Minimal Invasive Hallux Valgus Surgery

Review Article
Volume 1 Issue 1 - August 2015
Orthop Rheumatol Open Access J

Copyright All rights are reserved by Thinesh VS
Minimal Invasive Hallux Valgus Surgery:

Myth or Magic. A Systematic Review
Gopinath Mathavan1,2,3, Lynne Gaskell1, Anand Pillai2, Thinesh VS3* and Pravin DC3
1
University of Salford, United Kingdom
University Hospital of South Manchester, United Kingdom
Hospital Port Dickson, Malaysia
Submission: September 03, 2015; Published: September 10, 2015

*Corresponding author: Thinesh VS, Registrar, Orthopedic Department, Hospital Port Dickson, Negeri Sembilan, Malaysia, Lot 474, Jalan Terisu,
Batu 49, Kuala Terla, 39010 Cameron Highlands, Pahang, Malaysia, Tel: 6012-5884656; Email:
Abstract
A Better understanding of foot biomechanics coupled with technological advancement and governance to improve patient outcomes
have facilitated newer innovations in Hallux Valgus (HV) surgery. Minimally Invasive Surgery (MIS) is one of the greatest advances in modern
medicine and an emerging trend in foot and ankle surgeries. The needs to provide a quicker postoperative recovery, reduce operative time
and minimize complications have led to development of various MIS techniques in HV correction over the past decades. This systematic
review aims to establish the efficacy and safety of MIS for HV correction. A systematic search of Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Embase, Medline, Science Direct and Cochrane Central Registry of Controlled Trials from inception of database
till 28th February 2014 was conducted. A total of 27 English language articles published in peer reviewed journals with available clinical and
radiological outcome measures were deemed appropriate and were critically analyzed to determine the efficacy and safety of minimally
invasive HV surgery (MIHVS). These studies included a total of 1485 patients with 1952 surgical procedures using MIHVS. The clinical and
radiological outcomes achieved with MIHVS along the complications reported were comparable with the conventional open techniques.
The MIHVS within this review consisted of case series that differed in terms of procedure, patient selection, techniques, instrumentation,
rehabilitation protocol, use of fluoroscopy and reporting outcome measures. The complication rates were significantly lower in centers
specializing with MIHVS. Higher levels of evidence with large population studies are required to recommend MIHVS which have shorter
operating time, quicker recovery and reduced hospital stay compare to open surgery.
Level of clinical evidence: 4
Keywords: Percutaneous; Minimum Incision; Hallux Valgus; Arthroscopy; Osteotomy; Metatarsal
Abbreviations: AOFAS: American Orthopedic Foot and Ankle Society; CMS: Coleman Methodology Score; DLMO: Distal Linear Metatarsal
Osteotomy; DMAA: Distal Metatarsal Articular Angle; DSTR: Distal Soft Tissue Release; FAOS: Foot and Ankle Outcome Score; HV: Hallux
Valgus; HVA: Hallux Valgus Angle; IMA: Inter-Metatarsal Angle; K-Wire: Kirschner-Wire; MICA: Minimally Invasive Chevron and Akin;
MIDMO: Minimally Invasive Distal Metatarsal Osteotomy; MIHVS: Minimally Invasive HV Surgery; MIS: Minimally Invasive Surgery; MOXFQ:
Manchester-Oxford Foot Questionnaire; MP-IP: Metatarsophalangeal-Interphalangeal; MTPJ: Metatarsophalangeal Joint; NHS: National
Health Service; OA: Osteoarthritis; PDMO: Percutaneous Distal Metatarsal Osteotomy; PDO: Percutaneous Distal Osteotomy; RA: Rheumatoid
Arthritis; ROM: Range of Movement; SERI: Simple Effective Rapid Inexpensive: CONSORT: Consolidated Standards of Reporting Trials;
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Introduction
Foot surgery has greatly developed over the past two
decades. Continuous effort in understanding the anatomy and
biomechanics of foot with technological advancement and
growing social needs has facilitated newer innovations. Digital
deformities are the commonest forefoot presentation to the
foot and ankle clinic [1]. Among the common digital deformities,
Hallux Valgus (HV) has long been an area of interest to the foot
and ankle surgeons. The complex multifactorial nature and
biomechanical dysfunction have resulted in numerous surgical
Orthop Rheumatol Open Access J 1(1): OROAJ.MS.ID.555552 (2015)
correction techniques [2-4].
Minimal invasive HV surgery is one of the greatest advances

