Management of Hallux Valgus

1. Hallux Valgus
SUSHANT S. SONARKAR

2. Introduction
Hallux valgus means Complex progressive deformity affecting
forefoot with lateral deviation of great toe
Commonest of foot deformities
Not a single disorder; but a complex deformity of the first ray
Frequently accompanied by deformity and symptoms in lesser toes

3. Spectrum of hallux valgus
Varus deformity of first metatarsal
Valgus of great toe
Great toe bunion formation
Arthritis of 1st MTPjoint
Hammer toe
Toes corn
Calluses
Metatarsalgia
Stress fractures of lesser metatarsals

4. Anatomy
The head is grooved inferiorly
by medial and lateral sesamoid
bones in the tendons of Flexor
hallucis brevis
The proximal phalynx is round
on three sides but flat
inferiorly, even concave
inferiorly for the flexor hallucis
longus tendon

6. Causes of Hallux Valgus
Congenital :
Veryrare
Metatarsus primus varus is common atbirth
Concealed supernumerary phalynx may be thecause
Shortened secondmetatarsal
Hereditory :
Johnston(1956) : Transmitted as autosomal dominance with incomplete
penetration
Age:
14-16 in girls and little later inboys
Symptomatic hallux valgus is more common after 40 years of age, mostly
bilateral.

7. Causes of Hallux Valgus
Sex:
Women >Men
50:1 Ratio
Predisposed by pointed compressive high heeledshoes

8. Causes of Hallux Valgus
1 . Shoes:
Has been considered as extrinsic cause of HalluxValgus
In Chinese population, Hallux valgus was more common due to special
compressive shoe wearing habits.
Tight fitting shoe at toes have been proven as cause of bunion,corns.
“Shoes as at present worn, serve but to deform the toes
and cover the feet with corns” – Camper (1781)

9. Causes of Hallux Valgus
2 . Intrinsic Factors:
PesPlanus
Articular surface of 1st MP joint
Advanced position of great toe and its metatarsal.
Metatarsus primusvarus

10. Causes of Hallux Valgus
Intrinsic Factors:
PesPlanus
Articular surface of 1st MTP joint
Advanced position of great toe and itsmetatarsal.
Metatarsus primusvarus

11. Causes of Hallux Valgus
Intrinsic Factors:
PesPlanus
Articular surface of 1st MTP joint
Advanced position of great toe and itsmetatarsal.
Metatarsus primusvarus

12. Causes of Hallux Valgus
Intrinsic Factors:
PesPlanus
Articular surface of 1st MTP joint
Advanced position of great toe and itsmetatarsal.
Metatarsus primusvarus

13. Causes of Hallux Valgus
3 . Miscellaneous:
Muscular imbalance: Poliomyelitis, Spastic Cerebral Palsy
Trauma : Malunited # - Secondarydeformity
Congenitally absent, Amputated or hammered second toe

14. Pathogenesis
1st metatarsal inclines medially
Proximal phalynx deflects in opposite direction
Joint knuckles towards the midline –
prominence of forefoot at the tibial border
Great toe pronates – Nail and hallux slants
medially, pulp towards second toe
Great toe may ride over 2nd digit or slip under it
Lesser toe – crowded together, clawed,
hammered
Bunionette:- deformity at outer border of
forefoot
Forefoot is splayed

15. Anatomical changes in foot
In a full blown hallux valgus, several changes take place in and around
the first metatarso-phalyngeal joint. They Involve
1. Articular Bones
2. Capsular and ligamentous structure
3. Muscle and tendon
4. Bursa
5. Skin

16. Anatomical changes in foot
1. Articular bones
Mild cases: Outward deviation of proximal phalynx is the solefeature
Severe deformity: Axial rotation of proximalphalynx
: Subluxation of MP joint.
Crista on the undersurface of 1st Metatarsal smoothens out, effaceddue
to migration of sesamoid.

17. Anatomical changes in foot
In more advanced cases, the interior of metatarsal head is
cystic due to proliferation of marrow connective tissue in
response to denuded hyaline surface
Sesamoids: Lateral migration of Sesamoids is evidence of
Hallux valgus
In these new incongruent location, sesamoids wear out, loose
hyaline cartilage, become mushroomed, forms spurs and
fragments
Incarcerted in the first inter metatarsal space, the fibular
sesamoid may serve as a wedge and push the 1st metatarsal into
greater varus
Rarely, there is bony union between sesamoids and the
metatarsal head.

