Hallux Valgus

Hallux valgus is characterized as a great toe deflected laterally and bony prominence develops secondarily over the medial aspect of the 1^st metatarsal head and neck

Etiology of Hallux valgus

1. Hypermobility of 1^st Ray
2. Narrow footwear
3. Contracture of TA
4. Hereditary

Pathogenesis of Hallux valgus

Secondary deformities

1. Hammer toe deformity where 2^nd toe displaced dorsally by large toe
2. Callosities
3. Flat transverse arch
4. Heads of the middle metatarsals are prominent in soleàabnormal pressure; sore, callus

X-ray findings

1. Lateral displacement of large toes
2. Degenerative arthritis with narrowing
3. Spurs of the MT heads
4. Lateral displacement of sesamoids
5. Medial exostosis
6. Abducted and shortened 1^st MT
7. Widening of base
8. Abnormal obliquity of articulation with 1^st cuneiform

Different angles	Mild	Moderate	Normal
IMA (Intermetatarsal angle)	<13°	>20°	<9°
HVA (Hallux valgus angle)	<30°	>40°	<15°

Piggott Classification for Hallux Valgus

Type I: Congruent articular surface but valgus tilted

Type II: Non congruent articular surface

Type III: Non-congruent and subluxed

Treatment Options

Conservative treatment

• Mild deformity
• Contraindication to Surgery

Preventive measures include stretching exercises, and the use of a toe seperator at night.

Removal of pressure from medial bony prominences relieves bursitis pain

Footwear modification: Enlarged toe portion to accommodate the bunion is effective

Infected Bursa: Incision and Drainage is recommended

MTP Osteoarthritis: Heat, corticosteroids, rest, NSAIDs

Surgical Management

Surgery is not usually done for cosmetic reasons

Mild deformity with congruent MTP joint in Hallux Valgus

Silver Procedure

Medial eminence resection (simple exostectomy) is often done and flush with the medial border of the foot

McBride Procedure

Silver procedure along with releasing adductor tendon from proximal phalanx and transferring it to the neck of 1^st MT

Mild deformity with an incongruent MTP Joint in Hallux Valgus

Chevron Osteotomy

V-shaped osteotomy of distal MT is done in the coronal plane then the head is shifted laterally (up to 50% of bone width)

Later they are fixed with K-wires

Mitchells Procedure

Medial eminence is removed

Done step-cut osteotomy is done as shown in figure

Osteotomy is done proximal to the site of chevron osteotomy

Moderate deformity in Hallux Valgus

Needs more proximal metatarsal osteotomies to address deformities at the actual apex

However, they are combined with other bony or soft tissue procedure

Akin Procedure

When deformities are at the interphalangeal joint also

The silver procedure is done to closed medial wedge osteotomy of proximal phalanx

Scarf Osteotomy

Oblique diaphyseal osteotomy with distal and proximal cut

Allows displacement of MT shaft

Fixed with special (barouks) screws

Severe deformity in Hallux Valgus

Lapidus Procedure

Lapidus procedures are indicated in the following conditions:

• Failed other surgical management
• Neuromuscular and inflammatory arthropathy
• Advanced OA of 1^st MTP joint

• Kellers Procedure: Removal of at least ½ of the proximal portion of proximal phalanx
• Stone Operation/Mayos Procedure: Partial resection of the metatarsal head
• Both of above

Disadvantages of bone resection include shortening of 1^st ray with relative elongation of muscles and tendons acting on the distal phalanx of the great toe which leads to substantial weakness

• Arthroplasty of 1st MTP joint
• Arthrodesis of MTP joint

Arthrodesis of MTP joint recommended angles are:

Dorsal Bunion

A dorsal bunion is characterized as dorsiflexion of the 1^st metatarsal and plantar flexion of the great toe.

Pathophysiologically dorsal bunion is divided into three types:

1. Weak peroneus longus and strong tibialis anterior

Normally peroneus longus acts as plantar flexors for the 1^st Metatarsal and inner Cuneiform which counteracts the tibialis anterior that elevates the inner cuneiform and 1^st Metatarsal

2. Paralysis of all muscles controlling foot except tricep surae and long toe flexors (strong)

3. Hallux rigidus and flat foot with rocker bottom deformity

Management of Dorsal bunion

Flexible Type

Conservative treatment will correct muscle imbalance between ankle motors

Rigid type

Lapidus Procedure

Steps of Lapidus procedure