A. H. N. Robinson, BSc,
Box 37, Addenbrooke’s
Hospital, Cambridge CB2
Correspondence should be
sent to Mr A. H. N. Robinson;
©2005 British Editorial
More than 130 operations have been described
for the treatment of hallux valgus. The pleth-
ora of techniques indicates that no single oper-
ation is perfect, and none will address all cases.
Treatment which is poorly planned or executed
leads to high levels of patient dissatisfaction. In
recent years, a number of new osteotomies
have been described. Determining which to use
can be difﬁcult. This review will examine the
important factors in choosing the most appro-
The wearing of constricting and high heel
in the development of hallux valgus.
some patients, with up to 68% of patients
showing a familial tendency.
The role of pes planus is complex. It is
unlikely that it is an important initiating factor
in hallux valgus but in the presence of pes pla-
nus the progression of hallux valgus is more
rapid. This is particularly so in those patients
with a compromised medial joint capsule as in
rheumatoid arthritis, collagen deﬁciency or a
The presence of pes
planus does not reduce the rate of success of
operations for hallux valgus.
Hypermobility of the ﬁrst tarsometatarsal
joint is thought by some
to be a causative
component in some cases of hallux valgus. In
these patients a fusion of the ﬁrst tarsometa-
tarsal joint (the Lapidus procedure), should be
considered for surgical correction as opposed
to an osteotomy. There is a correlation
between hypermobility of the ﬁrst ray and hal-
and a higher incidence of hyper-
mobility at this site causes a hallux valgus
deformity which is painful.
clinical assessment of hypermobility of the ﬁrst
ray is difﬁcult.
valgus deformity by a distal soft-tissue pro-
cedure and a basal crescentic osteotomy signif-
icantly reduces hypermobility of the ﬁrst ray,
implying that the hypermobility maybe a sec-
ondary phenomenon in some cases.
The pathogenesis of hallux valgus has been
well described by Stephens.
tissues on the medial side of the ﬁrst metatarso-
phalangeal joint and erosion of the ridge on the
metatarsal head between the medial and lateral
sesamoids occur early (Fig. 1). The proximal
phalanx drifts into valgus and the metatarsal
head into varus. A groove appears on the
medial side of the articular cartilage of the
metatarsal head as it atrophies from the lack of
normal pressure and this gives rise to the
apparent prominence of the medial exostosis.
The medial bursa develops in response to the
excessive pressure of shoes over this promi-
nence. As the soft tissues on the medial side
become further attenuated, the metatarsal
head moves medially so that the medial sesam-
oid lies under the eroded metatarsal ridge and
the lateral sesamoid articulates with the lateral
side of the metatarsal head in the ﬁrst inter-
metatarsal space. The tendons of extensor hal-
lucis longus and ﬂexor hallucis longus are
carried laterally with the phalanx, thus becom-
ing adductors and exacerbating the deformity.
The adductor hallucis and lateral head of
ﬂexor hallucis brevis contribute further to this
and with time they become contracted, as does
the lateral joint capsule. The abductor hallucis
and medial head of ﬂexor hallucis brevis also
lose their abduction moment. The resultant
imbalance causes dorsiﬂexion and pronation
of the ﬁrst toe rendering its pulp non-func-
under the ﬁrst ray leads to insufﬁciency of the
ﬁrst ray and overload of the lesser rays. As a
result, the second toe may claw and eventually
the second metatarsophalangeal joint will dis-
Mann, Rudicel and Graves
patients present with restriction in the wearing
of their shoes in 80%, pain over the medial
MODERN CONCEPTS IN THE TREATMENT OF HALLUX VALGUS
VOL. 87-B, No. 8, AUGUST 2005
eminence (bunion) in 70%, cosmetic concerns in 60% and
pain underneath the second metatarsal head in 40%. Pain
may also be felt in the distribution of the dorsal cutaneous
nerve, due to pressure. Deformities of the lesser toes such as
corns and calluses are often a source of symptoms and are
largely due to insufﬁciency of the ﬁrst ray and overcrowd-
ing. Synovitis of the second metatarsophalangeal joint with
pain and swelling is particularly painful.
