HALLUX VALGUS

Moderator: Dr Prabhu E
Presenter: Dr Rohith C Sunil
 Overview
• Introduction
• Pathophysiology
• Presentation
• Imaging
• Management
 INTRODUCTION
• Hallux Valgus, commonly referred to as a bunion, is a complex valgus deformity of
the first ray that can cause medial big toe pain and difficulty with shoe wear.

• Diagnosis is made clinically with presence of a hallux that rests in a valgus and
pronated position. Radiographs of the foot are obtained to identify the severity of
the disease and for surgical planning.
 Epidemiology
• More common in women

• Risk factors
• Intrinsic

• Genetic predisposition
• 70% of pts with hallux valgus have family history
• Increased distal metaphyseal articular angle (DMAA)
• Ligamentous laxity (1st tarso-metatarsal joint instability)
• Convex metatarsal head
 • 2nd toe deformity/amputation
• Pes planus
• Rheumatoid arthritis
• Cerebral palsy
• Extrinsic

• Shoes with high heel and narrow toe box

 Etiology
• Two forms exist
• Adult hallux valgus
• Adolescent & juvenile hallux valgus

• Pathoanatamy
• Valgus deviation of phalanx promotes varus position of metatarsal
• The metatarsal head displaces medially, leaving the sesamoid complex laterally
translated relative to the metatarsal head
• Sesamoids remain within the respective head of the flexor hallucis brevis tendon
and are attached to the base of the proximal phalanx via the sesamoido-
phalangeal ligament
• This lateral displacement can lead to transfer metatarsalgia due to shift in weight
bearing
• Medial MTP joint capsule becomes stretched and attenuated while the lateral
capsule becomes contracted
• Adductor tendon becomes deforming force  
• Inserts on fibular sesamoid and lateral aspect of proximal phalanx
• Lateral deviation of EHL further contributes to deformity
• Plantar and lateral migration of the abductor hallucis causes muscle to plantar flex
and pronate phalanx
• Associated conditions
• Hammer toe deformity

• Juvenile and adolescent hallux valgus  

• Juvenile and adolescent hallux valgus  
• Factors that differentiate juvenile / adolescent hallux valgus from adults
• Often bilateral and familial
• Pain usually not primary complaint
• Varus of first MT with widened IMA usually present
• DMAA usually increased
• Often associated with flexible flatfoot
• Complications
• Recurrence is most common complication (>50%), also overcorrection and
hallux varus
 Presentation
• Symptoms
• Presents with difficulty with shoe wear due to medial eminence
• Pain over prominence at MTP joint
• Compression of digital nerve may cause symptoms
• Physical exam
• Hallux rests in valgus and pronated due to deforming forces
• Examine entire first ray for
• 1st MTP ROM
• 1st tarsometatarsal mobility
• Callous formation
• Sesamoid pain/arthritis
• Evaluate associated deformities
• Pes planus
• Lesser toe deformities. Midfoot and hindfoot conditions
 Imaging

• Radiographs
• Views
• Standard series should include weight bearing AP, lat, and oblique views
• Sesamoid view can be useful
• Findings
• Lateral displacement of sesamoids
• Joint congruency and degenerative changes can be evaluated
• Hallux valgus (HVA)
• Long axis of 1st MT and prox. phalanx
• Identifies MTP deformity
• Normal < 15°
• Intermetatarsal angle (IMA)
• Between long axis of 1st and 2nd MT
• Normal < 9 °
• Distal metatarsal articular (DMAA)
• Between 1st MT axis and line through base of distal articular cap
• Identifies MTP joint incongruity
• Normal < 10°
• Hallux valgus interphalangeus (HVI)
• Between long. axis of distal phalanx and proximal phalanx
• Normal < 10°
 Treatment - adult hallux valgus

• Nonoperative
• Shoe modification/ pads/ spacers/orthoses
• Indications
• First line treatment
• Orthoses more helpful in patients with pes planus or metatarsalgia
• Operative
• Surgical correction
• Indications
• When symptoms present despite shoe modification
• Do not perform for cosmetic reasons alone
• Technique
• Soft tissue procedure
• Indicated in very mild disease in young female (almost never)
• Distal osteotomy
• Indicated in mild disease (IMA < 13)
• Proximal or combined osteotomy
• Indicated in more moderate disease (IMA > 13)
• 1st TMT arthrodesis
• Arthritis at TMT joint or instability
• Fusion procedures
• Indicated in severe deformity/spasticity/arthritis 
• MTP resection arthroplasty
• Only indicated in elderly patients with low functional demands
 Treatment - juvenile and adolescent hallux valgus

• Nonoperative
• Shoe modification
• Indications
• Pursue nonoperative management until physis closes
• Operative
• Surgical correction
• Indications
• Best to wait until skeletal maturity to operate
• Can not perform proximal metatarsal osteotomies if physis is open
(cuneiform osteotomy OK)
• Surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
• Consider double MT osteotomy in adolescent patients with increased DMAA   
• Technique
• Soft tissue procedure alone not successful
• Similar to adults if physis is closed (except in severe deformity)
 Techniques
• Soft tissue procedures

