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Hallux Varus
- 1. HALLUX VARUS: DIAGNOSIS AND TREATMENT Andrew Bernhard, MS-IV Ohio College of Podiatric Medicine Highlands/Presbyterian St. Luke’s Hospital
- 3. HISTORY OF HALLUX VARUS In 1900, Clarke described hallux varus simply, as being the opposite of hallux valgus. Hawkins, in 1971, offered the most in depth paper on the cause, prevention, and correction of the deformity. Hawkins’ home: Toledo, OH
- 4. DIAGNOSIS OF HALLUX VARUS Diagnosis is based on both clinical presentation and radiographic evaluation. Cleveland Clinic Arnold and Sydell Miller Family Pavilion As described by Boike, the deformity is triplanar, with supination and hyperextension of the first MPJ and hyperflexion of the hallucal IPJ.
- 5. PRESENTATION Patients present with hallucal pain, shoewear difficulty, weakness with pushoff, metatarso- From: The Institute for Foot and Ankle Reconstruction at Mercy phalangeal joint instability, or possiblymetatarsalgia. Belczyk describes the presentation as including deformity, pain, decreased range of motion, first MPJ arthrosis, hallucal clawing, and shoewear problems. From: John Schuberth, DPM
- 6. RADIOGRAPHICALLY Patients present with the following radiographic findings: Negative hallux abductus angle/Hallux Varus angle Negative IM 1-2 angle Absence of the fibular sesamoid Medial subluxation of the tibial sesamoid/ Tibial sesamoid peaking Hallux IPJ flexion Staking of the 1st metatarsal head All of the radiographic angles associated with hallux valgus should also be evaluated with hallux varus
- 7. POTENTIAL CAUSES According to Skalley and Myerson, overcorrection of hallux valgus accounts for around 80% of hallux varus cases. Other causes include congenital defects, rheumatoid arthritis, psoriatic arthritis, trauma, Poliomyelitis, Charcot- Marie-Tooth, avascular necrosis, or contractures due to burns.
- 8. PATHOANATOMY, ADAPTED FROM DONLEY Cleveland Clinic Main Campus A brief review of the anatomy shows that four intrinsic and two extrinsic muscles cross the first MPJ. The crista, along with the medial and lateral sesamoid ligaments help provide balance.
- 9. VARUS AND VALGUS FORCES The adductor hallucis exerts a valgus force on the joint, while the abductor exerts a varus force. Once the toe is rotated out of a neutral position, those varus and valgus forces become deforming forces.
- 10. PATHWAY FOR CLASSIFICATION Vanore et. al. published this pathway for diagnosing and treating hallux varus. It is both very inclusive and arrives at a classification scheme.
- 11. VANORE CLASSIFICATION Based on these three types of deformities, viable treatment strategies are discussed.
- 12. BEVERNAGE CLASSIFICATION AND TREATMENT The first element to consider is mobility and flexibility of the first MPJ, followed by evaluation of the IPJ, and radiographic evaluation. They state that treatment should be aimed at the initial deforming force, the abductor hallucis.
- 13. TREATMENT OPTIONS As is usually the case, non-operative treatment should be attempted before surgery. Options include orthotics, splints, and tapings. Generally, treatment should begin as early as possible.
- 14. SURGICAL OPTIONS The mainstay of treatment is going to be surgery, most of the time. There are numerous surgical options available but the principles are all the same. Medial soft tissue release Lateral soft tissue tightening Tendon transfer to correct deformity/maintain correction Osseous repair
- 16. STATIC TRANSFERS
- 17. OSSEOUS BUTTRESSING If the metatarsal head was too aggressively resected, a bone graft should be used to stabilize the MTP joint. Bevernage states that this will help restore the intrinsic/extrinsic Fig. 11. Hallux Varus: Classification and Treatment from muscle balance to Bernhard Devos Bevernage, MD, Thibaut Leemrijse, MD (A) AP standing radiograph showing an excessive medial eminence resection, neutral. associated with an aggressive lateral release distal to the sesamoids, after failed hallux valgus surgery. The first MTP joint is mobile, reducible, and painless. (B) Intraoperative view with nice correction into a physiologic valgus position, illustrating the combination of an osseous allograft buttress and a static reversed abductor hallucis tendon transfer. (C) Postoperative AP standing radiograph at 2-year follow-up. (D) CT scan illustrating the persistence of the osseous trajectory of the tendinous transplant as well as the osteo-integration of the allograft buttress with the metatarsal head.
