2. Introduction
• Hueter defined the deformity as an
abduction contracture in which the great
toe is turned away from the mid-line of the
body.
• The adjective valgus implies a static
deformity and should not be used
interchangeably with abductus
which refers to movement
caused by muscle function
3. Lateral deviation of the great toe
and medial deviation of the first
metatarsal
Progressive subluxation of the
first metatarsophalangeal (MTP)
joint
Introduction
4. Anatomy
Four groups that encircle the first MTP
joint
1) Extensor hallucis longus and brevis
2) Flexor hallucis longus and brevis
3) Abductor
4) Adductor
Deforming Musculature
1. Abductor Hallucis
-Inserts in the plantar aspect of the proximal
phalanx
-Can draw the phalanx medial and push
metatarsal
head lateral
2. Adductor Hallucis
-2 origins
-common tendon to plantar aspect of proximal
phalanx and lateral aspect of plantar
plate/sesamoid complex
5. Anatomy
Plantar Plate
• 2 seasmoids
incorporated into
tendons of FHB
• Plantar Plate formed
by tendons of
Adductor Hallucis,
Abductor Hallucis,
FHL and Joint
Capsule
15. This windlass mechanism is responsible for:
• Depression of 1st
Metatarsal Head
• Weight transfer to hallux.
In HV this mech is disrupted
Transfer of weight laterally
*Surgery must minimize disruption of the windlass.
16. Patho anatomy
• Increased metatarsophalangeal angle
-plantar shift of abd.hallucis
-unopposed action of add.hallucis pulls
greater toe to further valgus
-medial capsular stuctures stretched and
attenuated
20. Clinical Presentation
PAIN over the medial eminence (Bunion).
• Pressure from footwear is the most frequent cause of
this discomfort.
• Bursal inflammation
• Irritation of the skin
• Breakdown of the skin may be noted.
• Bunion consists of:
• Bony exostosis / prominence of the metatarsal head
• Overlying subcutaneous bursa
• Hyperkeratosis of dermis
21. Signs and Symptoms
• Asymptomatic
• Pain- The primary
symptom of hallux
valgus is PAIN over the
medial eminence.
• Pressure from footwear
is the most frequent
cause of this
discomfort.
• deformity
• Tenderness
• Aesthetic
• Look for presence of:
– neurologic disorder
– ligamentous laxity
Sources of Pain in Hallux Valgus
• Medial Eminence
• 2nd Toe
• Metatarsosesamoid Articulation
• Dorsomedial Cutaneous Nerve
• Transfer Metatarsalgia
Sources of Pain in Hallux Valgus
• Medial Eminence
• 2nd Toe
• Metatarsosesamoid Articulation
• Dorsomedial Cutaneous Nerve
• Transfer Metatarsalgia
23. PHYSICAL EXAM
• Skin
– calluses, areas of redness
• Sites of pain
• Motion of 1st MTP joint-increased or decreased
• Mobility and structure of foot in general
• Gait analysis
• The patient sitting and standing
– accentuated with weightbearing
• Pes planus deformity
• Contracture of the Achilles tendon
• Magnitude of the Hallux Valgus deformity
• Pronation of the great toe
24. • Passive and active range of motion of the
MTP joint is measured
– Pain or crepitus, or both, with motion of
the MTP joint
• Metatarsocuneiform joint for hypermobility
– Examiner grasps the first metatarsal
with the thumb and index finger and
pushes it in a plantar lateral-to-
dorsomedial direction.
– Mobility of more than 9 mm represents
hypermobility
27. Radiographic Examination
Weightbearing AP/Lateral non weightbearing
oblique view and axial views (sesamoid)
• Assess for bone and joint deformity
• Length and shape of 1st MT
• Congruent vs. Incongruent joint
• Osteoarthrosis
• Forefoot alignment is evaluated for
metatarsus Adductus
• Hindfoot is Inspected for Pes Planus or Pes
Cavus.
28. IMA (normal <9°) [8-9]
HVA (normal <15°) [15-20]
DMAA (normal <10°) [10-15]
Hallux
valgus
angle
Intermetatarsal
angle
Distal
metatarsal
articular
angle
29. Measure Angles
–Hallux Valgus angle:
Intersection of longitudinal axis
of 1st MT and proximal
phalanx. Normal < 150
–Intermetatarsal angle
Intersection of 1st and 2nd
MT. Normal < 90
; increased
with metatarsus primus varus
30. Radiographic measurements
• Distal Metatarsal Articular Angle(DMMA)
Defines the relationship of the distal articular
surface of the 1st MT to the longitudinal axis.
Quantities the magnitude of lateral slope of
articular surface.
