal joint activity and so on. The preoperative baseline data was compared between the two groups and then all data extracted from the included literature were ananlyzed using the statistical software Stata 10 and Revman 5.0. If the indicators can't be combined, the descriptive systematic reviews were used to evaluate them.RESULTS:The proximal Chevron osteotomy versus Crescentic osteotomy in correction of moderate and sever hallux valgus:21 literatue were included,815 cases and 1078 feet in all. The proximal Chevron osteotomy group included 301 cases 381 feet, single foot 233 cases and double feet 74 cases,281 cases was female.The mean age was 51.39 years old, the mean followup time was 25.62 months, the preoperative HVA was 35.39°and the 1/2 IMA was 16.18°. In the proximal Crescentic osteotomy group the included cases were 508,651 feet in all, single in 365 cases and double in 143 cases, the female were 459 cases; the preoperative HVA and 1/2 IMA were 36.51°and 15.43°; the mean age was 47.25 years old and the mean followup time was 41.86 months. There were no statistically sinificant difference in gender,single and double between the two groups, the baseline is equivalent. The results of meta-analysis using Stata 10 were showed as follows. In the proximal Chevron osteotomy, the correction of HVA and 1/2 IMA was 22.99(19.21,26.77)and 9.71(8.37,11.06) respectively,the satisfaction rate was 0.961 (0.936,0.986),level deformity rate (deformity recurrence and hallux varus) was 0.028(0.009,0.047),the healing rate of preoperative transfer lesion was 0.845(0.721,0.969),the new transfer lesion postoperatively was 0.023(-0.022,0.068),the first metatarsal shotening was 1.833(1.167,2.499). In the proximal Crescentic osteotomy, the correction of HVA and 1/2 IMA was 24.56(22.34,26.78) and 10.02(9.32,10.72) respectively,the satisfaction rate was 0.926(0.904,0.948),level deformity rate (deformity recurrence and hallux varus) was 0.093(0.062,0.124),the healing rate of preoperative transfer lesion was 0.652(0.478,0.826),the new transfer lesion postoperatively was 0.049(0.016,0.083), the first metatarsal shotening was 2.553(1.610,3.496).The 95% confidence intervals of the indicators of the correction of HVA and 1/2 IMA, the satisfaction rate,the new transfer lesion and the transfer lesion healing rate and the first metatarsal shotening were overlapped between the two groups; there was no statistical significant difference. The difference in level deformity rate between the two groups was statistically significant. As the internal fixation, Kirschner wire or no internal fixation were usually used in proximal Chevron osteotomy group, however, the screw was used often in the proximal Crescentic osteotomy group. With Kirschner wire fixation,the infection rate and delayed union was higher in proximal Crescentic osteotomy than that in proximal Chevron osteotomy group (P=0.000,P=0.007).With no internal fixation, the malunion rate was higher in proximal Crescentic osteotomy than that in proximal Chevron osteotomy group (P=0.007). The proximal Chevron osteotomy stabilized much better, the Kirschner wire fixation was enough, however, the proximal Crescentic osteotomy must be fixed rigidly.According to a RCT result, the proximal Chevron osteotomy heal rapidly than the Crescetic osteotomy. The metatarsal head elevated easily in sagittal plane after proximal Crescentic osteotomy. The wound paresthesia occurred often after the proximal Crescentic osteotomy.The distal Chevron osteotomy versus proximal closing wedge osteotomy in correction of hallux valgus:4 literatue were included,232 cases and 263 feet in all. The DCO group included 128 cases 145 feet, single foot 111 cases and double feet 17 cases,114 cases were female.The mean age was 50.96 years old, the mean followup time was 32.73 months, the preoperative HVA was 29.02°and the 1/2 IMA was 14.83°. In the PCO group the included cases were 104,118 feet in all, single in 90 cases and double in 14 cases, the female were 88 cases; the preoperative HVA and 1/2 IMA were 31.54°and 16.05°; the mean age was 43.22 years old and the mean followup was 24.64 months.There were no statistically sinificant difference in gender,double and single between the two groups, the baseline is equivalent. The results of meta-analysis using Revman 5.0 were showed as follows. There was statistically significant difference in correction of HVA (Z=2.73,P=0.006), the 1/2 IMA (Z=9.85,P<0.00001) between the two groups, the proximal closing wedge osteotomy corrects the HVA and the 1/2 IMA much higher than the distal Chevron osteotomy.The transfer lesion occurred more frequently in the PCWO group than in the DCO group(Z=2.28,P=0.02). However, there wasn't any difference between the two groups in patient satisfaction(Z=1.41,P=0.16).As to the internal fixation method, the DCO group usually fixed with Kirschner wire or without any internal fixation,however, the PCWO group must be fixed rigidly. All these showed that the distal Chevron osteotomy was more stable than that after the proximal closing wedge osteotomy. With the limition of the first metatarsal diameter, the deformity recurrence was higher in the DCO group than that in the PCWO group, but the hallux varus happened frequently in the PCWO group due to overcorrection. According to the descriptive systematic reviews, the sesamoid reduction and the motion of the first metatarsophalangeal joint were better in the PCWO group than in the DCO group. There was no AVN occurred in the included literature, the distal Chevron was not vital to the AVN of the first metatarsal head。