- 18. VANORE TREATMENT ALGORITHM Vanore’s proposed treatment algorithm, which is fairly similar to Bevernage’s
- 19. CONCLUSIONS Based on clinical Medial release and findings of a painful, lateral tightening adducted hallux, should be performed. hallucal clawing, and Must address the apex shoewear problems. of deformity, which is Radiographically, generally the FHB. staking of the The medial eminence metatarsal head, tibial should be addressed if sesamoid peaking, staked. negative hallux abductus angle, and a Transfers of the EHL, negative IM 1-2 angle adductor hallucis, first are most likely dorsal interosseous, observed. abductor hallucis, and EHB muscles or tendons have all been described.
- 20. FINALLY, Cleveland Clinic Las Vegas A roundtable discussion between experienced surgeons from the Cleveland Clinic, UPMC, University of Connecticut School of Medicine, and Belfast, Ireland revealed startling discrepancies.
- 22. REFERENCES
Editor's Notes
- I took this picture at the Denver Museum of Nature and Science on my first full day in town. I had been working on a presentation dealing with how evolution has shaped the foot, so I thought this would fit well in it. When Dr. Farrett gave me hallux varus, I knew it would make an appearance. In our ancestors and primate relatives, hallux varus is the norm. An adducted hallux, in relation to the midline of the body, allows for climbing trees. The more abducted our hallux, the better propulsion humans were able to obtain.
- Clarke wrote in the Lancet, stating that hallux varus was largely a congenital problem. He had never seen it acquired, though he heard of it occurring with severe cases of genu valgum and thought it could occur with trauma or paralysis. It wasn’t until 1928 that McBride first described his “conservative operation for bunions,” which called for a transfer of the adductor hallucis to the distal metatarsal head, a fibular sesamoidectomy, and a medial eminence resection. This procedure has been described as having hallux varus complications up to 13% of the time. Hawkins wrote for Clinical Orthopedics and Related Research and astutely stated that “Once a post-operative hallux varus deformity occurs, the disability becomes greater than that of the original problem. He even described an abductor hallucis tendon transfer for treatment. He would offer the first comprehensive look at causes and correction of hallux varus.
- Allan Boike is a former chair of the Cleveland Clinic Foundation residency and still a big deal around the area. He wrote a chapter on hallux varus for a forefoot surgery book by Dr. Hetherington, our dean of academics. Perhaps more notably, he recently discussed Steven Tyler’s toes for an MSNBC article.
- Schuberth states that hallux varus requires two things: an incongruous first metatarsophalangeal joint and a negative hallux abductus angle. Other deformities are possible, but those two need to be present for it to be considered hallux varus. What patients will complain of, however, is hallucal pain, joint deformity, shoe gear problems, weak pushoff, MPJ instability, or possibly metatarsalgia.
- I grabbed this radiograph from George Wallace’s chapter in Dr. Hetherington’s book. It shows several of the findings that you may expect in a patient with hallux varus. They can include a negative Hallux abductus angle, also described as the hallux varus angle, negative IM 1-2 angle, fibular sesamoid absence, tibial sesamoid peaking, flexion of the hallux IPJ, and staking or spiking of the first metatarsal head. The radiographic findings of a bunion that should be evaluated include the hallux abductus angle, hallux interphalangeus angle, tibial sesamoid position, metatarsal parabola angle, metatarsal elevation/Seiberg’s index, intermetatarsal angle 1-2, first metatarsal protrusion, proximal articular set angle, distal articular set angle,metatarsus adductus angle, and joint condition.
- Hallux varus is a detrimental condition caused, usually, by surgical correction of hallux valgus or a bunion deformity. This accounts for roughly 80% of all Hallux Varus cases. Post operative complications of hallux valgus surgery that most often lead to hallux varus include fibular sesamoid removal, excessive lateral soft tissue release, excessive tightening of the medial capsule, excessive medial eminence removal, overcorrection of the intermetatarsal 1-2 angle, or excessive bandaging.
- Donley, in an article for foot and ankle international, gives a current topic review of hallux varus. He reminds us that the first metatarsophalangeal joint is crossed by four intrinsic muscles, the extensor hallucis brevis, flexor hallucis brevis, abductor hallucis, and adductor hallucis, and two extrinsic muscles, the flexor hallucis longus and extensor hallucis longus. The crista, along with the medial and lateral sesamoid ligaments help provide balance between the pull of the two heads of the flexor hallucis brevis.
- In the case of hallux varus, the abductor hallucis has the advantage. You can see that once the axis of motion is internally rotated, both the flexor hallucis brevis and abductor hallucis muscles gain more leverage. Usually, this is due to an overaggressive lateral release. Even Hawkins knew in the 1970s that release of both the adductor hallucis and the lateral head of the flexor hallucis brevis would lead to a varus deformity, though either could be sacrificed individually.
- This flow chart came from a panel put together to develop treatment guidelines for hallux varus. Other big names on the panel include Christensen, Schuberth, Weil, and Mendocino. They take into account the most common histories, findings, onset times, and etiologies in arriving at a classification.
