Hallux Valgus Treatment & Management

An adequate physical examination to determine the etiology and specific deformity is necessary for treatment planning. Medical therapy can be used to address the etiology, but it cannot change the irreversible cartilage, bony, and soft-tissue adaptations of the deformity. Therefore, most medical therapies are aimed at assuaging symptoms.

Adapting footwear

Spot-stretching shoes or using shoes with wider and deeper toe boxes may be considered. Padding and strapping have limited success in long-term management, other than to relieve footwear or digital pressure. However, in the elderly population, padding and strapping may be the best options if surgical correction is medically contraindicated.

Pharmacologic or physical therapy

Nonsteroidal anti-inflammatory drugs and physical therapy can be offered to relieve acute, episodic inflammatory processes. Corticosteroid injections can also be useful for acute inflammatory conditions in the first metatarsophalangeal joint. No evidence supports prolonged physical therapy for hallux valgus.

Functional orthotic therapy

Functional orthotic therapy may be implemented to control foot biomechanics. This approach can relieve symptomatic bunions, though the foot and first metatarsophalangeal joint must maintain some degree of flexibility.^[5] For example, the joint cannot be laterally track-bound on clinical examination, and the sesamoid position cannot be greater than 4 on radiography. These 2 findings indicate a nonreducible deformity, or one that cannot be manipulated to a neutral, pain-free position.

Flexibility is necessary, as it allows the orthotic to manipulate the joints and foot and reduce the deformity, providing stability and thus relief. A rigid deformity can only be corrected surgically, as it can no longer be manipulated.

If orthotics are to be manufactured for a patient, the physician must be familiar with the orthotic prescription form to control the patient's deformity, though this form varies among different manufacturers. A sufficient understanding of the patient's requirements may enable the physician to use simple over-the-counter devices instead of more costly custom-molded devices.

The physician should be aware of the following issues: the patient's activities and weight, the top cover of the orthotic, the rearfoot/forefoot post, the biomechanical examination, and the possible modifications. These are discussed in more detail below.

• Activity

  • When prescribing orthotics, the physician should ask questions such as these: "When will the patient primarily be using the orthotics? In dress shoes? During sports activities? During the day at work?"
  • Generally, dress shoes afford the patient the option to wear smaller devices, but these lack the control of larger orthotics. Patients participating in sports require more shock-absorbing capability from the orthotic; therefore, a more pliable material should be used.
  • Furthermore, the type of material used for the shell or orthotic can vary. A rigid material, such as graphite, is thin and lightweight, does not deform, and is durable. However, graphite has a tendency to crack; therefore, it should not be used for sports applications. Another option is polypropylene, a type of durable, flexible plastic that is resistant to breakage. It can easily be altered by grinding or heat molding in the office, whereas graphite cannot. One disadvantage of polypropylene is its tendency to deform over time and with use. Some physicians use leather or cork with success.
• Weight: The material used can be ordered in varying thicknesses. The heavier patient needs a thicker material that will not bend, crack, or deform under the patient's weight. As well, the bulkier the patient's shoe, the thicker the shell material that can be used without causing the orthotic to fit uncomfortably. A thicker material can add control.
• Top cover: Orthotics generally have liners on top of the shell, either for shock absorption or cushioning, or to act as the shoe liner. Choices include, but are not limited to, leather, vinyl, Spenco, ethylene vinyl acetate (EVA), Poron, and Pelite. Top covers do not contribute to the control of the orthotics and are not functionally necessary.
• Rearfoot/forefoot post: Applying a post, or exterior material, of a different material that is either molded with the shell or added on later can increase the stability and control of the orthotic. A rearfoot post is under the heel cup, and does not extend into the midfoot region. A forefoot post may be added for biomechanical control for a patient with a rigid deformity, such as rigid forefoot valgus, which cannot be controlled satisfactorily or comfortably with the orthotic because of the nonmaneuverability of the patient's foot. Therefore, the patient with rigid forefoot valgus requires a piece of material added extrinsically, or under the orthotic on the lateral aspect, to balance the forefoot to the rearfoot.
• Biomechanical examination

  • The physician must determine the type of deformity the patient has and obtain angular measurements to prescribe the correction.
  • A plaster non–weightbearing mold is made of the foot in a neutral position (rear foot neither everted or inverted), with the forefoot loaded to simulate weight bearing. From this cast, the orthotic manufacturer creates an orthotic with built-in corrections. For example, if the patient has a 4° flexible forefoot varus, the rear foot likely compensates for this deformity, thereby allowing the forefoot to bear weight evenly across all metatarsal heads. A well-built orthotic allows the foot to stand in a neutral position, both in the forefoot and rear foot, removing increased pressures and deforming forces caused by the compensation.
• Modifications

  • Modifications include measures such as increasing the height of the heel cup (for more control), creating a wider medial arch (for a collapsed, flat foot), providing plantar fascial groove (for a tight, painful plantar fascia), and using a metatarsal pad (for pain under the second metatarsal head from overloading due to inadequate weight bearing by the hallux).
  • If the etiology is determined to be a metabolic or systemic condition, it is best to work with a rheumatologist, neurologist, or primary care physician to stabilize, manage, and slow the progression of disease and to choose therapy for the hallux valgus deformity.

