Adult Hallux Valgus
- Hallux Valgus is not a single disorder, but it’s a complex deformity.
- It is defined as lateral deviation of the great toe, with medial deviation of first metatarsal.
- It’s more common in women.
- There ‘s a family history in 70 % of patients.
- Intrinsic factors:
- Genetic predisposition,
- Ligamentous laxity,
- Predisposing anatomy (convex metatarsal head, pes planus).
- Rheumatoid arthritis.
- Cerebral palsy..
- Extrinsic factors:
- Certain types of shoe wear (narrow toe box, high heels) also play a role.
Deformities in hallux valgus
- Medial capsular becomes attenuated and stretched.
- Proximal phalanx drifts laterally, leading to the following conditions:
- Plantar-lateral migration of abductor hallucis; change in position causes the muscle to plantar flex and pronate the hallux.
- Stretching of the extensor hood of the extensor hallucis longus.
- Lateral deviation of the extensor hallucis longus and flexor hallucis longus (FHL), causing a muscular imbalance and deforming force for valgus progression and pronation of the great toe.
- First metatarsal head moves medially off the sesamoids because of the unopposed pull of the adductor hallucis.
- Secondary contracture of the:
- lateral capsule
- adductor hallucis
- lateral metatarsal-sesamoid ligament
- intermetatarsal ligament.
- Flattens of the sesamoid ridge on the plantar surface of the first metatarsal head (the crista) because of pressure (abutment) from the tibial sesamoid.
- The valgus posture of the great toe frequently causes hammer toe–like deformity of the second toe.
The entire spectrum of hallux valgus is: varus deformity of the first metatarsal, valgus of the great toe, bunion formation, arthritis of the first metatarsophalangeal joint, hammer toe of one or more toes, corns, calluses, and metatarsalgia.
- Difficulty with shoe wear due to medial eminence.
- Pain over prominence at MTP joint.
- Compression of digital nerve may cause numbness and anesthesia.
- Physical Examination:
- Recommended X-ray views for the foot include:
- AP view.
- Lateral view.
- Oblique view.
- Sesamoid view.
|Hallux valgus angle (HVA)||Angle is formed by line along first metatarsal shaft and line along shaft of proximal phalanx.||< 15|
|First-second intermetatarsal angle (IMA)||Angle is formed by line along first metatarsal shaft and line along second metatarsal shaft.||< 9|
|Hallux valgus interphalangeus (HVI)||Angle is formed by line along shaft of proximal phalanx and line along shaft of distal phalanx.||< 10|
|Distal metatarsal articular angle (DMAA)||Angle is formed by line along articular surface of first metatarsal and line perpendicular to axis of first metatarsal.||< 10|
- First line of treatment in mild deformities.
- Methods include:
- Adjusting shoe wear and increasing the size of the toe box may limit pain with pressure along the prominent dorsomedial eminence.
- There is no role for “corrective” braces or splints.
- The best indication for operative intervention is pain that has not responded to adjusting shoe wear or activity.
- Surgical correction of a hallux valgus deformity is NOT a cosmetic procedure.
- All patients should undergo a soft tissue release and medial eminence resection and capsular repair with all associated osteotomies and first TMT arthrodesis (Lapidus).
- Procedures are not appropriate in isolation (high recurrence rate):
- Distal soft tissue release (modified McBride).
- Medial eminence resection.
- Medial capsular imbrication.
- Isolated osteotomy without associated soft tissue correction.
|IMA ≤ 13 degrees AND HVA ≤ 40 degrees||• Distal metatarsal osteotomy (chevron).|
|IMA > 13 degrees OR HVA > 40 degrees||• Proximal metatarsal osteotomy / scarf.|
|Instability of the first TMT/joint laxity||• Lapidus (fusion of first TMT joint).|
|Arthritis or spasticity||First MTP fusion|
|Increased DMMA||Distal metatarsal redirectional osteotomy in addition to metatarsal translational osteotomy|
- Avascular necrosis (AVN) of the metatarsal head.
- Recurrence: highly associated with:
- Undercorrection of IMA.
- Isolated soft tissue reconstruction (modified McBride) .
- Isolated resection of the medial eminence.
- Dorsal malunion.
- Hallux varus.
Images from Campbell 12th Ed book.