The physical examination begins with the patient stand-
ing as this often increases the hallux valgus and associated
deformities. It is important to assess the hindfoot as well as
the forefoot. Planovalgus deformities and tightness of the
gastrocnemius and soleus can often exacerbate loading and
pain under the forefoot. The severity of the hallux valgus
deformity and whether it is correctable is documented. Any
pronation of the great toe is noted. The ﬁrst metatarso-
phalangeal joint is examined to assess the range of move-
ment. The lesser toes should be examined for associated
deformities and callosities. The intermetatarsal spaces
should be palpated for interdigital neuromas. The plantar
surface of the foot should be checked for tender callosities
under the lesser metatarsal heads (transfer lesions). In order
to assess ﬁrst tarsometatarsal instability, the examiner
immobilises the lesser metatarsals with the thumb and ﬁn-
gers of one hand. The thumb and index ﬁnger of the other
hand grasp the ﬁrst metatarsal and move it from a plantar-
lateral to dorsomedial direction. Movement of more than 9
mm indicates hypermobility.
The patient should also be
examined for signs of generalised ligamentous laxity.
Weight-bearing anteroposterior (AP) and lateral radio-
and assist in pre-operative planning (Fig. 2). The hallux val-
gus angle (HVA) (normal < 15˚) and intermetatarsal angle
(IMA) (normal < 9˚) are measured. The distal metatarsal
articular angle (DMAA) (normal < 10˚) is the angle between
the articular surface of the head and shaft of the ﬁrst meta-
tarsal. In most cases the DMAA is normal and the ﬁrst
metatarsophalangeal joint is subluxed. This is commonly
termed an incongruent hallux valgus. In a small percentage
of patients who are usually young, the joint is congruent
and not subluxed. In these cases the DMAA is increased,
the metatarsal articulation points more laterally than nor-
mal, and there is no subluxation of the metatarso-
phalangeal joint. A congruent hallux valgus is less prone to
lucis brevis; AdH, adductor hallucis; EHL, extensor hallucis longus; EHB, extensor hallucis brevis; LC, lateral
capsule (lateral sesamoid suspensory ligament); TL, transverse ligament; LS, lateral sesamoid; FHL, flexor hal-
lucis longus; MS, medial sesamoid).
THE JOURNAL OF BONE AND JOINT SURGERY
progression than one which is incongruent. The DMAA is
Hallux valgus interphalangeus deformity is present if
there is signiﬁcant angulation between the proximal and
The relationship of the ﬁrst metatarsal head to the sesa-
moids, the size of the medial eminence and the presence of
degeneration should also be recorded.
It has become traditional to classify the severity of the
deformity using radiological criteria in order to help formu-
late an algorithm for surgical treatment: mild (HVA up to
19˚, IMA up to 13˚); moderate (HVA 20˚ to 40˚, IMA 14˚ to
20˚); severe (HVA > 40˚, IMA > 20˚).
The congruency of the ﬁrst metatarsophalangeal joint
should be noted.
Hallux valgus can be treated with accommodative foot-
and depth of the toe box can alleviate the symptoms in
many patients. This may be the treatment of choice in the
elderly and those with neurological or vascular compro-
The provision of orthoses is often discussed but there is
are often expensive. A support for the medial longitudinal
arch has been shown to relieve symptoms for approxi-
mately six months only.
orthoses prevent progression of hallux valgus.
The indication for surgery is pain which is not adequately
the bunion itself or in the second metatarsophalangeal joint
as a result of insufﬁciency of the ﬁrst ray. The management
of patient expectation is important. The outcomes from
hallux valgus surgery are not always ideal and extensive
pre-operative counselling is required. Only 60% of patients
can expect to wear unlimited shoes following surgery.
necessary to wear cushioned shoes or even insoles following
The surgical procedures available are numerous and dis-
cussed in detail here.
The Keller’s procedure.
This is a simple operation in which
great toe is resected. This decompresses the joint and
relaxes the tight lateral structures, allowing correction of
the deformity. Although once widely used this procedure
has signiﬁcant limitations. There is a high rate of recurrence
of the deformity and the IMA is improved little, if at all.
The procedure reduces the function of the ﬁrst ray with one
showing a mean 40% loss of power of plantar ﬂex-
ion of the hallux. Metatarsalgia from overload of the lesser
metatarsal heads is seen in between 20% and 40% of
A cock-up deformity and a reduced range of
movement of the ﬁrst metatarsophalangeal joint is com-
The salvage of a failed Keller’s procedure is difﬁcult.
Machacek et al
showed that a further Keller’s procedure
or an isolated soft-tissue release lead to very low levels of
patient satisfaction. Fusion of the ﬁrst metatarsophalangeal
joint is often the only viable operative option, but this is
made more difﬁcult by the shortening and loss of bone
stock. In many cases it is necessary to use an interpositional
bone graft in order to re-establish length, but this is techni-
cally-demanding and associated with a high rate of non-
union and other complications.
