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Outcomes and complications of surgical management for adult iatrogenic hallux varus: A systematic review
, Katherine Esserb, Alexander Thama, Guillaume Roberta, James J. Butlerc, Nathaniel P. Mercera, Bradley A. Lezaka, Garrett Espera, Rakan Joudia, John G. Kennedya,
⁎Corresponding author: John G. Kennedy. john.kennedy@nyulangone.org
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Hallux varus is an uncommon pathology with no consensus regarding outcomes following the various surgical techniques available for its management. The purpose of this systematic review was to evaluate clinical outcomes, radiographic parameters, and complications following surgical management of hallux varus.
During August 2025, the PubMed, Embase, and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical management of hallux varus.
Eleven studies comprising 152 patients (159 feet) were included. Among patients treated with soft-tissue procedures, the weighted mean age was 53.5 ± 5.1 years with a weighted mean follow-up time of 35.3 ± 11.1 months. The weighted mean American Orthopedic Foot and Ankle Society (AOFAS) score improved 25.6 points, with corresponding improvements in hallux valgus angle (HVA) of 17.5°. The complication and failure rates were 18.9% and 11.3%, respectively. In the osteotomy cohort, the weighted mean age was 52.4 ± 6.0 years and the weighted mean follow-up time was 44.3 ± 15.6 months. The weighted mean AOFAS score improved 23.7 points, with improvements in of 24.5°. The complication and failure rates were 1.7% and 3.3%, respectively. In the arthrodesis cohort, the weighted mean age was 63.3 ± 0.7 years and the weighted mean follow-up time was 44.2 ± 30.1 months. The mean AOFAS improved 51 points, with improvements in HVA of 25.2°. The overall complication and failure rates were 10.7% and 3.6%, respectively.
Surgical management of hallux varus is associated with meaningful improvements in clinical outcomes and radiographic alignment across a range of operative techniques. No technique could be definitively identified as superior given the absence of comparative studies and variability in reported outcomes. Future studies should prioritize prospective, comparative designs with standardized outcome measures and long-term follow-up to better establish optimal management strategies for hallux varus.
CRD420261280842 (Prospero identifier).
IV, systematic review
Keywords
Hallux varus
Osteotomy
Range of motion
Radiographic angles
1 Introduction
Hallux varus, a pathological medial deviation of the great toe at the 1st metatarsophalangeal joint (MTPJ), presents a complex challenge in foot and ankle surgery. Hallux varus most commonly arises following hallux valgus correction, with reported prevalences rates ranging from 2% to 15.4%.1,2 Iatrogenic hallux varus is thought to result from a combination of medial soft tissue overtightening, lateral structure disruption, and dynamic imbalances in muscle and tendon forces.3,4 Symptoms such as 1st MTPJ pain, instability, and intolerance to footwear often necessitate intervention.
Operative correction of hallux varus encompasses a variety of techniques tailored to the deformity's etiology, severity, and chronicity. Surgical options include tendon transfers, corrective osteotomies, and 1st MTPJ arthrodesis, with the latter reserved for severe or failed cases.4 Despite the wide range of approaches available to surgeons, there is a lack of high-quality, comparative studies evaluating outcomes following surgical intervention for the management of hallux varus. The lack of robust evidence leaves treatment decisions largely reliant on anecdotal experiences or small case series, underscoring the need for systematic studies to guide surgical management and evaluate outcomes.
To date, no study has systematically evaluated the surgical treatment options for the management of hallux varus. The purpose of this systematic review is to evaluate the available evidence regarding the clinical outcomes, radiographic parameters, and complications following surgical intervention for hallux varus.
2 Methods
2.1 Search strategy
During August 2025, the PubMed, Embase, and Cochrane library databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.5 The following search terms were used: (hallux and varus) or (metatarsophalangeal joint) and (surgical outcomes). Studies were included if they reported outcomes after surgical management of hallux varus, had follow-up times of at least 12 months, were published in a peer-reviewed journal, and were written in English. Studies were excluded if they included patients with congenital hallux varus, were review articles, case reports, cadaveric studies, or contained fewer than 5 patients per cohort. Following retrieval of the data, the titles, abstracts, and full-text articles were screened by 2 independent reviewers of all searched studies following the inclusion and exclusion criteria. In cases of disagreement, the senior author independently reviewed the full text to provide a final determination based on inclusion and exclusion criteria. Data are displayed in Fig. 1.
