Treatment of hallux valgus deformity

Abstract

Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone.Taking the patient's history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus.Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms.There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial.Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically.Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved. Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.

Keywords: bunion; hallux valgus; metatarsus primus varus; osteotomy, treatment.

Fig. 1

Angular measurements. a) intermetatarsal angle (IMA); b) hallux valgus angle (HVA); c) hallux valgus interphalangeus angle (HVI); d) position of the medial sesamoid in relation to the axis of the metatarsal head; e) distal metatarsal articular angle (DMAA).

Fig. 2

Operative treatment algorithm.

Fig. 3

Incision for McBride procedure.

Fig. 4

First metatarsal osteotomies. a) modified chevron osteotomy in shape of a reversed ‘L’; b) scarf osteotomy.

Fig. 5

Scarf osteotomy with simultaneous Akin osteotomy.

Fig. 6

Akin osteotomy as an adjunct to a chevron osteotomy.

Fig. 7

The modified Lapidus procedure: corrective TMT arthrodesis with two crossed screws through the first TMT joint and adjunctive Akin osteotomy.

Fig. 8

First MTP joint arthrodesis showing surfaces drilled with a fine Kirschner wire after achieving a ‘ball-and-socket’ situation.

Fig. 9

Positioning of first MTP joint in slight dorsiflexion to allow walking.

Fig. 10

Loosening of first MTP joint arthroplasty.