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Updated: Jun 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
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