Hallux Valgus

Author: Derek Moore

Topic updated on 04/05/13 5:47pm

Introduction

Not a single deformity, but rather a complex deformity of the first ray
- often accompanied by deformities and symptoms in lesser toe
- two forms exist
  - adult hallux valgus
  - adolescent & juvenile hallux valgus
Epidemiology of adult hallux valgus
- more common in women
- 70% of pts with hallux valgus have family history
  - genetic predisposition with anatomic anomalies
- risk factors
  - intrinsic
    - genetic predisposition
    - ligamentous laxity
    - convex metatarsal head
    - pes planus
    - rheumatoid arthritis
    - cerebral palsy
  - extrinsic
    - shoes with high heel and narrow toe box
Pathoanatamy
- valgus deviation promotes varus position of metatarsal
- sesamoid complex becomes lateral to the metatarsal head, which moves medially
- medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
- adductor tendon becomes deforming force
  - inserts on fibular sesamoid
- lateral deviation of EHL
- 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
- calluses
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 and hallux varus

Anatomy

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 illustrated above
- examine entire first ray for
  - 1st MTP ROM
  - 1st tarsometatarsal mobility
  - callous formation
- evaluate associated deformities
  - pes planus
  - lesser toe deformities
  - midfoot and hindfoot conditions

Imaging

Radiographs
- views
  - standard series should include weight bearing AP and Lat
  - sesamoid view can be useful
- findings
  - displacement of sesamoids
    - often displaced laterally
  - joint congruency and degenerative changes can be evaluated
  - radiographic parameters (see below) guide treatment

Radiographic Measurements in Hallux Valgus
Hallux valgus (HVA)	Long axis of 1st MT and prox. phal.	Identifies MTP deformity	Normal < 15°
Intermetatarsal angle (IMA)	Between long axis of 1st and 2nd MT		< 9°
Distal metatarsal articular (DMAA)	Between 1st MT long. axis and line through base of of distal articular cap	Identifies MTP joint incongruity	< 15°
Hallux valgus interphalangeus (HVI)	Between long. axis of distal phalanx and proximal phalanx		< 10 °

Treatment - Adult Hallux Valgus

Nonoperative
- shoe modification/ pads/ orthoses
  - indications
    - first line treatment
  - orthoses more helpful in patients with pes planus or metatarsalgia
Operative
- surgical correction
  - indications
    - when symptoms present and shoe modification fails
    - do not perform for cosmetic reasons alone
  - technique
    - soft tissue procedure
      - indicated in very mild disease in young female
    - distal osteotomy
      - indicated in mild disease
    - proximal or combined osteotomy
      - indicated in more moderate disease
    - fusion procedures
      - indicated in severe disease
    - 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 metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
    - surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
    - severe deformity with a DMAA > 20 perform a double MT osteotomy
  - technique
    - soft tissue procedure alone not successful
    - similar to adults if physis is closed (except in severe deformity)

Techniques

Soft Tissue Procedure
- modified McBride
  - indications
    - never appropriate in isolation
    - in conjunction with
      - medial eminence resection
      - osteotomy
  - technique
    - medial capsule of 2nd MTP is sutured to lateral capsule of 1st.
    - adductor hallucis is released and interposed.
Osteotomies
- distal metatarsal osteotomy
  - indications
    - mild disease (HVA ≤ 40, IMA < 13)
  - distal metatarsal osteotomies include
    - Chevron
    - biplanar Chevron
    - Mitchell
  - may be combined with proximal phalanx osteotomy
- proximal metatarsal osteotomy
  - indications
    - moderate disease (HVA >40°, IMA >13°)
  - proximal metatarsal osteotomies include
    - crescentric 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
Fusion procedures
- Lapidus procedure (1st metatarsocuneiform arthrodesis)
  - indications
    - severe deformity
    - Metatarsus primus varus
    - hypermobile 1st tarsometatarsal joint
- MTP Arthrodesis
  - indications are hallux valgus in
    - cerebral palsy
    - Down's syndrome
    - Rheumatoid arthritis
    - Gout
    - Severe DJD
    - Ehler-Danlos
Resection arthroplasty
- proximal phalanx (Keller) resection arthroplasty
  - indications
    - largely abandoned
    - still indicated in some elderly patient with reduced function demands

