Hallux Valgus - Foot & Ankle (2024)

Updated: May 3 2024

Tyler Paras MD San Diego, US
Joseph Park MD UVA Health Musculoskeletal Center

Hallux Valgus

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  • summary

    • 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.

    • Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear.

  • Epidemiology

    • Demographics

      • occurs in ~23% of patients 18 to 65 years old

      • more common in women (up to 15:1)

        • up to 30% of females

    • Risk factors

      • intrinsic

        • genetic predisposition

          • 70% of patients with hallux valgus have family history

        • increased distal metaphyseal articular angle (DMAA)

        • ligamentous laxity (1st tarsometatarsal 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 sesamoid-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

      • windlass mechanism becomes less effective

        • leads to transfer metatarsalgia

    • Associated conditions

      • hammer toe deformity

      • callosities

      • pes planus

        • associated with deformity progression

      • Marfan syndrome

      • Ehlers-Danlos syndrome

    • 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%)

        • overcorrection

        • hallux varus

  • Differential diagnosis

    • gout

    • hallux rigidus

    • rheumatoid arthritis

    • turf toe

    • hallux valgus interphalangeus

  • Anatomy

    • Pathoanatomy cascade

    • Osteology

      • valgus deviation of great toe and varus deviation of first metatarsal

      • sesamoids displace lateral to metatarsal head

      • loss of the windless mechanism results in transfer metatarsalgia

    • Musculature

      • muscles forming the plantar plate

        • abductor hallucis

        • flexor hallucis brevis

        • flexor hallucis longus (becomes deforming force)

        • adductor hallucis (becomes deforming force)

  • Imaging

    • Radiographs

      • recommended views

        • standard series should include weight bearing AP, Lat, and oblique views

      • optional views

        • sesamoid view can be useful

      • findings

        • lateral displacement of sesamoids

        • joint congruency and degenerative changes can be evaluated

        • radiographic parameters (see below) guide treatment

        • Radiographic Measurements in Hallux Valgus

        • Measurement

        • Importance

        • Normal

        • Hallux valgus (HVA)

        • Long axis of 1st MT and prox. phalanx

        • Identifies MTP deformity

        • < 15°

        • Intermetatarsal angle (IMA)

        • Between long axis of 1st and 2nd MT

        • Identifies deformity of the metatarsal

        • < 9 °

        • Distal metatarsal articular (DMAA)

        • Between 1st MT axis and line through base of distal articular cap

        • Identifies MTP joint incongruity

        • < 15°

        • Hallux valgus interphalangeus (HVI)

        • Between long axis of distal phalanx and proximal phalanx

        • Predisposing factor for hallux valgus

        • < 10°

        • Metatarsus adductus angle

        • Angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference)

        • Predisposing factor for hallux valgus

        • < 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 persist despite shoe modifications

            • do not perform for cosmetic reasons alone

        • technique

          • soft tissue procedure (modified McBride)

            • indications

              • only for mild disease (IMA < 11 degrees, HVA < 35 degrees)

              • typically performed in combination with an osteotomy (almost never alone)

              • usually in patients 30-50 years of age

            • outcomes

              • no studieshaveassessed deformity correction of modified McBride alone

          • akin osteotomy

            • indications

              • hallux valgus interphalangeus

              • congruent joint withDMAA <10°

              • as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) that did not provide sufficient correction due to a large DMAA or HVI

              • some authors perform Akin together with/at the time of proximal osteotomy+distal soft tissue correction because this results in progressive increase in HVI

            • outcomes

              • improves pain, radiographic outcomes, and PROMs

          • distal osteotomy

            • indications

              • mild disease (HVA < 30°, IMA < 13°)

              • unable to correct pronation deformity

            • outcomes

              • chevron osteotomy outperformed nonoperative treatment in an RCT

          • proximal or combined osteotomy

            • indications

              • proximal osteotomy: moderate disease (HVA >25°, IMA >13°)

              • double osteotomy:severe disease (HVA 41-50°, IMA 16-20°)

            • outcomes

              • after scarf osteotomy, decrease in VAS pain of 5.8 to 1.1 and improvement in IMA from 13 degrees to 5.6 degrees

          • 1st TMT arthrodesis (Lapidus)

            • indications

              • severe deformity (HVA > 40 degrees, IMA > 20 degrees)

              • arthritis at TMT joint or ligamentous laxity

            • outcomes

              • patient satisfaction of 81% with improvement in HVA and IMA at 24 months

              • no difference in radiographic outcomes of lapidus versus distal osteotomy in a RCT

          • 1st MTP arthrodesis

            • indications

              • severe deformity (HVA > 40 degrees, IMA > 20 degrees)

              • cerebral palsy

              • down syndrome

              • rheumatoidarthritis

              • gout

              • MTP arthritis

            • outcomes

              • ~90% patient satisfaction

          • MTP resection arthroplasty

            • indications

              • largely abandoned

              • only 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

          • first cuneiform osteotomy used for severe disease with open physis

          • similar to adults if physis is closed (except in severe deformity)

  • Techniques

    • Soft Tissue Procedures

      • modified McBride

        • goal is to correct an incongruent MTP joint (phalanx not lined up with articular cartilage of MT head)

        • 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

        • distal metatarsal osteotomies include

          • Chevron

            • medial approach

            • L-shaped capsulectomy

            • osteotomy cut at 55-60 degrees

            • fixation options include single screw or absorbable pin

          • biplanar Chevron (corrects DMAA)

            • same Chevron osteotomy with addition of

              • bone removal from dorsomedial and plantar medial limbs

              • oblique medial wedge removed

          • Mitchell

            • distal 1st MT osteotomy (extra-articular).

