Introduction
Hallux valgus (HV), with its accompanying bunion, is a common deformity of the forefoot (see images below).
Severe bunion deformity (intermetatarsal angle 16°), with elevated proximal phalangeal articular angle.
A 70-year-old woman with rheumatoid arthritis and severe bunion deformity. First-toe metatarsophalangeal fusion preoperative image (top) and 2 years' postoperative image (bottom).
Understanding and characterizing each component of the deformity is the key to treating it successfully. Many treatments have been proposed; the best choices are those that directly address the location of the deformity.
Problem
In order for the most effective surgical procedure to be chosen, the deformity must be carefully characterized (see Relevant Anatomy).
Frequency
In the United States, the number of forefoot operations for the 3 most common forefoot ailments (HV, hammertoe, and neuroma) is markedly higher in females than in males. This discrepancy is attributed to differences in footwear.1,2
Etiology
A connection has been found between shoes that are too narrow and forefoot complaints in women.1,2
Pathophysiology
See Relevant Anatomy.
Presentation
Patient demands and expectations, as well as footwear, should be assessed before treating the patient with a bunion deformity.3 Obviously, a directed history should be taken and physical examination should be performed to address vascular status, possible neuropathies, and medical comorbidities. Activity level must be assessed, as the athletic patient with high physical demands may place more emphasis on mobility of the joint than on correction of the deformity.4 Finally, footwear must be addressed. A good radiographic result does not necessarily translate into unrestricted footwear use; Mann and Coughlin5 reported that only 59% of their patients had unrestricted footwear use after bunion correction.
Indications
If footwear modifications (eg, shoes with a rounded and enlarged toe box; see Treatment, Medical therapy) fail to relieve the pain that comes with the deformity, surgical correction may be offered to the patient. For indications for specific surgical procedures used to address HV and bunion deformity, see Treatment, Surgical therapy.
Relevant Anatomy
Deformities encountered in hallux valgus (HV) surgery center around the first metatarsophalangeal joint (MTPJ). However, when assessing this deformity, one must analyze the interphalangeal joint (IPJ), the first metatarsocuneiform (MTC) joint, the hindfoot, and the ankle. The deformity may involve all of these levels, which can affect the success of a chosen operation.6,5
First MTPJ
The first MTPJ receives the most attention in HV surgery.7 It is a complex joint consisting of the proximal phalanx (PP), the first metatarsal (MT) head, and the medial and lateral sesamoids. The variations in bony anatomy and the soft tissues that cross this joint determine the stability of the joint and its tendency to deform into a valgus alignment.6,5 The rounded head of the first MT articulates with the concave base of the PP. The shape of the MT head plays a large role in the tendency to valgus deformity. A more rounded first MT head is unstable and, therefore, more subject to deformity when acted on by external forces, such as narrow-toed shoes.1,8 This is compounded when combined with other commonly associated deformities of the foot, such as pes planus, hindfoot valgus, and congenitally tight heel cord. Flatter MT heads are more stable and less likely to contribute to HV.
Distal metatarsal articular angle
The second characteristic that contributes to HV is the orientation of the articular surface of the MT head in relation to the long axis of the first MT (see image below).9
The distal metatarsal articular angle (DMAA) describes the lateral slope of the articular surface in relation to the long axis of the first MT. Normally, the DMAA is less than 10°. Surgical decision-making must take into account an increased DMAA angle.
Proximal phalanx articular angle
The orientation of the great toe is also determined by the proximal phalanx articular angle (PPAA). This is the angle formed by the intersection of a line along the long axis of the PP and a line along the proximal joint surface of the PP (see image below).
Deformity at this level contributes to an increased valgus deformity of the first toe; however, the deformity is expressed at the IPJ rather than the MTPJ. The importance of the DMAA and PPAA cannot be overstated, because these angles reflect the lateral inclination of the joint. Correction of these angles must be a goal of any surgery chosen to address the bunion deformity.
