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Bunion Treatment & Management

  • Author: Richard T Laughlin, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: Apr 05, 2016
 

Approach Considerations

The hallux valgus (HV) deformity is complex, often involving multiple levels of the first ray. Nonoperative treatment should be the initial option discussed. If footwear modifications (eg, shoes with a rounded and enlarged toe box; see 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 Surgical Options. Contraindications to surgery include vascular insufficiency.

Successful treatment requires careful definition of the deformity. Probably the most common reason for recurrence and less-than-optimal results is failure to carefully define the deformity. If the deformity is not carefully defined, the surgical procedure chosen may not address all components of the deformity. Recurrence or less-than-optimal results also occur when the procedure is used at the upper limits of its indications. When each component of the deformity is addressed, satisfactory results can be achieved.

It is worth repeating that it is critical to obtain high-quality standing radiographs in the anteroposterior (AP) and lateral directions prior to surgery.

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Medical Therapy

The first aspect of HV treatment is to have patients wear properly fitting shoes. The forefoot should be no more than 0.5 cm wider than the toe box of the shoe. Women who wear shoes narrower than this have a higher incidence of forefoot complaints.[7, 11] When compared to other women in the general population in the same age group, according to Thordarson et al,[29] women about to undergo bunion surgery reported significant increased body pain, decreased foot and ankle function, and decreased shoe comfort.

Foot problems are also very common in the elderly population. Using a questionnaire and clinical assessment, Menz et al[30] evaluated 176 patients aged 62 to 96 years with foot pain and deformity. They found that most of the patients wore shoes narrower than their feet and that women, in proportion to their feet, wore shoes that were shorter, were narrower, and had a smaller total area than those worn by men. This was associated with corns on the toes, HV deformity, and foot pain.

Orthoses have been shown to be more effective at reducing pain at 6 months of treatment, but at 12 months, no difference is noted in comparison with the control of no treatment. They also are not effective at increasing the ability to work at 1 year. Chevron osteotomy is superior to orthotic treatment.[31]

Shoe modifications, such as bubble stretching, can ease the pressure over a bony prominence. Orthotic inserts seem to be of limited help in treatment of HV, but custom orthotics can be of great assistance if the symptoms are caused mainly by a transfer lesion. A good orthotic prescription should include medial posting to control pronation (which increases valgus forces on the hallux), a metatarsal (MT) pad for transfer lesions, extra shoe depth with an oblique toe box, and possibly a bunion flare, which goes behind the bunion deformity to alleviate pressure from the shoe.[32]

A study by Reina et al was aimed at determining whether custom-made orthotics prevented or slowed the progression of HV in women with mild-to-moderate deformity. At 1-year follow up, no significant differences in the HV angle (HVA) and intermetatarsal (IM) angle (IMA) were noted. This study helps confirm that custom-made orthotics have no effect during a 12-month period.[33] Some nonprescription devices can provide symptomatic relief, though none has been demonstrated to achieve lasting correction.

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Surgical Options

A multitude of procedures are available to correct the deformity, though the results of surgery can be quite variable if the deformity is not addressed directly.[34] HV deformities may be categorized as mild, moderate, or severe (see Table 1 below). These categories are used extensively in order to simplify choosing the best procedure, though they are probably best used to choose a category of procedure rather than a specific procedure.

Table 1. Categories of Hallux Valgus Deformity (Open Table in a new window)

Angle Mild Subluxation Moderate Subluxation Severe Subluxation
Hallux valgus angle <20° 20°-40° >40°
1-2 Intermetatarsal angle <11° <15° >15°
Sesamoid <50° 50º-75º >75º

Surgical options fall into several broad categories, as follows: distal soft-tissue reconstruction (DSTR), proximal-phalanx (PP) and first-MT (distal and proximal) osteotomies, arthrodesis (metatarsophalangeal [MTP] joint [MTPJ] and first tarsometatarsal [TMT]), and resection.

Elliot et al conducted a prospective study investigating the use of intraoperative fluoroscopy by analyzing 28 cases of HV surgery during which fluoroscopic images were taken.[35] Results showed that no unforeseen intraoperative events were discovered and no surgical modifications were made as a result of the fluoroscopic images. Although intraoperative fluoroscopy is a reliable technique, it is not recommended that it be used routinely in HV surgery.

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Distal Soft-Tissue Reconstruction

A mild HV deformity can be corrected with a DSTR.[36] This consists of medial eminence excision and medial capsulorrhaphy. On the lateral side, the deforming structures must be released to balance the toe, a procedure that typically is performed through a dorsal longitudinal incision in the first webspace. The conjoined tendon is released from the lateral sesamoid. The transverse MT ligament is released from its attachment on the lateral sesamoid as well. The lateral joint capsule is divided parallel to the joint surface. The proximal portion of the released adductor tendon may be sutured to the proximal joint capsule of the MTPJ, or the capsule may be sutured to the medial capsule of the second MTPJ.

This soft-tissue procedure is considered an intra-articular realignment. It must be performed only in persons with a round MT head and a relatively normal distal MT articular angle (DMAA) and proximal phalanx (PP) articular angle (PPAA). This procedure realigns the toe, provided that the bony anatomy accepts this realignment. In reality, the DSTR is seldom used alone, usually being combined with a bony procedure.