          • may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy)

      • proximal metatarsal osteotomy

        • proximal metatarsal osteotomies include

          • crescentic osteotomy

            • osteotomy made with crescentic saw blade

            • distal fragment rotated laterally

          • Scarf

            • medial approach to the metatarsal shaft

            • metatarsal shaft Z osteotomy

              • longitudinal plantar sloping cut

              • proximal and distal chevron osteotomies

            • can correct deformity and adjust length

            • fixation with 2 screws

          • Broomstick osteotomy

          • Ludloff

      • double (proximal and distal) osteotomy

        • combines a distal and proximal metatarsal osteotomy

      • first cuneiform lateral opening osteotomy

        • dorsoplantar periosteal incision

        • osteotomy

          • parallel to TMT joint through 75% of the cuneiform

            • avoid completing the osteotomy laterally due to risk of over lengthening

            • osteotomy filled with bone graft

          • fixation with plate

    • Proximal phalanx osteotomies

      • Akin osteotomy

        • medial approach to the mid shaft of the proximal phalanx

        • medial closing wedge osteotomy

          • avoid breaching lateral cortex

        • fixation either with staple or screw

    • Fusion procedures

      • Lapidus procedure (1st metatarsocuneiform arthrodesis with modified McBride)

        • Lapidus procedure, in isolation, can fail to correct pronation of the first ray

        • performed with either 2 separate incisions or extended medial approach

          • medial approach to the metatarsal head

          • dorsal approach to the TMT joint

        • deformity corrected with adduction, supination, and neutral plantar flexion

        • fixation with either screws +/- plate

      • MTP Arthrodesis

        • medial or dorsal approach can be used

        • avoid the EHL and dorsomedial cutaneous nerve

        • conical reamers used for joint preparation

        • position of toe in

          • valgus: 5-10 degrees

          • neutral rotation

          • dorsiflexion: 5-10 degrees

          • may use flat platform to simulate weight bearing

        • fixation with screws or plate

    • Resection arthroplasty

      • proximal phalanx (Keller) resection arthroplasty

        • remove base of the proximal phalanx

        • can add interposition with allograft

      • Surgical Indications for Specific Conditions

      • Juvenile/Adolescent with open physis

      • First cuneiform osteotomy

      • Hypermobile 1st MT

      • Lapidus procedure

      • DJD

      • MTP arthrodesis

      • Skin breakdown

      • Simple bunionectomy with medial eminenceremoval

      • Gout

      • MTP arthrodesis

      • Recurrence with pain in 1st TMT joint

      • Lapidus procedure

      • Rheumatoid arthritis

      • MTP arthrodesis

      • Down's syndrome, CP, Ehlers-Danlos

      • MTP arthrodesis

      • Surgical Indications for Various Techniques to Treat Hallux Valgus

      • HVA

      • IMA

      • Modifier

      • Procedure

      • Mild

      • < 30°

      • < 13°

      • Distal MT osteotomy

      • Chevronosteotomy

      • Biplanar if DMAA > 10° with mod McBride

      • Moderate

      • 30-40°

      • 13-20°

      • Proximal MT +/- distal MT osteotomy

      • Chevron/mod McBride+ Akin

      • Proximal MT osteotomy and mod McBride

      • Severe

      • > 40°

      • > 20°

      • Double osteotomy, DMAA > 15°

      • Proximal MT osteotomy plus biplanar chevron, mod McBride

      • Lapidus procedure plus Akin

      • > 40°

      • > 20°

      • Elderly/very low demand patient

      • Keller resection arthroplasty

      • > 40°

      • > 20°

      • Juvenile/Adolescent with DMAA > 20

      • Double osteotomy of first ray

      • Various Hallux valgus procedures

      • Procedure

      • Technique

      • Indications

      • Complications

      • Modified McBride

      • Includes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication

      • HVA < 35°

      • IMA < 11°

      • HVI< 15°

      • Recurrence

      • Hallux varus

      • Original McBride

      • Includes lateral sesamoidectomy and has been abandoned

      • Not indicated

      • Hallux Varus

      • Chevron

      • Distal 1st MT osteotomy (intra-articular).

      • Can perform in two planes (Biplanar distal Chevron)

      • Reserved for mild to moderate deformities in adults andchildren

      • Biplanar chevron--> corrects increased DMAA

      • AVN of MT head

      • Recurrence

      • Dorsal malunion with transfer metatarsalgia

      • Mitchell

      • Distal 1st MT osteotomy (extra-articular).