MTPJ congruence
MTPJ congruence is another factor that is considered when choosing a procedure for bunion correction. The congruence of the joint is determined by combining the PPAA and the DMAA. The lines drawn parallel to the joint surface of both the PP and the first MT head should be parallel (see image below).
Congruent joint.
When the lines are parallel, a congruent joint exists. When they are not parallel, an incongruous or subluxed joint exists. This relationship is important to consider when choosing the surgical procedure; intra-articular procedures (eg, distal soft-tissue realignment) should not be used with a congruent joint that has an increased DMAA, PPAA, or both.
Congruent joints with an increased DMAA must be addressed with extra-articular procedures (ie, osteotomies) in order to prevent converting a congruent joint to an incongruent one. An incongruent joint, because of the unusual stresses on it, would be more prone to develop osteoarthritic changes.
Hallux valgus and intermetatarsal angles
The 2 angles most commonly used to describe the HV deformity are the hallux valgus angle (HVA) and the angle formed by the first and second metatarsals (1-2 intermetatarsal angle [IMA]) (see image below).
The HVA is formed by the intersection of the lines along the long axis of the PP and the first MT. This angle is measured easily. The normal angle should be less than 15°. The next important measurement is the angle formed by the intersecting long axis lines along the first and second MTs. Normally, this angle should be less than 9°.
MTC joint
The final joint that must be assessed carefully is the MTC joint. The shape and orientation of this joint vary and affect the medial inclination for the first MT. Reliable radiographic measurements of this joint are difficult to obtain, because these measurements can vary depending on the plane of the radiographic beam.
Excessive obliquity is associated with hypermobility instability of the first MTC joint. Hypermobility of the first MT as it moves through its oblique axis from dorsomedial to plantar lateral is believed to contribute to the deformity and is accentuated by the obliquity of the joint.
Excessive medial obliquity is associated with instability. In an in vitro biomechanical study, Khaw and colleagues10 were able to demonstrate that while the first intermetatarsal (IM) ligament is important in stabilizing the first MT in all directions, the plantar aponeurosis is a secondary stabilizer that resists medial and dorsal rotation of the first MT after the first IM ligament is divided. It is important to recognize that both the first IM ligament and the plantar aponeurosis stabilize the first MT head.
Sesamoids
The final bony anatomic considerations involve the sesamoids. The sesamoids are located in the flexor hallucis brevis (FHB) tendon and lie under the first MT head. They have an important function for weightbearing and improve the biomechanical axis of the FHB action. The plantar aspect of the first MT head has a longitudinal intersesamoid ridge in its center termed the crista. The sesamoids lie on either side of this ridge as they articulate with the plantar surface of the first MT head. Normally, they should be centered under the first MT head on the standing anteroposterior (AP) radiograph of the foot. As the great toe develops a valgus deformity, the first MT head deviates medially, and rotation occurs at the MTPJ. The great toe pronates, the intrinsic musculature rotates laterally, and the first MT head displaces medially, subluxing off the sesamoids.
Normally, the sesamoids should be centered under the first MT head, and corrective procedures that restore this relationship should be chosen.
Other considerations
Other considerations in assessing the deformity include associated pes planus deformity, pronation of the great toe, and Achilles tendon (AT) contraction. The AT has a dynamic effect on ambulation. A contracted AT compromises the ability to dorsiflex the foot. During gait, the result is external rotation, with increased demands placed on the medial structures of the forefoot. HV deformity is believed to be a result of this repetitive stress. A contracted AT can be idiopathic or can result from neuromuscular disease. Which of these it derives from should be noted during the physical examination, because the presence of contracted AT, if not addressed, can contribute to recurrence of deformity.
