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Updated: Feb 21 2024

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
      • 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
      • windlass mechanism becomes less effective
        • leads to transfer metatarsalgia
    • Associated conditions
      • hammer toe deformity
      • callosities
      • pes planus
        • associated with deformity progression
    • 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
  • Anatomy
    • Pathoanatomy cascade 
  • 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
        • 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
        • radiographic parameters (see below) guide treatment
        • Radiographic Measurements in Hallux Valgus
        • 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
          • 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
        • Lapidus procedure, in isolation, can fail to correct pronation of the first ray
      • 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 Specific Conditions
      • Juvenile/Adolescent with open physis
      • First cuneiform osteotomy
      • Hypermobile 1st MT
      • Lapidus procedure
      • DJD
      • MTP arthrodesis
      • Skin breakdown
      • Simple bunionectomy with medial eminence removal
      • Gout
      • MTP arthrodesis
      • Recurrence with pain in 1st TMT joint
      • Lapidus procedure
      • Rheumatoid arthritis
      • MTP arthrodesis
      • Down's syndrome, CP, Ehler-Danlos
      • MTP arthrodesis
      • Surgical Indications for Various Techniques to treat Hallux Valgus
      • HVA
      • IMA
      • Modifier 
      • Procedure
      • Mild
      • < 25°
      • < 13°
      • Distal MT osteotomy215737
      •  Chevron osteotomy
      • Biplanar if DMAA > 10° with mod McBride
      • Moderate
      • 26-40°
      • 13-15°
      • Proximal MT +/- distal MT osteotomy
      •  Chevron/mod McBride + Akin
      • Proximal MT osteotomy and mod McBride
      • 41-50°
      • 16-20°
      • Double osteotomy, DMAA > 15°
      • Proximal MT osteotomy plus biplanar chevron, mod McBride
      • Lapidus procedure plus Akin
      • 41-50°
      • 16-20°
      • Elderly/very low demand patient
      • Keller resection arthroplasty
      • 41-50°
      • 16-20°
      • 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 15-25°
      •  IMA < 13°
      • 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 and children
      • 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
      • 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
      • Recurrence
      • Proximal Crescentic or Broomstick 
      • Proximal metatarsal osteotomy plus modified McBride
      • Severe deformity
      • IMA > 20°
      • HVA > 50°
      • 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
      • 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)
  • 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
      • associated with incomplete reduction of the sesamoids
    • 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)
        • 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
        • overresection of medial first metatarsal head
        • lateral sesamoidectomy
    • Cock up toe deformity
      • due to injury of FHL
      • most severe complication with Keller resection
      • 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 (Weil) 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.
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