Surgical treatment can be offered when conservative therapy is impractical or fails to relieve the patient's symptoms. The goals of surgical treatment are to relieve symptoms, restore function, and correct the deformity. The clinician must consider the patient's history, physical examination, and radiographic findings before selecting a procedure. On occasion, the final procedure is determined intraoperatively when the physical appearance of the joint, bone, and tissue can be observed directly.^{[6, 7, 8, 9, 10, 11]}

The following features of the surgical repair allow successful correction of the deformity:

• Establishment of a congruous first metatarsophalangeal joint
• Reduction of the intermetatarsal angle
• Realignment of the sesamoids underneath the metatarsal head
• Restoration of the ability of the first ray to bear weight
• Maintenance or increase of the first metatarsophalangeal joint ROM
• Realignment of the hallux to a rectus position
• Correction and/or control of etiologic factors

The specific procedures vary depending on the surgeon's preference, the nature of the deformity, and the particular needs of the patient, though the surgeon can follow a simple algorithm based on clinical and radiographic findings to determine the procedure of choice (see image below).

The procedure is chosen to reduce the patient's symptoms most effectively and prevent recurrence. Selection is based on particular components of the hallux valgus, which can include positional and structural deformities of the metatarsophalangeal joint, adaptive changes of the first metatarsophalangeal joint, and the position and condition of the sesamoid apparatus.

The classes of surgical procedures include capsulotendon balancing or exostectomy, osteotomy, resectional arthroplasty, resectional arthroplasty with implant, first metatarsophalangeal joint arthrodesis, and first metatarsocuneiform joint arthrodesis.

Capsulotendon balancing or exostectomy

This procedure can be performed independently, but it is usually performed in conjunction with an osteotomy. It is designed to restore the integrity of the first metatarsophalangeal joint and reduce the medial osseous prominence of the metatarsal head.

Indications include a painful osseous medial prominence of the metatarsal head; deviated or subluxated first metatarsophalangeal joint; adequate, pain-free ROM; and reducible deformity. The patient's postoperative course includes limited-to-full weight bearing in a surgical shoe immediately following the procedure.

Osteotomy

Osteotomy (see images below) is performed to correct structural deformities associated with the cuneiform, metatarsal, and phalanges of the first ray, and typically includes a lateral release and capsulorraphy. These procedures should be performed at the level of the deformity.^{[8, 12]}

Akin first proposed osteotomy of the hallux in 1925 for the correction of hallux valgus. However, experience has shown that this is not a primary procedure to be used for the repair of hallux valgus deformity, as it does not directly restore the sesamoid position, address adaptive changes of the cartilage of the metatarsal phalangeal joint, or correct metatarsal deviations. Instead, hallux osteotomies are used to address deformity of the proximal phalanx and correct an abnormal hallux abductus interphalangeus angle, long proximal phalanx, abnormal distal articular set angle (DASA), or frontal plane rotational position of the hallux.

The common proximal phalanx osteotomy performed is the Akin procedure, in which a medial wedge is removed from the proximal phalangeal shaft. This procedure often is performed concomitantly with a procedure that addresses hallux valgus, should deformity of the proximal phalanx be present. Its use is best considered intraoperatively once the primary surgical procedures have been performed.

If an Akin operation is performed independently for correction of hallux valgus, the surgeon should anticipate even greater lateral subluxation of the first metatarsophalangeal joint that leads to rapid recurrence of the original condition despite the initial clinical improvement.

Metatarsal/cuneiform osteotomies address deformities along the metatarsal/cuneiform complex. Indications include an increased intermetatarsal angle, metatarsus primus elevatus, or increased proximal articular set angle with articular adaptation of the first metatarsal head. The levels at which they are performed include the distal, diaphyseal, and proximal levels along the metatarsal shaft.

Distal osteotomies are performed in the metaphyseal region and achieve only a relative correction of the intermetatarsal angle. They are inherently stable and are associated with fewer occurrences of head displacement/rotation or shaft elevation. The joint congruency is corrected primarily with this osteotomy. They may be performed for both a congruent joint as well as an incongruent joint with an intermetatarsal angle less than 15°. Following distal osteotomies, the patient typically has 2-6 weeks of limited weight bearing in a surgical shoe. Common complications include shortened first metatarsals, second metatarsalgia, restriction of motion, and recurrence of deformity.