Keller’s procedure should only be considered in an elderly
person with extremely low functional demands who would
not tolerate a larger procedure.
In essence, a Keller’s
procedure is not an operation for hallux valgus.
Radiological assessment of hallux valgus (HVA, hallux valgus angle; IMA,
intermetatarsal angle; DMAA, distal metatarsal articular angle).
Usually through an inci-
lateral joint capsule, also known as the lateral sesamoid
suspensory ligament, are released (Fig. 1). This allows the
sesamoids to be reduced underneath the ﬁrst metatarsal
head. The lateral collateral ligament is usually left intact as
its release predisposes to hallux varus. The medial eminence
of the ﬁrst metatarsal is excised with plication of the medial
Mann and Coughlin
found that a distal soft-tissue pro-
cedure in isolation reduced the HVA by 14.8˚ and the IMA
by 5.2˚, but there was an incidence of hallux varus of 11%.
A distal soft-tissue procedure showed signiﬁcantly worse
results in the presence of a pre-operative IMA > 15˚.
Johnson et al
in a signiﬁcantly greater radiological correction than an iso-
lated distal soft-tissue procedure in patients with a mild to
moderate deformity. A distal soft-tissue procedure is an
important part of the armamentarium of the correction of
hallux valgus, but it is not the complete answer.
Simple bunionectomy and capsular plication is ineffec-
tive, with the HVA increasing by 4.8˚ and the IMA by 1.7˚
at ﬁve years after operation.
The patients were dissatisﬁed
in 41% of cases.
Osteotomies of the ﬁrst metatarsal.
Osteotomy may be under-
greater correction of the increased intermetatarsal angle
than distal osteotomies which are usually used for mild or
moderate deformities. Distal osteotomies usually require a
less extensive exposure, which allows a shorter recovery
time. In recent years, intermediate diaphyseal osteotomies
such as the scarf and Ludloff procedures have become pop-
be remembered when selecting a ﬁrst metatarsal osteotomy:
1. The technique should be technically easy to undertake
2. The osteotomy should be stable so that re-displace-
ment does not occur.
3. The length of the ﬁrst metatarsal should be maintained
to prevent the development of transfer lesions and meta-
tarsalgia. Similarly, dorsiﬂexion, with the resultant eleva-
tion of the metatarsal head, should be avoided.
4. The technique should be versatile so that the HVA, the
IMA and the DMAA can be corrected.
5. The metatarsal blood supply should be preserved in
order to avoid avascular necrosis of the metatarsal head.
6. The long-term outcome should show a low recurrence
rate of the deformity.
This is an oblique metaphyseal osteo-
placement of the metatarsal head laterally and proximally.
This technique allows correction of the IMA and HVA. Sat-
isfactory results have been described in approximately 90%
Pouliart, Haentjens and Opdecam
average of 8.5 mm shortening of the ﬁrst metatarsal and a
24% incidence of dorsal angulation with this operation.
Metatarsalgia occurred in 35% of their patients post-oper-
atively and correlated with the amount of shortening. Cal-
losities were present under the second metatarsal head in
78% of their patients. More than 5 mm of shortening has
been shown to correlate strongly with the onset of transfer
Due to these shortcomings this operation
is not recommended.
The Mitchell osteotomy.
This involves a double cut through
This step is used to ‘hitch’ on to the metatarsal head. The
capital fragment is displaced laterally and plantarward and
held with a suture through drill holes. Good clinical results
have been reported with this procedure with a 91% rate of
15˚ and HVA up to 35˚. Good correction of the deformity
has been reported.
Nevertheless, shortening of the ﬁrst
metatarsal occurs due to removal of bone to create the step-
cut. This, combined with a lack of inherent stability result-
ing in dorsal malunion, has led to reports of transfer meta-
tarsalgia in between 10% and 30% of patients.
decrease in these complications by the use of internal ﬁxa-
tion in order to increase stability.
This is a V-shaped osteotomy
ment of the capital fragment. This procedure leads to min-
imal shortening and is intrinsically stable against
dorsiﬂexion. It is indicated for mild to moderate deformi-
Excellent clinical results have been reported
been used within limits of correction of the IMA of 4˚ to 8˚
and the HVA of 11˚ to 18˚.
Loss of correction and
recurrence can occur from extending the indications to
more severe deformities and from loss of position at the
osteotomy site. The latter complication can be minimised
by cutting the osteotomy with a long dorsal or plantar arm
and using internal ﬁxation.
