eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Hallux Varus: Treatment

Author: Amy Jo Ptaszek, MD, Assistant Professor, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Mar 10, 2009

Treatment

Surgical Therapy

Various authors have described numerous procedures for the treatment and correction of hallux varus. A sampling of procedures, used both alone and in conjunction with others, are as follows:

  • Lengthening of the medial capsular structures
  • Lengthening of the extensor hallucis longus (EHL)
  • Relocation of the sesamoid(s)
  • Skin resection of the first webspace
  • Syndactyly of the great and second toes
  • Total joint release
  • Abductor hallucis transfer8
  • Ligapro suture/technique
  • Split extensor hallucis brevis (EHB) transfer and reverse Akin procedure
  • EHL transfer with IP arthrodesis
  • EHB transfer
  • Keller resection arthroplasty
  • Implant arthroplasty
  • MTP arthrodesis

In 1971, Hawkins described transfer of the abductor hallucis tendon to the lateral aspect of the proximal phalanx with release of the medial capsule and mobilization of the medial sesamoid.9 Patients demonstrated maintenance of alignment between 5 and 54 months. A few years later, Miller described a proximal phalangeal resection for treatment of early-acquired hallux varus (ie, before the deformity became fixed and clawing was present). However, no functional outcome was published.

In 1984, Johnson and Spiegl advocated transfer of the EHL tendon to the proximal phalanx as a dynamic stabilizer, coupled with IP joint arthrodesis for flexible hallux varus without MTP arthrosis.10 This improved flexion of the MTP joint from –23° to +6°, and total ROM increased from 38° to 67°. The varus was corrected an average of 18°. Later, modification utilized a split EHL transfer with preservation of the IP joint in the absence of deformity at the IP joint, which resulted in less MTP motion.

Skalley and Myerson reported their experience with EHL transfer and IP arthrodesis in a retrospective study; the split EHL transfer resulted in symptomatic joint stiffness.11 Later, Myerson and Komenda described a tenodesis of the EHB tendon in conjunction with a medial soft-tissue release for correction of a flexible hallux varus deformity.12 The tenodesis was thought to act as a static restraint, as opposed to a dynamic restraint to varus-deforming forces. The authors reported restoration of alignment to an average of 0°, minimal loss of sagittal plane motion, and no stiffness and/or weakness.12,13

Tourne et al published a report of a case series of 14 French patients with iatrogenic hallux varus.14 The authors performed MTP arthrodesis in 9 patients who had stiffness and arthrosis. In 5 cases, the lateral ligament complex was reconstructed with use of a Ligapro suture (an elastic polyethylene terephthalate device that is not available in the United States). Arthrolysis was performed in all patients. Tourne et al reported excellent outcomes using this technique in patients who were younger, had a mobile MTP joint, and had no evidence of degenerative changes on radiographs. The reported results were an average postoperative correction of 20° of plantar flexion and 60-90° of dorsiflexion of the MTP joint.

Resection arthroplasty can decompress the joint at the same time the tendons and capsule are balanced. Loss of strength and floppiness has been reported postoperatively but may not be bothersome in patients who are elderly or in those who have significant degenerative disease. Note, however, that implant arthroplasty is ill-advised in light of the soft-tissue imbalance that is present in patients who have hallux varus.

MTP arthrodesis remains a logical salvage technique for patients who have hallux varus deformity with arthrosis and bone loss. Moderate to severe degenerative changes should probably be addressed with arthrodesis or osteotomy.

Correction of the first IM angle may require metatarsal osteotomy in addition to a soft-tissue balancing procedure for the MTP joint.15,16

Complications

Potential complications include overcorrection (ie, hallux valgus), avascular necrosis of the metatarsal head, stiffness, progression of degenerative changes in the MTP joint, shortening of the medial column, transfer metatarsalgia, and medial wound complications.17

More on Hallux Varus

Overview: Hallux Varus
Workup: Hallux Varus
Treatment: Hallux Varus
Follow-up: Hallux Varus
Multimedia: Hallux Varus
References
Further Reading
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References

  1. Jahss MH. Disorders of the hallux and first ray. Disorders of the Foot and Ankle: Medical and Surgical Management. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1991:1084-9.

