Hallux Valgus Treatment & Management

Indications for repair of hallux valgus include the following:

• Painful joint range of motion (ROM)
• Deformity of the joint complex
• Pain or difficulty with footwear
• Inhibition of activity or lifestyle
• Associated foot disorders that can be caused by this condition

Associated foot disorders include the following:

• Neuritis/nerve entrapment
• Overlapping/underlapping second digit
• Hammer digits
• First metatarsocuneiform (MTC) joint exostosis
• Sesamoiditis
• Ulceration
• Inflammatory conditions ( bursitis,  tendinitis) of the first metatarsal head

Contraindications for surgical treatment include the following:

• Extensive  peripheral vascular disease
• Active infection
• Active osteoarthropathy
• Septic arthritis
• Lack of pain or deformity
• Advanced age
• Lack of compliance
• Myocardial infarction within the previous 6 months
• Comorbid conditions that place the patient at significant cardiovascular or respiratory risk

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

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

Adaptation of footwear

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

Pharmacologic or physical therapy

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

Functional orthotic therapy

Functional orthotic therapy may be implemented to control foot biomechanics. ^[19] This approach can relieve symptomatic bunions, though the foot and first MTP joint must maintain some degree of flexibility. ^[20] For example, the joint cannot be laterally track-bound on clinical examination, and the sesamoid position cannot be greater than 4 on radiography. These two findings indicate a deformity that is nonreducible or that cannot be manipulated to a neutral, pain-free position.

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

If orthotics are to be manufactured for a patient, the physician must be familiar with the orthotic prescription form to control the patient's deformity, though this form varies among different manufacturers. A sufficient understanding of the patient's requirements may enable the physician to use simple over-the-counter devices instead of more costly custom-molded devices. ^{[21, 22, 23]}

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

Activity

When prescribing orthotics, the physician should ask questions such as these: "When will the patient primarily be using the orthotics? In dress shoes? During sports activities? During the day at work?"

Generally, dress shoes afford the patient the option to wear smaller devices, but these lack the control of larger orthotics. Patients participating in sports require more shock-absorbing capability from the orthotic; therefore, a more pliable material should be used.

Furthermore, the material used for the shell or orthotic can vary. A rigid material (eg, graphite) is thin and lightweight, does not deform, and is durable. However, graphite has a tendency to crack and therefore should not be used for sports applications. Another option is polypropylene, a durable, flexible plastic that resists breakage. It can easily be altered by grinding or heat molding in the office, whereas graphite cannot. A disadvantage of polypropylene is its tendency to deform over time and with use. Some physicians use leather or cork with success.

Weight

The material used can be ordered in varying thicknesses. The heavier patient needs a thicker material that will not bend, crack, or deform under the patient's weight. Moreover, the bulkier the patient's shoe, the thicker the shell material that can be used without causing the orthotic to fit uncomfortably. A thicker material can add control.

Top cover

Orthotics generally have liners on top of the shell, either to provide shock absorption or cushioning or to act as the shoe liner. Choices include, but are not limited to, leather, vinyl, Spenco, ethylene vinyl acetate (EVA), Poron, and Pelite. Top covers do not contribute to the control of the orthotics and are not functionally necessary.

Rearfoot/forefoot post

Applying a post, or exterior material, of a different material that is either molded with the shell or added on later can increase the stability and control of the orthotic. A rearfoot post is under the heel cup, and does not extend into the midfoot region.

A forefoot post may be added for biomechanical control for a patient with a rigid deformity (eg, rigid forefoot valgus) that cannot be controlled satisfactorily or comfortably with the orthotic because of the nonmaneuverability of the patient's foot. Therefore, the patient with rigid forefoot valgus requires a piece of material added extrinsically, or under the orthotic on the lateral aspect, to balance the forefoot to the rearfoot.

Biomechanical examination

The physician must determine the type of deformity the patient has and obtain angular measurements to prescribe the correction.

A plaster nonweightbearing mold is made of the foot in a neutral position (rear foot neither everted or inverted), with the forefoot loaded to simulate weightbearing. From this cast, the orthotic manufacturer creates an orthotic with built-in corrections. For example, if the patient has a 4° flexible forefoot varus, the rear foot likely compensates for this deformity, thereby allowing the forefoot to bear weight evenly across all metatarsal heads.

