HALLUX VARUS

(“Sandal Gap”)

Submitted To: Prof. Freddie M. Omar RN, MAN

Submitted By: Zamiera T. Pamate

BSN III-C
 Hallux Varus

The term Hallux Varus describes a clinical condition of the foot characterized by medial deviation of the
great toe relative to the first metatarsal ray, a deformity of the great toe joint where the hallux is deviated medially
(towards the midline of the body) away from the first metatarsal bone. It is also known as the “sandal gap”. The hallux
usually moves in the transverse plane. Hallux Varus has variable degrees of severity, symptomatology, and etiology.
Causes range from the most common iatrogenic postoperative variety to idiopathic, rheumatic, and posttraumatic (tear
of the hallux lateral collateral ligament) forms.

Fossilized evidence of modern humans in Africa from 3 million years ago reveals footprints that show hallux
varus. Other imprints uncovered in northern Japan are dated to 2300 BC and also show varus alignment of the great
toe. The later impact of shoe wear had a definite influence on alignment of the hallux. Flexible hallux varus is a
common finding in newborns and is a reflection of intrauterine positioning. It usually corrects to valgus in early
childhood when walking begins. On the other hand, the normal 0-20º deviation that is seen in hallux valgus occurs
after walking has begun in the child and after shoes have been introduced to the child's feet.
 Etiology

Acquired hallux varus is an uncommon complication following the correction of hallux valgus. The deformity
can be noticed immediately postoperatively, or several months after the initial surgery. In a review of 1100 McBride
bunionectomy, Janis and Donick reported the rate of acquired hallux varus to be 1.6%. Peinstein and Brown reported
an occurrence rate of L.10/o in a review of B7B hallux valgus procedures of different varieties. The majority of these
procedures were a McBride bunionectomy with a fibular sesamoidectomy. Several factors can play a role in creating
an acquired hallux varus, including staking of the metatarsal head, excessive tightening of the medial capsule,
excessive plantar lateral release, adductor tendon transfer, fibular sesamoidectomy, overcorrection of the
intermetatarsal angle, overcorrection of the PASA, and aggressive postoperative bandaging. The lack of a sagittal
groove or the presence of a round metatarsal head are also important contributing factors. It is often a combination of
these factors that creates the deformity.

Congenital hallux varus is less common than the acquired type and is best addressed in infancy. If the
deformity is not addressed or is uncorrected, the soft tissue imbalance will create osseous changes that will maintain
the deformity into adulthood. Historically, congenital hallux varus has been classified into three types:

I. The primary type involves a tight band of tissue which extends from the medial aspect of the base
of the first metatarsal and inserts into the base of the proximal phalanx, pulling the toe to the midline.
The tight band of tissue described in the early literature is probably the abductor halluces.
II. The secondary type is associated with forefoot deformities (metatarsus adductus). It is related to
great toe polydactyly, a delta phalanx longitudinal epiphyseal bracket syndrome, and metatarsus
adductus.
III. The tertiary type is associated with severe skeletal abnormalities such as diastrophic dwarfism.
Congenital hallux varus is not considered to be hereditary. The greatest deforming factor in
congenital hallux varus is the pull of the abductor halluces into the base of the proximal phalanx.
This is more critical and has more of a tendency to result in the development of hallux varus when
the pull is primarily medial. The insertion to the abductor halluces occurs at the medial aspect of the
base of the proximal phalanx 20o/o of the time. It inserts into the plantar medial aspect of the base
B0% of the time.

- Risk Factors: longitudinal epiphyseal bracket of the first metatarsal or proximal phalanx
- Associated Condition: Often associated with Polydactyly (meaning “many” and “finger”)

Rarely, hallux varus is congenital. Flexible hallux varus may be found in newborns and reflects their
intrauterine positioning. It corrects to valgus in early childhood when walking begins. More frequently this deformity
develops after a surgical procedure for hallux valgus because of overcorrection, excessive lateral release, over-
resection of medial eminence, over-plication of the medial capsule, zero-degree or negative intermetatarsal angle, or
immobilization of the toe in excessive varus after surgery. Other causes include trauma and certain systemic
inflammatory diseases such as psoriasis and rheumatoid arthritis.