Some authors maintain that
the results are not as good in patients > 60 years.
others have not found this to be the case.
is most often used in a non-congruent deformity with a nor-
mal DMAA. However, it can also be employed to correct an
increased DMAA by taking a medially-based closing wedge
by allowing medial rotation of the metatarsal head.
is termed a biplanar Chevron osteotomy.
A concern with the
avascular necrosis of the ﬁrst metatarsal head with a
reported incidence of between 0% and 20%.
lateral release is performed
and have cautioned against
such a combined procedure. Others have not found this to
be the case.
have described the blood supply
of the head of the ﬁrst metatarsal. Laterally it is derived
from the ﬁrst dorsal and ﬁrst plantar metatarsal artery and
artery. From these vessels a multitude of capillaries envelop
the capsule and periosteum of the metatarsal head, includ-
ing a leash of vessels which enter the head just proximal to
its inferior surface. It is possible to dissect through the ﬁrst
dorsal webspace and release the tendon of adductor hallu-
cis and the intermetatarsal ligament, performing a longitu-
dinal incision in the capsule of the ﬁrst metatarso-
phalangeal joint without damaging the dorsolateral blood
supply to the head.
the lateral cortex of the metatarsal it may damage the ﬁrst
dorsal metatarsal artery. The blood supply to the meta-
tarsal head will also be seriously damaged if the dorsal, lat-
eral or inferior capsular attachments are disrupted. It is
therefore important when performing a distal osteotomy
that the surgeon ensures that the dorsal and plantar cuts
exit the bone proximal to the capsular attachments, the
plantar soft tissues to the metatarsal head are left intact and
the sawblade passes through, but not beyond, the lateral
cortex. It is crucial to follow these guidelines in order to
avoid avascular necrosis following a Chevron osteotomy.
Diaphyseal osteotomies have been recommended if the
They allow longitudinal
division of the diaphysis and either translation (scarf) or
rotation (Ludloff) of the metatarsal to correct the IMA. Pli-
cation of the medial capsule and lateral release are usually
the dorsal cortex, 2 mm distal to the metatarsocuneiform
joint, to the plantar cortex.
The osteotomy forms an angle
of 30˚ to the long axis of the metatarsal. The distal frag-
ment is rotated laterally on the proximal fragment and held
with two screws. It is also possible to displace the meta-
tarsal head plantarwards by angling the osteotomy. This
ensures that elevation of the metatarsal head does not occur
and can help relieve pressure on the second metatarsal
head. Excellent clinical results have been reported with the
Ludloff osteotomy, with good correction of the deformity
and without subsequent transfer metatarsalgia.
mechanically more stable than the proximal chevron and
proximal crescentic osteotomies.
This is a Z-shaped step-cut
A longitudinal cut is made along the length of the diaphysis,
sloping plantarward as it passes laterally, allowing plantar
displacement and off-loading of the lesser rays. Chevrons
Lateral view of the osteotomy cuts for the scarf and Ludloff osteotomies.
A post-operative view of hallux valgus treated with scarf and Akin osteot-
are made at each end of the osteotomy to connect it to the
dorsal cortex distally and the plantar cortex proximally.
The head and the plantar cortical fragment are then trans-
lated laterally and the osteotomy held with two compres-
sion screws. As the technique relies on translation of the
metatarsal head rather than rotation, shortening and
increase in the DMAA is avoided.
By altering the geom-
etry of the cuts it is possible to shorten the metatarsal, or
reduce an abnormally-elevated DMAA. It can be modiﬁed
so that an abnormally increased DMAA can be cor-
This osteotomy has a high degree of inherent
biomechanical stability and is more stable than the basal
Studies have shown that the clinical outcomes of the
scarf osteotomy compare favourably with those of basal
osteotomies, but there is an incidence of signiﬁcant compli-
cations of between 4% and 11%.
studies have reported less favourable results with a much
higher incidence of complications,
technically-demanding procedure with a learning curve.
However, once mastered, it is a highly effective and versa-
tile procedure. It has traditionally been recommended for
an IMA of up to 18˚ to 20˚
but with experience it can be
used for more severe deformities.
power can be increased by adding a varus osteotomy of the
proximal phalanx (Akin procedure) (Fig. 4). It is our pre-
ferred operation for deformities with an IMA > 14˚ as we
believe that it best fulﬁlls the previously mentioned guide-
lines for osteotomies.
Diaphyseal osteotomies are technically demanding and
require an extensive surgical exposure. This necessitates
post-operative physiotherapy to prevent stiffness.
