Hallux Valgus

synonyms: bunion, HV

Hallux Valgus ICD-9

• 735.0 (hallux valgus)

Hallux Valgus Etiology / Epidemiology / Natural History

• Lateral deviation of the great toe, increased intermetatarsal angle and an enlarged medial emminence.
• associated with: genetc predisposition, inappropriate footwear, anatomic/structural abnormalities( hindfoot pronation, metatarsus primus varus, Achilles contracture, 1st metatarsocuneiform hypermobility), neuromuscular disorders(stroke, cerebral palsy), ligmanetous laxity, hereditary predisposition.

Hallux Valgus Anatomy

• when HV angle >@30 degrees great toe pronates moving abductor hallucis further plantarward leaving the medial capsular ligaments as only medial restraint.  Unopposed adductor hallucis pulls toe further into valgus.
• Sesamoid bones eventually sublux, once sesamoids are subluxed deformity almost always increases.
• Dorsomedial cutaneous nerve of the hallux is a distal branch of the superficial peroneal nerve which supplies sensation to the dorsal and medial half of the hallux and can be injured during chevron bunionectomies (Miller SD, Foot Ankle INt 2001;22:198).

Hallux Valgus Clinical Evaluation

• Cosmetic deformity
• Pain and swelling over the medial eminence mainly associated with shoe wear. May have medial callus.
• Evaluate for numbness / tingling over the medial great toe (medial plantar sensory nerve).
• Evaluate MTP ROM / stability. Document amount of planterflexion and dorsiflexion.
• Great toe pronation. Lesser toe aligment.
• 1st metatarsocuneiform joint stability.
• Foot NV exam.
• Evaluate for associated diagnoses which will affect outcome
• Note.

Hallux Valgus Xray / Diagnositc Tests

• Weightbearing AP view, lateral view, standing axial xrays.
• Evaluate MTP joint congruity and degree of arthritis.
• HV angle = angle between the long axes of the first metatarsal and proximal phalanx; normal<15 degrees. 
• intermetatarsal (IM) angle=angle between the first and second metatarsals; normal< 9 degrees 
• tibial sesamoid postion relative to 1^st MT bisecting line: Grade0=no displacement; Grade 1<50% overlap; Grade 2>50% overlap; Grade 3=complete displacement.

Hallux Valgus Classification / Treatment

• Initially treatment: wide-laced (high toe box) shoes; activity modifications
• Classification =congruent vs incongruent joint (lateral deviation of the proximal phalanx on the metatarsal head. Sesmoids gradually displace).
• Congruent joint: lateral deviation of the articular surgaces of the 1st MTP joint without sesamoid displacement, hallux rotation or sequential progression to the hallux valgus. May be treated with proximal phalangeal osteotomy (Akin Procedure), Chevron osteotomy(Chou, Foot Ankle Int 19:579;1998), or a distal soft tissue procedure.
• Incongruent Joint, Mild deformity (HV <30, IM <13): chevron osteotomy or distal soft tissue procedure. 
• Incongruent Joint, Moderate deformity (HV <40, IM >13): distal soft tissue procedure with proximal metatarsal osteotomy. If there is hypermobility of the metatarso-tarsal (cuneiform) joint, metatarso-cuneiform arthrodesis with a distal soft tissue procedure is used.  Lapidus procedure=1^st metatarsocuneiform arthrodesis(Sangeorzan Foot ankle 9:262;1989)
• Incongruent Joint, Severe deformity (HV <40, IM >13): Metatarso-phalangeal arthrodesis is used in severe deformities, particularly in older patients or patients with rheumatoid arthritis, spasticity, or arthrosis. Arthrodesis--Optimal arthrodesis angle = 25-30 degrees, metatarsal inclination angle = 25-30 degrees. Sagittal plane position should be checked intraoperatively and the proximal phalanx should clear the table by 5-10mm with simulated weightbearing.
• Arthritic joint with limited ROM: primary arthrodesis.
• Treatments that have fallen out of favor include metatarsophalangeal resection arthroplasty and removal of the medial eminence (Keller procedure), or simply excision of the medial eminence with plication of the capsule (bunionectomy).  The former results in destabilization of the first MTP joint and subsequent metatarsalgia and deformity, while the latter often fails to correct the deformity
• Mitchell osteotomy=extracapsular; medial eminence excised, osteotomy 2cm proximal to medial border of articular surface; osteotomy laterally displaced.

Hallux Valgus Associated Injuries / Differential Diagnosis

• corns, calluses, warts, interdigital neuroma, bunionettes, havver tooes, claw toes.
• spasticity--The only way to adequately eliminate spastic deforming forces is with an arthrodesis of the MTP joint. Any other procedure will most likely lead to a high incidence of either hallux varus or recurrent hallux valgus.
• Hallux Valgus Interphalangeus: lateral deviation of the great toe at the interphalangeal joint.

Hallux Valgus Complications

• Distal chevron osteotomy with soft tissue release complications = incomplete correction and avascular necrosis (1 – 2%).
• Distal soft tissue realignment only complications = recurrence of deformity, inadequate lateral release, and hallux varus.
• Aken procedure complications = increase in the hallux valgus deformity.
• Proximal first metatarsal osteotomy complications = hallux varus and shortening.
  
• hallux varus--asociated with a bunionectomy that included a fibular sesamoidectomy.  Rx=dynamic correction using EHL or EHB for painfree joint, arthrodesis for arthritic joint(Ouzounian Foot Ankle Clin 2:741;1997).  If IP joint does not have fixed deformity a split EHL transfer with medial capsulotomy can be used. (Johnson KA, Spiegl PV: Extensor hallucis longus transfer for hallux varus deformity.  J Bone Joint Surg 1984;66A:681-686)  
• tenodesis-type transfer of the extensor hallucis brevis.  The tendon is cut at its musculotendinous junction and transferred beneath the transverse metatarsal ligament proximally into the lateral aspect of the first metatarsal.  Medial release of the abductor hallucis and medial capsule may also be necessary.  The transfer is a static tenodesis and does not function dynamically.  Myerson MS, Komenda GA: Results of hallux varus correction using an extensor hallucis brevis tenodesis.  Foot Ankle Int 1996;17:21-27.
• resection of both sesmoids risk development of cock-up toe deformity
• Dorsomedial cutaneous nerve of the hallux neuroma (Miller SD, Foot Ankle INt 2001;22:198).

Hallux Valgus Follow-up Care

Hallux Valgus Review References

1. Mann, Disorders of the first metatarsophalangeal joint, JAAOS, 3(1):  34-43, 1995
2. Coughlin MJ: Roger A. Mann Award.  Juvenile hallux valgus: Etiology and treatment.  Foot Ankle Int 1995;16:682-697.
3. Zimmer TJ, Johnson KA, Klassen RA: Treatment of hallux valgus in adolescents by the chevron osteotomy.  Foot Ankle 1989;9:190-193.
4. Coughlin MJ, ICL 1997;46:357
5. Gould AAOS OKO Topic

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