  2. Miller JW. Acquired hallux varus: a preventable and correctable disorder. J Bone Joint Surg Am. Mar 1975;57(2):183-8. [Medline]. [Full Text].

  3. Granberry WM, Hickey CH. Idiopathic adult hallux varus. Foot Ankle Int. Apr 1994;15(4):197-205. [Medline].

  4. Orzechowski W, Dragan S, Romaszkiewicz P, Krawczyk A, Kulej M, Morasiewicz L. Evaluation of follow-up results of McBride operative treatment for hallux valgus deformity. Ortop Traumatol Rehabil. May-Jun 2008;10(3):261-73. [Medline].

  5. Popelka S, Vavrík P, Hromádka R, Sosna A. [Our results of the Lapidus procedure in patients with hallux valgus deformity]. Acta Chir Orthop Traumatol Cech. Aug 2008;75(4):271-6. [Medline].

  6. Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM, Schuberth JM. Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity. J Foot Ankle Surg. Jul-Aug 2008;47(4):267-72. [Medline].

  7. Mann RA, Coughlin MJ, eds. Adult hallux valgus. Surgery of the Foot and Ankle. 6th ed. St. Louis, Mo: Mosby, Inc; 1993:284-92.

  8. Leemrijse T, Hoang B, Maldague P, Docquier PL, Devos Bevernage B. A new surgical procedure for iatrogenic hallux varus: reverse transfer of the abductor hallucis tendon: a report of 7 cases. Acta Orthop Belg. Apr 2008;74(2):227-34. [Medline].

  9. Hawkins FB. Acquired hallux varus: cause, prevention and correction. Clin Orthop Relat Res. May 1971;76:169-76. [Medline].

  10. Johnson KA, Spiegl PV. Extensor hallucis longus transfer for hallux varus deformity. J Bone Joint Surg Am. Jun 1984;66(5):681-6. [Medline]. [Full Text].

  11. Skalley TC, Myerson MS. The operative treatment of acquired hallux varus. Clin Orthop Relat Res. Sep 1994;(306):183-91. [Medline].

  12. Myerson MS, Komenda GA. Results of hallux varus correction using an extensor hallucis brevis tenodesis. Foot Ankle Int. Jan 1996;17(1):21-7. [Medline].

  13. Juliano PJ, Myerson MS, Cunningham BW. Biomechanical assessment of a new tenodesis for correction of hallux varus. Foot Ankle Int. Jan 1996;17(1):17-20. [Medline].

  14. Tourné Y, Saragaglia D, Picard F, et al. Iatrogenic hallux varus surgical procedure: a study of 14 cases. Foot Ankle Int. Aug 1995;16(8):457-63. [Medline].

  15. Tanaka Y, Takakura Y, Kumai T, Sugimoto K, Taniguchi A, Hattori K. Proximal spherical metatarsal osteotomy for the foot with severe hallux valgus. Foot Ankle Int. Oct 2008;29(10):1025-30. [Medline].

  16. Chow FY, Lui TH, Kwok KW, Chow YY. Plate fixation for crescentic metatarsal osteotomy in the treatment of hallux valgus: an eight-year followup study. Foot Ankle Int. Jan 2008;29(1):29-33. [Medline].

  17. Sanders M. Complications of hallux valgus surgery. Complications of Foot and Ankle Surgery. 1998:1-18.

  18. Vanore JV, Christensen JC, Kravitz SR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 3: hallux varus. J Foot Ankle Surg. May-Jun 2003;42(3):137-42. [Medline].

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Keywords

hallux varus, medial deviation of the great toe, flexible hallux varus, hallux valgus, congenital hallux varus, primary dynamic infantile hallux varus, traumatic hallux varus, idiopathic hallux varus, first metatarsophalangeal joint arthrodesis, MTP arthrodesis, intermetatarsal angle, IM angle

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Contributor Information and Disclosures

Author

Amy Jo Ptaszek, MD, Assistant Professor, Department of Orthopedic Surgery, University of Texas Southwestern Medical Center
Amy Jo Ptaszek, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center
John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, and Texas Medical Association
Disclosure: Zimmer Inc Consulting fee Independent contractor; Smith Nephew Consulting fee Independent contractor; AO North America Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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