- This is the last section of the previous flow chart. Basically, Vanore establishes three categories of hallux varus. Type one is the easiest to treat, with just metatarsophalangeal joint adduction. Type two has the addition of hallux malleus and type three is more complex, with rotation of the hallux and is non-reducible. Based on these three classifications, a separate chart would lead you to treatment options. I’ll discuss those findings in a few minutes.
- This flowchart may be too small to read but it basically describes a treatment algorithm. Bevernage and Leemrijse first take into consideration the flexibility or mobility of the MPJ, followed by IPJ motion. From there, it goes through things like arthrosis of the joints involved, osseous positions, and ligament integrity. These authors state that the abductor hallucis muscle is the initial deforming force. Many other sources state that the flexor hallucis brevis muscle is the apex of the deformity. I think the take home message is that both of these muscles have an adductory effect when unchallenged by lateral soft tissues.
- Bevernage and Leemrijse state that conservative treatment must begin within a few weeks of hallux valgus surgery. Aggressive taping in a valgus position, if a varus problem is immediately recognized, can be corrective for the problem. The taping will need to be maintained for three months, but this can correct the varus non-surgically. This dynasplint was used in a study by John, which stated that low-torque stretching for prolonged durations using the splint was effective in reducing both hallux varus and valgus without requiring surgery. There were no long term results, however. The longest patient follow up visit was around 6 months.
- One or more of these techniques needs to be used to correct the problem. Bevernage and Leemrijse offer multiple treatment options in their 2009 article from the Foot and Ankle Clinics. They describe several options, which fall into dynamic or static treatments, all of which are performed with a medial soft tissue release.
- So, this slide gets a little busy. Dynamic procedures seek to restore muscle balance by redirecting tendons and their direction of pull. These include adductor tendon transfer to the lateral sesamoid (Top left, B), abductor tendon transfer through the lateral aspect of the proximal phalanx (top right, C), EHL transfer to the lateral base of the proximal phalanx (bottom left, C), and transfer of the first dorsal interosseous muscle to the base of the proximal phalanx (bottom right, B).
- Static procedures use muscle and tendon to simply hold a position. These include the reversed abductor hallucis tendon transfer (top left, C), which releases the tendon from the muscle and routes it through the first metatarsal and proximal phalanx, the split EHL tendon transfer (middle right, B), which allows motion to be conserved at the IPJ while routing the tendon, split distally, to be rerouted through the first metatarsal, and an EHB tenodesis (bottom left, C), which uses the tendon in a similar fashion as the abductor transfer. Those with Ehlers-Danlos or other ligamentous laxity conditions can require ligamentoplasties in addition to the other described treatments, which could be performed with autologous fascia lata or Ligapro suture.
- Osseous buttressing is the treatment of choice if there is obvious overresection of the first metatarsal head. Again, staking of the head and tibial sesamoid peaking will be noted on the radiograph. This buttress will reapproximate a metatarsal head and help stabilize the muscles of the first MPJ. The picture shows a patient who had osseous buttressing to recreate a metatarsal head along with the static abductor hallucis tendon transfer, which was nearly described by Hawkins in 1971. The combination of procedures performed is likely to produce satisfactory results.
- Again, type 1 deformities are simply an adducted hallux. Type 2 include those deformities with an adducted hallux and IPJ flexion. Type 3 are complex deformities with adduction and extension of the MPJ, IPJ flexion, hallucal rotation, and is non-reducible. Subtype A lacks arthritic changes while subtype B has some degree of arthritic changes. As expected, if the joint is not in good condition, the primary procedures are joint destructive type procedures: arthrtoplasty, implants, or arthrodesis. You can also see that for type one and type 2 A classifications, a medial release and lateral tissue repair procedures are ideal. It is only when you get to more advanced deformities that tendon transfers become the modality of choice. You can also see the connection between EHL transfer and interphalangeal joint arthrodesis. If the fusion is not performed, a flail toe deformity can occur.
- Published in a 2011 issue of Foot and Ankle Specialist, these four surgeons offered very different answers for questions ranging from simply “What is the single most intraoperative maneuver that can lead to hallux varus?” to “If hallux varus is discovered within the first 3 months after hallux valgus surgery, what is the best method of correction?” For the first question, their answers include fibular sesamoid excsion, excessive medial eminence resection, excessive medial capsulorraphy, and excessive intermetatarsal angle reduction. Their treatment options are just as varied, which makes sense. If they don’t agree on the cause, they are unlikely to agree on how to treat it. The editor of the issue, John Schuberth, notes that better studies are needed on the topic of hallux varus, to ensure that there is a better understanding of cause and treatment of this condition.