A well-built orthotic allows the foot to stand in a neutral position, both in the forefoot and rear foot, removing increased pressures and deforming forces caused by the compensation.

Modifications

Possible modifications include measures such as the following:

• Increasing the height of the heel cup (for more control)
• Creating a wider medial arch (for a collapsed, flat foot)
• Providing plantar fascial groove (for a tight, painful plantar fascia)
• Using a metatarsal pad (for pain under the second metatarsal head from overloading due to inadequate weightbearing by the hallux)

If the etiology is determined to be a metabolic or systemic condition, it is best to work with a rheumatologist, neurologist, or primary care physician to stabilize, manage, and slow the progression of disease and to choose therapy for the hallux valgus deformity.

Surgical treatment can be offered when conservative therapy is impractical or fails to relieve the patient's symptoms. The goals of surgical treatment are to relieve symptoms, restore function, and correct the deformity. The clinician must consider the patient's history, physical examination, and radiographic findings before selecting a procedure. On occasion, the final procedure is determined intraoperatively when the physical appearance of the joint, bone, and tissue can be observed directly. ^{[24, 25, 26, 27, 28, 29]}

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

• Establishing a congruous first MTP joint
• Reducing the intermetatarsal angle (IMA)
• Realigning the sesamoids underneath the metatarsal head
• Restoring the ability of the first ray to bear weight
• Maintaining or increasing the first MTP joint's range of motion (ROM)
• Realigning the hallux to a rectus position
• Correcting or controlling etiologic factors

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

Arthroscopically assisted correction of hallux valgus is an attractive option, in that it is minimally invasive; however, there remains a need for further study of criteria for patient selection, as well as long-term outcomes. ^[30]

The procedure is chosen with the aims of reducing the patient's symptoms most effectively and preventing recurrence. The choice is based on particular components of the hallux valgus, which can include positional and structural deformities of the MTP joint, adaptive changes of the first MTP joint, and the position and condition of the sesamoid apparatus. Classes of surgical procedures include the following:

• Capsulotendon balancing or exostectomy
• Osteotomy
• Resectional arthroplasty
• Resectional arthroplasty with implant
• First MTP joint arthrodesis
• First MTC joint arthrodesis

Capsulotendon balancing or exostectomy

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

• Painful osseous medial prominence of the metatarsal head
• Deviated or subluxated first MTP joint
• Adequate, pain-free ROM
• Reducible deformity

The postoperative course includes limited-to-full weightbearing in a surgical shoe immediately following the procedure. 

Osteotomy

Osteotomy (see the images below) is performed to correct structural deformities associated with the cuneiform, metatarsal, and phalanges of the first ray and typically includes a lateral release and capsulorrhaphy. These procedures should be performed at the level of the deformity. ^{[26, 31]}  (See Hallux Valgus Osteotomy.)

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

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

If an Akin operation is performed independently for correction of hallux valgus, the surgeon should anticipate even greater lateral subluxation of the first MTP joint that leads to rapid recurrence of the original condition despite the initial clinical improvement. ^{[32, 33]}

MTC osteotomies address deformities along the MTC complex. Indications include an increased IMA, metatarsus primus elevatus, or an increased proximal articular set angle (PASA) with articular adaptation of the first metatarsal head. The levels at which these osteotomies are performed include the distal, diaphyseal, and proximal levels along the metatarsal shaft.

Distal osteotomies are performed in the metaphyseal region and achieve only a relative correction of the IMA. They are inherently stable and are associated with fewer occurrences of head displacement/rotation or shaft elevation. The joint congruency is corrected primarily with this osteotomy. They may be performed for both a congruent joint and an incongruent joint with an IMA of less than 15°.

After a distal osteotomy, the patient typically has 2-6 weeks of limited weightbearing in a surgical shoe. Common complications include shortened first metatarsals, second metatarsalgia, restriction of motion, and recurrence of deformity.