• Modified mcbride
• Indications  
• Goal is to correct an incongruent MTP joint (phalanx not lined up with articular
cartilage of MT head). Usually done in patients with
• A HVA less than 25 degrees  
• IMA deformity less than 15 degrees
• Usually in patient 30-50 years of age
• Rarely appropriate in isolation
• Usually performed in conjunction with
• Medial eminence resection
• MT osteotomy
• 1st TMT arthrodesis (lapidus procedure)
• Technique
• Includes
• Release of adductor from lateral sesamoid/proximal phalanx
• Lateral capsulotomy
• Medial capsular imbrication
• (Original mcbride included lateral sesamoidectomy)
• Metatarsal osteotomies
• Distal metatarsal osteotomy
• Indications
• Mild disease (HVA 15-25°, IMA < 13°)   
• Unable to correct pronation deformity 
• Distal metatarsal osteotomies include
• Chevron  
• Biplanar chevron (corrects DMAA)  
• Mitchell
• May be combined with proximal phalanx osteotomy
• Proximal metatarsal osteotomy 
• Indications
• Moderate disease (HVA 25-40°, IMA >13°)
• Proximal metatarsal osteotomies include
• Crescentic osteotomy
• Broomstick osteotomy
• Ludloff
• Scarf  
• Double (proximal and distal) osteotomy
• Indications
• Severe disease (HVA 41-50°, IMA 16-20°)

• First cuneiform osteotomy

• Indications
• Severe deformity in young patient with open physis
• Proximal phalanx osteotomies

• Akin osteotomy   
• Indications
• Hallux valgus interphalangeus
• Congruent joint with DMAA <10°
• As a secondary procedure if a primary procedure (e.G., Chevron or distal soft-
tissue procedure) did not provide sufficient correction due to a large DMAA or
HVI
• Fusion procedures
• Lapidus procedure (1st metatarsocuneiform arthrodesis with modified mcbride)    
• Indications
• Severe deformity (very large IMA)
• Arthritis at 1st TMT
• Metatarsus primus varus
• Hypermobile 1st TMT joint  
• Concomitant pes planus
• MTP arthrodesis

• Indications are hallux valgus in

• Cerebral palsy
• Down's syndrome
• Rheumatoid arthritis
• Gout
• Resection arthroplasty
• Proximal phalanx (keller) resection arthroplasty
• Indications
• Largely abandoned
• Rarely indicated in some elderly patient with reduced function demands
Resection of proximal phalanx, release of adductor tendon, and resection of medial eminence
 Complications

• Recurrence    
• Most common cause of failure is insufficient preoperative assessment and failure
to follow indications  

• E.G., Failure to recognize DMAA > 10°

• Inadequate correction of IMA

• E.G., Failure to do adequate distal soft tissue realignment

• More common in juvenile/adolescent population

• Noncompliant patient that bears weight
• Rounded shape to the first metatarsal head
• Residual tibial sesamoid lateral displacement
• Increased preoperative IMA and HVA
• Failure to perform a lateral release of the adductor hallucis tendon  
• Avascular necrosis  
• Medial capsulotomy is primary insult to blood flow to metatarsal head
• Distal metatarsal osteotomy and lateral soft tissue release inconjunction do not
increase risk for AVN
• Treat with MTP arthrodesis with or without structural graft  
• Dorsal malunion with transfer metatarsalgia
• Due to overload of lesser metatarsal heads
• Risk associated with shortening of hallux MT
• Lapidus
• Proximal crescentric osteotomies
• Hallux varus   
• Caused by   
• Overcorrection of 1st IMA
• Excessive lateral capsular release with overtightening of medial capsule
• Over resection of medial first metatarsal head
• Lateral sesamoidectomy  
• Hallux Varus
• Cock up toe deformity
• Due to injury of FHL
• Most severe complication with keller resection
• 2nd MT transfer metatarsalgia
• Often seen concomitant with hallux valgus
• Can occur secondary to malpositioning of MTP fusion
• Shortening metatarsal osteotomy indicated with extensor tendon and capsular
release 
• Neuropraxia   
• Painful incisional neuromas after bunion surgery frequently involve the medial
dorsal cutaneous nerve (a terminal branch of the superficial peroneal nerve).
• It is most commonly injured during the medial approach for capsular imbrication
or metatarsal osteotomy.
 Conclusion
• Hallux Valgus is abduction contracture deformity resembling big toe displaced laterally

• Women have a higher incidence which is directly proportional with increase age.

• Aetiology is divided into extrinsic and intrinsic factors

• Treatment usually nonsurgical first, then if failed surgical option is advised.

• Surgery most often involves a combination of soft tissue and bony procedure
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