Updated: 6/7/2021

Hallux Varus

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  • summary
    • Hallux Varus is a condition characterized by the medial deviation of the hallux relative to the 1st metatarsal bone, most often the result of overcorrection from prior bunion surgery. 
    • Diagnosis is made clinically with varus angulation of the great toe.
    • Treatment may be observation or operative depending on severity of varus, prior surgeries to the hallux, and patient symptoms.
  • Epidemiology
    • Incidence
      • varies between 2-14% after corrective surgery for hallux valgus deformities
    • Demographics
      • more commonly seen in women
  • Etiology
    • Pathophysiology
      • causes
        • congenital
          • metatarsal physeal bracket
        • acquired
          • iatogenic (overcorrection from surgery)
          • trauma
          • inflammatory (e.g. rheumatoid arthritis, ankylosis spondylitis)
          • neurological (e.g. Charcot-Marie-Tooth, post-polio)
      • pathoanatomy
        • loss of osseous support
        • excessive resection of the medial eminence
        • excision of fibular (lateral) sesamoid
        • overrelease of lateral capsular structures
        • overplication of medial capsule
        • overtranslation of intermetatarsal angle or hallux valgus interphalangeus
    • Orthopaedic manifestations
      • hallux varus usually presents with three possible components
        • medial deviation of the hallux relative to first MTP joint
        • supination of the phalanx
        • claw toe deformity
  • Presentation
    • History
      • main complaint
        • appearance of the great toe as being "too straight" to excessive medial deviation
        • difficulty wearing shoes
    • Symptoms
      • often asymptomatic
      • pain indicates underlying joint arthritis or trauma
      • may also complain of decreased ROM, instability, weakness with push-off
    • Physical exam
      • inspection
        • varus anglulation of great toe
        • dorsal contracture of the MTP joint with or without IP joint contracture
        • EHL may be medially displaced, creating a "bowstring" deformity
        • tibial (medial) sesamoid may be medially displaced
      • motion
        • determine if fixed or flexible deformity
  • Imaging
    • Radiographs
      • recommended views
        • weight-bearing AP & lateral views of the foot,
      • additional views
        • non-weightbearing oblique views, and sesamoid axial views
      • findings
        • hallux valgus angle < 0 degrees (normal 5-15 degrees)
        • excessive medial eminence resection
        • overcorrection osteotomies
        • reduced IMA between first and second metatarsals
        • medial subluxation of tibial seasmoid
        • absent lateral seasmoid
        • degenerative changes at MTP or IP joint
    • CT scan or MRI
      • indications
        • not usually required
        • may be considered if underlying osteonecrosis of first metatarsal
  • Treatment
    • Nonoperative
      • shoe modifications to accommodate the deformity
        • indications
          • flexible, longstanding and asymptomatic deformities
          • patient preference
        • modalities
          • wider and more flexible toe box shoes
          • padding boney prominences
        • outcomes
          • mild flexible and stable deformities are usually well tolerated
      • taping or splinting the deformity
        • indications
          • early post-operative varus deformities after hallux correction surgery
        • modalities
          • frequent taping and follow-up
          • duration should be maintained for up to 3 months or until soft-tissues have healed
        • outcomes
          • may correct deformity if initiated within the first few weeks from surgery
    • Operative
      • lateral closing wedge osteotomy
        • indications
          • overcorrection of proximal/distal metatarsal osteotomy, or proximal phalangeal osteotomy
        • techniques
          • revision osteotomy to re-establish alignment
          • consider release of scar tissue and repair of the lateral ligaments
      • tendon transfer with medial release
        • indications
          • flexible first MTP joint deformities
        • techniques
          • aDDuctor hallucis tendon re-attachment with medial release
            • may be difficult in cases of previous McBride-type surgery
          • aBDuctor hallucis tendon transfer on the base of the lateral base of proximal phalanx
            • combined with the reattachment or reefing of the conjoined tendon in the web space
          • transfer or EHL or EHB, medial release, with or without IP joint arthrodesis
            • transfer portion of EHL or EHB under the transverse intermetatarsal ligament to the distal metatarsal neck (from lateral to medial)
      • first MTP arthrodesis
        • indications
          • absolute
            • fixed (not passively correctable) first MTP joint with significant deformity and non-functioning hallux
            • painful joint arthritis
          • relative
            • excessive medial eminence resection beyond tibial seasmoid sulcus
  • Prognosis
    • Natural history of disease
      • in established hallux varus, the role of nonoperative management is limited
Flashcards (2)
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Questions (4)

(SBQ12FA.62) A 60-year-old woman presents with the condition seen in Figure A following corrective forefoot surgery 6 years ago. She has attempted to manage her condition with shoe wear modifications, taping and splinting but has consistent pain. Her metatarsophalangeal (MTP) joint is not completely reducible on exam. Which of the following treatment options offers her predictable alignment and pain relief?

QID: 3869

MTP joint hemiarthroplasty



Lateral metatarsal opening wedge osteotomy



First metatarso-cuneiform arthrodesis



MTP joint arthrodesis



MTP joint interpositional arthroplasty



L 1 B

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