2.2 Assessment of level of evidence and methodological quality
The Level of Evidence (LOE) was assessed using established criteria in the Journal of Bone and Joint Surgery.6 The methodological quality was assessed by 2 independent reviewers using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) criteria (Fig. 2). Any discrepancies between reviewers were resolved by the senior author, who independently reviewed the full text and applied the ROBINS-I criteria to determine the final evaluation.
2.3 Data extraction and evaluation
Two independent reviewers extracted and assessed the data from each study. Data on patient demographics and the characteristics of any index surgical procedures as well as correction hallux varus procedures were collected. Objective and subjective outcomes including range of motion (ROM), postoperative imaging, complications, failures, reoperations, and patient-reported outcomes were evaluated. Failures were defined as loss of anatomical correction or recurrence of hallux varus. Due to heterogeneity in outcome reporting, not all outcomes could be extracted consistently across included studies. Furthermore, quantitative meta-analysis was not feasible, and therefore results were synthesized descriptively in accordance with PRISMA recommendations for systematic reviews without meta-analysis.
2.4 Statistical analysis
SAS software version 9.3 (SAS Institute, Inc., Cary NC) was used to complete statistical analyses. Descriptive statistics were calculated for all continuous and categorical variables. Continuous variables were reported as weighted mean and estimated standard deviation, whereas categorical variables were reported as frequencies with percentages.
3 Results
3.1 Study characteristics and patient demographics
The initial search generated 2490 studies. Of these, 11 met the inclusion and exclusion criteria and were included in the final analysis (Fig. 1). Study characteristics and patient demographic data are listed in Table 1. Of the 11 included studies, 1 study was LOE II,7 1 study was LOE III,8 and the remaining 9 studies were LOE IV.3,9–16 Five studies had moderate risk of bias,8,9,12,13,15 3 studies had serious risk of bias,10,14,16 and 3 studies had critical risk of bias (Fig. 2).3,7,11
| Soft-Tissue Procedures | ||||||||||
| Author (Year) | LOE | Patients (n) | Feet (n) | Follow-up Time (mo) | Age (years) | M/F | L/R/B | Hallux Varus Etiology | Time from Initial Hallux Valgus Procedure to Hallux Varus Procedure (mo) | Hallux Varus Primary Procedure |
| Johnson et al. (1984) | IV | 14 | 15 | 37.5 ± 7.3 | 53.0 ± 12.0 | 0/14 | 6/7/1 | Postoperative hallux varus – 14; rheumatoid arthritis - 1 | 84.8 | EHLT + arthrodesis of the 1st IPJ |
| Goldman et al. (1993) | IV | 9 | 9 | 20.0 ± 13.8 | - | - | - | Postoperative hallux varus – 9 | - | EHLT + arthrodesis of the 1st IPJ |
| Myerson et al. (1996) | IV | 6 | 6 | 28.0 ± 2.0 | 47.0 ± 11.8 | 1/5 | - | Postoperative hallux varus – 5; Traumatic dislocation of the 1st MTPJ - 1 | 42.0 | EHB tenodesis |
| Leemrijse et al. (2008) | IV | 5 | 7 | 25.2 ± 10.3 | 48.0 ± 6.5 | 0/5 | - | Postoperative hallux varus - 7 | - | LCL reconstruction with reverse transfer of ABH |
| Schwagten et al. (2020) | II | 16 | 16 | 48.0 ± 22.8 | 58.0 ± 14.0 | 0/16 | - | Postoperative hallux varus - 16 | - | LCL reconstruction with reverse transfer of ABH |
| Osteotomies | ||||||||||
| Author (Year) | LOE | Patients (n) | Feet (n) | Follow-up Time (mo) | Age (years) | M/F | L/R/B | Hallux Varus Etiology | Time from Initial Hallux Valgus Procedure to Hallux Varus Procedure (mo) | Hallux Varus Primary Procedure |
| Choi et al. (2011) | IV | 19 | 19 | 25.0 ± 7.0 | 45.2 ± 11.3 | 0/19 | - | Postoperative hallux varus - 19 | 6.0 | Distal chevron osteotomy + medial closing wedge osteotomy |
| Kannegieter et al. (2011) | IV | 5 | 5 | 38.0 ± 16.5 | 55.0 ± 6.3 | 0/5 | 3/2/0 | Postoperative hallux varus - 5 | 48.0 | Reverse scarf osteotomy + opening wedge osteotomy |