Surgical Indications for Various Techniques to treat Hallux Valgus
	HVA	IMA	Modifier	Procedure
Mild	< 25°	<12°	Distal osteotomy	Chevron osteotomy (or Mitchell). Biplanar if DMAA > 15°
				Chevron osteotomy (oM) with Distal ST realignment
Moderate	26-40°	13-15°	Proximal osteotomy +/- distal osteotomy	Chevron (oM) + Akin osteotomy
				Proximal MT osteotomy and distal ST realignment (oM)
Severe	41-50°	16-20°	Double osteotomy	- Proximal MT osteotomy and distal ST realignment
			DMAA > 15°	Lapidus combined with Reverdin procedure
			Elderly patient	Keller
			Juvenile/Adolescent with DMAA > 20	Double osteotomy of first ray
Surgical Indications for Specific Conditions
Juvenile/Adolescent with open physis				First cuneiform osteotomy
Hypermobile 1st MT				Lapidus
DJD				Arthrodesis
Skin breakdown				simple bunionectomy with medial eminance removal
Gout				arthrodesis
Recurrence with pain in 1st TMT joint				Lapidus
Rheumatoid arthritis				Fusion
Down's syndrome, CP, Ehler-Danlos				Arthrodesis first MTP joint

Procedure	Technique	Indications	Complications
Modified McBride	a soft tissue only procedure: medial capsule of 2nd MTP is suture to lateral capsule of 1st. interposition of adductor hallucis is realeased and interposed.	30-50 y/o female withHVA 15-25 IMA <13 IPA < 15	-Recurrence -Hallux varus
Original McBride	included lateral sesamoidectomy and has been abandoned	-never indicated
Chevron	Distal 1st MT osteotomy (intra-articular). Can perform in two planes (Biplanar distal Chevron)	reserved for mild to moderate deformities in adults and children	-AVN of MT head -recurrence -dorsal malunion with transfer metatarsalgia
Mitchell	Distal 1st MT osteotomy (extra-articular). More proximal than Chevron)	same as Chevron. eserved for mild to moderate deformities	-recurrence -malunion -transfer metatarsalgia
Akin	proximal pahalanx medial closing wedge osteotomy	-combined with Chevron in moderate to severe deformities -hallux valgus interphalangeus
Scarf / Ludloff / Mau	Metatarsal shaft osteotomies.	-IMA 14-18° -DMAA is normal or increased	-dorsal malunion with transfer metatarsalgia -recurrence
Proximal crescentric or Broomstick	Proximal metatarsal osteotomies. Combined with medial eminence removal and first web space lateral capsular and adductor tendon release	Severe deformity IMA > 20 HVA > 50	-hallux varus -dorsal malunion with transfer metatarsalgia -recurrence
Keller resection arthroplasty	Include medial eminence removal and resection of base of proximal phalanx	largerly 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		-indicated in moderate to severe hallux valgus - DJD of 1st MTP - 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 iliac crest bone graft)	-chilren with ligamentous laxity, flatfoot, and hypermobile first ray - adolescent with an open physis	Nonunion (may or may not be symptomatic)

Complications

Recurrence
- most common cause of failure is insufficient preoperative assessment and failure to follow indications
  - e.g., failure to recognize DMAA > 15°
  - e.g., failure to do adequate distal soft tissue realignment
- more common in juvenile/adolescent population
- noncompliant patient that bears weight
Avascular necrosis
- medial capsulotomy is primary insult to blood flow to metatarsal head
- distal metatarsal oseotomy and lateral soft tissue release inconjuction do not increase risk for AVN
Dorsal malunion with transfer metatarsalgia
- due to overload of lesser metatarsal heads
- risk associated with
  - Lapidus
  - proximal crescentric osteotomies
Hallux Varus
- caused by
  - overcorrection of 1st IMA
  - excessive lateral capsular release with overtightening of medial capsule
  - overresection of medial first metatarsal head
  - lateral sesamoidectomy
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
- shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release
Neuropraxia
- Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.