DSTR can be summarized as follows:

  • Indications - Mild to moderate bunion deformity; HVA less than 35°; IMA less than 15°; nonelevated DMAA; noncongruent joint
  • Expected corrections - HVA 14°; IMA 5°
  • Complications - Hallux varus (usually asymptomatic if less than 10°; the incidence is significantly lowered by not excising the lateral sesamoid); recurrence of deformity (occurs when the procedure is extended to larger deformities or when the bony alignment is not favorable (eg, elevated DMAA)
  • Results - After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first-ray mobility in cadaver specimens was significantly reduced (with several studies having demonstrated that patients with HV deformities have increased first-ray sagittal mobility) [37]

A study by Schneider evaluated the efficacy of individual steps of the lateral release and assessed which surgical steps are essential to HV deformity correction, which steps are not effective, and which steps may pose risk.[38] Transecting the lateral metatarsosesamoid ligament appeared to be the key step to a successful lateral release. The release of the deep transverse MT ligament and the adductor hallucis muscle did not help correct HV. The author suggested that the lateral short sesamophalangeal ligament and the plantar attachment of the articular capsule should be preserved to minimize possible joint instability.[38]

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Akin Osteotomy

Osteotomy of the PP, the first MT, or both is used extensively to correct alignment of the first ray. The PP osteotomy (Akin procedure) is a medially based closing-wedge osteotomy of the PP.[39, 40, 41, 42] It is combined with medial eminence excision and medial capsulorrhaphy. This procedure is best for deformity in the PP, manifesting as HV interphalangeus in which the PPAA is abnormal. The Akin osteotomy may also be combined with a first MT osteotomy to compensate for alignment created by an elevated DMAA (see the image below).[43, 44]

Akin proximal phalanx closing-wedge osteotomy to c Akin proximal phalanx closing-wedge osteotomy to correct high proximal phalangeal articular angle.

The incision is made just proximal to the medial eminence and is extended distally to the interphalangeal (IP) joint (IPJ). The dissection is taken down to the joint capsule. Once this is exposed, a vertical capsulotomy is made, with not more than 2-4 mm of capsule removed. The medial eminence is then excised in line with the shaft of the first MT and just medial to the sagittal sulcus.

Next, the osteotomy of the PP is completed, and 3-4 mm of bone is removed. Care must be taken at the proximal cut to ensure that the articular surface is not violated. The medial capsule is then repaired first in order to observe the amount of correction that must be completed with the osteotomy. The osteotomy is subsequently fixed with Kirschner wires (K-wires) or suture. Care must be taken to check for correct rotation as the osteotomy is fixed.

Akin osteotomy can be summarized as follows:

  • Indications - HV interphalangeus; also can be combined with other procedures to compensate for an increased DMAA in a congruent joint
  • Expected corrections - May correct 10-15° of deformity in PP; HVA tends to recur, according to long-term follow-up results; has no effect on 1-2 IMA
  • Complications - Recurrence of deformity; poor cosmetic appearance
  • Results - Used alone, the Akin osteotomy should be reserved for deformity in the proximal phalanx; Basile et al [45] compared the distal first-MT chevron-Akin osteotomy with the DSTR-Akin osteotomy for correction of mild HV and noted a statistically significant outcome in which the distal first-MT chevron-modified Akin double osteotomy resulted in a greater correction of 1-2 IMA, HVA, and tibial sesamoid position than that accomplished with the DSTR-modified Akin osteotomy
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First-Metatarsal Osteotomy

The next category of procedure for HV correction is the first-MT osteotomy, which can be divided into distal and proximal osteotomies.[46] Distal osteotomies are mainly for individuals with mild deformities (eg, HVA <30°, 1-2 IMA <13°).[47, 48, 49] Some authors have advocated the use of these in deformities as large as 15° in the 1-2 IMA.

Distal MT osteotomies performed through a percutaneous approach have been used in Europe but have not been widely accepted in the United States. Statistically significant improvements in the postoperative mean HVA, first IMA, DMAA, and sesamoid position were observed with the percutaneous method. A shorter operating time and reduced risks of complications were noted as well.[50, 51]

Mitchell osteotomy is another means of distal correction; it involves a double cut through the MT neck, leaving a step in the lateral cortex to hitch onto the MT head. The capital fragment is displaced laterally and plantarward and then is held in place with a stitch through drill holes.[52, 53] A Japanese study found that this procedure can produce MTP malalignment, metatarsalgia, and plantar callosity after surgery[54] ; combining a modified Mitchell osteotomy with an oblique MT osteotomy of the lesser MT bones significantly improved callosity and metatarsalgia and the use of commercially available shoes at 5-year follow-up.

Chevron distal metatarsal osteotomy

One of the more commonly used distal osteotomies is the chevron osteotomy (see the image below).[55, 56]

Distal chevron metatarsal osteotomy fixed with a K Distal chevron metatarsal osteotomy fixed with a Kirschner wire.

This procedure is performed through a medial incision. An L-shaped capsulotomy is carried out to expose the medial eminence. The exostosis is removed with a saw, using a cut parallel to the medial border of the foot. Making the exostectomy cut parallel to the medial border increases the surface area of contact for the chevron osteotomy. On the other hand, making the cut parallel to the medial metatarsal shaft obviates the danger of removing too much medial eminence. If too much medial eminence is removed, it can result in loss of support for the PP, with a resultant varus deformity.

Once the medial eminence is resected, an ink marker is used to outline the chevron, the apex of which is placed in the center of the MT head. The osteotomy is V-shaped; the angle of the chevron may vary. Making one limb longer than the other is advantageous because this simplifies fixation. The author makes the plantar limb longer. Care is taken not to overpenetrate the lateral cortex; doing so may lead to damage of the lateral soft tissues.

The chevron osteotomy angle was investigated at 60° versus 90° with longer plantar limb, by cohort and finite element analysis (FEA). The FEA demonstrated that there were more compressive forces and less shear stresses at the osteotomy site with a 90° cut, which is more conducive to bone formation, with at least similar results between the cohorts.[57]

Once the osteotomy is complete, the MT head is translated laterally; a skin hook or towel clamps are placed on the proximal fragment, and then the capital fragment is translated laterally. Sometimes, an osteotome must be inserted along the osteotomy cuts to free the soft tissues enough to allow the lateral translation. Also, when a long plantar limb is used, the soft issue is more likely to impede lateral translation; thus, gently mobilizing the capital fragment with an osteotome is advantageous.