| Piat et al. (2021) | III | 34 | 36 | 56.0 ± 36.0 | 56.0 ± 10.0 | 0/34 | - | Postoperative hallux varus - 36 | 132.0 | Reverse scarf osteotomy |
| Arthrodesis | ||||||||||
| Author (Year) | LOE | Patients (n) | Feet (n) | Follow-up Time (mo) | Age (years) | M/F | L/R/B | Hallux Varus Etiology | Time from Initial Hallux Valgus Procedure to Hallux Varus Procedure (mo) | Hallux Varus Primary Procedure |
| Tourné et al. (1995) | IV | 8 | 9 | 64.8 ± 30.0 | 64.0 ± 5.5 | 0/8 | - | Postoperative hallux varus - 9 | - | 1st MTPJ arthrodesis |
| Geaney et al. (2015) | IV | 18 | 18 | 13.3 | - | - | - | Postoperative hallux varus - 18 | - | 1st MTPJ arthrodesis |
| Belfiore et al. (2024) | IV | 18 | 19 | 66.0 ± 30.0 | 63.0 ± 7.8 | 1/17 | 10/8/1 | Postoperative hallux varus - 19 | 87.6 | 1st MTPJ arthrodesis |
There were 50 patients (53 feet) who underwent soft-tissue procedures for the management of hallux varus.3,7,10,11,13 Two studies evaluated patients who underwent extensor hallucis longus transfer (EHLT),10,11 2 studies evaluated patients who underwent LCL reconstruction with reverse transfer of the abductor hallucis longus (ABH),3,7 and 1 study evaluated patients who underwent extensor hallucis brevis (EHB) tenodesis.13 Among the studies that reported sex, 1 (2.4%) patient was male and 40 (97.6%) patients were female.3,7,10,13 Of these patients, the weighted mean age was 53.5 ± 5.1 years (range 47-58 years).3,7,10,13 The weighted mean follow-up time was 35.3 ± 11.1 months (range 20.0-48.0 months).3,7,10,11,13 One study reported laterality, in which 6 cases were performed on the left foot, 7 cases were performed on the right foot and 1 case was performed on bilateral feet.10 In regards to hallux varus etiology, 51 (96.2%) cases were postoperative hallux varus, 1 (1.9%) case was due to rheumatoid arthritis, and 1 (1.9%) case was due to traumatic dislocation of the 1st MTPJ.3,7,10,11,13 The weighted mean time from initial hallux valgus procedure to hallux varus procedure was 72.6 ± 30.3 months (range 42.0-84.8 months).
There were 58 patients (60 feet) who underwent osteotomies for the management of hallux varus.8,9,14 One study evaluated patients who underwent distal chevron osteotomy and medial closing wedge osteotomy,9 1 study evaluated patients who underwent reverse scarf osteotomy and opening wedge osteotomy,14 and 1 study evaluated patients who underwent reverse scarf osteotomy.8 There were 58 (100%) females who underwent the procedures, with a weighted mean age of 52.4 ± 6.0 years (range 45.2-56.0 years).8,9,14 The weighted mean follow-up time was 44.3 ± 15.6 months (range 25.0-56.0 months).8,9,14 One study reported laterality, in which 3 cases were performed on the left foot and 2 cases were performed on the right foot.14 In regards to hallux varus etiology, 60 (100%) cases were postoperative hallux varus.8,9,14 The weighted mean time from initial hallux valgus procedure to hallux varus procedure was 83.5 ± 64.2 months (range 6.0-132.0 months).8,9,14
There were 44 patients (46 feet) who underwent 1st MTPJ arthrodesis for the management of hallux varus.12,15,16 Among the studies that reported sex, there was 1 (3.8%) male and 25 (96.2%) females.12,16 Of these patients, the weighted mean age was 63.3 ± 0.7 years (range 63.0-64.0 years).12,16 The weighted mean follow-up time was 44.2 ± 30.1 months (range 13.3-66.0 months).12,15,16 One study reported laterality, in which 10 cases were performed on the left foot, 8 cases were performed on the right foot, and 1 case was performed on bilateral feet.12,15,16 In regards to hallux varus etiology, 46 (100%) cases were postoperative hallux varus.12,15,16 One study reported the mean time from initial hallux valgus procedure to hallux varus procedure of 87.6 months.16
3.2 Hallux valgus primary procedure surgical characteristics
