Updated: 12/29/2018

Hallux Varus

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Introduction
  • Characterized by medial deviation of great toe relative to the 1st metatarsal bone
  • Epidemiology
    • incidence
      • varies between 2-14% after corrective surgery for hallux valgus deformities
    • demographics
      • more commonly seen in women
  • 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
  • Prognosis
    • natural history of disease
      • in established hallux varus, the role of nonoperative management is limited
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
 

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