In addition to the bony anatomy of the deformity, the soft-tissue envelope at the first MTPJ plays a role in the HV deformity. The first MT head has no direct muscle attachments, so its position is influenced greatly by the alignment of the PP. Essentially, 4 groups of muscles and tendons cross the first MTPJ and attach on the proximal aspect of the PP. The balance of these structures and the bony contour of the joint determine whether the PP stays aligned on the MT head. Dorsally, the extensor hallucis longus (EHL) and extensor hallucis brevis (EHB) insert centrally on the distal and proximal phalanges, respectively. They are kept in a central position by the hood ligaments, a fibrous band of tissue that is anchored to the collateral ligaments.
On the plantar surface, the flexor hallucis longus (FHL) runs centrally between the sesamoids and inserts on the distal phalanx. The FHB has 2 tendon slips, which insert onto the medial and lateral sesamoids. The sesamoids then connect onto the PP through the plantar plate. Medially, the abductor hallucis tendon inserts onto the plantar medial PP and plantar medial joint capsule. The capsule becomes much thinner dorsally.
A similar relationship exists on the lateral side of the joint, with the adductor hallucis tendon inserting onto the lateral sesamoid and plantar lateral joint capsule. The abductor hallucis has 2 muscle bellies, which are the transverse head and the oblique head. These come together in the conjoined tendon and insert on the lateral sesamoid. Comparatively, more muscle mass is present in the adductor hallucis when the muscle bellies are combined, creating a natural tendency to pull the PP into valgus.
These 4 groups of attachments create a delicate balance for keeping the PP centered on the first MT head. This balance is enhanced greatly when the first MT head is relatively flat. When the head is rounded, it is much easier for the PP to deviate. Once a deviation is created, the forces are quickly unbalanced. The insertion of the adductor hallucis onto the lateral plantar base of the PP becomes the primary deforming force as the HV increases. Because its insertion is on the plantar half of the capsule and sesamoid, it tends to pronate the toe. As the rotation occurs, the abductor hallucis becomes more plantar and the only medial restraint left is the thin dorsal joint capsule, which readily becomes attenuated.
Once an angular deformity exists, the EHL and extensor digitorum brevis (EDB) are no longer centered on the PP and bowstring across the lateral side of the deformity, creating further imbalance. In considering the treatment of HV, one must address both the bony deformity and the soft-tissue balance, because both contribute to the pathologic condition.
Contraindications
Contraindications to surgery include vascular insufficiency and active infection of the foot.
More on Bunion |
 Overview: Bunion |
| Workup: Bunion |
| Treatment: Bunion |
| Follow-up: Bunion |
| Multimedia: Bunion |
| References |
| Further Reading |
| Next Page » |
References
Coughlin MJ, Thompson FM. The high price of high-fashion footwear. In: Jackson DW, ed. Instructional Course Lectures. Rosemont, Ill:. American Academy of Orthopaedic Surgeons;1995: 371-377.
Frey C, Thompson F, Smith J, et al. American Orthopaedic Foot and Ankle Society women's shoe survey. Foot Ankle. Feb 1993;14(2):78-81. [Medline].
Tai CC, Ridgeway S, Ramachandran M, Ng VA, Devic N, Singh D. Patient expectations for hallux valgus surgery. J Orthop Surg (Hong Kong). Apr 2008;16(1):91-5. [Medline].
Kennedy JG, Collumbier JA. Bunions in dancers. Clin Sports Med. Apr 2008;27(2):321-8. [Medline].
Mann RA, Coughlin MJ. Adult hallux valgus. In: Mann RA, Coughlin MJ, eds. Surgery of the Foot and Ankle. 6th ed. St. Louis, Mo:. Mosby;1993:167-296.
Coughlin MJ. Hallux valgus. Instr Course Lect. 1997;46:357-91. [Medline].
Lui TH. First metatarsophalangeal joint arthroscopy in patients with hallux valgus. Arthroscopy. Oct 2008;24(10):1122-9. [Medline].