in operating field of orthopedic. Advantages like short operating
time, quicker recovery, reduced hospital stay and fewer
complications compare to traditional open surgeries contributed
to diversity. Invention of new techniques and modification of
existing techniques have changed the operating principle of HV
surgery. Despite all of the available minimal invasive techniques
on correction of HV, scientific validation of the safety and efficacy
of these techniques is still inconclusive. Previously published
001
Orthopedics and Rheumatology Open Access Journal
systematic reviews by Maffulli et al. [5], Roukis [1] National

Institute for Clinical Excellence (NICE) guidelines and Trnka [1,57] have well identified the limitations of the available evidence to
determine clear recommendations for MIS in HV correction [1,57]. The renewed interest in the recent past has seen emerging
trends of newer techniques such as the Minimally Invasive
Chevron and Akin (MICA) and Endolog that aim to improve
clinical outcomes [8,9]. However, the topic remains highly
controversial due to limited evidence.
This systematic review aims to establish the efficacy and
safety of minimally invasive surgery for HV correction and to
provide patients and medics with evidence in determining their
choice of surgery. Furthermore, if the procedure is safe and
efficacious, does it offer cost effective management.
Materials and Methods
A systematic search of the following databases CINAHL,

Embase, Medline, Science Direct and Cochrane Central Regristry
of Controlled Trials from inception of database till 28th February
2014 was conducted. Combinations of words used to locate
appropriate studies were Percutaneous, Minimally invasive, HV,
Bunion, SERI (simple effective, rapid, inexpensive), Riverdin,
Riverdin-isham Osteotomy, Endolog system, less invasive,
minimal incision and MICA. Full text English articles were
obtained based on search strategy and keywords. Only articles
found in peer-reviewed journals are considered. Each article
is reviewed and information gathered regarding study details
including name and type of the study, number of patients
involved, year of publication and procedure or technique used.
Selected articles show minimal invasive Hallux Valgus surgery
with clinical or radiological assessment score to determine the
efficacy of the procedure. Safety of the procedure was based
on specific complications analysis reported by individual
publications. Conference abstracts were not included due to
limitation to appraise study methodology.
Quality assessment of the included studies was done

by two independent assessors using the modified Coleman
Methodology Scale (CMS) which are based on the subsections
of the Consolidated Standards of Reporting Trials (CONSORT)
statement [5,10]. The obtained values were based on the average
obtained from both the assessors. The reporting of this systematic
review was also done in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement [11]. The authors used Review manager (Version 5.1)
to evaluate the magnitude of intervention assessed if pooling of
data was possible. However, based on the evidence level of the
available literature and between study heterogeneity, narrative
synthesis of the study findings were undertaken.
Results
Electronic searches of the database resulted in retrieval of 71

relevant articles and a further 33 articles were identified from
the review of the references. Only 27 articles were selected based
on this reviews inclusion and exclusion criteria. These articles
002
included a total of 1485 patients with 1952 various techniques

of MIHVS.
The evidence reviewed included 24 retrospective case series

with level IV evidence, 3 retrospective comparative studies with
level III evidence and 1 prospective comparative study with level
II evidence. Various techniques of MIS were used and summarized
in (Table 1).
CMS assesses the methodology of the study by using 10
criteria with a total score of 0 to 100. Chance, various biases
and confounding factors are absent if the study has a total score
of 100. Average CMS values for all of the 27 articles agreed by
two assessors were calculated and shown in (Table 2). Highest
score was 60 and lowest was 31. Most of the studies had
methodological drawbacks such as poor study sample and short
follow up time with average score of 40.6.13 studies used the
American Orthopedic Foot and Ankle Society (AOFAS) score to
assess the clinical outcome. AOFAS score ranges from 0 to 100
with high scores indicate better outcome clinically. Average
preoperative scores were 48.5 and average postoperative
scores were 87.5. Radiological measurements of hallux valgus
angle (HVA) preoperative and postoperative are 31.7 and 14.2.
Intermetatarsal angle (IMA) showed preoperative average
value of 13.9 and postoperative average value of 7.7. List of
complications associated with minimally invasive hallux valgus
surgery are summarized in (Table 3).
Discussion
The increasing trend towards MIHVS aims to reduce surgical