18. Anatomical changes in foot
2. Capsular and ligamentous structures
Capsule on the tibial side show elongation and on the fibular
side show shortening
Extent of these contractions depend on the degree of deviation
and displacement of sesamoids

19. Anatomical changes in foot
3. Muscles and tendons:
With axialrotation:
Abductor halluces – NO Abduction, works as flexor
Short flexors – Aid in adductor pull’
Bowstringed extensors and laterally displaced
flexors further accentuste the valgus deformity

20. Anatomical changes in foot
4. Bursae:
Adventitious bursae occurs on the dorsal, plantar and
medial aspect of 1st metatarso phalyngeal joint.
MayUndergo
1. Suppurative bursitis with regional cellulitis
2. Sinus formation
3. lymphangitis

21. Anatomical changes in foot
5. Skin:
Skin on the medial and plantar aspect of toe
undergoes cornification
Repeated pressure on the skin causes callosity
formation

22. Anatomical changes in foot
6. Changes affecting the lesser toes
Relative or real plantar descent of the central
metatarsal heads
Proximal phalynx subluxates dorsally with PIP
joint in flexion
Skin over these knuckled IP jointdevelops
callosities
2nd toe is usually hammered.
Splaying of foot: Side to side span of foot is
increased.
5th metatarsal inclines fibularwards, with its
head presenting as lateral eminence
Bursa over this eminence is known as
Bunionette.

23. Clinical features
Symptoms:
Pain infoot
Difficulty in being fitted withshoes
Gaitchanges
Corns
Keratosis
Cosmeticdeformity

24. Pain in foot
Bursitis:
Bursa develops between skin and medial eminence
Complications like inflammation result in regional cellulitis,
Rupture and pus discharge through sinus
May also lead to osteomyelitis of the adjacent bones
Arthritic pain:
Movement of toes are limited with crepitus and painful movement
Metatarsalgia:
Most distressing and disabling
Frequently associated with hallux valgus

25. Investigations:
Xrays:
3 views:
1. AP view
2. Oblique views
3. Axial exposure of Sesamoid.
Xray of opposite foot for comparison
should be taken

26. Angle between 1st and 2nd metatarsal
Usually less than 8 degree
More than 10 degree – Metatarsus varus

27. Valgus angle
Usually between 10-15 degree
Depending on angle
Mild- 20 degree
Moderate -30 degree
Marked- 40 degree

28. Classification of hallux valgus
Pigott (1960) classified into 3 types based on congruity of 1st MTP
joint
Type 1: Congrous joint
Type 2: Deviated non congruous joint
Type 3: Subluxated joint

29. Classification of hallux valgus
Mann and conghlin(1993) classified into 3 types based on Hallux
valgus angle
Mild: Angle < 20 degree, intermetatarsal angle usually less than 11degree
Moderate: Angle 20 - 40 degree, intermetatarsal angle between 11 and 18
degree
Severe: Angle > 40 degree, intermetatarsal angle > 16-18degree
Normal <15
Mild <20
Moderate 20-40
Severe >40

30. Classification of hallux valgus
From surgical point of view ,it can be classified as
1. Simple hallux valgus
1. Without sagittal groove
2. With sagittal grove
2. Hallux valgus with axial rotation
1. Reducible
2. Irreducible
3. Hallux valgus with metatarsus primus varus
1. Mobile/ hypermobile first metatarsal
2. Fixed varus
4. Hallux varus with degenerative arthritis of joint
5. Hallux valgus with mixed deformities

31. Treatment of hallux valgus
Conservative Management:
Young and asymptomatic patients
• Proper fitting shoes with wide deep toe boxes
• Night splinting and other orthosis
 Once the deformity is established, it is difficult
to check the progression of disease by
conservative measures.