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Qbank (8 Questions)

TAG

(OBQ10.138) A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Physical exam is notable for tenderness over the medial prominence of the first metatarsophalangeal joint and hypermobility of the first ray. Shoe modifications have failed to provide relief. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. Each of the following are associated with a better clinical outcome EXCEPT: Topic

Review Topic

FIGURES: A

1. Multiple screw fixation across the metatarsocuneiform arthrodesis
2. Augmentation of the metatarsocuneiform arthrodesis with bone grafting
3. Dorsiflexion unloading of the first metatarsal
4. Correction of the first intermetatarsal angle
5. Failure of conservative treatments prior to surgery

PREFERRED RESPONSE ▶

DISCUSSION: The clinical photograph and radiograph demonstrate hallux valgus with a large first intermetatarsal angle. Metatarsus primus varus and hypermobility of the first ray are both indications for including metatarsocuneiform arthrodesis in the surgical correction of hallux valgus. Anatomic plantarflexion of the first metatarsal is crucial to prevent loading of the lesser metatarsals following surgery. Myerson et al reports the results of 53 patients treated with metatarsocuneiform arthrodesis for hallux valgus and metatarsus primus varus. They found that 92% acheived clinical satisfaction despite numerous complications including 7 superficial pin tract infections, 3 dorsal bunions, 7 nonunions, 1 hallux varus, and 3 neuromas of the deep peroneal nerve. Only 1 of the complications needed secondary surgery. Sangeorzan et al reports the results of metatarsocuneiform arthrodesis in 33 patients with hallux valgus and a hypermobile first ray and 7 patients with previous failed bunion surgery. Successful union occured in 90%, and 75% were considered successful clinical results. Best results were acheived with bone grafting, multiple screw fixation, and accurate plantarflexion of the first metatarsal.

REFERENCES:

1. Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle. 1992Mar-Apr;13(3):107-15. PMID:1601337 (Link to Abstract)

2. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1989 Jun;9(6):262-6. PMID:2744666 (Link to Abstract)

Question Authors:

John Badylak MD,

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TAG

(OBQ09.211) A 67-year old female presents with the bilateral foot deformity shown in Figures A and B. All of the following contribute to the risk of recurrence after surgery EXCEPT: Topic

Review Topic

FIGURES: A

1. Resection of the lateral sesamoid
2. Lack of lateral capsular release
3. Lack of medial metatarsophalangeal joint capsule closure
4. Use of an Akin procedure alone for a moderate to severe deformity
5. Undercorrection of the widened 1-2 intermetatarsal (IMA) angle

PREFERRED RESPONSE ▶

DISCUSSION: The patient has bilateral hallux valgus. Resection of the lateral sesamoid would likely lead to hallux varus and not hallux valgus recurrence. Akin procedure is a closing wedge osteotomy of the proximal phalanx when the proximal phalangeal articular angle >10° but does not correct hallux valgus well. Metatarsal osteotomies, such as the Chevron, are used to bring the metatarsal shaft laterally to reduce the IMA but undercorrection of the IMA would likely lead to hallux valgus recurrence. Lateral soft tissue release and medial capsular reefing can be used to correct hallux valgus in combination with bony procedures, but its important to avoid an extensive lateral capsular release to minimize the risk of metatarsal head osteonecrosis.

REFERENCES:

1. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15

2. Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 150-269

Question Authors:

Michael Hughes MD,

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TAG

(OBQ08.166) A 55-year-old female attorney complains of progressive pain and deformity of the great toe. The pain is localized to a prominence of the medial metatarsal head. A clinical image is provided in figure A. Which of the following best describes the hallux deformity? Topic

Review Topic

FIGURES: A

1. Valgus and supination
2. Valgus and pronation
3. Valgus and hyperextension
4. Varus and supination
5. Varus and pronation

PREFERRED RESPONSE ▶

DISCUSSION: Bunions are a common deformity of the great toe that is most prevalent in the aging female cohort. The etiology is multi-factorial including genetic predisposition and chronic exposure to narrow toe box shoes. The static soft tissue constraints attenuate medially and contract laterally, and the plantar dynamic flexors deviate laterally pulling the great toe into valgus and pronation. Illustration A is an example of this deformity. Coughlin summarizes the evaluation, diagnosis, and treatment of hallux valgus.