Excessive manipulation should be avoided. It also is important to not let the saw cut extend across the apex, because this can create a stress riser in the capital fragment when fracture may occur during manipulation of the MT head. The MT head should be translated 3-5 mm laterally but no more than one third the width of the MT shaft. It is then fixed with a single K-wire (0.62), which is inserted from dorsal-proximal to plantar-distal. Care must be taken to avoid violating the MT head–sesamoid articulation.[58]

The pin is left in place for 3-5 weeks and removed in the office. The osteotomy is inherently stable and is through metaphyseal bone, which heals quickly. Screws and more complex fixation methods are not necessary. Because of the mild risk of sterile abscess, the author chooses to avoid bioabsorbable implants. However, DeOrio and Ware[59] showed that a single poly-p-dioxanone pin attached to a K-wire can be used routinely for fixation, obviating the need for external pin placement.

After the osteotomy is fixed, the excess medial cortex of the proximal fragment is resected in line with the MT head. All edges are smoothed with a rasp or rongeur. The capsule can be shortened to gain further correction by resecting the redundant segment from the proximal aspect of the limb of the capsulotomy made parallel to the joint.

One concern with distal osteotomies is the risk of avascular necrosis (AVN). Kuhn et al[60] showed that blood flow to the head of the MT decreases by 71% over baseline recordings, with the largest drop coming after capsulotomy (45%). The total blood flow goes up to 58% after lateral release and adductor tenotomy, then to a 71% decrease from baseline when the osteotomy is added. This explains why AVN is one of the possible complications of this surgery. However, clinically significant AVN necessitating treatment is actually quite rare.

Standard compression bunion dressings are used for 7-8 weeks and changed every 1-2 weeks. The pin is removed after 4 weeks. The patient should expect to return to full-time footwear in 10-12 weeks. This may vary depending on any additional procedures performed on the foot (eg, hammertoe correction, bunionette correction).

Chevron distal MT osteotomy can be summarized as follows:

  • Indications - HVA less than 30°; 1-2 IMA less than 13°; DMAA less than 15°
  • Expected corrections - HVA 12-13°; 1-2 IMA 4-5
  • Complications - Undercorrection when indications are extended to large deformities [8, 61] ; AVN in 12-20% (theoretically, there is an increased risk when adductor release is performed, but this has not been observed in clinical series)
  • Results - In a comparison study after 2 and 5 years of follow-up, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age [62, 63] ; subsequently, a systematic review involving 1028 participants in the chevron osteotomy group confirmed a mean reduction in pre-to-post 1-2 IMA of 5.33° [64]

Proximal metatarsal osteotomy

Proximal MT osteotomies are used for larger deformities, generally those with an IMA of greater than 15°.[65, 66] These osteotomies usually are combined with a DSTR, which is necessary to correct MTP subluxation with an HVA of greater than 35°.

Many types of osteotomy have been described, including medial opening-wedge, lateral closing-wedge, proximal chevron, and crescentic osteotomies.[3] The wedge osteotomies, which can change the length of the first MT, have not been widely advocated. Additional osteotomies include the scarf,[67, 68, 69] Ludloff,[70] and Mao[71, 72] types. Presently, the proximal chevron and crescentic osteotomies are widely used, and with proper technique, they can achieve excellent correction.[73, 74, 75, 76]

When comparing the Ludloff and chevron osteotomies, the Ludloff has been reported to have better correction of the IMA but results in greater shortening of the first ray.[77]

The proximal chevron osteotomy is described by Sammarco et al (see the image below).[74] This is combined with a DSTR. After the distal releases have been performed, the medial incision is extended proximally to the level of the first TMT joint (TMTJ).

Proximal chevron osteotomy fixed with 2 screws. No Proximal chevron osteotomy fixed with 2 screws. Note Akin proximal phalanx osteotomy fixed with Kirschner wires and hammertoe correction held with Kirschner wire.

The periosteum is elevated just enough to expose the medial cortex of the first MT. The osteotomy is designed with the apex pointing proximally with a long plantar limb. The angle of the osteotomy is approximately 70-80°. The osteotomy is performed using a microsagittal saw. Care must be taken not to extend the cuts past the apex of the osteotomy; doing so may create a stress riser and increase the risk of fracture.

After the osteotomy is completed, the distal fragment is rotated laterally with the osteotome; the upper limb behaves like an opening-wedge osteotomy, and the lower limb acts as a shelf to prevent elevation or depression of the distal fragment. Once the desired correction is achieved, the osteotomy can easily be fixed by using a pair of 2.7-mm cortical lag screws placed dorsal to plantar. The resected medial eminence is morselized and packed into the opening-wedge portion of the osteotomy. Two screws provide very stable fixation, and the technique of using an osteotomy with a plantar shelf has been demonstrated to be biomechanically sound.

Similar correction can be obtained by using a proximal crescentic osteotomy.[73, 75] This procedure is analogous to the focal dome osteotomy used in the correction of lower-extremity deformity. The main advantage of the proximal crescentic osteotomy is that it results in minimal shortening. Although proximal chevron osteotomy and proximal crescentic osteotomy were similar at reducing the HVA, the chevron osteotomy was better at reducing healing time and was associated with a lower incidence of dorsiflexion malunion.[78]

The proximal crescentic osteotomy is performed through a dorsal incision. Care must be taken to protect the extensor hallucis longus (EHL) and to avoid injury to the terminal portion of the medial branch of the superficial peroneal nerve, which passes over the first TMTJ. The osteotomy is performed 1-1.5 cm distal to the first TMTJ. The crescentic cut is made perpendicular to the plantar surface of the foot or at a 120° angle to the long axis of the first MT. Some literature supports either a concave distal or concave proximal cut orientation. Either way, care must be taken to avoid overcorrection.