      • More proximal than Chevron

      • Same as Chevron (rarely utilized)

      • Recurrence

      • Malunion

      • Transfer metatarsalgia

      • Akin

      • Proximal phalanx medial closing wedge osteotomy

      • Combined with Chevron in moderate to severe deformities

      • Hallux valgus interphalangeus

      • Scarf / Ludloff / Mau

      • Metatarsal shaft osteotomies.

      • HVA > 25°, IMA > 13°

      • DMAA is normal or increased

      • Dorsal malunion with transfer metatarsalgia

      • Recurrence

      • Proximal Crescentic or Broomstick

      • Proximal metatarsal osteotomy plus modified McBride

      • Severe deformity

      • IMA > 13°

      • HVA > 25°

      • Hallux varus

      • Dorsal malunion with transfer metatarsalgia

      • Recurrence

      • Keller resection arthroplasty

      • Includes medial eminence removal and resection of base of proximal phalanx

      • Largely abandoned due to complications

      • Indicated only in older patients with reduced functional demands

      • Cock-up toe deformity

      • Poor potential for correction of deformity

      • MTP arthrodesis

      • HVA > 40 degrees, IMA > 20 degrees

      • DJD of 1st MTP

      • Neuromuscular conditions

      • Painful callosities beneath lesser MT heads

      • Lapidus procedure

      • First TMT joint arthrodesis with distal soft tissue procedures (medial eminence removal, first web space release of AdH, lateral capsule release)

      • Moderate or severe deformity

      • Hypermobility of first ray

      • Nonunion (may or may not be symptomatic)

      • Dorsiflexion of the first metatarsal with transfer metatarsalgia

      • First Cuneiform Osteotomy

      • Opening wedge osteotomy (often requires autograft)

      • Children with ligamentous laxity, flatfoot, and hypermobile first ray

      • Adolescent with an open physis

      • Nonunion (may or may not be symptomatic)

  • Complications

    • Recurrence

      • incidence

        • 10-47% risk depending on the procedure performed

      • risk factors

        • 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

        • 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

        • associated with incomplete reduction of the sesamoids

      • diagnosis

        • clinical exam and radiographs

      • treatment

        • pain does not correlate with deformity recurrence

        • treat with revision surgery if patient is symptomatic

    • Avascular necrosis

      • incidence

        • rare with modern techniques

      • risk factors

        • medial capsulotomy is primary insult to blood flow to metatarsal head

        • distal metatarsal osteotomy and lateral soft tissue release in conjunction do not increase risk for AVN (Chevron plus lateral release thought to increase risk in the past)

      • diagnosis

        • clinical exam, radiographs +/- advanced imaging

      • treatment

        • MTP arthrodesis with or without structural graft

    • Dorsal malunion with transfer metatarsalgia

      • incidence

        • about 5%

      • risk factors

        • due to overload of lesser metatarsal heads

        • risk associated with shortening of hallux MT

          • Lapidus

          • proximal crescentic osteotomies

      • diagnosis

        • clinical exam and radiographs

      • treatment

        • osteotomy to correct deformity

        • arthrodesis with bone grafting

    • Hallux Varus

      • incidence

        • 6% overall risk after surgery

      • risk factors

        • overcorrection of 1st IMA

        • excessive lateral capsular release with overtightening of medial capsule

        • over resection of medial first metatarsal head

        • lateral sesamoidectomy

      • diagnosis

        • clinical exam and radiographs

      • treatment

        • surgical options for symptomatic patients include

          • reveres Scarf, reverse Chevron, reverse Akin

          • MTP arthrodesis

    • Cock up toe deformity

      • most severe complication with Keller resection

      • incidence

        • up to 41%

      • risk factors

        • due to injury of FHL

      • diagnosis

        • clinical exam and radiographs

      • treatment

        • Z-lengthening EHL

        • revision Keller resection

        • MTP arthrodesis

    • 2nd MT transfer metatarsalgia

      • incidence

        • occurs in up to 50% of hallux valgus patients

      • risk factors

        • often seen concomitant with hallux valgus

        • can occur secondary to malpositioning of MTP fusion

      • diagnosis

        • clinical exam

      • treatment

        • shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release

    • Neuropraxia

      • incidence

        • overall risk of nerve injury ~3%

      • risk factors

        • 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.

      • diagnosis

        • clinical exam

      • treatment

        • neuropraxia typically improves over several months

    • Nonunion

      • incidence

        • occurs in ~10% of lapidus and MTP arthrodesis patients

        • only ~33% are symptomatic

      • risk factors

        • arthrodesis procedures

      • diagnosis

        • clinical exam, radiographs +/- advanced imaging

      • treatment

        • revision arthrodesis with bone grafting

  • Prognosis

    • may take 6-12 weeks to return to work

    • improvement may take 1year

    • dissatisfaction

      • 10-50% risk after surgical intervention

        • not related to surgical outcome

        • may be related to unmet expectations

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