Illustrations: A

REFERENCES:

1. Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 150-269

2. Coughlin MJ. Hallux valgus. J Bone Joint Surg Am. 1996 Jun;78(6):932-66. PMID:8666613 (Link to Abstract)

Question Authors:

John Badylak MD,

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TAG

(OBQ08.211) A 57-year-old female underwent surgery for severe hallux rigidus. Postoperative radiographs are shown in Figure A. One year later she complains of pain at the 2nd metatarsal head and her exam shows a plantar callosity under the 2nd metatarsal head. What procedure should have been combined with her initial operation to prevent this outcome? Topic

Review Topic

FIGURES: A

1. Second metatarsalphalangeal joint arthrodesis
2. Second metatarsal osteotomy (Weil) with extensor tendon and dorsal capsular release
3. Flexor to extensor tendon transfer (Girdlestone-Taylor)
4. Second metatarsal osteotomy (Helal) with extensor tendon and dorsal capsular release
5. Second metatarsal head resection with extensor tendon and dorsal capsular release

PREFERRED RESPONSE ▶

DISCUSSION: The second metatarsal osteotomy (Weil), is an intra-articular osteotomy that achieves longitudinal decompression through shortening and will correct the longer 2nd metatarsal in relation to the first metatarsal. The first metatarsal bears half the weight of the forefoot and this patient's plantar callosity under the 2nd metatarsal head is clinical evidence of abnormal pressure transfer due to the longer 2nd metatarsal (seen in Figure A). The foot tripod can also be altered by hallux valgus as the proximal phalanx moves into valgus, the splay between the first and second rays increases (IM angle), the metatarsal moves into varus and elevates, and weight-bearing is transferred from the 1st metatarsal head to the the 2nd metatarsal head. A shortening osteotomy with extensor tendon and dorsal capsular release is the most appropriate option listed to address the second MTP metatarsalgia.

The Weil osteotomy of the metatarsal head is preferable to the Helal osteotomy of the metatarsal shaft to correct metatarsalgia due to higher rates of nonunion and pseudarthrosis with shaft osteotomies as demonstrated in the article by Trnka et al. Illustration A shows the difference between the Weil osteotomy (osteotomy B) and the Helal osteotomy (osteotomy A).

Illustrations: A

REFERENCES:

1. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15

2. Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79 PMID:10063974 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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TAG

(OBQ07.237) Which of the following clinical scenarios regarding hallux valgus could be appropriatley treated with a modified McBride procedure? Topic

Review Topic

1. 35-year-old female with a 20 degree HVA, a 11 degree IMA, and an incongruent 1st MTP joint
2. 40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a congruent 1st MTP joint
3. 70-year-old female with a 35 degree HVA, and a 13 degree IMA with a hypermobile 1st ray
4. 65-year-old female with a 25 degree HVA, a 14 degree IMA, and severe hallux rigidus
5. 85-year old minimally ambulatory male with a 45 degree HVA, and a 20 degree IMA

PREFERRED RESPONSE ▶

DISCUSSION: The Modified McBride procedure is indicated in patients 30-50 years old with an incongruent joint, a HVA less than 25 degrees, and an IMA deformity less than 15 degrees. This soft tissue procedure should be avoided in moderate or severe hallux valgus deformity due to the increased risk of recurrence. Surgical technique includes release of adductor hallucis, transverse metatarsal ligament, and lateral capsule combined with excision of medial eminence and plication of the capsule medially. In patients with moderate hallux valgus deformity (HVA 26-40 deg, IMA 13-15 deg) a proximal osteotomy should be performed. In patients with moderate deformity and a hypermobile 1st ray, a Lapidus procedure (includes 1st TMT fusion) should be considered. A MTP arthodesis is indicated when concomitant severe hallux rigidus is present, and a Keller (includes partial resection of proximal phalanx) procedure should be considered in an elderly, low demand individual with severe deformity. Illustration A is an AP radiograph of the foot demonstrating the technique used in measuring the HVA and IMA.

Illustrations: A

REFERENCES:

1. Mizel MS, Miller RA, Scioli MW (eds). OKU: Foot and Ankle 2. 1998. pg 135-150.

Question Authors:

Joshua Blomberg MD,

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TAG

(OBQ06.267) A 34-year-old woman presents with right foot pain and and a callus over the 1st metatarsalphalangeal joint. A clinical image is shown in Figure A. Accomodative shoewear has failed to relieve symptoms. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures B and C. This distal metatarsal articular angle (DMAA) is measured at 15 degrees. Which of the following operative procedures is most appropriate for this deformity? Topic

Review Topic

FIGURES: A

1. Closing wedge osteotomy of the proximal phalanx (Akin)
2. Distal soft-tissue release
3. Distal metatarsal osteotomy
4. Medial eminence resection and exostectomy (Silver)
5. Scarf osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: This patient has a moderate hallux valgus deformity as shown by the intermetatarsal angle of 15 degrees shown in Figure B, and the hallux valgus angle of 40 degrees shown in Figure C. A Scarf osteotomy is the only procedure of the available options in isolation appropriate for this amount of deformity.