Three-dimensional computer analysis has shown that the osteotomy started distal to the TMTJ and angled at 22° toward the proximal sesamoid articulation allows for a longer osteotomy and, therefore, less shortening and MT-head elevation. Adding a 10° plantarward coronal tilt also can help limit MT-head elevation.[79] The osteotomy is fixed with a cortical lag screw going dorsal, distal to plantar proximal.

Two K-wires may be added to provide a significantly more stable fixation, providing a viable option to the limited methods of additional fixation. Achieving rigid stabilization is an important means of avoiding loss of fixation and elevation of the first MT. Jung et al[80]  showed that when screw purchase is poor with the second screw, the use of two K-wires can provide fixation without a significant loss of strength. Rigid fixation may be difficult to obtain, especially in osteoporotic bone.

The postoperative course is much the same as that of the distal MT osteotomy. Depending on the fixation, a postoperative shoe, fracture walker, or cast may be used. An immobilization orthosis is an option that makes walking possible on postoperative day 1 by supporting the first MT and shifting weight to the other MT shafts. This orthosis could be an effective solution for patients who, for whatever reason, need to walk right away or for patients having bilateral hallux valgus correction.[81]

Weightbearing is protected for the first 4 weeks. Generally, most patients do not bear weight much in the first 3-4 weeks, because of pain. Once wound healing is ensured, weightbearing progresses. Patients with more proximal procedures have a slightly longer recovery period.

Proximal first-MT osteotomy with DSTR can be summarized as follows:

  • Indications - HVA greater than 30°; 1-2 IMA greater than 14°
  • Expected outcome - HVA 23-24° (HV correction is directly proportional to the severity of the preoperative deformity); 1-2 IMA greater than 8-11° (crescentic), 3-6° (closing wedge), 7° (opening wedge)
  • Complications - Shortening of first ray (closing wedge); elevation of first ray, causing transfer lesion to the second MT head (however, crescentic osteotomies have variable pressure patterns under the second MT head, which were thought to result from the overall geometric design of the crescenteric osteotomy, which is well suited for rotation in the horizontal plane but inherently unstable in the sagittal plane [82] ); undercorrection; overcorrection; stiffness of first MTPJ; delayed union or malunion
  • Results - Jones et al [83] showed that total range of motion and dorsiflexion were significantly decreased postoperatively when compared to their preoperative range of motion, and the magnitude of correction showed no correlation with the change; this immediate decrease in motion underscores the importance of joint mobilization early in recovery to prevent long-term loss of mobilization

A 1- and 3-year follow-up study showed that patients with first-MT pain and metatarsalgia at 1 year postoperatively were also more likely to experience pain and metatarsalgia at 3 years. The same study showed that in 87% of patients, radiologic changes were minimal or nonexistent between 1 and 3 years, providing evidence that a patient's 1-year follow-up clinical status is predictive of long-term outcome.[84]

In the same recent systematic review cited above, the scarf osteotomy group consisting of 300 participants was associated with a mean reduction in pre-to-post 1-2 IMA of 6.21°.[64]

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Arthrodesis and Resection

First-tarsometatarsal fusion

The first-TMT arthrodesis can be used to correct moderate-to-severe HV. Its main use is in the patient with a hypermobile first ray and a moderate-to-severe deformity (1-2 IMA >15°, HVA >30°).[85, 61, 86, 87, 88] The incidence of hypermobile first ray has been debated. Mann and Coughlin reported that a hypermobile first ray is present in fewer than 5% of patients with HV.[4]

TMT arthrodesis can also be used as a salvage operation after a failed bunion repair, when there is still an increased 1-2 IMA. In a prospective observational cohort study of patients who presented with a recurrent HV deformity after undergoing surgery between May 1996 and August 1999, Coetzee  et al[89] showed that first-TMT arthrodesis is a dependable and successful option for revision after failure of surgical treatment of HV. Contraindications are juvenile HV with an open epiphysis, short first ray, and MTP degenerative arthritis.

The procedure is performed through a dorsal incision extending from the first webspace proximally to the TMTJs. The EHL is retracted laterally. The subchondral bone is exposed, using a small osteotome to scrape off the cartilage.

In people who truly have a hypermobile first ray,[90] resection of wedges of bone may not be necessary. Often, the 1-2 IMA can be reduced and the joint pinned with wires for provisional reduction. A radiograph is obtained. If the positioning of the first ray is acceptable, it can be fixed after the preparation of the subchondral surface by feathering using an osteotome or with multiple drill holes. The margins of the fusion are bone grafted with local bone obtained from the bunion resection, distal tibia, or calcaneus.

If the first TMT cannot be reduced, joint resection is performed with a microsagittal saw, removing biplanar wedge based laterally and plantarward. This resection must be performed carefully to avoid excessive shortening.

Fixation is performed with 3.5-mm cortical screws placed in lag fashion. Cannulated screws may be used in persons in whom wire fixation is performed first to ensure acceptable positioning. The screw configuration consists of three screws, with the first going dorsal distal to plantar proximal, the second going dorsal proximal to plantar distal and crossing the TMTJ, and the third going transversely medial to lateral across the base of MTs 1 and 2. Care must be taken to maintain compression across the TMTJ.

This procedure is always combined with DSTR. The postoperative course typically involves a longer recovery period than procedures that are more distal. Patients are placed in a standard soft bunion dressing, with a plaster splint to immobilize the ankle. At the first dressing change, this is converted to a short leg cast with a soft spica dressing to hold the great toe in place.

Patients are kept nonweightbearing for the first month and are then allowed to engage in touchdown weightbearing for balance in the second month. The bunion dressing is continued until the 2-month postoperative check. At that point, if radiographs demonstrate fusion, the patient can progress slowly to wearing a firm-soled shoe. Typically, it can take another 6 weeks before patients are comfortably wearing a shoe full-time.

