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  • 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
        • 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
  • 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
    • windlass mechanism becomes less effective
      • leads to transfer metatarsalgia  
  • Associated conditions
    • hammer toe deformity
    • callosities
  • 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
  • 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
      • sesamoid pain/arthritis
    • evaluate associated deformities
      • pes planus
      • lesser toe deformities
      • midfoot and hindfoot conditions
  • 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 
      • 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 distal articular cap Identifies MTP joint incongruity < 10°
Hallux valgus interphalangeus (HVI) Between long. axis of distal phalanx and proximal phalanx   < 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°
        • severe deformity with a DMAA > 20 consider a double MT osteotomy to correct orientation of MT head articular cartilage
      • technique
        • soft tissue procedure alone not successful
        • similar to adults if physis is closed (except in severe deformity)
  • 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 ≤ 40, IMA < 13) 
      • distal metatarsal osteotomies include
        • Chevron     
        • biplanar Chevron (corrects DMAA)
        • Mitchell
        • may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy)
    • proximal metatarsal osteotomy    
      • indications
        •  moderate disease (HVA >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
        • some authors perform Akin together with/at the time of proximal osteotomy+distal soft tissue correction because this results in progressive increase in 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
        • Severe DJD
        • Ehler-Danlos
  • Resection arthroplasty
    • proximal phalanx (Keller) resection arthroplasty
      • indications
        • largely abandoned
        • rarely indicated in some elderly patient with reduced function demands
Surgical Indications for Various Techniques to treat Hallux Valgus
< 25°
Distal osteotomy
Chevron osteotomy. Biplanar if DMAA > 10° usually with mod McBride
Proximal osteotomy +/- distal osteotomy
Chevron/mod McBride + Akin osteotomy
Proximal MT osteotomy and mod McBride
Double osteotomy DMAA > 15°
- Proximal MT osteotomy plus biplanar chevron, mod McBride

Lapidus procedure plus Akin
Elderly/very low demand patient
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 procedure
MTP Arthrodesis
Skin breakdown
simple bunionectomy with medial eminance removal
MTP Arthrodesis
Recurrence with pain in 1st TMT joint
Lapidus procedure
Rheumatoid arthritis
MTP Arthrodesis
Down's syndrome, CP, Ehler-Danlos
MTP Arthrodesis

Modified McBride

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

30-50 y/o female withHVA 15-25
IMA <13
IPA < 15
-Hallux varus
Original McBride included lateral sesamoidectomy and has been abandoned -never indicated -Hallux Varus

Distal 1st MT osteotomy (intra-articular). Can perform in two planes (Biplanar distal Chevron)

reserved for mild to moderate deformities in adults and children, biplanar chevron-->correct increased DMAA


-AVN of MT head
-dorsal malunion with transfer metatarsalgia
Mitchell Distal 1st MT osteotomy (extra-articular). More proximal than Chevron) same as Chevron. reserved for mild to moderate deformities, rarely utilized -recurrence
-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. -IMA 14-18°
-DMAA is normal or increased
-dorsal malunion with transfer metatarsalgia
Proximal crescentric or Broomstick Proximal metatarsal osteotomies. (plus modified McBride) Severe deformity
IMA > 20
HVA > 50
-hallux varus
-dorsal malunion with transfer metatarsalgia
Keller resection arthroplasty

Include 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  

-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 autograft)

-children with ligamentous laxity, flatfoot, and hypermobile first ray
- adolescent with an open physis

Nonunion (may or may not be symptomatic)

  • 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
  • Avascular necrosis 
    • medial capsulotomy is primary insult to blood flow to metatarsal head
    • distal metatarsal oseotomy and lateral soft tissue release inconjunction do not increase risk for AVN (Chevron plus lateral release thought to increase risk in the past)
  • 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
      • 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 medial branch of the 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.  

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