Hattrup SJ, Johnson KA. Chevron osteotomy: analysis of factors in patients' dissatisfaction. Foot Ankle. May-Jun 1985;5(6):327-32. [Medline].
Richardson EG, Graves SC, McClure JT, et al. First metatarsal head-shaft angle: a method of determination. Foot Ankle. May 1993;14(4):181-5. [Medline].
Khaw FM, Mak P, Johnson GR, et al. Distal ligamentous restraints of the first metatarsal. An in vitro biomechanical study. Clin Biomech (Bristol, Avon). Jul 2005;20(6):653-8. [Medline].
Chhaya SA, Brawner M, Hobbs P, Chhaya N, Garcia G, Loredo R. Understanding hallux valgus deformity: what the surgeon wants to know from the conventional radiograph. Curr Probl Diagn Radiol. May-Jun 2008;37(3):127-37. [Medline].
Thordarson D, Ebramzadeh E, Moorthy M, et al. Correlation of hallux valgus surgical outcome with AOFAS forefoot score and radiological parameters. Foot Ankle Int. Feb 2005;26(2):122-7. [Medline].
Menz HB, Morris ME. Footwear characteristics and foot problems in older people. Gerontology. Sep-Oct 2005;51(5):346-51. [Medline].
Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin. Mar 2005;10(1):191-209. [Medline].
Hart ES, deAsla RJ, Grottkau BE. Current concepts in the treatment of hallux valgus. Orthop Nurs. Sep-Oct 2008;27(5):274-80; quiz 281-2. [Medline].
McBride ED. The McBride bunion hallux valgus operation. J Bone Joint Surg Am. Dec 1967;49(8):1675-83. [Medline].
Coughlin MJ, Jones CP, Viladot R, et al. Hallux valgus and first ray mobility: a cadaveric study. Foot Ankle Int. Aug 2004;25(8):537-44. [Medline].
Akin OF. The treatment of hallux valgus: a new operative procedure and its results. Medical Sentinel. 1925;33:678-679.
Brahms MA. Hallux valgus—the akin procedure. Clin Orthop Relat Res. Jun 1981;47-9. [Medline].
Goldberg I, Bahar A, Yosipovitch Z. Late results after correction of hallux valgus deformity by basilar phalangeal osteotomy. J Bone Joint Surg Am. Jan 1987;69(1):64-7. [Medline].
Plattner PF, Van Manen JW. Results of Akin type proximal phalangeal osteotomy for correction of hallux valgus deformity. Orthopedics. Sep 1990;13(9):989-96. [Medline].
Mitchell LA, Baxter DE. A Chevron-Akin double osteotomy for correction of hallux valgus. Foot Ankle. Aug 1991;12(1):7-14. [Medline].
Barouk LS, Barouk P, Baudet B, et al. The great toe proximal phalanx osteotomy: the final step of the bunionectomy. Foot Ankle Clin. Mar 2005;10(1):141-55. [Medline].
Basile A, Battaglia A, Campi A. Retrospective analysis of the Ludloff osteotomy for correction of severe hallux valgus deformity. Foot and Ankle Surgery. 2001;7(1):1â€"8.
Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally directed "V" displacement osteotomy of the metatarsal head for hallux valgus and primus varus. Clin Orthop Relat Res. Jun 1981;(157):25-30. [Medline].
Johnson JE, Clanton TO, Baxter DE, et al. Comparison of Chevron osteotomy and modified McBride bunionectomy for correction of mild to moderate hallux valgus deformity. Foot Ankle. Oct 1991;12(2):61-8. [Medline].
Johnson KA, Cofield RH, Morrey BF. Chevron osteotomy for hallux valgus. Clin Orthop Relat Res. Jul-Aug 1979;44-7. [Medline].
Magnan B, Pezzè L, Rossi N, et al. Percutaneous distal metatarsal osteotomy for correction of hallux valgus. J Bone Joint Surg Am. Jun 2005;87(6):1191-9. [Medline].