When this procedure was used in conjunction with a bunionectomy and distal soft-tissue realignment (Lapidus procedure; see the image below),[91, 92] according to Kopp et al,[93] good clinical results were achieved, with significant improvements in pain, activity, limitations, and footwear requirements. Radiographically, the investigators also reported significant improvements in the IM and HV angles, with an average correction of 8-10° and 10-15°, respectively.

Postoperative films after Lapidus procedures in 50 Postoperative films after Lapidus procedures in 50-year-old woman with bilateral severe hallux valgus deformity.

First-TMT fusion can be summarized as follows:

  • Indications - HVA greater than 30°; 1-2 IMA greater than 15°; MTP subluxation and hypermobile first ray
  • Expected corrections - HVA 18°; 1-2 IMV 6-8°
  • Complications - Nonunion (10-12%); pain (42%); dorsiflexion plantar flexion malunion; overcorrection; undercorrection; painful hardware
  • Results - In a clinical follow-up study using radiologic and pedobarographic examinations in 56 patients with arthrodesis of the first TMTJ, bony consolidation occurred at 9 weeks postoperatively; average first IM angle improved from 20.4° to 11.2°, and the American Orthopaedic Foot and Ankle Society (AOFAS) score significantly improved, from 51 to 92 points at 8.2 months postoperatively [94]

The final procedures to consider in bunion correction are joint-sacrificing surgeries. These are arthrodesis of the first MTPJ and resection arthroplasty.

Metatarsophalangeal joint arthrodesis

Arthrodesis of the first MTPJ is used for salvage after failed bunion surgery, for bunions associated with osteoarthritis or rheumatoid arthritis, and for severe HV (HVA >40°, IMA >16°). With modern internal fixation methods, high rates of fusion can be achieved.[95, 96, 97, 98, 99, 100]

Results of first-MTPJ arthrodesis as a treatment for severe hallux valgus deformities resulted in a high percentage (>85%) of successful results at an average follow-up of over 8 years, with a significant reduction in postoperative pain.[101] Also, the IMA will correct without the addition of a basal osteotomy in patients undergoing MTPJ arthrodesis.[102] Rarely, however, when the IMA associated with the HV deformity is in the severe range, a combination of a more proximal procedure with a first MTPJ arthrodesis (Mau osteotomy or modified Lapidus) may be necessary and is safe and clinically successful.[103]

Many methods for preparing the joint have been described. Resection may be performed with flat surfaces or with reamers that shape the PP and MT head in mirror images. The advantage of this latter technique is that less shortening is achieved and the position of the toe can be adjusted when hemispheric reamers are chosen.

The most critical aspect of the arthrodesis is the position of the first toe. Generally, it should be fused in 10-15° of valgus and 30° of dorsiflexion in relation to the first MT and neutral rotation. The best landmarks are clinical, though, because the first toe should be positioned adjacent to the second toe and have enough dorsiflexion for the surgeon to be able to place the tip of his or her finger under the distal phalanx of the toe being fused, when this foot is placed in a plantigrade position on a hard, flat surface.

Too much dorsiflexion leads to pain at the tip of the toe when the patient wears shoes; too little dorsiflexion can lead to premature arthrosis or instability of the first IPJ. Too much valgus can cause impingement on the second toe; one must anticipate the gradual decrease in the IMA that will occur after an MTP fusion, so that late impingement does not occur.

The technique currently used by the author for fusion is hemispheric reaming and compression screw fixation. Currently, the author uses a 2.7-mm lag screw with a one-quarter tubular plate. This provides very stable fixation, allowing early weightbearing. The head of the 2.7-mm screws is very shallow, so hardware prominence has not been problematic. When no previous scars are present, the joint is approached through a dorsal incision, although the arthrodesis can also be accomplished through a previous medial incision if it is performed for recurrent HV. Full-thickness flaps are raised sharply off the MT head.

The collateral ligaments are elevated and released, if necessary, to achieve correction. The medial eminence is removed using a rongeur or oscillating saw. The articular cartilage is removed using an osteotome to expose the subchondral bone. At this point, the cannulated hemispheric reamer is used to ream the surfaces, removing the subchondral bone to expose cancellous surfaces, which are best for achieving fusion. Care must be taken not to remove too much bone. Additionally, when a dorsal approach is used, a tendency may exist to remove too much bone dorsally, leading to excessive dorsiflexion. This can be avoided by increased exposure and plantar flexion of the PP during the reaming.

Once the joint is prepared, the surfaces are opposed in the desired position and pinned with a K-wire. The author uses an intraoperative fluoroscan to check position of the fusion and hardware. A low-profile plate is best chosen, with 2.7-mm screws. In this case, only one screw crosses the joint, using a lag technique. The plate is applied dorsally, with two or three screws proximal and distal.

Postoperatively, bulky gauze compression dressing and a surgical shoe are used. When fixation is tenuous, a cast or fracture walker may be used for additional immobilization. Patients are allowed to bear weight once wound healing is ensured, usually after 2-3 weeks. After 6 weeks, if fusion is evident on radiographs, patients are allowed to start bearing weight in a firm-soled shoe. Most patients have returned to full-time footwear use by 8-10 weeks postoperatively.