The surgical characteristics of the primary hallux valgus procedure are summarized in Table 2. For patients who underwent soft-tissue procedures for hallux varus, the most common surgical approach to address hallux valgus was the McBride technique performed on 21 (43.8%) feet.3,7,10,13 Other procedures performed included 9 (18.8%) distal metatarsal osteotomies, 6 (12.5%) proximal chevron osteotomies, 6 (12.5%) akin osteotomies, 3 (6.3%) soft tissue releases, 2 (4.2%) scarf osteotomies, and 1 (2.1%) resection arthroplasty.3,7,10,13 For patients who underwent osteotomies for hallux varus, the most common surgical approach to address hallux valgus was an akin osteotomy performed on 24 (32.4%) feet.8,9,14 Other procedures performed included 19 (25.7%) scarf osteotomies, 13 (17.6%) Peterson techniques, 9 (12.2%) McBride techniques, 6 (8.1%) proximal chevron osteotomies, and 3 (4.1%) metatarsal base wedge osteotomies.8,9,14 One study reported on primary hallux valgus procedures for patients who underwent 1st MTPJ arthrodesis.16 The most common procedure performed was 11 (57.9%) proximal chevron osteotomies, followed by 8 (42.1%) distal metatarsal osteotomies.16
| Soft-Tissue Procedures | |||||||||||
| Author (Year) | Scarf Osteotomy | Metatarsal Base Wedge Osteotomy | McBride | Petersen | Proximal Chevron Osteotomy | Akin Osteotomy | Distal Metatarsal Osteotomy | Soft Tissue Release | Resection Arthroplasty | Keller-Brandes | Silicone Button Prosthesis |
| Johnson et al. (1984) | 0 | 0 | 13 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| Goldman et al. (1993) | - | - | - | - | - | - | - | - | - | - | - |
| Myerson et al. (1996) | 0 | 0 | 3 | 0 | 0 | 0 | 0 | 2 | 0 | 0 | 0 |
| Leemrijse et al. (2008) | 2 | 0 | 5 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Schwagten et al. (2020) | 0 | 0 | 0 | 0 | 6 | 6 | 9 | 1 | 0 | 0 | 0 |
| Osteotomies | |||||||||||
| Author (Year) | Scarf Osteotomy | Metatarsal Base Wedge Osteotomy | McBride | Petersen | Proximal Chevron Osteotomy | Akin Osteotomy | Distal Metatarsal Osteotomy | Soft Tissue Release | Resection Arthroplasty | Keller-Brandes | Silicone Button Prosthesis |
| Choi et al. (2011) | 13 | 0 | 0 | 0 | 6 | 19 | 0 | 0 | 0 | 0 | 0 |
| Kannegieter et al. (2011) | 5 | 0 | 0 | 0 | 0 | 5 | 0 | 0 | 0 | 0 | 0 |
| Piat et al. (2021) | 1 | 3 | 9 | 13 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Arthrodesis | |||||||||||
| Author (Year) | Scarf Osteotomy | Metatarsal Base Wedge Osteotomy | McBride | Petersen | Proximal Chevron Osteotomy | Akin Osteotomy | Distal Metatarsal Osteotomy | Soft Tissue Release | Resection Arthroplasty | Keller-Brandes | Silicone Button Prosthesis |
| Tourné et al. (1995) | - | - | - | - | - | - | - | - | - | - | - |
| Geaney et al. (2015) | - | - | - | - | - | - | - | - | - | - | - |
| Belfiore et al. (2024) | 0 | 0 | 0 | 0 | 11 | 0 | 8 | 0 | 0 | 0 | 0 |
3.3 Clinical outcomes and range of motion
The clinical outcomes and ROM analyzed in this systematic review are summarized in Table 3. The most commonly utilized patient reported outcome measures were the American Orthopedic Foot and Ankle Society (AOFAS) score and the Visual Analogue Scale (VAS). For patients who underwent soft-tissue procedures, the weighted mean AOFAS score was 61.0 pre-operatively (range 61.0-61.0) and 86.6 ± 2.1 post-operatively (range 85.0-88.0), for an overall increase of 25.6 points.3,13 The weighted mean 1st MTPJ dorsiflexion was 60.1° ± 2.1° (range 58.0°-61.0°) pre-operatively and 60.5° ± 11.1° (range 48.0°-61.0°) post-operatively, for an overall change of 0.4°.3,10,13 The weighted mean 1st MTPJ plantarflexion was −14.4° ± 21.2° (range −23.0°-7.0°) pre-operatively and 9.8° ± 4.7° (range 6.0°-15.0°) post-operatively, for an overall change of 24.2°.3,10,13 The weighted mean total 1st MTPJ ROM was 45.7° ± 19.1° (range 38.0°-65.0°) pre-operatively and 70.2° ± 12.5° (range 61.0°-85.0°) post-operatively, for an overall change of 24.5°.3,10,13
| Soft-Tissue Procedures | |||||||||||