Sanna P, Ruiu GA. Percutaneous distal osteotomy of the first metatarsal (PDO) for the surgical treatment of hallux valgus. Chir Organi Mov. Oct-Dec 2005;90(4):365-9. [Medline].
Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. Aug 2005;87(8):1038-45. [Medline].
Nikolaou VS, Korres D, Xypnitos F, Lazarettos J, Lallos S, Sapkas G, et al. Fixation of Mitchell's osteotomy with bioabsorbable pins for treatment of hallux valgus deformity. Int Orthop. Oct 28 2008;[Medline].
Yamamoto K, Imakiire A, Katori Y, et al. Clinical results of modified Mitchell's osteotomy for hallux valgus augmented with oblique lesser metatarsal osteotomy. J Orthop Surg (Hong Kong). Dec 2005;13(3):245-52. [Medline].
Lee KB, Seo CY, Hur CI, Moon ES, Lee JJ. Outcome of proximal chevron osteotomy for hallux valgus with and without transverse Kirschner wire fixation. Foot Ankle Int. Nov 2008;29(11):1101-6. [Medline].
Kürklü M, Demiralp B, Yurttas Y, Ciçek EI, Atesalp AS. Modified chevron osteotomy fixed with stofella pin for hallux valgus. Foot Ankle Int. May 2008;29(5):478-82. [Medline].
Deorio JK, Ware AW. Single absorbable polydioxanone pin fixation for distal chevron bunion osteotomies. Foot Ankle Int. Oct 2001;22(10):832-5. [Medline].
Kuhn MA, Lippert FG, Phipps MJ. Blood flow to the metatarsal head after chevron bunionectomy. Foot Ankle Int. Jul 2005;26(7):526-9. [Medline].
Maguire WB. The Lapidus procedure for hallux valgus. J Bone Joint Surg Am. 1973;55B:221.
Trnka HJ, Zembsch A, Easley ME, et al. The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up. J Bone Joint Surg Am. Oct 2000;82-A(10):1373-8. [Medline].
Ozkurt B, Aktekin CN, Altay M, Belhan O, Tabak Y. Range of motion of the first metatarsophalangeal joint after chevron procedure reinforced by a modified capsuloperiosteal flap. Foot Ankle Int. Sep 2008;29(9):903-9. [Medline].
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].
Okuda R, Kinoshita M, Yasuda T, Jotoku T, Shima H. Proximal metatarsal osteotomy for hallux valgus: comparison of outcome for moderate and severe deformities. Foot Ankle Int. Jul 2008;29(7):664-70. [Medline].
Paczesny L, Kruczynski J, Adamski R. Scarf versus proximal closing wedge osteotomy in hallux valgus treatment. Arch Orthop Trauma Surg. Sep 18 2008;[Medline].
Gupta S, Fazal MA, Williams L. Minifragment screw fixation of the Scarf osteotomy. Foot Ankle Int. Apr 2008;29(4):385-9. [Medline].
Lipscombe S, Molloy A, Sirikonda S, Hennessy MS. Scarf osteotomy for the correction of hallux valgus: midterm clinical outcome. J Foot Ankle Surg. Jul-Aug 2008;47(4):273-7. [Medline].
Trnka HJ, Hofstaetter SG, Hofstaetter JG, Gruber F, Adams SB Jr, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. J Bone Joint Surg Am. Mar 2008;90(3):531-9. [Medline].
Hyer CF, Glover JP, Berlet GC, Philbin TM, Lee TH. A comparison of the crescentic and Mau osteotomies for correction of hallux valgus. J Foot Ankle Surg. Mar-Apr 2008;47(2):103-11. [Medline].
Glover JP, Hyer CF, Berlet GC, Lee TH. Early results of the Mau osteotomy for correction of moderate to severe hallux valgus: a review of 24 cases. J Foot Ankle Surg. May-Jun 2008;47(3):237-42. [Medline].
Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J Bone Joint Surg Am. Jan 1992;74(1):124-9. [Medline].
Sammarco GJ, Brainard BJ, Sammarco VJ. Bunion correction using proximal Chevron osteotomy. Foot Ankle. Jan 1993;14(1):8-14. [Medline].
Thordarson DB, Leventen EO. Hallux valgus correction with proximal metatarsal osteotomy: two-year follow-up. Foot Ankle. Jul-Aug 1992;13(6):321-6. [Medline].
Wanivenhaus AH, Feldner-Busztin H. Basal osteotomy of the first metatarsal for the correction of metatarsus primus varus associated with hallux valgus. Foot Ankle. Jun 1988;8(6):337-43. [Medline].
Beischer AD, Ammon P, Corniou A, et al. Three-dimensional computer analysis of the modified Ludloff osteotomy. Foot Ankle Int. Aug 2005;26(8):627-32. [Medline].
Jung HG, Guyton GP, Parks BG, et al. Supplementary axial Kirschner wire fixation for crescentic and Ludloff proximal metatarsal osteotomies: a biomechanical study. Foot Ankle Int. Aug 2005;26(8):620-6. [Medline].
Unver B, Sampiyon O, Karatosun V. Postoperative immobilisation orthosis for surgically corrected hallux valgus. Prosthet Orthot Int. Dec 2004;28(3):278-80. [Medline].
Brodsky JW, Beischer AD, Robinson AH, et al. Surgery for hallux valgus with proximal crescentic osteotomy causes variable postoperative pressure patterns. Clin Orthop Relat Res. Feb 2006;443:280-6. [Medline].
Jones CP, Coughlin MJ, Grebing BR. First metatarsophalangeal joint motion after hallux valgus correction: a cadaver study. Foot Ankle Int. Aug 2005;26(8):614-9. [Medline].
Okuda R, Kinoshita M, Morikawa J, et al. Proximal metatarsal osteotomy: relation between 1- to greater than 3-years results. Clin Orthop Relat Res. Jun 2005;191-6. [Medline].
Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. Jan 1994;15(1):9-13. [Medline].
Mauldin DM, Sanders M, Whitmer WW. Correction of hallux valgus with metatarsocuneiform stabilization. Foot Ankle. Oct 1990;11(2):59-66. [Medline].
Myerson M. Metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus primus varus. Orthopedics. Sep 1990;13(9):1025-31. [Medline].
Sangeorzan BJ, Hansen ST. Modified Lapidus procedure for hallux valgus. Foot Ankle. Jun 1989;9(6):262-6. [Medline].
Coetzee JC, Resig SG, Kuskowski M, et al. The Lapidus procedure as salvage after failed surgical treatment of hallux valgus: a prospective cohort study. J Bone Joint Surg Am. Jan 2003;85-A(1):60-5. [Medline].
Coughlin MJ, Smith BW. Hallux valgus and first ray mobility. Surgical technique. J Bone Joint Surg Am. Oct 2008;90 Suppl 2 Pt 2:153-70. [Medline].
Gérard R, Stern R, Assal M. The modified Lapidus procedure. Orthopedics. Mar 2008;31(3):230-6. [Medline].
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].
Kopp FJ, Patel MM, Levine DS, et al. The modified Lapidus procedure for hallux valgus: a clinical and radiographic analysis. Foot Ankle Int. Nov 2005;26(11):913-7. [Medline].
Fuhrmann RA. Arthrodesis of the first tarsometatarsal joint for correction of the advanced splayfoot accompanied by a hallux valgus. Oper Orthop Traumatol. Jun 2005;17(2):195-210. [Medline].
Coughlin MJ, Abdo RV. Arthrodesis of the first metatarsophalangeal joint with Vitallium plate fixation. Foot Ankle Int. Jan 1994;15(1):18-28. [Medline].