MTPJ arthrodesis can be summarized as follows:

  • Indications - HV with arthrosis and/or rheumatoid arthritis; neuromuscular conditions (spasticity); recurrent valgus (HVA >40°); fixed hallux valgus deformity; severe HV with severe IMA (when IMA will not be fixed with MTPJ arthrodesis alone)
  • Complications - Nonunion (generally <10% with internal fixation techniques); malunion (too little valgus, increased IPJ arthrosis); excessive plantar flexion (pressure at the tip of the toe and increased IPJ arthrosis); excessive dorsiflexion (intractable plantar keratosis in the first metatarsal head, pain at the tip of the toe or nail, dorsally); painful hardware; infection
  • Results - Coughlin et al [101] evaluated the results of first-MTPJ arthrodesis as treatment for severe and moderate HV deformities, using data derived over a 22-year period in a single surgeon's practice; arthrodesis of the first MTPJ for idiopathic HV resulted in a high percentage of successful results, at an average follow-up of over 8 years; in addition to a significant reduction in postoperative pain, postoperative AOFAS scores averaged 84 (range, 72-90), and there was complete resolution of lateral metatarsalgia at final follow-up

Rippstein et al evaluated the results when a MTPJ arthrodesis was combined with a more proximal procedure to fix the associated severe IMA. Mean HVA decreased from 49.9º (range, 40.1º-66.7º) preoperatively to 9.7º (range, 4.2º-17.7º). Mean IMAs decreased from 18.8º (range, 15.1º-21.4º) to 4.6º (range, 0.7º-8º). Of the total 18 patients, 15 were very satisfied and three were satisfied.[103]

When compared with the Hohmann osteotomy in patients with first-ray hypermobility, the Lapidus procedure (arthrodesis) was equally effective at reducing pain at 2 years and equal at correcting the HVA (N=101; 50 Homan, 51 Lapidus).[104]

Excisional arthroplasty (Keller)

Resection arthroplasty is rarely used for correction of HV. It should be employed for moderate deformity with coincident arthrosis, in patients who are elderly and have low demands.[105, 106, 107, 108] The procedure, which can accomplish mild correction, decompresses the MTPJ and allows quick healing. However, it does result in shortening of the toe and loss of push-off power; in cases when excessive resection is performed, it may produce a cockup deformity resulting from loss of the plantar attachment of the flexor hallucis brevis (FHB).

Compared with a distal osteotomy, a Keller arthroplasty is less effective at improving the IMA and range of motion at 3-year follow-up.[109] However, the Keller arthroplasty is better than arthrodesis at retaining mobility at 2 years, though there was no demonstratable difference in pain or dissatisfaction.[110] The Keller arthroplasty should be used mainly as a salvage procedure in patients with low physical demands.

The procedure can be performed through either a dorsal or medial incision. A medial incision is preferred because it allows medial capsular plication to accomplish correction of alignment.

The capsule is elevated from distal to proximal, leaving the proximal attachment. It is tagged with a resorbable suture. The medial eminence is excised. The base of the PP is exposed. Care must be taken to preserve the plantar capsule. The cut is made at the metaphyseal flare. Excessive resection leads to shortening and increases the chances of a cockup deformity; thus, not more than the proximal 25% of the phalanx should be excised.

After excision, the capsule is repaired to the remaining phalanx through drill holes. Repairing the plantar capsule is essential because it minimizes the risk of postoperative cock-up deformity. Medial capsular repair corrects the valgus deformity. The joint is then pinned with 2 crossed, 0.062-inch K-wires, which are removed 3-5 weeks postoperatively.

A standard soft gauze postoperative bunion dressing is used, and the patient is allowed limited weightbearing in a postoperative shoe. Walking should be restricted to avoid the complication of pin breakage.

Excisional arthroplasty (Keller) can be summarized as follows:

  • Indication - Moderate HV in a low-demand patient with osteoarthrosis of the MTPJ
  • Expected corrections - HVA correction up to 50%, with best results achieved when the HVA is less than 30°; IMA correction minimal
  • Complications - Metatarsalgia resulting from the loss of weightbearing function of the great toe (results tend to deteriorate with time); cockup deformity; shortening; flail toe; diminished pushoff strength
  • Results - In a long-term retrospective analysis of an uncontrolled series of basal metatarsal closing-wedge osteotomies and Keller excision arthroplasties performed in patients aged 14-40 years, statistical analysis revealed significantly better clinical and radiologic outcomes after osteotomy; in fact, it was recommended that Keller arthroplasty be abandoned for the treatment of HV in young and active patients [111]
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Less Invasive Techniques

Various less invasive techniques have been developed in attempts to decrease soft-tissue injury (primarily), decrease healing time and morbidity, and improve cosmesis. The three categories of techniques include percutaneous, minimally invasive, and arthroscopic procedures. Currently, the majority of articles published on minimally invasive, percutaneous, and arthroscopic techniques are of low-quality, level IV evidence.[112] Only a handful of prospective comparative trials have been performed.

Percutaneous forefoot surgery

Percutaneous forefoot surgery (PFS) is typically performed with a 1- to 3-mm incision using a miniblade and power rotary burr by way of tactile sensation and intraoperative image intensification.[113]

A 2-year prospective study was performed on the percutaneous Reverdin-Isham osteotomy and included 104 cases.[1] For the procedure, a 3- to 5-mm plantar-medial incision is created over the metatarsal head. Capsule detachment and resection of the medial and dorsal protrusions of the MTP head are performed with a low-speed conical burr under fluoroscopic guidance. This is followed by the actual Reverdin-Isham osteotomy created by a straight burr with the same medial approach, conserving the lateral cortex.

A lateral capsule and ligamentous release is then performed via a second 3-mm incision medial to the EHL using a Beaver blade.[1] In addition to this, a varisation osteotomy of the first phalanx is performed via a dorsal approach medial to the EHL with a straight burr, again preserving the lateral cortex.

Complete weightbearing was resumed immediately in a rigid postoperative shoe.[1] Several complications included four first-MT and five first proximal phalanx lateral cortex fractures, six DMAA hypercorrections of less than 0°, two subjects with painful severe joint rigidity, two with complex regional pain syndrome, three with recurrence of deformity, and two with transfer metatarsalgia after 18 months. The results of functional outcomes via AOFAS were comparable to other studies of percutaneous or standard open hallux valgus procedures such as chevron osteotomy or scarf osteotomy.

