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Hallux valgus / bunion

Percutaneous or open — and at which deformity does that answer change?

Starting point, not a verdict

Drafted from the published literature and machine-assisted, then checked so that every citation resolves to a real indexed paper. It has not yet been reviewed by a clinician. Treat it as a starting point for the discussion, not as guidance.

Indication

Hallux valgus affects 23–35 % of adults and surgery is indicated when conservative management fails to control pain and functional limitation. The decision point dividing surgeons is whether to correct the deformity at the metatarsal head (distal osteotomies), the metatarsal shaft (scarf), or the first tarsometatarsal joint (Lapidus), and whether to do so through open or percutaneous approaches [1] [2].

The techniques

  • Minimally invasive / percutaneous (3rd–4th generation): Percutaneous burr-based osteotomies (e.g., chevron, Reverdin‑Isham, Bosch) with or without Akin phalangeal osteotomy, fixed percutaneously with screws under fluoroscopic guidance [3] [4].
  • Open chevron + Akin: Open V‑shaped distal metatarsal osteotomy with lateral translation, often combined with medial eminence resection and Akin phalangeal osteotomy, fixed with screws or staples [5] [6].
  • Scarf osteotomy: Open longitudinal Z‑shaped diaphyseal osteotomy of the first metatarsal allowing multiplanar correction and stable internal fixation [5] [7].
  • Lapidus / first TMT fusion: Arthrodesis of the first tarsometatarsal joint with plate/screw fixation, addressing metatarsus primus varus and rotational deformity at the apex [8].

What the evidence says

The 2024 Cochrane review (25 RCTs, 1597 participants) found insufficient high‑certainty evidence to declare any single procedure superior for pain, function, or quality of life [1]. A 2021 overview of 32 RCTs (2184 patients) reported that only 12.5 % showed statistically significant differences between interventions; scarf and chevron were the most studied and yielded similar clinical outcomes [2]. A meta‑analysis of four studies (384 feet) found no significant difference between chevron and scarf for HVA, IMA, AOFAS scores, or complication rates, noting chevron is less technically demanding [5]. Another meta‑analysis (10 RCTs, 985 patients) reported distal chevron achieved 2.18° greater IMA correction than scarf (p=0.004), while proximal chevron corrected IMA 1.08° more than distal chevron (p=0.007) [9]. For MIS versus open, a 2020 meta‑analysis (11 studies, 2201 feet) found MIS had higher rates of excellent‑good radiographic results (OR 6.28, p<0.01) but similar complication rates (OR 0.67, p=0.45), recovery time, and satisfaction [10]. A 2026 meta‑analysis of six studies (352 feet) comparing MIS chevron to open chevron found no significant differences in AOFAS, VAS, HVA, or DMAA at any follow‑up; early VAS favored MIS [11]. A 2025 RCT (40 feet) comparing percutaneous transverse osteotomy + Akin to open chevron‑Akin found no differences in surgical time, PROMs, AOFAS, or radiology at 1 year; only 6‑week wound scores favored MIS [6]. MIS complication profiles include joint stiffness (up to 18.5 %), recurrence (15.2 %), shortening (15.2 %), and nerve injury; a 2024 review of third‑generation MIS chevron (766 feet) reported a 21.3 % total complication rate with reoperation, infection, recurrence, and nerve injury most common [12] [13]. The Lapidus procedure shows significant improvements in IMA, HVA, and sesamoid position, but only 78 % of studies report HVA and 33 % report sesamoid position [8]. Learning curve for MIS averages 35.5 cases (range 27–40) to plateau, with increased OR time and fluoroscopy use during learning but no increase in complications [14].

What members see

How does your 1‑year recurrence rate for MIS chevron compare to the 15.2 % reported in systematic reviews [12]? Do you observe the 21 % overall complication rate for third‑generation MIS chevron in your practice, and which complications drive reoperation [13]? At what case number did your MIS fluoroscopy time and OR time plateau, and did you see the 35‑case learning curve described in the literature [14]?