| Author (Year) | Patients (Feet) | Preop AOFAS | Postop AOFAS | Preop VAS | Postop VAS | 1st MTPJ DF Preop | 1st MTPJ DF Postop | 1st MTPJ PF Preop | 1st MTPJ PF Postop | Total 1st MTPJ ROM Preop | Total 1st MTPJ ROM Postop |
| Johnson et al. (1984) | 14 (15) | - | - | - | - | 61° | 61° | −23° | 6° | 38° | 67° |
| Goldman et al. (1993) | 9 (9) | - | - | - | - | - | - | - | - | - | - |
| Myerson et al. (1996) | 6 (6) | 61 | 85 | - | - | 58° | 48° | 7° | 13° | 65° | 61° |
| Leemrijse et al. (2008) | 5 (7) | 61 | 88 | - | - | - | 70° | - | 15° | - | 85° |
| Schwagten et al. (2020) | 16 (16) | - | - | - | - | - | - | - | - | - | - |
| Osteotomies | |||||||||||
| Author (Year) | Patients (Feet) | Preop AOFAS | Postop AOFAS | Preop VAS | Postop VAS | 1st MTPJ DF Preop | 1st MTPJ DF Postop | 1st MTPJ PF Preop | 1st MTPJ PF Postop | Total 1st MTPJ ROM Preop | Total 1st MTPJ ROM Postop |
| Choi et al. (2011) | 19 (19) | 77 | 95 | - | - | - | - | - | - | - | - |
| Kannegieter et al. (2011) | 5 (5) | 89 | 74 | - | - | - | 26° | - | 19° | - | 45° |
| Piat et al. (2021) | 34 (36) | 47 | 79 | 6.7 | 2.3 | 34° | 33° | 15° | 15° | 49° | 48° |
| Arthrodesis | |||||||||||
| Author (Year) | Patients (Feet) | Preop AOFAS | Postop AOFAS | Preop VAS | Postop VAS | 1st MTPJ DF Preop | 1st MTPJ DF Postop | 1st MTPJ PF Preop | 1st MTPJ PF Postop | Total 1st MTPJ ROM Preop | Total 1st MTPJ ROM Postop |
| Tourné et al. (1995) | 8 (9) | - | - | - | - | - | - | - | - | - | - |
| Geaney et al. (2015) | 26 (29) | - | - | - | - | - | - | - | - | - | - |
| Belfiore et al. (2024) | 18 (19) | 30 | 81 | 7.3 | 1.5 | - | - | - | - | - | - |
For patients who underwent osteotomies, the weighted mean AOFAS score was 60.0 ± 21.6 (range 47.0-89.0) pre-operatively and 83.7 ± 11.0 (range 74.0-95.0) post-operatively, for an overall increase of 23.7 points.8,9,14 One study reported VAS of 6.7 pre-operatively and 2.3 post-operatively, for an overall improvement of 4.4 points.8 The mean 1st MTPJ dorsiflexion was 34° pre-operatively and the weighted mean 1st MTPJ dorsiflexion was 32.1° ± 4.9° (range 26.0°-33.0°) post-operatively.8,14 The mean 1st MTPJ plantarflexion was 15° pre-operatively and the weighted mean 1st MTPJ plantarflexion was 15.5° ± 2.8° (range 15.0°-19.0°) post-operatively.8,14 The mean total 1st MTPJ ROM was 49° pre-operatively and the weighted mean total 1st MTPJ ROM was 47.6° ± 2.1° (range 45.0°-48.0°) post-operatively.8,14
For patients who underwent 1st MTPJ arthrodesis, one study reported an AOFAS score of 30 pre-operatively and 81 post-operatively, for an overall increase of 51 points.16 The same study reported VAS of 7.3 pre-operatively and 1.5 post-operatively, for an overall improvement of 5.8 points.16
3.4 Radiographic parameters
Radiographic parameters included in this systematic review are summarized in Table 4. For patients who underwent soft-tissue procedures, the weighted mean hallux valgus angle (HVA) was −14.3° ± 14.2° (range −26°-6.6°) pre-operatively and 3.2° ± 5.5° (range 0°-11.7°) post-operatively, for an overall change of 17.5°.7,10,11,13 The weighted mean intermetatarsal angle (IMA) was 4.5° ± 2.0° (range 3.0°-6.9°) pre-operatively and 4.8° ± 4.6° (range 0°-10.8°) post-operatively, for an overall change of 0.3°.3,7,10,11 The weighted mean tibial sesamoid bone position was 3.0 ± 2.5 mm (range 1.4-5.0 mm) pre-operatively and 1.9 ± 0.4 mm (range 1.6-2.2 mm) post-operatively, for an overall change of 1.1 mm.3,11
| Soft-Tissue Procedures | |||||||||
| Author (Year) | Patients (Feet) | Preop HVA | Postop HVA | Preop IMA | Postop IMA | Preop DMAA | Postop DMAA | Preop TSBP | Postop TSBP |
| Johnson et al. (1984) | 14 (15) | −18° | 0° | 3° | 0° | - | - | - | - |
| Goldman et al. (1993) | 9 (9) | 6.6° | 11.7° | 6.9° | 7.8° | - | - | 1.4 mm | 2.2 mm |
| Myerson et al. (1996) | 6 (6) | −26° | 0° | - | - | - | - | - | - |
| Leemrijse et al. (2008) | 5 (7) | - | - | 6.6° | 10.8° | - | - | 5.0 mm | 1.6 mm |