Coughlin MJ, Mann RA. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. J Bone Joint Surg Am. Jan 1987;69(1):68-75. [Medline].
Coughlin MJ. Arthrodesis of the first metatarsophalangeal joint with mini-fragment plate fixation. Orthopedics. Sep 1990;13(9):1037-44. [Medline].
Mann RA, Katcherian DA. Relationship of metatarsophalangeal joint fusion on the intermetatarsal angle. Foot Ankle. Aug 1989;10(1):8-11. [Medline].
Mann RA, Oates JC. Arthrodesis of the first metatarsophalangeal joint. Foot Ankle. Nov 1980;1(3):159-66. [Medline].
Turan I, Lindgren U. Compression-screw arthrodesis of the first metatarsophalangeal joint of the foot. Clin Orthop Relat Res. Aug 1987;292-5. [Medline].
Coughlin MJ, Grebing BR, Jones CP. Arthrodesis of the first metatarsophalangeal joint for idiopathic hallux valgus: intermediate results. Foot Ankle Int. Oct 2005;26(10):783-92. [Medline].
Cronin JJ, Limbers JP, Kutty S, et al. Intermetatarsal angle after first metatarsophalangeal joint arthrodesis for hallux valgus. Foot Ankle Int. Feb 2006;27(2):104-9. [Medline].
Richardson EG. Keller resection arthroplasty. Orthopedics. Sep 1990;13(9):1049-53. [Medline].
Vallier GT, Petersen SA, LaGrone MO. The Keller resection arthroplasty: a 13-year experience. Foot Ankle. Feb 1991;11(4):187-94. [Medline].
Wrighton JD. A ten-year review of Keller's operation. Review of Keller's operation at the Princess Elizabeth Orthopaedic Hospital, Exeter. Clin Orthop Relat Res. 1972;89:207-14. [Medline].
Becerro de Bengoa Vallejo R, Losa Iglesias ME, Viejo Tirado F, Prados Frutos JC, Jules KT. Use of a Kirschner wire for distraction and capsular flaps in the Keller interpositional arthroplasty. J Am Podiatr Med Assoc. Jul-Aug 2008;98(4):326-9. [Medline].
Zembsch A, Trnka HJ, Ritschl P. Correction of hallux valgus. Metatarsal osteotomy versus excision arthroplasty. Clin Orthop Relat Res. Jul 2000;(376):183-94. [Medline].
[Best Evidence] Best Evidence: Apfelbaum JL, Desjardins PJ, Brown MT, Verburg KM. Multiple-day efficacy of parecoxib sodium treatment in postoperative bunionectomy pain. (Also available at http://www.medscape.com/pages/features/newsletters/bestevidence/bestevidence_about?src=nlbest). Clin J Pain. Nov-Dec 2008;24(9):784-92. [Medline].
Thordarson DB, Ebramzadeh E, Rudicel SA, et al. Age-adjusted baseline data for women with hallux valgus undergoing corrective surgery. J Bone Joint Surg Am. Jan 2005;87(1):66-75. [Medline].
Further Reading
Ankle and foot complaints. American College of Occupational and Environmental Medicine - Medical Specialty Society. 1997 (revised 2004). 27 pages. NGC:004757
Diagnosis and treatment of first metatarsophalangeal joint disorders. American College of Foot and Ankle Surgeons - Medical Specialty Society. 2003 May-Jun. 43 pages. NGC:003064
Hallux abductovalgus. Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society. 2000 (revised 2003 Sep). 10 pages. NGC:003240
Hammertoe syndrome. Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society. 2000 (revised 2003 Sep). 9 pages. NGC:003242
Metatarsalgia/intractable plantar keratosis/Tailor's bunion. Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society. 2000 (revised 2003 Sep). 7 pages. NGC:003246
Keywords
bunion, hallux valgus deformity, HV deformity, metatarsus primus varus, foot deformity, bunionette