 Medial insertion of the abductor tendon causes primary dynamic infantile hallux varus.
 Acquired adult hallux varus is an inflammatory arthropathy which includes psoriatic and rheumatoid arthritis.
The mechanism of arthropathies combines destruction of the articular surfaces by distention of the joint
capsule with subsequent laxity of the collateral ligaments, intrinsic muscular contracture, and panus.
 Traumatic hallux varus occurs with sports injuries secondary to rupture of the lateral collateral ligament and
conjoined tendon.
 Spontaneous idiopathic hallux varus is noted incidentally, and the cause is not usually demonstrable.

Figure 2: Idiopathic Hallux Varus of Figure 1: Anteroposterior radiograph of foot Figure 3: Lateral radiograph of foot shows
the Left foot depicts idiopathic hallux varus. idiopathic hallux varus.

The initial deforming force is likely over-pull of the abductor tendon, which is related to medial insertion
into the proximal phalanx; this may be influenced by an inflammatory process or by minor trauma. The imbalance
leads to varus deformity and subsequent contracture of the medial capsule, decrease of the intermetatarsal (IM) angle,
and medial subluxation of the flexor and extensor mechanisms. Shoe wear tends to correct the varus deformity rather
than exacerbate it, as it does for hallux valgus. Therefore, spontaneous idiopathic hallux varus may be more common
than is reported.

 Classical Deformity – The classic deformity of hallux varus occurs most frequently after a surgical procedure
involving aggressive lateral soft-tissue releases, typically a distal soft-tissue or McBride, type of
bunionectomy, but it can also be produced after Silver, Chevron, Mitchell, Keller, and Lapidus procedures.

Classically, the deformity is characterized by the following:

 Hyperextension of the metatarsophalangeal (MTP) joint

 Flexion of the interphalangeal (IP) joint
 Medial deviation of the hallux
 Supination of the entire ray
 Figure 4: Anteroposterior radiograph of foot shows Figure 5: Lateral radiograph of foot depicts iatrogenic
iatrogenic hallux varus following proximal osteotomy hallux varus following proximal osteotomy and distal
and distal soft-tissue realignment. soft-tissue realignment.

This posture results from muscle imbalance that is brought about by the medial subluxation of the tibial
sesamoid. Release or transfer of the adductor hallucis alone is not sufficient to produce dynamic hallux varus; however,
when coupled with excision of the fibular sesamoid or transection of the lateral head of the flexor brevis tendon, hallux
varus likely results. Other predisposing factors for hallux varus are a small IM angle and a round metatarsal head.

Flexion of the MTP joint is brought about by the flexor hallucis brevis through its pull on the sesamoid sling.
If the fibular sesamoid is excised, the metatarsal may buttonhole through the defect and result in hyperextension and
medial deviation of the MTP joint. Medial deviation is exacerbated when the adductor tendon is detached and nothing
opposes the pull of the abductor hallucis.

Potential contributing factors include overplication of the medial capsular structures, medial displacement of
the tibial sesamoid, overpull of the abductor hallucis against an incompetent lateral ligamentous complex, excessive
resection of the medial eminence, and overcorrection with a postoperative dressing that holds the MTP joint in a varus
position. Another cause of hallux varus is overcorrection of a proximal first metatarsal osteotomy, leading to a negative
IM angle.
 Epidemiology

The incidence of iatrogenic postoperative hallux varus ranges from 0% for distal osteotomies without a lateral
release to 15% for proximal osteotomies (specifically, the Lapidus procedure) with distal soft-tissue release. Most
reports are of crescentic osteotomies, which have an overall varus rate of 10%. The incidence of idiopathic,
congenital/infantile, traumatic, and otherwise acquired hallux varus, however, is unknown.