Common distal or head osteotomies include the following: (1) the Reverdin-Laird procedure, a medially based wedge resection with lateral transposition of the metatarsal head; (2) the Austin or Chevron procedure, a horizontally directed V displaced osteotomy with lateral transposition of the metatarsal head; and (3) the Mitchell procedure, a lateral transpositional transverse osteotomy with preservation of a lateral cortical block of bone.

Diaphyseal osteotomy is associated with a decreased blood supply and is less stable than a distal procedure, but it can achieve a greater correction of the deformity and address a true proximal articular set angle (PASA) deviation. It can lengthen the first metatarsal after rotation or translocation to correct the intermetatarsal angle; therefore, it is a procedure of choice for short metatarsals. The midshaft osteotomy is performed for mild-to-moderate hallux valgus deformities, with an intermetatarsal angle greater than 15° but a hallux valgus angle less than 40°, though large degrees of correction can also be achieved with greater rotation of the fragments. In addition, this can be performed as an alternative to a base procedure. This procedure is best used in patients with good bone quality (ie, without significant osteopenia).

Common midshaft or diaphyseal osteotomies include (1) the Scarf procedure, in which a Z -shaped osteotomy in the transverse plane extends from the metatarsal head to the base with lateral rotation of the distal fragment; and (2) the Ludlof procedure, in which an oblique osteotomy is oriented dorsal and proximal to plantar distal from the head to the base with distal bone fragment transposed laterally.

The proximal osteotomy is considered to be the least stable, with the greatest risk for metatarsal elevation and fixation failure, but it achieves an actual instead of relative correction of the intermetatarsal angle. Base osteotomies are considered for hallux valgus deformities with an intermetatarsal angle greater than 15° and a hallux valgus angle greater than 40°, and in which the first metatarsocuneiform joint does not demonstrate hypermobility.

Proximal procedures necessitate the use of a non–weightbearing cast for 4-8 weeks until complete ossification occurs to prevent elevation of the metatarsal.

Common base or proximal osteotomies as follows: (1) In the crescentic method, a crescentic blade is used to transect the first metatarsal, resulting in a dome-shaped osteotomy. The distal segment can be rotated in the transverse and sagittal planes for correction of the deformity. (2) The closing abductory wedge (Loison/Balacescu type) procedure is a transverse osteotomy with the lateral wedge removed and the medial hinge kept intact. (3) The closing abductory wedge (Juvara) procedure is a long, oblique osteotomy extending proximal-medial to distal-lateral with the lateral wedge removed and medial hinge left intact.

Resectional arthroplasty

Resectional arthroplasty (see images below) is a joint-destructive procedure that most commonly is reserved for elderly patients with advanced degenerative joint disease and significant limitation of motion.

The typical resectional arthroplasty that is performed is known as a Keller procedure. It is performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected. The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups. The technique is inherently unstable and should be used judiciously. The postoperative course includes limited-to-full weight bearing in a surgical shoe immediately after the procedure.

Resectional arthroplasty with implant

Resectional arthroplasty with implant (see images below) is the same procedure as the resectional arthroplasty, with similar indications, but stability is markedly improved with the addition of the total implant. However, this operation is not without the complications inherent to implants, which include foreign-body reactions, synovitis, lysis of the bone, and implant failure.

First metatarsophalangeal joint arthrodesis

First metatarsophalangeal joint arthrodesis (see images below) is a joint-destructive procedure that offers a higher degree of stability and functionality. It is considered the definitive procedure for degenerative joint disease. It results in complete loss of motion at the first metatarsophalangeal joint and is reserved for patients with high activity levels and functional demands.

This is a difficult procedure to perform in elderly persons because of the need for non–weightbearing status for 4-8 weeks postoperatively. Indications include painful or severely limited first metatarsophalangeal joint ROM, significant degenerative arthritis, revision or repair of prior arthroplasty with implant or osteotomy (salvage procedure), extensive trauma to the first metatarsophalangeal joint not reparable with osteotomy, ligamentous laxity, and neuromuscular disease.

First metatarsocuneiform joint arthrodesis

Significant and/or hypermobile hallux abductovalgus may be reduced with arthrodesis of the first metatarsocuneiform joint (see images below). Indications include metatarsus primus varus, hypermobility of the first ray, metatarsalgia of the lesser metatarsals, and degenerative joint disease of the metatarsocuneiform joint.