Common distal or head osteotomies include the following:

• Reverdin-Laird procedure, a medially based wedge resection with lateral transposition of the metatarsal head
• Austin or chevron procedure, a horizontally directed V-shaped displaced osteotomy with lateral transposition of the metatarsal head
• Mitchell procedure, a lateral transpositional transverse osteotomy with preservation of a lateral cortical block of bone

In a prospective, randomized trial comparing Mitchell osteotomy (MO) with chevron osteotomy (CO) in 120 female patients with hallux valgus, Buciuto found that patients treated with CO had significantly better results with regard to American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating System (CRS) scores, number of postoperative complications, patient satisfaction, and length of sick leave (for employed patients). ^[34] The results suggested that in female patients, CO should be regarded as the first-line procedure for treatment of mild and moderate hallux valgus.

A study by Seo et al found that despite concerns about aggravation of osteoarthritis and fixation failure, distal chevron osteotomy with lateral release for moderate-to-severe hallux valgus was safe in patients aged 60 years or older. ^[35]

In a cadaveric study, Chen et al described an alternative approach to Kirschner wire (K-wire) fixation in distal chevron osteotomy of the first metatarsal whereby a tricortical technique was used rather than a unicortical technique. ^[36]  They found tricortical K-wire fixation to be biomechanically superior to unicortical K-wire fixation and not significantly different from single-screw fixation.

Diaphyseal osteotomy is associated with a decreased blood supply and is less stable than a distal procedure, but it can achieve a greater correction of the deformity and address a true PASA deviation. ^[37] It can lengthen the first metatarsal after rotation or translocation to correct the IMA; therefore, it is a procedure of choice for short metatarsals.

The midshaft osteotomy is performed for mild-to-moderate hallux valgus deformities, with an IMA greater than 15° but a hallux valgus angle (HVA) smaller than 40°, though large degrees of correction can also be achieved with greater rotation of the fragments. In addition, this can be performed as an alternative to a base procedure. This procedure is best used in patients with good bone quality (ie, without significant osteopenia).

Common midshaft or diaphyseal osteotomies include the following:

• Scarf procedure, in which a Z-shaped osteotomy in the transverse plane extends from the metatarsal head to the base with lateral rotation of the distal fragment ^{[37, 38]}
• Ludlof procedure, in which an oblique osteotomy is oriented dorsal and proximal to plantar distal from the head to the base with distal bone fragment transposed laterally

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

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

Common base or proximal osteotomies are as follows:

• Crescentic procedure, in which a crescentic blade is used to transect the first metatarsal, resulting in a dome-shaped osteotomy; the distal segment can be rotated in the transverse and sagittal planes for correction of the deformity
• Closing abductory wedge (Loison/Balacescu type) procedure, which is a transverse osteotomy with the lateral wedge removed and the medial hinge kept intact
• Closing abductory wedge (Juvara) procedure, which is a long, oblique osteotomy extending from proximal-medial to distal-lateral with the lateral wedge removed and medial hinge left intact

Minimally invasive osteotomy

Minimally invasive surgical techniques have been applied to hallux valgus surgery. A 2009 study by Lin et al found minimally invasive distal metatarsal osteotomy to be associated with good satisfaction, functional improvement, and a low rate of complications, suggesting that this could be an effective, safe, and simple means of treating mild-to-moderate hallux valgus. ^[31]  

In a 2020 randomized controlled trial, Kaufmann et al compared minimally invasive with open distal metatarsal osteotomy for treatment of hallux valgus over a 5-year study period. ^[39]  Follow-up included assessment of the AOFAS Forefoot Score, a visual analogue scale (VAS) pain score, and a patient satisfaction score at 6 weeks, 12 weeks, 9 months, and 5 years; radiographic outcomes (hallux valgus correction, joint degeneration) and ROM were also evaluated. At 5 years, no significant differences between the two surgical approaches were noted.

Resectional arthroplasty

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

The typical resectional arthroplasty that is performed is known as a Keller procedure. It is performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected. The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups. The technique is inherently unstable and should be used judiciously. ^{[40, 41]} The postoperative course includes limited-to-full weightbearing in a surgical shoe immediately after the procedure.