33. Surgical Treatment
 Indications of operative treatment
Failure of non operative measures
Persistent pain that interferes with daily work
Severe deformity of joint complex and painfull joint Range of
movements unlikely to respond to conservative
measures
 Associated 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

34. Surgical
procedures
Soft tissue
procedures
Modifies
McBride
bunionectomy
Combined bony
and soft tissue
procedures
Keller resection
arthroplasty
Modified Keller
technique
Bony procedures
Metatarsal
osteotomy
Distal
metatarsal
osteotomy
Mitchell
osteotomy
Distal chevron
osteotomy
Reverdin
osteotomy
Proximal
metatarsal
osteotomy
Proximal
crescentic
osteotomy
Proximal
chevron
osteotomy
Osteotomy of
medial
cuneiform
Proximal
phalynx
osteotomy
Arthrodesis of
1st MTPjoint
Arthrodesis of
1st metatarso
cuneiform joint

36. Keller resection arthroplasty

37. Mitchell osteotomy

38. Chevron osteotomy

39. Reverdin osteotomy

40. Proximal crescentic osteotomy

41. Medial cuneiform osteotomy

42. Proximal phalynx osteotomy (akin)

43. Mann Algorithm for selection of appropriate
operative procedure in treatment of hallux
valgus
Hallux valgus < 25 degree
Congruent joint
Chevron osteotomy
Mitchell Osteotomy
Incongruent joint
Distal soft tissue realignment
Chevron osteotomy
Mitchell Osteotomy

44. Mann Algorithm for selection of appropriate
operative procedure in treatment of hallux
valgus
Hallux valgus 25 - 40 degree
Congruent joint
Chevron osteotomy with akin procedure
Mitchell Osteotomy
Incongruent joint
Distal soft tissue realignment with proximal metatarsal osteotomy
Mitchell Osteotomy

45. Mann Algorithm for selection of appropriate
operative procedure in treatment of hallux
valgus
Severe Hallux valgus >40 degree
Congruentjoint
Double osteotomy
Akin and chevronosteotomy
Akin and 1st metatarsal proximal osteotomy
Akin and 1st cuneiform opening wedge osteotomy
Incongruentjoint
Distal soft tissue realignment with Proximal osteotomy
First metatarsal crescentic osteotomy
1st cuneiform open wedge osteotomy
Hypermobile 1st Metatarso-cuneiform joint
Distal soft tissue realignment and fusion 1st metatarso-cuneiform joint

46. Conclusion
Hallux valgus is the most common deformity of foot
Commonly seen an adolescent females and becomes symptomatic in
middle age
Can be treated conservatively if diagnosed early
Surgery is the only option after the deformity develops.

47. NAME - M/O SGT S SARKAR
AGE - 56 F
UNIT - HQ SAC Unit
SERVICE NO - 900971 S
DIAGNOSIS - B/L HALLUX VALGUS
MODE – MILD DEFORMITY NOTED BY PATIENT HERSELF
INITIALLY WHICH GOT ADVANCED TILL DATE BECAUSE OF
INCORRECT FOOTWEARS
Patient is having difficulty in wearing tight Sandals & shoes .
Hallux Vallgus Angle – 27 DEGREE
Metatarsophalangeal Angle – 55 DEGREE

50. ORTHO SURGEONS - W/C PANKAJ RAI (M.B.B.S., DNB.ORTHO) CL SPL
S/L SUSHANT SONARKAR (M.B.B.S., D.ORTHO) MO SPL

55. NAME - L/HAV GULAB PAWAR
AGE - 39 M
UNIT - 110 ENGR REGT
SERVICE NO - S 15566191 P
DIAGNOSIS - B/L HALLUX VALGUS
Opearted RT foot at MH KIRKEE with CHEVRON
OSTEOTOMY 07 years back
MODE – MILD DEFORMITY NOTED BY PATIENT HIMSELF
IN EARLY AGE (10YRS) WHICH GOT ADVANCED TILL DATE
Since past 08 years patient is unable to wear shoes .
Hallux Vallgus Angle – 32 DEGREE
Metatarsophalangeal Angle – 56 DEGREE

56. IAP 4303 4TH EDITION
CHAPTER NO 8 MUSCULOSKELETAL SYSTEM
2.8.5.

57. IAP 4303 4TH EDITION
CHAPTER 9- MUSCULOSKELETAL SYSTEM AND PHYSICAL CAPACITY
3.9.13.

61. Thankyou