| Schwagten et al. (2020) | 16 (16) | −18.3° | 2.7° | 3.6° | 4.9° | - | - | - | - |
| Osteotomies | |||||||||
| Author (Year) | Patients (Feet) | Preop HVA | Postop HVA | Preop IMA | Postop IMA | Preop DMAA | Postop DMAA | Preop TSBP | Postop TSBP |
| Choi et al. (2011) | 19 (19) | −11.6° | 4.7° | −0.3° | 3.3° | 9.5° | 2.3° | - | - |
| Kannegieter et al. (2011) | 5 (5) | −10° | 10.7° | 5.0° | 8.9° | - | - | - | - |
| Piat et al. (2021) | 34 (36) | −20.8° | 8.5° | 2.9° | 8.1° | - | - | - | - |
| Arthrodesis | |||||||||
| Author (Year) | Patients (Feet) | Preop HVA | Postop HVA | Preop IMA | Postop IMA | Preop DMAA | Postop DMAA | Preop TSBP | Postop TSBP |
| Tourné et al. (1995) | 8 (9) | −16° | 15° | - | - | - | - | - | - |
| Geaney et al. (2015) | 26 (29) | - | - | - | - | - | - | - | - |
| Belfiore et al. (2024) | 18 (19) | −22.7° | 13.1° | 4.4° | 8.9° | - | - | - | - |
For patients who underwent osteotomies, the weighted mean HVA was −17.0° ± 5.8° (range −20.8° to −10.0°) pre-operatively and 7.5° ± 3.0° (range 4.7°-10.7°) post-operatively, for an overall change of 24.5°.8,9,14 The weighted mean IMA was 2.1° ± 2.7° (range −0.3°-5.0°) pre-operatively and 6.6° ± 3.0° (range 3.3°-8.9°) post-operatively, for an overall change of 4.5°.8,9,14 One study reported the distal metatarsal articular angle of 9.5° pre-operatively and 2.3° post-operatively, for an overall change of 7.2°.9
For patients who underwent 1st MTPJ arthrodesis, the weighted mean HVA was −20.5 ± 4.7 (range −22.7 to −16.0) pre-operatively and 13.7 ± 1.3 (range 13.1-15.0) post-operatively, for an overall change of 25.2°.12,16 Of note, Geaney et al. reported a change in HVA of 27.9° for patients with iatrogenic hallux varus.15 One study reported the IMA of 4.4° pre-operatively and 8.9° post-operatively, for an overall change of 4.5°.16 Of note, Geaney et al. reported a change in IMA of 3.7° for patients with iatrogenic hallux varus.15
3.5 Complications, failures and reoperations
Data regarding complications, failures and reoperations are outlined in Table 5. In total, 10 (18.9%) complications were observed in patients who underwent soft-tissue procedures. The most common complications were 5 (9.4%) cases of 1st MTPJ stiffness, followed by 2 (3.8%) cases of neurologic complications, 1 (1.9%) case of painful hardware, 1 (1.9%) case of tibial sesamoiditis, and 1 (1.9%) avulsion fracture.3,7,10,11,13 There were a total of 6 (11.3%) failures in this cohort, however no patients underwent reoperations.3,7,10,11,13 For patients who underwent osteotomies, there was 1 (1.7%) complication that was an infection resolved with antibiotics.8,9,14 There were a total of 2 (3.3%) failures in this cohort, with 1 (1.7%) patient requiring a reoperation of a repeat distal metatarsal osteotomy.8,9,14 For patients who underwent 1st MTPJ arthrodesis, there were 3 (10.7%) complications consisting of 2 (7.1%) wound complications and 1 (3.6%) case of painful hardware.12,16 There was 1 (3.6%) failure that required a reoperation of percutaneous drilling and secondary stabilization with K-wires.16
| Soft-Tissue Procedures | ||||||||
| Author (Year) | Patients (Feet) | Wound Complication | Infection | Neurologic Complication | Painful Hardware | Other | Failure | Reoperations |
| Johnson et al. (1984) | 14 (15) | 0 | 0 | 1 | 1 | 0 | 1 | 0 |
| Goldman et al. (1993) | 9 (9) | 0 | 0 | 1 | 0 | 2 | 1 | 0 |
| Myerson et al. (1996) | 6 (6) | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Leemrijse et al. (2008) | 5 (7) | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Schwagten et al. (2020) | 16 (16) | 0 | 0 | 0 | 0 | 5 | 4 | 0 |
| Osteotomies | ||||||||
| Author (Year) | Patients (Feet) | Wound Complication | Infection | Neurologic Complication | Painful Hardware | Other | Failure | Reoperations |
| Choi et al. (2011) | 19 (19) | 0 | 0 | 0 | 0 | 0 | 2 | 1 |