Incidence: Varies between 2-14% after corrective surgery for hallux valgus deformities

Demographics: More commonly seen in women

Anatomy

Cadaveric biomechanical studies have revealed that the anatomic restraints to hallux varus, in descending
order, are the lateral capsule, the adductor hallucis, and the lateral flexor brevis tendon.

Pathophysiology

With a chevron osteotomy, if the capital fragment is excessively displaced lateral ward, a hallux varus
deformity can develop. Likewise, with a proximal osteotomy, the distal segment can be translated too far laterally.
For classical McBride procedure, the fibular sesamoid is excised which causes MTP joint hyperextension,
interphalangeal (IP) joint flexion and medial deviation of the hallux. With time, the deformity becomes fixed, and it
is difficult for the patient to obtain comfortable footwear. The deformity usually manifests itself as the medial
deviation of the great toe, supination of the phalanx and claw tow deformity.

Anatomically, cadaveric biomechanical studies reveal the restraints in descending order are the lateral
capsule, the adductor hallucis, and the lateral flexor brevis tendon.

 Possible Causes: (1) According to Skalley and Myerson, overcorrection of hallux valgus accounts
for 80% of hallux varus cases. (2) Other causes include congenital defects, rheumatoid arthritis,
trauma, poliomyelitis, psoriatic arthritis, Charcot Marie-Tooth, avascular necrosis or contractures
due to burns.
 Diagnosis

Diagnosis is based on both clinical and radiographic evaluation. As described by Boike, the deformity is
triplanar, with supination and hyperextension of the first Metatarsal phalangeal joint (MPJ) and hyperflexion of the
hallucal IPJ. Hallux varus is usually obvious just by visual inspection of the foot. Standing X-rays of the foot can
confirm the deformity and the severity of the angulation can be measured. X-rays can also look for problems that may
have occurred from the previous surgery as well as for arthritis of the big toe joint. Physical examination by the
orthopedic foot specialist will look specifically for how easily the deformity can be corrected and if there is any
stiffness in the toe joint present.

 Presentation: Patients with hallucal pain, shoe-wear difficulty, weakness with push-off,
metatarsophalangeal joint instability, or possibly metatarsalgia. It is describe that the presentation includes
deformity, pain, and decreased range of motion, first metatarsophalangeal joint arthrosis, hallucal clawing,
and shoe-wear problems.
 Radiographically: Patient presents with the following radiographic findings:
a. Negative Hallux abductus angle/ Hallux varus angle
b. Negative IM 1-2 angle
c. Absence of fibular sesamoid
d. Medial subluxation of the tibial sesamoid/ Tibial sesamoid peaking
e. Hallux IPJ flexion
f. Staking of the 1st metatarsal head
- All of the radiographic angles associated with hallux valgus should also be evaluated with hallux varus.

Prognosis

Surgery is aimed at improving the overall position of the hallux, not necessarily its motion. Preoperatively,
surgeons must inform patients that further salvage procedures may be necessary and that most surgical procedures
directed at correcting iatrogenic hallux varus are 60-80% effective. In one series of patients treated with extensor
hallucis brevis tenodesis, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux MTP-IP score improved
from 61 to 85.

Treatment

Treatment of acquired hallux varus depends on the degree of severity of the deformity, and whether the
deformity is symptomatic. Asymptomatic hallux varus is usually very flexible and not very severe. The tibial sesamoid
is usually peaking but not dislocating over the medial aspect of the metatarsal head. These generally go untreated and
are monitored for an extended period of time. Symptomatic hallux varus usually requires surgical interventions, and
can involve soft tissue releases and tendon transfers, soft tissue procedures and osseous correction, or joint destructive
procedures. Congenital hallux varus cases are usually treated in infancy with manipulation, casting, and splinting.
Cases which are resistant to conservative treatment are treated with abductor tendon releases and skin-plasty
techniques.
 Abductor hallucis tenotomies are frequently performed with Heyman, Herndon, and Strong procedures in
correction of a congenital hallux varus with concomitant metatarsus adductors. Congenital hallux varus cases which
go untreated and are symptomatic will require soft tissue and osseous correction. If the patient is older and significant
arthrosis has developed, joint destructive procedures may be considered. In order to address each specific case and
determine a surgical procedure it is necessary to carefully evaluate the deformity through preoperative and
intraoperative assessment.