complications, reduce operative times and provide patients
with quicker recovery time [1,36,37,38]. However, the technical
maturity and advancement achieved are not proportionate to
the quality of available publications. The present systematic
review reinforces the issue that most of the available evidence
is observational in nature which consists of case series. Only one
prospective and 3 retrospective comparative case control studies
were available in this systematic review [4,14,24,29].
The lack of homogeneity among studies reviewed is the major
limiting factor towards generalizing the available evidence. The
broad term of HV surgery consists of a wide variety of procedures
including percutaneous distal metatarsal osteotomy with
percutaneous lateral release and proximal phalanx osteotomy,
percutaneous distal metatarsal osteotomy without soft tissue
procedure, minimally invasive distal metatarsal osteotomy,
modified minimal incision distal metatarsal osteotomy, minimal
incision distal oblique osteotomy using the Endolog system,
percutaneous double metatarsal osteotomy,percutaneous distal
soft tissue release with Akin procedure and the arthroscopic
assisted HV correction [8,9,20,24,26,28,31]. No techniques have
shown superiority to others due to lack of randomized control
trials and insufficient comparative case control studies.
Metatarsal osteotomy plays an important role in determining
the outcome of the procedure. Most authors practicing the
MIHVS correction have always used the conventional distal
How to cite this article: Mathavan G, Gaskell L, Pillai A, Thinesh VS, Pravin DC. Minimal Invasive Hallux Valgus Surgery: Myth or Magic. A Systematic
Review. Orthop Rheumatol Open Access J. 2015;1(1): 555551.

Table 1: Details of the studies included.
No
1
2
Study (year of Publications)
Type of Study (Level of Evidence)
Angthong et al. (2013)[12]
Retrospective Case series (IV)
Bauer et al.(2010)[8]
Procedure/Technique
Number of
Patients
(Feet)
*CMS
30(36)
35
MIDLMO
Reverdin-Isham Osteotomy
82(104)
Chiang et al.(2012)[14]
Retrospective Comparative Study (III)
Modified Bosch Technique
30(32)
53
Gadek & Liszka(2013)[16]
Minimal Incision Mitchell-Kramer
54(54)
33
Giannini et al.(2013)[4]
Prospective Comparative Study(II)
SERI
10
Huang et al.(2011)[18]
12
Lavigne et al.(2011)[20]
Bsch et al.(2000)[13]
Enan, Abo-Hegy & Seif(2010)[15]
Giannini & Ceccarelli(2003)[17]
Giorgio et al.(2013)[9]
11
Kadakia et al.(2007)[21]
15
Lui et al.(2008)[23]
16
17
18
19
Maffulli et al.(2009)[24]
Maffulli et al.(2005)[25]
26
27
24(36)
Minimal Incision-ENDOLOG
Bosch Technique(MIDMO)
37(54)

42
72(85)
47
6(6)
32
13(13)
35
MIDMO
31(47)
32
MIDMO
36(36)
60
Arthroscopic Assisted Percutaneous

Screw Fixation
83(94)
MIDMO
37
82(125)
MIDMO
59
25(33)
Percutaneous Double Metatarsal