An additional article mentions that to decrease complications and maintain corrections performed during surgery, specifically designed dressings are used. Dressing management requires specific training and close monitoring is required to make sure the correction is maintained while the patient resumes ambulation.[114]

This procedure does seem to fall short on reliably reducing the DMAA.[1, 115] Bauer et al therefore concluded that this procedure should be restricted to medium-to-moderate HV correction without significant metatarsus varus (IMA ≤15°).[1] It also is a difficult procedure to perform with a long learning curve. A few studies have shown higher complication rates with the percutaneous distal metatarsal osteotomy for HV, including a high rate of recurrence of HV and dorsal malunion.[116]

A technique of distal percutaneous metatarsal osteotomy has been described.[50] A 2-mm-diameter K-wire is inserted extraperiosteally from the medial corner of the nail of the great toe along the medial side of the hallux. A 3- to 5-mm incision is made down to bone at the metatarsal neck, and the periosteum around the osteotomy site is detached.

The osteotomy is made through the subcapital region of the first metatarsal under fluoroscopy in the sagittal plane, perpendicular to the long axis of the shaft of the first metatarsal, but with slight mediolateral obliquity in the frontal plane. The K-wire is then driven down the central axis of the metatarsal through the osteotomy. Patients are allowed to bear weight in a firm-soled postoperative shoe on the first postoperative day. This procedure is for mild-to-moderate HV with a first intermetatarsal angle of 10-20°.[50]

Minimally invasive techniques

Minimally invasive surgery is performed via a 1- to 2-cm incision with a traditional blade and power saw under direct visualization, possibly with fluoroscopic guidance.[113] The SERI (simple, effective, rapid, inexpensive) technique is similar to the percutaneous method described above, except it is performed through a slightly larger incision under direct visualization and the osteotomy is made via an oscillating saw.

The SERI technique is indicated to correct mild-to-moderate reducible deformity when the HV ankle is 40° or less and the IMA is 20º or less, with only mild arthritis. Contraindications include age older than 75 years, severe arthritis or stiffness of the MTPJ, and severe instability of the cuneometatarsal joint and MTPJ.[117] Mixed studies exist regarding the results, and the procedure may require a significant learning curve in order to achieve acceptable results.[116, 117]

Another described minimally invasive surgical technique is the Bösch osteotomy. This was compared with the open scarf osteotomy in a comparative retrospective study with 36 subjects in each group.[118] The procedure is indicated for HVA of 20-40°, IMA up to 20°, and a DMAA up to 25°, with no radiographic evidence of degenerative MTP arthritis.

The Bösch osteotomy is performed via a medial approach, approximately 2-cm incision, and osteotomy customized to correct the patient’s individual deformities. The head is freed with an osteotome, and the osteotomy is fixed with 2 K-wires. Immediate heel walking was allowed for both groups. There was decreased operating room time for the minimally invasive Bösch procedure, shorter hospital stay, and equivalent AOFAS and FAOS scores at 2-year follow-up.[118]

The Bösch osteotomy was also compared with the open Kramer technique. The minimally invasive Bösch approach did allow earlier discharge; however, it had a trend toward a higher complication rate (was not statistically significant, but may have been underpowered) and had lower patient satisfaction with a trend toward more shortening compared with the open Kramer procedure.[119]

Another minimally invasive technique involves reconstruction of the medial collateral ligament in the correction of HV deformity with primary medial collateral ligamentous insufficiency.[120] There will be times when medial capsular plication is not strong enough to provide strong and lasting stability to the first MTP joint. Medial collateral reconstruction by means of extensor hallucis brevis (EHB) tendon graft can be performed in cases of medial collateral ligament rupture, metatarsus adductus with a disproportionate HVA, and recurrent HV deformity with a relatively normal IMA.

Arthroscopic techniques

Proposed advantages of arthroscopic procedures, in addition to the advantages of other lesser invasive techniques, include improved assessment of sesamoid reduction and minimization of overcorrection.[6]

An arthroscopic Lapidus procedure has been described.[121] This was a limited study on 5 patients with 1 year of follow-up. The procedure included an arthroscopic Lapidus as well as a minimally invasive chevron osteotomy distally on patients with severe HV (>16°) and hypermobility of the first MCP. The procedure involves a percutaneous release of the lateral joint capsule and adductor tendon, followed by insertion of three portals: medial to the tibialis anterior, superior between the tibialis anterior and the EHL, and lateral between the EHL and the deep peroneal neurovascular bundle.

The working space is created just around the joint capsule.[121] The joint cartilage is removed with a Beaver blade, followed by limited abrasion of subchondral bone with a bone resector to prevent shortening. Then, several holes are drilled into the subchondral bone. An intermetatarsal screw is inserted between the first and second metatarsals to correct the IMA. Fixation of the joint is achieved with two percutaneously placed screws.

Next, the minimally invasive chevron osteotomy is performed to correct the HVA.[121] In a study analyzing results from 59 cases of first-MTP arthroscopy, osteotomy sites from a distal chevron osteotomy were fixed with one 1.4-mm K wire and proximal chevron osteotomy sites were fixed with three 1.4-mm K wires.