 The patient who has hallux varus and is symptomatic despite conservative measures for the condition, such
as shoe modification, is a surgical candidate. The treatment options consist of either soft-tissue or bony
reconstruction, including arthrodesis.
 Relevant contraindications for tendon transfer reconstruction for hallux varus include, but are not limited to,
degenerative arthrosis, inflammatory arthritides, active infection, peripheral neuropathy, and vascular
compromise, in addition to excessive resection of the medial eminence and fixed deformity of the
metatarsophalangeal (MTP) joint.

Surgical Treatment:

Conservative Treatment of hallux varus includes:

 Wider shoes or open toe foot wear

 Strapping or taping the big toe to the second toe
 Padding the big toe with a silicone toe sleeve
 Appropriate nail care

Custom made Hallux Varus Sandals

If conservative treatment fails and the hallux varus deformity is significantly affecting the patient’s work or recreation,
surgical correction may be necessary. Surgery for hallux varus falls into two main categories, reconstruction or fusion:

1. Reconstruction – In hallux varus, the pull of the muscles and ligaments on one side of the toe is
overpowering the opposite side resulting in the deformity. Hallux varus surgery re-balances the pull of these
muscles and ligaments equally on both sides of the big toe joint. This is done using tendon transfers and
suture devices implanted into the bones to maintain the correct alignment. Sometimes a bone cut may also
may necessary to achieve a perfect balance.
 2. Fusion – Fusion of the big toe involves making the two bones on either side of the joint heal together into
one solid piece of bone. This is done by scraping and perforating the opposing sides of the joint and then
holding the bones compressed tightly together with metal plates and screws. Fusion is usually reserved for
hallux varus patients who are stiff or arthritic. Patients with big toe fusions walk normally and have very few
limitations with sports or work.

Various authors have described numerous procedures for the treatment and correction of hallux varus. A sampling of
these procedures, which have been used both alone and in conjunction with others, is as follows:

 Lengthening of the medial capsular structures

 Lengthening of the extensor hallucis longus (EHL)
 Relocation of the sesamoid(s)
 Skin resection of the first webspace
 Syndactyly of the great and second toes
 Total joint release
 Abductor hallucis transfer
 Ligapro suture/technique (an elastic polyethylene terephthalate device that is not available in the United
States)
 Split extensor hallucis brevis (EHB) transfer and reverse Akin procedure
 EHL transfer with interphalangeal (IP) arthrodesis
 EHB transfer
 Keller resection arthroplasty
 Implant arthroplasty
 MTP arthrodesis

In 1971, Hawkins described transfer of the abductor hallucis tendon to the lateral aspect of the proximal
phalanx with release of the medial capsule and mobilization of the medial sesamoid. Patients demonstrated
maintenance of alignment between 5 and 54 months. A few years later, Miller described a proximal phalangeal
resection for treatment of early acquired hallux varus (i.e., before the deformity became fixed and clawing was
present). However, no functional outcome was published.