With subluxation, the articular surface deviates
laterally in relationship to the 1st Metatarsal.
Usually < 60
.
34. CLASSIFICATION MILD
MODERA
TE
SEVERE
Hallux valgus angle < 20° 20° to 40° >40°
1-2 intermetatarsal
angle
11° or less. 12- 15° 16° or more
Subluxation of the
lateral sesamoid, as
measured on an AP
< 50% 50% to 75% > 75%
SEVERITY OF
DEFORMITY
35.
36. TREATMENT
• Non-operative vs. Operative
• All patients should be treated non-operatively
first.
Despite conservative measures, some patients
eventually need surgical intervention.
37. Nonoperative
Footwear modification
• Widen toe box
– decrease lateral deviation of great toe
– decrease inflammation and pain
• Decrease heel height
– prevent forward slide of the foot
• Arch support
– may negate effects of pes planus
• Contracture of the Achilles tendon
– Stretching exercises
– Lengthening of the Achilles tendon
38.
39. Painful joint ROMPainful joint ROM
Deformity of the joint complexDeformity of the joint complex
Pain or difficulty with footwearPain or difficulty with footwear
Inhibition of activity or lifestyleInhibition of activity or lifestyle
Indications for surgeryIndications for surgery
40. Associated foot disordersAssociated foot disorders
- Neuritis/nerve entrapment
- Overlapping/underlapping 2nd
digit
- Hammer digits
- First metatarsocuneiform joint exostosis
- Sesamoiditis
- Ulceration
- Inflammatory conditions (bursitis, tendinitis)
of 1st
metatarsal head
Indications for surgeryIndications for surgery
41. Extensive peripheral vascular diseaseExtensive peripheral vascular disease
Active infectionActive infection
Active osteoarthropathyActive osteoarthropathy
Septic arthritisSeptic arthritis
Lack of pain or deformityLack of pain or deformity
Advanced ageAdvanced age
Lack of complianceLack of compliance
ContraindicationsContraindications
42. MIMI within the previouswithin the previous 66 monthsmonths
Comorbid conditions that place theComorbid conditions that place the
patient at significantpatient at significant CVCV or respiratory riskor respiratory risk
ContraindicationsContraindications
44. 1. Valgus deviation of the great toe
2. Varus deviation of the 1st
metatarsal
3. Pronation of hallux and/or 1st
metatarsal
4. Hallux valgus interphalangeus
5. Arthritis and limitation of motion of the
1st
metatarsophalangeal joint
6. Length of the 1st
metatarsal relative to
lesser metatarsals
Preoperative evaluationPreoperative evaluation
45. 7. Excessive mobility or obliquity of the 1st
metatarsomedial cuneiform joint
8. The medial eminence (bunion)
9. The location of the sesamoid apparatus
10. Intrinsic and extrinsic muscle-tendon
balance and synchrony
Preoperative evaluationPreoperative evaluation
46. Hallux Valgus <25Hallux Valgus <25°°
Congruent Joint
Chevron osteotomy
Mitchell osteotomy
Incongruent Joint
Distal soft-tissue realignment
(subluxation)
Chevron osteotomy
Mitchell osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
47. Hallux Valgus 25Hallux Valgus 25°°-40-40°°
Congruent Joint
Chevron osteotomy + Akin procedure
Mitchell osteotomy
Incongruent Joint
Distal soft-tissue realignment +
proximal osteotomy
Mitchell osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
48. Severe Hallux Valgus >40Severe Hallux Valgus >40°°
Congruent Joint
Double osteotomy
Akin + chevron osteotomy
Akin + 1st
metatarsal osteotomy
Akin + 1st
cuneiform opening wedge
osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
49. Severe Hallux Valgus >40Severe Hallux Valgus >40°°
Incongruent Joint
Distal soft-tissue realignment +
proximal osteotomy
First metatarsal crescentic
osteotomy
First cuneiform opening wedge
osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
50. Hypermobile 1Hypermobile 1stst
MTC JointMTC Joint
Distal soft-tissue realignment +
fusion 1st
metatarsocuneiform joint
Degenerative joint diseaseDegenerative joint disease
Fusion or Keller procedure or prosthesis
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
51. Surgical Algorhythm
HVA IMA Procedure
< 40° < 13° to 15° modified McBride or
distal chevron osteotomy
< 40 ° > 13° to 15° modified McBride and
proximal osteotomy
>40° > 20° modified McBride and
proximal osteotomy or arthrodesis
54. • Mitchell osteotomy
Removal of medial eminance
Osteotomy of distal portion of 1st
MT shaft
Lateral displacement&angulation of capital fragment
Medial capsulorrrhaphy