Resectional arthroplasty with implant

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

First metatarsophalangeal joint arthrodesis

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

This is a difficult procedure to perform in elderly persons because of the need for nonweightbearing status for 4-8 weeks postoperatively. Indications include the following:

• Painful or severely limited ROM in the first MTP joint
• Significant degenerative arthritis
• Revision or repair of prior arthroplasty with implant or osteotomy (salvage procedure)
• Extensive trauma to the first MTP joint that is not reparable with osteotomy
• Ligamentous laxity
• Neuromuscular disease

First metatarsocuneiform joint arthrodesis

Significant and/or hypermobile hallux abductovalgus may be reduced with arthrodesis of the first MTC joint ^[42] (see the images below). Indications include the following:

• Metatarsus primus varus
• Hypermobility of the first ray
• Metatarsalgia of the lesser metatarsals
• Degenerative joint disease of the MTC joint

Preparation for surgery

A complete history and physical examination are required for surgical correction. The history should include allergies, complications with anesthesia, bleeding disorders, use of anticoagulants, immunocompromised status, and tobacco use. Preoperative evaluation may include the following:

• Electrocardiography (ECG)
• Chest radiography
• Laboratory workup, including a complete metabolic panel, complete blood count, coagulation studies, and urinalysis if warranted

The patient should be well informed of the etiology, course, and prognosis of the deformity, as well as the risks and benefits of conservative and surgical options.

Hallux valgus can generally be corrected surgically on an outpatient basis. ^[43] Situations that may warrant hospital admission include the need for parenteral medications, perioperative complications or anesthetic complications, an inability to function independently, and coexisting medical conditions. Patients undergoing complex surgical procedures may also require hospitalization.

The choice of anesthetic techniques for the surgical procedure depend on the surgeon's, patient's, and anesthesiologist's preferences. These choices include general anesthesia, spinal anesthesia, or monitored anesthesia with local blocks. The block typically is performed with a short- and/or long-acting local anesthetic. For maximum benefit and preemptive analgesic effect, it is administered prior to the initial incision. ^[44] A pneumatic ankle tourniquet is generally used to achieve hemostasis for better intraoperative visualization.

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

Procedure

A linear dorsomedial longitudinal incision is created, extending from the midshaft of the first metatarsal distally to the midshaft of the proximal phalanx medial to the extensor hallucis longus (EHL) tendon. The incision is deepened through skin and soft tissue, with care taken to identify and retract all vital neurovascular structures. Cauterization is used for bleeding as needed.

The lateral release is then performed in stepwise fashion to achieve release of lateral contractures, with the hallux able to reduce without restriction (see the image below). Capsulotomy is then performed and the periosteum is reflected to expose the metatarsal head.

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

Once fixed, the capsule, subcutaneous tissue, and skin are reapproximated, with capsulorrhaphy ^[45]  performed if warranted. Dressings consist of nonadherent gauze with dressings to splint the hallux in its newly corrected position.

The type of procedure performed and its inherent stability determine postoperative management of the osteotomy. Dressings applied at the time of the surgery should supply corrective forces (eg, derotation, plantarflexion, adduction) while the soft tissue remodels, with mild compression to control postoperative edema. Orthotics may be employed for postoperative immobilization. ^{[46, 47]}

Pain should be well controlled postoperatively. The patient's weightbearing status is determined on the basis of the procedure performed but generally is limited during the first 2 weeks to prevent deviation or displacement and to minimize edema. The patient may begin ROM exercises on a daily basis after the sutures are removed, and weightbearing is advocated to prevent limitation of joint motion from excessive scarring. ^[6]

Radiographs to assess alignment, fixation, and progression of ossification are obtained immediately after surgery and when a change in activity level is anticipated. ^[16]

Complications that may occur after surgery include the following ^{[48, 49, 50, 51]} :

• Delayed healing of the incision
• Osseous malunion or nonunion
• Numbness or tingling
• Hematoma
• Hardware failure
• Displacement of the osteotomy
• Delayed suture reaction
• Cellulitis
• Osteomyelitis
• Avascular necrosis
• Elevation of the metatarsal
• Transfer lesions
• Limitation of joint motion
• Hallux varus
• Recurrence

These complications can vary, depending on the surgical technique and procedure. Preoperative education and realistic patient expectations can help in minimizing or managing these sequelae.

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

Patients may require functional orthotic control. Several studies have shown that orthotic devices are beneficial, especially in patients with diseases such as rheumatoid arthritis, in which excessive forces accelerate degeneration. Control of these forces may postpone further destruction to the joints and provide the best long-term results after surgery. ^[52]