Osteotomy
42
20(20)
PDMO
35
36
15(21)
PDMO
33
82(118)
44
Bosch technique(PDMO)
Radwan & Mansor (2012)[29]
PDMO
24(29)
51
Scala & Vendettuoli (2013)[31]
Modified MIDMO
126(146)
45
Tong & Ho( 2012)[33]
Bosch Technique(PDMO)
20(23)
PDMO
Sanna & Ruiu(2005)[30]
25
Bosch Technique (PDMO)
42
22
24
64(98)
SERI
Magnan et al.(2005)[26]
Bosch Technique (PDMO)
Markowski et al.(1991)[27]
Martinez-Nova et al.(2011)[28]
23
Lin et al.(2009)[22]
20
21
Iann et al.(2013)[19]
13
14
51
CMS was used with permission from Maffulli N [24].
38
83(90)
MIDMO
31
79(79)
PDLMO
Valles- Figueroa et al. (2010)[34]

Weinberger et al. (1991)[35]
DSTR-Akin Procedure
Sun et al.(2010)[32]
44(64)
38
79(150)
Bosch Technique(PDMO)
49
31
40(58)
33
204(301)
33
Table 2: Clinical and radiological outcome measure from available studies.

No
Study
(year of Publications)
Angthong et al. (2013)[12]
Bsch et al. (2000)[13]
87.5 (67-93.5)
Chiang et al. (2012)[14]
44.3 14.9
84.5 6.2
Gadek & Liszka (2013)[16]
37.0
Giannini & Ceccarelli(2003)[17]
Giorgio et al. (2013)[9]
10
003
95 6.4
49 (44-52)
Enan, Abo-Hegy & Seif (2010)[15]
70.2 11.3
Bauer et al.(2010)[8]
5
6
AOFAS
HVA
IMA
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
Giannini et al. (2013)[4]

Huang et al. (2011)[18]
NA
NA
NA
32.3 8.2
15 (11-18)
14 (12-15)
35.1 4.2
11.3 7.1
14.9 2.2
33.9
14.2
14.8
36 (14-54)
91.1 6.8
27.7 3.8
90.7
14.2 4.0
30 (25-32)
NA
81.0
10.3 7.5
NA
19 (7-40)
14.6 5.8
NA
7.1 8.0
11(9-13)
13 (6-18)
10(3-18)
11.2 1.8
5.8 2.4
NA
6.6 2.9
9.7
NA
51 10
81.2 15.1
38.5 3.5
21.8 4.1
16.1 3.9
6.8 4.3
NA
NA
26.7(15-43.8)
15.5(3-32.4)
11.9(7.2-15.4)
7.2(2-12.7)
22.1 11.1
88.2 6.2
36.6 8.1
22.7 6.7
16.0 1.9
6.1 2.9

11
Iann et al. (2013)[19]
47.6 13.3
87.3 11.5
13
Kadakia et al. (2007)[21]
34
84
15
Lui et al. (2008)[23]
12
14
Lavigne et al.(2011)[20]
NA
34.7 8.2
14.8 7.8
14.7 4
6.6 3.6
NA
25 (16-33)
12 (1-24)
10.3 (7-14)
6.4 (2-10)
26 4.9
14.2 6.7
11.6 1.6
5.3 2.3
43
16
22
11
Lin et al. (2009)[22]
NA
92.7 6.2
Maffulli et al. (2009)[24]
54 10
85 11
Magnan et al. (2005)[26]
NA
88.2 12.9
31.5 10.2
13.7 6.7
12.3 3
7.3 2.7
20
Martinez-Nova et al. (2011)[28]
68.5 10.6
86.6 8.5
24.1 3.7
11 1.7
11.8 0.5
9.4 0.5
22
Sanna & Ruiu (2005)[30]
NA
NA
32 (14-55)
12.5
15 (10-23)
9.1
84.2 4.3
33.28 9.59
12.31 4.64
11.75 2.89
6.80 1.95
91.1
NA
13.1 5.6
NA
7.5 2.1
16
17
18
19
21
23
24
25
26
27
Maffulli et al. (2005)[25]
Markowski et al.
(1991)[27]
NA
NA
NA
Radwan & Mansor,(2012)[29]
44.6 16.8
Scala & Vendettuoli (2013)[31]
54.6
Sun et al.(2010)[32]
Tong & Ho ( 2012) [33]
Valles- Figueroa et al.(2010)[34]