| Kannegieter et al. (2011) | 5 (5) | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| Piat et al. (2021) | 34 (36) | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Arthrodesis | ||||||||
| Author (Year) | Patients (Feet) | Wound Complication | Infection | Neurologic Complication | Painful Hardware | Other | Failure | Reoperations |
| Tourné et al. (1995) | 8 (9) | 0 | 0 | 0 | 1 | 0 | 0 | 0 |
| Geaney et al. (2015) | 18 (18) | - | - | - | - | - | - | - |
| Belfiore et al. (2024) | 18 (19) | 2 | 0 | 0 | 0 | 0 | 1 | 1 |
4 Discussion
The most important finding of this systematic review is that surgical management for hallux varus is associated with meaningful improvements in clinical outcomes and deformity correction across multiple operative techniques. In addition to enhanced patient-reported outcomes and radiographic parameters, soft-tissue procedures, osteotomies, and 1st MTPJ arthrodesis are associated with low complication and failure rates for the treatment of hallux varus.
Hallux varus most commonly develops as a complication following surgical correction of hallux valgus. Multiple mechanisms contribute to its development, including overcorrection, medial soft tissue tightening, or lateral soft tissue attenuation. Clinically, hallux varus deformities may present as either flexible or rigid, and are often associated with excessive 1st MTPJ dorsiflexion, hallux supination, or adduction of the lesser toes. In chronic cases, additional mechanical challenges exist, such as 1st MTPJ dorsal capsule contracture and medial displacement of the EHLT, which can further hinder functional restoration. In contrast to hallux valgus, where standardized techniques and evidence-based guidelines have evolved, hallux varus correction is often more individualized due to the complex underlying pathophysiology.
Tendon transfers are commonly utilized in the treatment of hallux varus to address the dynamic soft-tissue imbalances contributing to the deformity, described in 5 studies included in this systematic review.3,7,10,11,13 EHLT techniques involve distal release of the tendon, redirection beneath the intermetatarsal ligament, and fixation to the lateral proximal phalanx.10,11 For EHB tenodesis, the redirected ligament is instead secured to the 1st metatarsal using suture anchors or a bone tunnel.13 A third soft-tissue procedure included harvesting of the ABH, passing it through bone tunnels in the proximal phalanx and 1st metatarsal, and is anchored while maintaining its bony insertion.3,7 Patients who underwent soft-tissue procedures experienced clinically meaningful improvements, including a mean increase in AOFAS score of 25.6 points, a gain in total ROM of 24.5°, and a reduction in HVA of 17.5°. By rebalancing lateral soft tissue restrains and correcting dynamic deformities, soft-tissue procedures may facilitate improvements in both alignment and ROM, translating into improved functional outcomes for patients. Despite these favorable results, an 11.3% failure rate was observed, likely reflecting cases in which residual osseous malalignment or joint incongruity limited the durability of tendon transfer or tenodesis correction. In addition, the overall complication rate was 18.9%, with 1st MTPJ stiffness comprising of the most common complication, which may also relate to residual malalignment or articular incongruity contributing to postoperative stiffness. A previous systematic review by Plovanich et al. evaluated soft-tissue release and tendon transfer procedures for the treatment of hallux varus among 68 feet.17 The authors reported favorable clinical outcomes with a complication rate of 16.2% and a recurrence rate of 4.4%, findings that are consistent with the complication and failure rates observed in the present systematic review. Overall, soft-tissue procedures appear effective in select cases for hallux varus management, though residual structural deformity may limit the durability of correction and contribute to complications.