Cost and access

MIS requires dedicated fluoroscopy, specialized burrs, and percutaneous instrumentation, increasing per‑case implant and equipment cost. Open procedures use standard instrumentation but may require longer theatre time for soft‑tissue dissection and closure. Lapidus procedures typically involve plate fixation systems and may require longer non‑weight‑bearing periods, affecting indirect costs. Second procedures for hardware removal occur across all techniques but rates are not consistently reported in the available evidence [4] [15] [8].

Open questions

  • Does MIS chevron maintain radiographic correction beyond 2 years compared to open chevron or scarf?
  • What is the true reoperation rate for Lapidus versus distal osteotomies in moderate‑to‑severe deformities (IMA >15°)?
  • How does the MIS learning curve affect outcomes in low‑volume surgeons (<20 cases/year)?
  • Are there patient subgroups (e.g., hypermobility, severe DMAA, revision) where one technique consistently outperforms others?
  • What is the cost‑effectiveness ratio of MIS versus open when accounting for fluoroscopy time, specialized equipment, and potential reoperations?

References

15 of 23 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/hallux-valgus.json.

  1. 1Surgical interventions for treating hallux valgus and bunions. Cochrane Database Syst Rev 2024 · PMID 39051477 Meta-Analysis, Systematic Review
  2. 2Overview of randomised controlled trials in hallux valgus surgery (2,184 patients). Foot Ankle Surg 2021 · PMID 32518028 Systematic Review
  3. 3Evolution of Minimally Invasive Surgery in Hallux Valgus. Foot Ankle Clin 2020 · PMID 31997749 Systematic Review
  4. 4Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques. Int Orthop 2019 · PMID 30218181 Systematic Review
  5. 5Chevron osteotomy versus scarf osteotomy for hallux valgus correction: A meta-analysis. Foot Ankle Surg 2019 · PMID 30391038 Meta-Analysis, Systematic Review
  6. 6Minimally Invasive vs Open Distal Metatarsal Osteotomy for Hallux Valgus: A Randomized Controlled Trial of Short-term Wound Healing and 1-Year Outcomes. Foot Ankle Int 2025 · PMID 40931943 Randomized Controlled Trial
  7. 7Hallux Valgus Correction With Rotational Scarf Combined With Adductor Hallucis Tendon Transposition. J Foot Ankle Surg 2019 · PMID 30448186 Randomized Controlled Trial
  8. 8Modified Lapidus Procedure and Hallux Valgus: A Systematic Review and Update on Triplanar Correction. Orthop Clin North Am 2022 · PMID 36208892 Systematic Review
  9. 9Distal chevron osteotomy versus different operative procedures for hallux valgus correction: a meta-analysis. J Orthop Surg Res 2022 · PMID 35135564 Meta-Analysis
  10. 10Comparison of Minimally Invasive and Traditionally Open Surgeries in Correction of Hallux Valgus: A Meta-Analysis. J Foot Ankle Surg 2020 · PMID 32600562 Meta-Analysis, Review
  11. 11Minimally invasive chevron osteotomy provides comparable outcomes to open surgery for hallux valgus: A systematic review and meta-analysis. Foot Ankle Surg 2026 · PMID 41330787 Systematic Review, Meta-Analysis
  12. 12Complications on Percutaneous Hallux Valgus Surgery: A Systematic Review. J Foot Ankle Surg 2021 · PMID 33579548 Systematic Review
  13. 13Complication Rates of Minimally Invasive Chevron Osteotomy for Correction of Hallux Abductovalgus: A Systematic Review. J Am Podiatr Med Assoc 2024 · PMID 39546363 Systematic Review
  14. 14Learning curve associated with minimally invasive surgery for hallux valgus: A systematic review. Foot Ankle Surg 2023 · PMID 37524619 Systematic Review
  15. 15Complications of Minimally Invasive Surgery for Hallux Valgus and How to Deal with Them. Foot Ankle Clin 2020 · PMID 32736737 Systematic Review

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