The distal Chevron osteotomy (DCO) versus Mitchell osteotomy in correction of hallux valgus:24 literatue were included,986 cases and 1207 feet in all. The DCO group:13 studies were included,433 cases 543 feet in all,390 cases were female, the mean age was 45.89 years old. Single foot in 323, bilateral feet in 110; the mean followup time was 32.73 months; the preoperative HVA was 29.49°and the 1/2 IMA was 13.99°; the mean followup was 38.55 months.In the Mitchell group:11 studies were included,553 cases 764 feet in all,513 cases were female, the mean age was 46.00 years old. Single foot in 342, bilateral feet in 211; the mean followup time was 32.73 months; the preoperative HVA was 32.62°and the 1/2 IMA was 15.60°; the mean followup was 39.47 months. There were no statistically sinificant difference in gender,double and single between the two groups, the baseline is equivalent. The results of meta-analysis using Stata 10 were showed as follows. In the Mitchell osteotomy, the correction of HVA and 1/2 IMA was 16.336(14.60,18.13)and 6.77(5.11,8.42) respectively,the satisfaction rate was 0.899(0.854,0.944),deformity recurrence rate was 0.135(0.047,0.224), the rate of transfer lesion postoperatively was 0.144(0.078,0.210), the first metatarsal shotening was 4.694(3.874,5.513).In the distal Chevron osteotomy, the correction of HVA and 1/2 IMA was 14.32(12.45,16.19) and 6.28(5.18,7.39) respectively, the satisfaction rate was 0.881(0.841,0.921), deformity recurrence rate was 0.076(0.016,0.136), the rate of transfer lesion postoperatively was 0.184(0.094,0.274), the first metatarsal shotening was 2.310(1.495,3.125).The 95% confidence intervals of the indicators of the correction of HVA and 1/2 IMA, the satisfaction rate,the rate of postoperative transfer lesion and the deformity of recurrence rate were overlapped between the two groups; there was no statistical significant difference. The 95% confidence intervals of the first metatarsal shortening wasn't overlapped, the difference in the first metatarsal shortening was statistically significantly, the Mitchell osteotomy makes the first metatarsus shorter than that in the distal Chevron osteotomy.As the internal fixation, Kirschner wire or no internal fixation were usually used in distal Chevron osteotomy group, the screw or absorbable screw used occasionally and no suture fixation were used. Mitchell osteotomy has to be fixed rigidly, the suture fixation and Kirschner wire used mostly, secondly was the screw or absorbable screw. The deformity recurrence rate after screw and Kirschner wire fixation was 0.27 (0.09,0.46),0.15 (0.01,0.28) respectively in Mitchell osteotomy group,it was 0.06 (-0.05,0.16),0.21 (0.11,0.31) respectively in distal Chevron osteotomy group, the 95% CI overlapped each other, there was no statistical significant difference in deformity recurrence between the two group after the Kirschner wire and screw fixation. The deformity recurrence with no internal fixation in distal Chevron osteotomy was 0.01 (-0.01,0.03),it was 0.14 (0.05, 0.23) with suture fixation in Mitchell osteotomy, the 95% CI cann't overlap each other,the difference was statistical significant, the deformity recurrence rate was much higher in Mitchell osteotomy than that in distal Chevron osteotomy. The evidence showed that the distal Chevron osteotomy stabilized much better, no internal fixation or Kirschner wire was enough; the Mitchell osteotomy was unstable, stable internal fixation has to be used. Although the AVN of the first metatarsal head occurred in two groups, the incidence was not high, mainly due to osteotomy, soft tissue release which affect the blood supply of the metatarsal head, the fracture of the metatarsal head can cause the AVN of the metatarsal head. Because the distal osteotomy was small, the screw can disturb the blood supply to the metatarsal head.CONCLUSIONS:For moderate and severe hallux valgus, there was no statistical significant difference in HVA,1/2 IMA, patient satisfaction, the recurrence rate of sagittal deformity and the rate of transfer lesions between the proximal Chevron osteotomy and Crescentic osteotomy. However, the rate of level deformity recurrence, malunion with no internal fixation, the infection and delayed union with Kirschner wire in the proximal Chevron osteotomy group were much lower than those in the Crescentic osteotomy group. The proximal Chevron osteotomy usualy fixed with Kirschner wire with good stability and rapid union.For mild and moderate hallux valgus, there was no statistical significant difference in patient satisfaction and the rate of metatarsal head necrosis between the distal Chevron osteotomy and the proximal closing wedge osteotomy. The proximal closing wedge osteotomy was much better in correction of HVA,1/2 IMA, sesamoid reduction and the postoperative function of metatarsophalangeal joint than the distal Chevron osteotomy. The rate of transfer lesion and first metatarsal shortening were also higher in proximal Crescentic ostetotomy group. However, the Chevron osteotomy procedure performed simply and easily, the end of the V osteotomy has high stability without internal fixation or fixed with Kirschner wire in most cases. The proximal closing wedge osteotomy performed difficultly, the stump of the fracture displaced easily and the stable internal fixation was necessary.Due to the limition of the metatarsal diameter, the distal Chevron osteotomy and Mitchell osteotomy usualy perform to correct mild and moderate hallux valgus, the effect in correction of HVA,1/2 IMA and the patient satisfaction was equivalent. There was also no statistical difference in deformity recurrence and the incidence of transfer lesions. The metatarsal shortening and recurrence rate with no internal fixation were much higher in Mitchell osteotomy group. The distal Chevron osteotomy can be performed easily and the internal fixation was simple, the stability of the osteotomy was better than that of the Mitchell osteotomy.The number, quality, evidence level of the included literatures and the heterogeneity between the included literatures, can affect the accuracy of the results and the reliability of conclusion. However, this study is the reliable evidence on efficacy and safety evaluation of the first metatarsal osteotomy for correction of hallux valgus. It will be helpful to investigate the hallux valgus and help the podiatrists to correct the hallux valgus apprpriately.
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