Osteotomies of the 1st metatarsal or proximal phalanx have also been described to address hallux varus, as evidenced by 3 studies included in this systematic review.8,9,14 Sliding osteotomies utilize a Z-shaped cut that allows controlled translation and rotation of the bony segments to restore alignment while preserving MTPJ motion.8,9,14 Opening wedge osteotomies correct deformity by creating a controlled gap to lengthen or realign the metatarsal, whereas closing wedge osteotomies achieve correction through resection of a bone wedge to shorten and reorient the ray.9,14 Across the included studies, osteotomies were associated with meaningful improvements in both function and alignment, with a mean improvement in AOFAS score of 23.7 points and a reduction in HVA of 24.5°. By directing addressing structural malalignment of the first ray and restoring joint congruency, osseous realignment may allow for reliable correction of the deformity and therefore improvement clinical outcomes in patients. Notably, complication (1.7%), failure (3.3%), and reoperation (1.7%) rates were low, which may reflect the ability of the osteotomy techniques to restore alignment without additional reliance on soft-tissue reconstruction. Overall, osteotomies may offer durable correction with favorable safety profiles in appropriately selected patients with predominantly structural deformities.
Arthrodesis of the 1st MTPJ is an additional surgical technique to correct anatomical alignment in hallux varus, reported in 3 of the included studies in this systematic review.12,15,16 Across these studies, patients demonstrated substantial improvements in AOFAS and VAS scores, as well as significant correction of deformity with a mean improvement in HVA of 25.2°. These favorable outcomes likely reflect the ability of the fusion to provide definitive correction of alignment and elimination of painful joint motion, particularly in cases of rigid deformity or advanced degenerative changes. Despite these improvements, arthrodesis was associated with complication, failure, and reoperation rates of 10.7%, 3.6%, and 3.6%, respectively. Arthrodesis permanently sacrifices joint mobility and can increase stress on adjacent joints, which may create biomechanical problems in patients.4,18 Arthrodesis of the 1st MTPJ may be a dependable surgical option for correction and pain relief in advanced cases of hallux varus.
A key strength of this systematic review is its comprehensive synthesis of the available literature for surgical management of adult iatrogenic hallux varus, an uncommon and clinically challenging condition for which guidance is limited. By organizing outcomes by operative technique, this review provides a consolidated reference that reports the clinical, radiographic, and complication profiles across soft-tissue procedures, osteotomies, and arthrodesis for hallux varus treatment. Additionally, this study highlights important gaps in the existing evidence database, including the absence of comparative studies and standardized outcome reporting, therefore providing the foundation for areas of future research.
4.1 Limitations
This systematic review has several limitations. This systematic review is limited by the heterogeneity of included studies, which varied in surgical techniques, patient populations, and outcome measures. Most studies were retrospective case series with Level IV evidence, introducing potential selection and reporting biases. Small sample sizes and the lack of randomized controlled trials further limit the generalizability and robustness of our findings. Additionally, the absence of direct comparative studies precludes meaningful comparison between techniques and prevents determination of the superiority of one of the included surgical approaches. Finally, variability in reporting long-term outcomes and changes in surgical techniques over the years further confound the interpretation of results.
5 Conclusion
Surgical management of hallux varus is associated with meaningful improvements in clinical outcomes and radiographic alignment across a range of operative techniques. Soft-tissue procedures, osteotomies, and 1st MTPJ arthrodesis each demonstrated postoperative improvement, though no technique could be definitively identified as superior given the absence of comparative studies and variability in reported outcomes. The conclusions are further limited by the predominantly low level, non-comparative evidence available in the current literature. Future studies should prioritize prospective, comparative designs with standardized outcome measures and long-term follow-up to better establish optimal management strategies for hallux varus.
Patient consent
There was no guardian or patient consent for this study as it was a systematic review and did not use primary patient data.
Ethics approval statement
No ethical approval was required for this study.
CRediT authorship contribution statement
Jared Rubin: Writing – review & editing, Writing – original draft, Investigation, Formal analysis, Data curation, Conceptualization. Katherine Esser: Writing – review & editing, Supervision, Project administration, Methodology, Data curation, Conceptualization. Alexander Tham: Writing – original draft, Writing – review & editing, Validation, Supervision, Investigation, Conceptualization. Guillaume Robert: Writing – review & editing, Data curation, Validation. James J. Butler: Writing – original draft, Writing – review & editing, Data curation. Nathaniel P. Mercer: Writing – original draft, Writing – review & editing, Data curation. Bradley A. Lezak: Writing – review & editing, Validation, Supervision, Project administration, Methodology, Investigation. Garrett Esper: Writing – review & editing, Validation, Supervision, Project administration, Formal Analysis. Rakan Joudi: Writing – review & editing, Validation, Supervision, Project administration, Formal Analysis. John G. Kennedy: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Project administration, Methodology, Investigation.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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