Bunions and Foot Surgery

Abstract & Commentary

Synopsis: Mild-to-moderate bunions (hallux valgus) causing foot pain and deformity had the best outcomes when surgically repaired in this randomized, controlled trial. Foot orthoses provided only short-term relief.

Source: Torkki M, et al. JAMA. 2001;285:2474-2480.

Using a catchment area of 500,000 population in Finland, 4 hospitals in a health district pooled all referrals for mild and moderate hallux valgus over a 1-year period with a 1-year follow-up, resulting in 211 potential candidates for study. Patients agreed to be randomized to 1 of 3 groups for either "watchful waiting" (no treatment), customized foot orthoses, or surgical repair with distal chevron osteotomy. Patients with previous surgery or significant comorbidities and rheumatoid arthritis were excluded. They also excluded persons older than 60 years of age.

Outcomes were assessed using patient self-assessements of pain intensity, global improvement, footwear problems, and treatment satisfaction both before the intervention and at 6- and 12-month follow-ups. The study was discontinued after 12 months because Torkki and colleagues did not feel it was ethical to continue to withhold treatment any longer from the control group.

Pain intensity was clearly worse in the orthotic group at 6-month follow-up, and by 12 months the surgically treated group continued to improve while the orthotic group returned to the same level of pain as the control group. Footwear problems were also much improved with surgery, with 35% having no problems and 62% having moderate problems compared to 86% of both the control and orthotic-treated groups with moderate problems. Overall satisfaction with treatment after 12 months was 83% in the surgical group vs. 46% in the orthotic group and 24% of the untreated group (of which 34% felt they were worse compared to only 6% of the surgical group).

COMMENT BY MARY ELINA FERRIS, MD

This is a useful and rigorously designed study to clarify the outcomes of different treatments for a widespread problem. Bunions are estimated to plague at least 33% of adults "who wear shoes," and the problem increases with advancing age. Even though surgical repair of the affected metatarsal joint is widely used for treatment, no previous randomized trial had evaluated its efficacy. Unfortunately this study excluded older persons, so further research should be done for these results to be extended to our growing geriatric population.

The results showed a clear advantage for surgical treatment in the long-term relief of pain and improved footwear problems, although the nonsurgical groups also had a subset who were satisfied with their treatments. As with all surgery, 100% success is not guaranteed, and 6% of the surgical group felt they were actually worse after 12 months compared to 11% of the orthotic group and 34% of the control group.

A possible explanation for the mixed results with foot othoses is that their main benefit is to improve foot pain rather than to correct the bunion deformity. Mild-to- moderate levels of hallux valgus may not cause widespread pain until the problem worsens, and the orthoses cannot correct problems with footwear.

Using the conclusions of this study, clinicians can now offer middle-aged adults with mild-to-moderate hallux valgus a more evidence-based choice of treatments for foot pain and footwear problems. Surgical repair has a clear advantage for long-term relief, but moderate improvement may still be predicted with specially designed orthoses.