Weinberger et al.(1991)[35]
NA
93 8
NA
NA
90.2 6.8
85.3
53
91.8 7.9
NA
NA
NA
linear metatarsal osteotomy and frequently associated with

postoperative complications like nonunion, delayed union and
loss of correction. However, Sun et al. operated on 150 feet using
oblique technique for metatarsal osteotomy and there was no
reported nonunion, delayed union, avascular necrosis, infection
and recurrence. Oblique osteotomy which provides a larger
surface area for bony contact and union may have resulted in
lesser incidence of postoperative nonunion [32].
Stabilization techniques in HV surgery differ and need to be

highlighted due to its importance [39,40]. Bosch started with
the use of a single extra articular Kirschner-wire (K-wire) as a
stabilization technique of the osteotomy site [13]. Several other
authors have used a similar pattern of stabilization using a
single k-wire [4,25,26] while others have modified the available
techniques to use two k-wires to provide greater stability [24].
Sun et al. and Martinez et al. [28,32] have described sole use
of postoperative bandaging without hardware placement for
stabilization of metatarsal osteotomy [28,32]. Newer innovations
led to the emergence of Endolog system and percutaneous screws
for stabilization [9,20].
The varying use of intraoperative fluoroscopy is another
technical aspect that differs among the studies reviewed. Several
studies have advocated the use of fluoroscopy as part of MIHVS
[15,19,26,33]. However, some studies have excluded the use of
intraoperative fluoroscopy aimed at reducing intraoperative
radiation exposure [4,24,32]. Several experienced authors
have stressed the importance of radiological control to avoid
complications arising from decreased visualization of the
surgical field and improve the accuracy of positioning the
surgical instrumentation [41]. Although fluoroscopy provides
reassurance towards the correction achieved, but efficacy and
cost effectiveness of this procedure may be affected significantly
due to its influence on increasing operative time, radiation
exposure and manpower requirements.
004
33 7
27 6
32 12
36 (24-61)
27.9 4.4
32.3
31.3 5.3
26 8.3
14 5
17 4
14.1 4.7
19(5-40)
13.1 2.8
4.5
15.7 7.7
7.5 6.3
14 3
15 6
11.5 4
13
12.6 1.9
14.4
16.7 2.8
NA
92
83
7.5 3
8
7.8 1.3
4.8
7.7 3.8
NA
The feasibility of applying a surgical treatment modality to

the general population very much relies on patient selection. This
review highlights an important setback to the current available
evidence in deciding the efficacy and reproducibility of this
procedure. Most studies have correctly excluded patients with
inflammatory arthritis, adjacent joint degeneration, peripheral
vascular disease and systematic conditions such as diabetes
mellitus [4,24,29]. However several studies lacked appropriate
exclusion of patients and have a potential to influence
interpretation of the available evidence. The studies that have
included patients with underlying systemic comorbidities have
failed to relate their association with complications reported [31].
HV in rheumatoid arthritis is a complex interaction of both soft
tissue and osseous elements [42]. When procedure like minimally
invasive distal metatarsal osteotomy (MIDMO) is used to correct
this complex HV deformity purely relying on bony component,
neglecting the soft tissue correction may lead to recurrence of
the deformity. This once again reinforces that patient selection
within the studies reviewed may have potential of skewing the
available evidence due to poorly specified exclusion criteria.
The outcome measures used are of fundamental importance
when evaluating the success of surgical procedure. In HV
surgery the post-surgical assessment is commonly based
on clinical and radiological assessment. AOFAS score is the
commonest clinical outcome that has been utilized in the current
review. Unfortunately, the AOFAS score has not been validated
[43,44,45,46]. It is known to be a surgeon designed outcome
scale, lacks quality of life assessment and patient based outcome
assessment [47].
Soo Hoo et al. [43] evaluated the validity of the AOFAS clinical
rating system in 2003. Pearson correlation coefficient for patients
with forefoot disorders ranged from -0.05 -0.25 when AOFAS score
is compared to Medical Outcome Study Short Form-36(SF-36)
that has been well validated. The relatively low correlation
005
Valles- Figueroa et
al. [34]
Weinberger et al.
[35]
Tong & Ho [33]
Sun et al. [32]
Scala & Vendettuoli