In 1984, Johnson and Spiegl advocated transfer of the EHL tendon to the proximal phalanx as a dynamic
stabilizer, coupled with IP joint arthrodesis for flexible hallux varus without MTP arthrodesis. This improved flexion
of the MTP joint from –23° to +6°, and total ROM increased from 38° to 67°. The varus was corrected an average of
18°. Later, modification utilized a split EHL transfer with preservation of the IP joint in the absence of deformity at
the IP joint, which resulted in less MTP motion. Skalley and Myerson reported their experience with EHL transfer
and IP arthrodesis in a retrospective study; the split EHL transfer resulted in symptomatic joint stiffness.
 Subsequently, Myerson and Komenda described a tenodesis of the EHB tendon in conjunction with a medial
soft-tissue release for correction of a flexible hallux varus deformity. The tenodesis was thought to act as a static
restraint, as opposed to a dynamic restraint to varus-deforming forces. The authors reported restoration of alignment
to an average of 0°, minimal loss of sagittal plane motion, and no stiffness or weakness.

Figure 2: Intraoperative view of the metatarsal head. Note

Figure 1: Lengthening of the long extensor tendon is performed. the degenerative changes at the dorso-medial aspect.

Tourne et al reported a case series of 14 French patients with iatrogenic hallux varus. They performed MTP
arthrodesis in nine patients who had stiffness and arthrosis; in five, the lateral ligament complex was reconstructed by
using a Ligapro suture. Arthrolysis was performed in all patients. Outcomes were excellent in patients who were
younger, had a mobile MTP joint, and had no radiographic evidence of degenerative changes. Results included an
average postoperative correction of 20° of plantar flexion and 60-90° of dorsiflexion of the MTP joint.

Resection arthroplasty can decompress the joint at the same time that the tendons and capsule are balanced.
Loss of strength and floppiness has been reported postoperatively but may not be bothersome in patients who are
elderly or who have significant degenerative disease. Note, however, that implant arthroplasty is ill-advised in light
of the soft-tissue imbalance that is present in patients who have hallux varus.

MTP arthrodesis remains a logical salvage technique for patients who have hallux varus deformity with
arthrosis and bone loss. Moderate-to-severe degenerative changes should probably be addressed with arthrodesis or
osteotomy. Correction of the first intermetatarsal (IM) angle may require metatarsal osteotomy in addition to a soft-
tissue balancing procedure for the MTP joint with or without MTP arthrodesis.

 Complications: Potential complications include the following:

- Overcorrection (i.e., hallux valgus)
- Avascular necrosis of the metatarsal head
- Stiffness
- Progression of degenerative changes in the MTP joint
- Shortening of the medial column
- Transfer metatarsalgia
 - Wound complications

Surgical correction is generally recommended for congenital hallux varus and various surgical techniques
have been described. McElvenny described the removal of accessory bones, medial sesamoidectomy and capsulotomy,
release of the medial fibrous band, reinforcement of the lateral capsule, transfixing of the metatarsophalangeal joint
with a Kirschner wire and a partial syndactylization of the first and second toes. Farmer addressed soft tissue
contractures and described a rotational skin flap and syndactylization of the first and second toes. Resection of the
entire abductor hallucis muscle and tendon, tenotomy of the abductor hallucis tendon, metatarsal osteotomy and also
arthrodesis have been reported. However, most previous studies of outcomes after surgical treatment of congenital
hallux varus have been based on a small number of case series or have included several mixed disease cases. Few
studies have reported surgical outcomes of several cases with long-term follow-up.

Figure 1: (A) Preoperative photograph showing bilateral hallux varus with widening of the first web space. Preoperative
scars due to removal of accessory toes are also noted. (B) Preoperative radiograph of the right foot at 58 months of age
showing a short thicken.

Figure 2: (A) Preoperative photograph showing marked medial deviation of the broad great toe and widening of the first
web space. (B) Preoperative radiograph showing varus angulation of the first metatarsophalangeal joint and accessory bone
of the great toe. (C) Follow-up photograph. (D) Sufficient correction with cosmetically satisfactory appearance of the foot
was observed at four years after the Farmer technique and medial open wedge osteotomy at the proximal phalanx. The final
result was graded as excellent at 10 years after surgery.
References:

https://www.ncbi.nlm.nih.gov/books/NBK470261/
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