This document discusses hallux valgus, also known as a bunion. It begins by defining the deformity and listing associated symptoms. It then discusses causes, classifications based on x-ray measurements, conservative and surgical treatment options. For surgery, it explains various procedures that can be used to correct deformities ranging from mild to severe, including soft tissue releases, osteotomies of the metatarsal and phalanx bones, and arthrodesis or fusion procedures. Potential complications of surgery are also outlined.

1. Dr (Major) Parthasarathy S
Pg Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref:Campbell’s operative orhopaedics 13th
edition

2.  Valgus of great toe & varus of 1rst MT
 Carl Hueterto defined the deformity
 Controversy
 Not a single disorder,complex deformity of
the first ray
 Deformity & symptoms in lesser toes
 Hammer toe 2nd
 Forefoot Splaying
 Corns
 Bursal hypertrophy 1rst MT head(BUNION)
 Osteoarthritis
 metatarsalgia

4.  Two forms exist
 adult hallux valgus
 adolescent & juvenile hallux valgus
 Common in female

5.  Familial 70%
 Role of footwear
 Hypermobility
 Pes planus
 Abnormal posterior tibial tendon insertion
 Increased obliquity of medial cuneiform MTjt
 Abnormal long 1rst ray
 Incongrous articular surface 1rst MTP jt
 RA
 Cerebral palsy

6.  2nd
toe amputation
 Cystic degneration of medial capsule
 Achilles Contracture
 Hyperpronated 1st
ray

8.  Valgus deviation of phalanx promotes varus
position of metatarsal
 MT head displaces medially, leaving the
sesamoid complex laterally
 Sesamoids remain within the respective head
of the flexor hallucis brevis tendon and are
attached to the base of the proximal phalanx
via the sesamoido-phalangeal ligament
 This lateral displacement can lead to
transfer metatarsalgia due to shift in weight
bearing

9. LIGAMENTOUS ATTATCHMENTS AROUND HALLUX

11.  Medial MTP joint capsule becomes stretched
and attenuated while the lateral capsule
becomes contracted
 Adductor tendon becomes deforming force
 inserts on fibular sesamoid and lateral aspect of
proximal phalanx
 Lateral deviation of EHL further contributes
to deformity
 Plantar and lateral migration of the abductor
hallucis causes muscle to plantar flex and
pronate phalanx

13. o Asymptomatic
o Pain- the primary symptom of hallux
valgus is PAIN over the medial
eminence.
o Pressure from footwear is the most
frequent cause of this discomfort.
o Valgus deformity
o Aesthetic or cosmetic concerns

14.  Standard radiograph
 Weight bearing
AP
Lateral
 Non standing
Oblique
Axial sesamoid view

17. HALLUX VALGUS ANGLE
Normal <15
Mild <20
Moderate 20-40
Severe >40

19. 1st
/2nd
Inter Metatarsal Angle (IMA)
Normal <9
Mild <11
Moderate 11-16
Severe >16

28. CLASSIFICATION NORMAL MILD MODERATE SEVERE
HALLUX VALGUS ANGLE < 15* < 20° 20° to 40° > 40°
1-2 INTERMETATARSAL
ANGLE
< 9* 11° or less. 12 - 15° 16° or more
SUBLUXATION OF THE
LATERAL
SESAMOID, AS MEASURED
ON AN AP RADIOGRAPH
Nil or
minimal
< 50% 50% to 75% > 75%
Classification

29. Conservative Management :
o FOOT WEAR MODIFICATION
• First line of treatment
• Widening of toe box
• Decreasing the heel height
• Enhanced arch support may negate effects of pes
planus.
o TA STRETCHING EXERCISES AND TA
LENGTHENING.
o THERMOPLASTIC NIGHT SPLINTS
o BUNION AIDS AND STRAPPING –
Bunion pads (like a Polo/doughnut shape) can help to offload
the tender bunion,

30.  To correct all pathologic elements and
yet maintain a biomechanically functional
fore foot
 To obtain a pliable plantigrade and
cosmetically acceptable foot