[31]
Sanna & Ruiu [30]
Martinez-Nova et
al. [28]
Radwan & Mansor,
[29]
Markowski et al. [27]
Magnan et al. [26]
Maffulli et al. [25]
Maffulli et al. [24]
Lui et al. [23]
Lin et al. [22]
Lavigne et al. [21]
Kadakia et al. [20]
Iann et al. [19]
Huang et al. [18]
Giorgio et al. [9]
Giannini et al. [4]
Giannini & Ceccarelli

[17]
Gadek & Liszka [16]
Enan, Abo-Hegy &

Seif [15]
Chiang et al. [14]
8.3 (2-39)
22
11
7.5 years
12
11
2)
30.5 (25-46)
12
28.1
16 (8-32)
25 3.2
35.9 10.9
2.5
years(2.1-3.2
years)
30.5(24-74)
24
23.7 weeks
(16-68 weeks)
73.3 38.1
130 days(50207)
18.3(9-38)
18.2(12-36)
84
36 (22-52)
18
21
24
105
24(12-40)
Bsch et al. [13]
Bauer et al. [8]
10
Angthong et al. [12]
Study
Superficial inMean follow

fection/
up (months)
skin irritation
Table 3: Complications seen in minimally invasive hallux valgus surgery.
16
29
9
-
--
24
2(
Deep
NonMalDeep
Bro- DMMA
infec- HalDis- union/
De- Transfer Osteo- union/ M1/P1 MTP1 MTPJ
vein
ken hyper- Recurtion/
lux
CRPS placed Pseudolayed Metatar- necrosis angu- Fracstiff- arthri- Numbnes
thromhard- correc- rence
Dehiss- Varus
K-wire arthrounion
salgia
N(%)
lation ture
ness
tis
bosis
ware
tion
cence
sis
N(%)

reflects poor validity and reliability of AOFAS to assess functional
outcome in forefoot disorders. The current review deals with
majority of case series that have used retrospective collection of
preoperative data that may have potential to overestimate the
improvement achieved using the AOFAS scale [48]. Maffulli et al.
[24] in 2009 was the only study in our review that had utilized
the validated Foot and Ankle Outcome Score (FAOS) [24]. The
FAOS and MOFQ have been validated and are a reliable patient
orientated assessment although their usage remains limited in
our review [49,50]. The dependence on a non- validated scale to
define the efficacy of a procedure reflects the poor reliability of
the available evidence.
The outcome analysis that relates radiological assessment

needs to be reviewed with caution. This review includes HVA
and IMA but excludes DMMA due to its poor inter and intraobserver reliability [51,52,53]. Radiological outcome may not
be a true reflection of the clinical outcome. Angthong et al. [12]
reviewed 36 feet with predominant moderate HV treated with
DLMO at mean follow up of 10 months in 2013 [12]. The mean
AOFAS scores improved from 70.2 11.3 to 95 6.4. At final
follow up, they observed nine feet (25%) with recurrence of
deformity (HVA>15, significant sagittal malunion in twenty-four
feet (66.7%) and significant sesamoid lateralization observed
(p<0.05). These radiological abnormalities did not correlate
with reported clinical outcomes including the postoperative
AOFAS score (p>0.05). It is therefore important to bear in mind
that radiological assessment may not represent the measure of
clinical and functional efficacy.
The review of complications encountered following MIHVS

revealed contrasting reports. While some authors [4,9] have
revealed no major complications with the procedure, others [19]
have described significant complications that include recurrence
of deformity in 18.8%, stiffness of first MTPJ in 8.8%, hallux
varus in 9.4%. Dorsal malunions in 15.6% and infection rates
ranging from 3.5-8.9%. Comparative case control studies using
MIS revealed equal or less complication rates in comparison to
conventional open techniques such as scarf osteotomy, Ludloff
and Chevron osteotomy. Maffulli et al. [24] in 2009 reported
higher rates of intraoperative fractures (8.3%) and hardware
intolerance (13.9%) with conventional scarf osteotomy as
compared to the MIDMO technique [24]. Gianini et al. [4] in 2013
compared the scarf technique with SERI technique in 20 patients
with bilateral HV [4]. Each patient was subjected to a separate
procedure on either foot. They reported higher incidence of
hardware intolerance (10%) in patients with scarf osteotomy.
One possible explanation to this is the low rates experienced
using the minimally invasive technique is that the reporting done
by the centers with extensive experience and expertise dealing
with MIHVS.
Conclusion
MIHVS have several advantages such as shorter operating