If there is an incongruent joint, a soft tissue rebalancing is appropriate to make the joint congruent. With a congruent MTP joint and a DMAA of greater than 10 degrees, the distal articular surface needs to be realigned to create an appropriate correction.

The review article by Jones et al describes multiple methods of proximal osteotomies including crescentic, chevron, and oblique osteotomies. Overcorrection of IMA can lead to hallux varus and dorsiflexion at osteotomy can lead to transfer metatarsalgia. Double osteotomies can also be utilized for moderate deformities with Jones et al describing 92% satisfaction with a combined Akin and scarf osteotomy (Illustration A).

The Level 5 review article by Robinson et al discussing management of hallux valgus. They review several surgeries and note that the distal chveron is most often used in a non-congruent deformity with a normal DMAA. A complication with the Chevron and other distal osteotomies is the development of AVN of the first metatarsal head with an estimated incidence of up to 20% reported in the literature.

Illustration B demonstrates a hallux valgus deformity with a congruent MTP joint, as is also the case for the patient in this question. A distal soft-tissue release, including a release of the lateral structures, would be an appropriate procedure combined with a proximal metatarsal osteotomy if the MTP joint was incongruent.

Illustrations: A

REFERENCES:

1. Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005 Aug;87(8):1038-45. Review. PMID:16049235 (Link to Abstract)

2. Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br. 2004 Aug;86(6):830-6. PMID:15330023 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Ben Taylor MD, Daniel Farber MD,

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Cases

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Videos

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Posts

Tested Article: Scarf Osteotomy for Hallux Valgus. A Prospective Clinical and Pedobarographic Study.

Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. J Bone Joint Surg Br...

Foot & Ankle - Journal Club - Hallux Valgus

3/4/2013

28 responses

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Groups

ABOS II: Hallux Valgus

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Saro C, Andren B, Wildemyr Z, Fellander-Tsai L. Outcome after distal metatarsal osteotomy for hallux valgus: a prospective randomized controlled trial of two methods. Foot Ankle Int. 2007 Jul;28(7):778-87. PMID:17666169 (Link to Abstract)

Level of Evidence 4 (Case Series)

Chiodo CP, Schon LC, Myerson MS. Clinical results with the Ludloff osteotomy for correction of adult hallux valgus. Foot Ankle Int. 2004 Aug;25(8):532-6. PMID:15363373 (Link to Abstract)
Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ. Scarf osteotomy for hallux valgus. A prospective clinical and pedobarographic study. J Bone Joint Surg Br. 2004 Aug;86(6):830-6. PMID:15330023 (Link to Abstract)
Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle. 1992Mar-Apr;13(3):107-15. PMID:1601337 (Link to Abstract)
Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1989 Jun;9(6):262-6. PMID:2744666 (Link to Abstract)
Trnka HJ, Hofstaetter SG, Hofstaetter JG, Gruber F, Adams SB Jr, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. J Bone Joint Surg Am. 2008 Mar;90(3):531-9. Erratum in: J Bone Joint Surg Am. 2008 Jun;90(6):1337. PMID:18310703 (Link to Abstract)
Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79 PMID:10063974 (Link to Abstract)
Trnka HJ, Zembsch A, Easley ME, Salzer M, Ritschl P, Myerson MS. The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up. J Bone Joint Surg Am. 2000 Oct;82-A(10):1373-8. PMID:11057464 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Easley ME, Trnka HJ. Current concepts review: hallux valgus part II: operative treatment. Foot Ankle Int. 2007 Jun;28(6):748-58. Review PMID:17592710 (Link to Abstract)
Coughlin MJ. Hallux valgus. J Bone Joint Surg Am. 1996 Jun;78(6):932-66. PMID:8666613 (Link to Abstract)
Easley ME, Trnka HJ. Current concepts review: hallux valgus part II: operative treatment. Foot Ankle Int. 2007 Jun;28(6):748-58. Review. PMID:17592710 (Link to Abstract)
Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005 Aug;87(8):1038-45. Review. PMID:16049235 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 150-269
Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 150-269
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15

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Mizel MS, Miller RA, Scioli MW (eds). OKU: Foot and Ankle 2. 1998. pg 135-150.

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Hallux Valgus

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