In the five patients, no complications were reported, and all returned to preoperative activities within 4 months. One-year postoperative AOFAS scores improved by an average of 51 points, to a range of 87-90. Radiographic evaluation confirmed fusion in all patients by 4 months, with an average HVA improvement of 26° and IMA improvement of 11°. Functional results are similar to other reported outcomes with open Lapidus,[122, 93] and radiographic results were at least equivalent.[123, 122, 86]

In a subsequent study analyzing 59 MTPJ arthroscopy procedures, the AOFAS score improved from an average of 71 preoperatively to 95 points for those patients with HV.[124] Radiographic results showed a mean HVA improvement from 29.2° to 9.7° and a mean IMA improvement from 14.8° to 7.7°. Of the 36 patients with HV, all cases showed an improvement in medial sesamoid positioning postoperatively, no hallux varus, and no postoperative stiffness. The authors assume that the minimal invasiveness of the arthroscopy may contribute to the results. Additionally, all 36 were without any recurrences of the deformity at the latest follow-up.

An arthroscopic technique with the claimed benefit of affording an improved view of the articular surface allows for more-controlled resection of only the cartilage, and no subchondral bone, to limit shortening and promote bone healing, in addition to minimizing soft-tissue damage and offering a better cosmetic result. The author noted that it is a more technically demanding procedure, requiring a skilled arthroscopist.[121]

Whereas several less invasive techniques are beginning to be performed more frequently, and early results have been published, larger comparative trials are needed to provide the proof of the additional proposed benefits without increased failure and morbidity.

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Postoperative Care

A liposomal form of the local anesthetic bupivacaine was approved by the US Food and Drug Administration (FDA) in October 2011. A single dose infiltrated into the surgical site produces postsurgical analgesia for bunionectomy. The recommended dose for bunionectomy is 93 mg (7 mL) infiltrated into tissues surrounding the osteotomy and the remaining 13.3 mg (1 mL) into the subcutaneous tissue.

In two randomized, placebo-controlled studies, Apfelbaum et al found that the cyclooxygenase (COX)-2 inhibitor parecoxib, along with supplemental analgesia provided as needed, was effective for pain relief over 1-3 days in patients who underwent bunionectomy[125] ; however, this agent is not approved by the FDA for use in the United States.

In patients with arthroscopic correction of mild-to-moderate HV, active dorsiflexion exercises begin 2 days postoperatively and passive dorsiflexion and plantarflexion are started 7 days postoperatively. An HV strapping and postoperative shoe is worn for 8 weeks. The percutaneous K-wire used for the DCMO is removed 4 weeks after surgery, and the three K-wires used for PCMO are removed 8 weeks after surgery under local anesthesia.

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Complications

Recurrence is the most common complication after bunionectomy, particularly in cases where the deformity and soft tissues at the first MTPJ are undercorrected. For additional complications related to specific surgical procedures, see Distal Soft-Tissue Reconstruction, Akin Osteotomy, First-Metatarsal Osteotomy, Arthrodesis and Reconstruction, and Less Invasive Techniques.

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Contributor Information and Disclosures
Author

Richard T Laughlin, MD Professor and Chair, Department of Orthopedic Surgery, Sports Medicine and Rehabilitation, Wright State University Boonshoft School of Medicine; Co-Director, Foot and Ankle Care Center, Active Staff, Miami Valley Hospital

Richard T Laughlin, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Mid-America Orthopaedic Association, American College of Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association

Disclosure: Received grant/research funds from AOFAS for none; Received grant/research funds from Ohio Third Frontier for none; Received grant/research funds from Wright State University Boonshoft School of Medicine Seed Grant for none; Received none from AOFAS for post grad education committee; Received none from Dayton Area Graduate Medical Education Consortium (DAGMEC) for member; Received none from Mid-America Orthopaedic Association for education committee; Received ownership interest from South Surger.

Coauthor(s)

Roman Trimba, MD Resident Physician, Department of Orthopedic Surgery, Sports Medicine, and Rehabilitation, Miami Valley Hospital, Wright State University, Boonshoft School of Medicine

Disclosure: Nothing to disclose.

Daniel F Drake Wright State University, Boonshoft School of Medicine

Daniel F Drake is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

Acknowledgements

Emmanuel K Konstantakos, MD Resident Physician, Department of Orthopedic Surgery, Sports Medicine, and Rehabilitation, Miami Valley Hospital, Wright State University, Boonshoft School of Medicine

Disclosure: Nothing to disclose.

Kyle L Randall, MD Resident Physician, Department of Orthopedics, Medical College of Wisconsin

Disclosure: Nothing to disclose.

G Ryan Rieser, MD Resident Physician, Department of Orthopedic Surgery, Miami Valley Hospital, Wright State University, Boonshoft School of Medicine

G Ryan Rieser, MD is a member of the following medical societies: Student National Medical Association

Disclosure: Nothing to disclose.

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Akin proximal phalanx closing-wedge osteotomy to correct high proximal phalangeal articular angle.
Distal chevron metatarsal osteotomy fixed with a Kirschner wire.
Proximal chevron osteotomy fixed with 2 screws. Note Akin proximal phalanx osteotomy fixed with Kirschner wires and hammertoe correction held with Kirschner wire.
Proximal chevron osteotomy fixed with 2 screws.
A 22-year-old woman with hypermobile first ray, first and second intermetatarsal angle of 18°. Lapidus procedure preoperative image (left) and 6 months' postoperative image (right).
Proximal phalanx articular angle (normal &lt; 10°). This deformity is within the proximal phalanx.
Distal metatarsal articular angle (normal &lt; 10°, average in normal feet 7°).
Metatarsophalangeal joint congruence.
Intermetatarsal angle (normal &lt; 9°).
Hallux valgus angle (normal &lt; 15°).
Severe bunion deformity.
Fifty-year-old woman with bilateral severe hallux valgus deformity.
Postoperative films after Lapidus procedures in 50-year-old woman with bilateral severe hallux valgus deformity.
Table 1. Categories of Hallux Valgus Deformity
Angle Mild Subluxation Moderate Subluxation Severe Subluxation
Hallux valgus angle <20° 20°-40° >40°
1-2 Intermetatarsal angle <11° <15° >15°
Sesamoid <50° 50º-75º >75º
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