time, quicker recovery and return to work or sports, reduced
hospital stay and fewer complications compare to open surgery.
But, the MIHVS studies available at present differ in terms of
procedure, patient selection, techniques, instrumentation and
006
rehabilitation protocol, use of fluoroscopy and outcome measure.

. These factors may have a significant influence on study outcomes
and limit the generalizability of this procedure. Future research
involving MIHVS should include adequately sized randomized
control trials, standardization of treatment protocols, use of
validated tools for measurement of clinical outcome and future
reporting by non-specialized centers to accept overwhelming
evidence and theoretical advantage of MIHVS compare to open
surgeries.
Acknowledgement
A special thanks to Professor Nicola Maffulli and Professor

Hans-Joerg Trnka for their support, guidance and encouragement.
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Minimal Invasive Hallux Valgus Surgery

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Minimal Invasive Hallux Valgus Surgery

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Review Article

Volume 1 Issue 1 - August 2015

Orthop Rheumatol Open Access J

Minimal Invasive Hallux Valgus Surgery:

University of Salford, United Kingdom

University Hospital of South Manchester, United Kingdom

Hospital Port Dickson, Malaysia

Submission: September 03, 2015; Published: September 10, 2015

Keywords: Percutaneous; Minimum Incision; Hallux Valgus; Arthroscopy; Osteotomy; Metatarsal

correction techniques [2-4].

Minimal invasive HV surgery is one of the greatest advances

Orthopedics and Rheumatology Open Access Journal

systematic reviews by Maffulli et al. [5], Roukis [1] National

Materials and Methods

A systematic search of the following databases CINAHL,

Quality assessment of the included studies was done

Electronic searches of the database resulted in retrieval of 71

included a total of 1485 patients with 1952 various techniques

The evidence reviewed included 24 retrospective case series

The increasing trend towards MIHVS aims to reduce surgical

Orthopedics and Rheumatology Open Access Journal

Study (year of Publications)

Type of Study (Level of Evidence)

Angthong et al. (2013)[12]

Retrospective Case series (IV)

Retrospective Case series (IV)

Retrospective Comparative Study (III)

Modified Bosch Technique

Gadek & Liszka(2013)[16]

Retrospective Case series (IV)

Minimal Incision Mitchell-Kramer

Prospective Comparative Study(II)

Retrospective Case series (IV)

Enan, Abo-Hegy & Seif(2010)[15]

Giannini & Ceccarelli(2003)[17]

Retrospective Case series (IV)

Retrospective Case series (IV)

Retrospective Comparative Study (III)

Arthroscopic Assisted Percutaneous

Retrospective Case series (IV)

Retrospective Case series (IV)

Percutaneous Double Metatarsal

Retrospective Case series (IV)

Retrospective Case series (IV)

Radwan & Mansor (2012)[29]

Retrospective Comparative Study (III)

Scala & Vendettuoli (2013)[31]

Retrospective Case series (IV)

Tong & Ho( 2012)[33]

Retrospective Case series (IV)

Retrospective Case series (IV)

Sanna & Ruiu(2005)[30]

Bosch Technique (PDMO)

Retrospective Case series (IV)

Retrospective Case series (IV)

Bosch Technique (PDMO)

Retrospective Case series (IV)

Retrospective Case series (IV)

Retrospective Case series (IV)

Retrospective Case series (IV)

CMS was used with permission from Maffulli N [24].

Retrospective Case series (IV)

Retrospective Case series (IV)

Valles- Figueroa et al. (2010)[34]

Retrospective Case series (IV)

Table 2: Clinical and radiological outcome measure from available studies.

Angthong et al. (2013)[12]