Hallux Varus Treatment & Management

Updated: May 28, 2020
  • Author: Amy Jo Ptaszek, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Treatment

Approach Considerations

The patient who has hallux varus and is symptomatic despite conservative measures for the condition, such as shoe modification, is a surgical candidate. The treatment options consist of either soft-tissue or bony reconstruction, including arthrodesis.

Relative contraindications for tendon transfer reconstruction for hallux varus include, but are not limited to, degenerative arthrosis, inflammatory arthritides, active infection, peripheral neuropathy, and vascular compromise, in addition to excessive resection of the medial eminence and fixed deformity of the metatarsophalangeal (MTP) joint.

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Surgical Therapy

Various authors have described numerous procedures for the treatment and correction of hallux varus. [10, 14, 15]  A sampling of these procedures, which have been used both alone and in conjunction with others, is as follows:

  • Lengthening of the medial capsular structures
  • Lengthening of the extensor hallucis longus (EHL)
  • Relocation of the sesamoid(s)
  • Skin resection of the first webspace
  • Syndactyly of the great and second toes
  • Total joint release
  • Abductor hallucis transfer [16]
  • Ligapro suture/technique (an elastic polyethylene terephthalate device that is not available in the United States)
  • Split extensor hallucis brevis (EHB) transfer and reverse Akin procedure
  • EHL transfer with interphalangeal (IP) arthrodesis
  • EHB transfer
  • Keller resection arthroplasty
  • Implant arthroplasty
  • MTP arthrodesis [17]

In 1971, Hawkins described transfer of the abductor hallucis tendon to the lateral aspect of the proximal phalanx with release of the medial capsule and mobilization of the medial sesamoid. [18] Patients demonstrated maintenance of alignment between 5 and 54 months. A few years later, Miller described a proximal phalangeal resection for treatment of early acquired hallux varus (ie, before the deformity became fixed and clawing was present). However, no functional outcome was published.

In 1984, Johnson and Spiegl advocated transfer of the EHL tendon to the proximal phalanx as a dynamic stabilizer, coupled with IP joint arthrodesis for flexible hallux varus without MTP arthrodesis. [19] This improved flexion of the MTP joint from –23° to +6°, and total ROM increased from 38° to 67°. The varus was corrected an average of 18°. Later, modification utilized a split EHL transfer with preservation of the IP joint in the absence of deformity at the IP joint, which resulted in less MTP motion.

Skalley and Myerson reported their experience with EHL transfer and IP arthrodesis in a retrospective study; the split EHL transfer resulted in symptomatic joint stiffness. [20]

Subsequently, Myerson and Komenda described a tenodesis of the EHB tendon in conjunction with a medial soft-tissue release for correction of a flexible hallux varus deformity. [21, 22] The tenodesis was thought to act as a static restraint, as opposed to a dynamic restraint to varus-deforming forces. The authors reported restoration of alignment to an average of 0°, minimal loss of sagittal plane motion, and no stiffness or weakness.

Tourne et al reported a case series of 14 French patients with iatrogenic hallux varus. [23] They performed MTP arthrodesis in nine patients who had stiffness and arthrosis; in five, the lateral ligament complex was reconstructed by using a Ligapro suture. Arthrolysis was performed in all patients. Outcomes were excellent in patients who were younger, had a mobile MTP joint, and had no radiographic evidence of degenerative changes. Results included an average postoperative correction of 20° of plantar flexion and 60-90° of dorsiflexion of the MTP joint.

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

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

Correction of the first intermetatarsal (IM) angle may require metatarsal osteotomy in addition to a soft-tissue balancing procedure for the MTP joint with or without MTP arthrodesis. [24, 25, 26, 27, 28]

Koboayashi et al described a case in which traumatic hallux varus associated with medial subluxation of the second MTP joint and second metatarsocuneiform (MTC) joint arthrosis was successfully treated with metatarsal hemicallotasis with medial soft-tissue release, a proximal second metatarsal shortening osteotomy, and second MTC joint arthrodesis. [29]  After 1 year and 6 months, suitable correction had been maintained, no discomfort or pain was present, and the patient was satisfied with the results. The authors suggested that this technique should be indicated only for hallux varus with a decreased distal metatarsal articular angle, an angular-type metatarsal head, and good MTP joint congruence.

Surgical repair of a traumatic hallux varus using a suture-and-button fixation device has been described. [30]

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Complications

Potential complications include the following [31] :

  • Overcorrection (ie, hallux valgus)
  • Avascular necrosis of the metatarsal head
  • Stiffness
  • Progression of degenerative changes in the MTP joint
  • Shortening of the medial column
  • Transfer metatarsalgia
  • Wound complications
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