33.  Modified McBride
 Goal is to correct an incongruent MTP joint
(phalanx not lined up with articular cartilage of
MT head)
 HVA <25 degrees
 IMA deformity <15 degrees
 Patient 30-50 years of age
 Rarely appropriate in isolation
 Usually performed in conjunction with
 medial eminence resection
 MT osteotomy
 1st TMT arthrodesis (Lapidus procedure)

34.  Release of adductor from lateral
sesamoid/proximal phalanx
 Lateral capsulotomy
 Medial capsular imbrication
 original McBride included lateral
sesamoidectomy

35. MEDIAL CAPSULAR INCISION , JOINT REDUCTION
AND MEDIAL EMINENCE REMOVAL.

37. RELEASE OF VALGUS DEFORMING FORCES

38. FIBULAR SESMOIDECTOMY (if needed) AND MEDIAL
CAPSULAR IMBRICARTION

39.  Distal metatarsal osteotomy
 Mild disease (HVA ≤ 40, IMA < 13)
 Distal metatarsal osteotomies include
 Chevron
 biplanar Chevron (corrects DMAA)
 Mitchell
 may be combined with proximal phalanx
osteotomy (Akin-medial closing wedge
osteotomy)

40.  Proximal metatarsal osteotomy
 Moderate disease (HVA >40°, IMA >13°)
 proximal metatarsal osteotomies include
 crescentic osteotomy
 Broomstick osteotomy
 Ludloff
 Scarf

41.  double (proximal and distal) osteotomy
 Severe disease (HVA 41-50°, IMA 16-20°)
 First cuneiform osteotomy
 severe deformity in young patient with open
physis

42.  Proximal phalanx osteotomies
 Akin osteotomy
 Hallux valgus interphalangeus
 congruent joint with DMAA <10°
 As a secondary procedure if a primary procedure (e.g.,
chevron or distal soft-tissue procedure) did not
provide sufficient correction due to a large DMAA or
HVI

43.  Lapidus procedure (1st metatarsocuneiform
arthrodesis with modified McBride)
 Severe deformity (very large IMA)
 Arthritis at 1st TMT
 metatarsus primus varus
 hypermobile 1st TMT joint
 concomitant pes planus

44.  MTP Arthrodesis
 Cerebral palsy
 Down's syndrome
 Rheumatoid arthritis
 Gout
 Severe DJD
 Ehler-Danlos

45.  proximal phalanx (Keller) resection
arthroplasty
 Largely abandoned
 Rarely indicated in some elderly patient with
reduced function demands

46.  Recurrence
Most common cause of failure is insufficient
preoperative assessment and failure to follow
indications
 e.g., failure to recognize DMAA > 10°
Inadequate correction of IMA
Failure to do adequate distal soft tissue realignment
More common in juvenile/adolescent population
Noncompliant patient that bears weight

47.  Avascular necrosis
 Medial capsulotomy is primary insult to blood
flow to metatarsal head
 Distal metatarsal oseotomy and lateral soft
tissue release inconjunction do not increase risk
for AVN
 Dorsal malunion with transfer metatarsalgia
 Due to overload of lesser metatarsal heads
 Risk associated with shortening of hallux MT
 Lapidus
 Proximal crescentric osteotomies

48.  Hallux Varus
 Overcorrection of 1st IMA
 Excessive lateral capsular release with
overtightening of medial capsule
 Overresection of medial first metatarsal head
 Lateral sesamoidectomy

49.  Cock up toe deformity
 Due to injury of FHL
 Most severe complication with Keller resection

50.  2nd MT transfer metatarsalgia
 Often seen concomitant with hallux valgus
 Shortening metatarsal osteotomy Neuropraxia
 Painful incisional neuromas
 Frequently involve the medial branch of the
dorsal cutaneous nerve-a terminal branch of the
superficial peroneal nerve
 It is most commonly injured during the medial
approach for capsular imbrication or metatarsal
osteotomy.