A complete history and physical examination are required for surgical correction. Preoperative evaluation may include ECG; chest radiography; and laboratory workup, including a complete metabolic panel, complete blood count, coagulation studies, and urinalysis if warranted.

The history should include allergies, complications with anesthesia, bleeding disorders, use of anticoagulants, immunocompromised status, and tobacco use. The patient should be well informed of the etiology, course, and prognosis of the deformity, as well as the risks and benefits of conservative and surgical options.

Hallux valgus can generally be corrected surgically on an outpatient basis. Situations that may warrant hospital admission include the need for parenteral medications, perioperative complications or anesthetic complications, an inability to function independently, and coexisting medical conditions. Patients undergoing complex surgical procedures may also require hospitalization.

The choice of anesthetic techniques for the surgical procedure depend on the surgeon's, patient's, and anesthesiologist's preferences. These choices include general anesthesia, spinal anesthesia, or monitored anesthesia with local blocks. The block typically is performed with a short- and/or long-acting local anesthetic. For maximum benefit and preemptive analgesic effect, it is administered prior to the initial incision. A pneumatic ankle tourniquet is generally used to achieve hemostasis for better intraoperative visualization.

Prophylactic antibiotics generally are not warranted unless the surgery is anticipated to last longer than 2 hours, the patient is immunocompromised, or an implant is being inserted.

A linear dorsomedial longitudinal incision is created, extending from the mid shaft of the first metatarsal distally to the mid shaft of the proximal phalanx medial to the extensor hallucis longus tendon. The incision is deepened through skin and soft tissue, with care taken to identify and retract all vital neurovascular structures. Cauterization is used for bleeding as needed. The lateral release is then performed in stepwise fashion to achieve release of lateral contractures, with the hallux able to reduce without restriction, as seen in the image below. Capsulotomy is then performed and the periosteum is reflected to expose the metatarsal head.

The initial goals of the anatomic dissection are to provide access to the surgical area, to establish hemostasis, to identify and release any soft-tissue contractures, and to prepare the site for the osteotomy. Once this is accomplished, the predetermined osteotomy is performed. Fixation is achieved by using the lag technique described by the Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF).

Once fixed, the capsule, subcutaneous tissue, and skin are reapproximated, with capsulorraphy performed if warranted. Dressings consist of nonadherent gauze with dressings to splint the hallux in its newly corrected position.

The type of procedure performed and its inherent stability determine postoperative management of the osteotomy. Dressings applied at the time of the surgery should supply corrective forces (eg, derotation, plantarflexion, adduction) while the soft tissue remodels, with mild compression to control postoperative edema.

Pain should be well controlled postoperatively. The patient's weightbearing status is determined on the basis of the procedure performed, but generally is limited during the first 2 weeks to prevent deviation or displacement and to minimize edema. The patient may begin ROM exercises on a daily basis after the sutures are removed, and weight bearing is advocated to prevent limitation of joint motion from excessive scarring.^[2]

Radiographs to assess alignment, fixation, and progression of ossification are obtained immediately after surgery and when a change in activity level is anticipated.^[1]

Once the immediate postoperative period has passed, ensuring that the deformity does not recur is important. Therefore, the etiology must again be considered and addressed properly. If the practitioner can control such factors, he or she should do so at this time to optimize surgical results.

Patients may require functional orthotic control. Several studies have shown that orthotic devices are beneficial, especially in patients with diseases such as rheumatoid arthritis, in which excessive forces accelerate degeneration. Control of these forces may postpone further destruction to the joints and provide the best long-term results after surgery.^[13]

Complications include delayed healing of the incision, osseous malunion or nonunion, numbness or tingling, hematoma, hardware failure, displacement of the osteotomy, delayed suture reaction, cellulitis, osteomyelitis, avascular necrosis, elevation of the metatarsal, transfer lesions, limitation of joint motion, hallux varus, and recurrence.^{[14, 15, 16, 17]} These complications can vary depending on the surgical technique and procedure. Preoperative education and realistic patient expectations can help in minimizing or managing these sequelae.

Hallux valgus is a complex deformity, and various approaches are available. To date, no satisfactory studies have been performed to compare the various procedures and their success rates. If the deformity and etiology are addressed successfully, the benefits of treatment far outweigh the risks.^{[18, 19]}

For excellent patient education resources, visit eMedicine's Foot Care Center. Also, see eMedicine's patient education article Corns and Calluses.

In the future, surgeons and patients will benefit from prospective, randomized studies to compare various procedures, their indications, and their success rates. The surgeon must continually search for the most stable procedure that offers the greatest degree of correction with the fewest complications. Surgeons must first be familiar with what has been attempted previously to avoid the mistakes of the past.