The ﬁnal group of procedures are the proximal (basal)
basal chevron osteotomies have all been described. They
are normally combined with a distal soft-tissue procedure.
They have high corrective power due to their proximal
location providing a long lever arm. They can therefore be
used for moderate and severe deformities, but if the DMAA
is increased pre-operatively, a congruent deformity, they
will worsen this problem. Coughlin and Carlson
came this by adding a distal osteotomy to rotate the meta-
tarsal head medially (a double osteotomy), and in some
cases also an Akin osteotomy to correct hallux valgus inter-
phalangeus (triple osteotomy). They reported a rate of
patient satisfaction of 81% but an incidence of major com-
plications of 19% and a mean of 5 mm of metatarsal short-
An opening wedge osteotomy
and requires a bone graft. It therefore has greater potential
for stiffness and nonunion. A closing wedge osteotomy is
easier to perform but leads to excessive shortening of the
It is inherently unstable and dorsal
malunion occurs in up to 38%, leading to the potential for
post-operative transfer lesions.
available to ﬁx opening wedge osteotomies and these may
improve the results.
The crescentic osteotomy.
This osteotomy is associated
It is created 1 cm distal to the
metatarsocuneiform joint with a crescentic sawblade and
the concavity directed proximally, through a dorsal
approach. The metatarsal shaft is rotated laterally and the
osteotomy held with a lag screw, a Steinmann pin or multi-
ple Kirschner wires. It leads to minimal shortening of the
ﬁrst metatarsal. Excellent results have been described with
rates of patient satisfaction of > 90% and good correction
of the IMA and HVA even in severe cases.
some have found it technically difﬁcult and its instability
has led to dorsal malunion in up to 17% of patients with
consequent transfer metatarsalgia.
This is technically easier
centic osteotomy. It has been shown to cause less transfer
Good results have been described.
of a proximally based V-shaped osteotomy. The metatarsal
shaft is rotated laterally on the inferior limb of the cut and
a bone graft from the excised medial eminence is inserted
into the superior limb for stability. The corrected position is
held with a suture between the ﬁrst and second metatarsals,
although other forms of internal ﬁxation can be added if
when there are signiﬁcant degenerative changes in the meta-
tarsophalangeal joint. It is also an option in severe or recur-
rent deformity, particularly in the older patient. Other
indications include hallux valgus secondary to neuro-
muscular diseases and as a salvage procedure following
failed surgery. Various techniques have been described with
an overall success rate of 90% and high levels of patient sat-
isfaction in appropriately-selected patients. The increased
IMA will be reduced after operation even in the most severe
deformities and a concomitant basal osteotomy is not indi-
This is indi-
the patient with hypermobility of the ﬁrst tarsometatarsal
joint, especially if associated with generalised ligamentous
laxity. Mann and Coughlin
approximately 3% to 5% of patients. Hypermobility can
be determined clinically as outlined previously but it is dif-
ﬁcult to estimate accurately and reproducibly. The pro-
cedure is also indicated in the presence of degenerative
changes in the ﬁrst or second tarsometatarsal joint and is an
option in severe deformity with an IMA of > 20˚. It is
contraindicated in the adolescent with an open physis at the
base of the ﬁrst metatarsal and also in patients with a short
ﬁrst metatarsal or degenerative changes in the ﬁrst meta-
tarsophalangeal joint. The procedure is technically demand-
increased morbidity when compared to metatarsal oste-
It also leads to shortening and care must be
taken to resect as little bone as possible to avoid this. As the
varus of the ﬁrst metatarsal is corrected the ﬁrst ray should
be plantarﬂexed slightly to avoid elevation and transfer
metatarsalgia. The rate of patient satisfaction varies
between 75% and 90% with fusion rates of approximately
Surgery for hallux valgus, while technically demanding, has
However, a small number of patients have poor outcomes
following operation. Randomised, controlled trials are
needed to elucidate the factors which determine a good out-
come. There is also a need for a good validated outcome
A comparison of foot forms among the non-shoe and shoe-
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Juvenile hallux valgus: etiology and treatment.
Hypermobility of the ﬁrst ray.
Clinical, quantitative assessment of ﬁrst tar-
Measurement of ﬁrst-ray mobility in normal vs. hallux valgus
First ray dorsal mobility in relation to hallux
Clinical signiﬁcance of
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experience. Foot Ankle 1991;11:187-94.
Mild hallux valgus (IMA
up to 14˚)
Chevron osteotomy with a long inferior limb; internally ﬁxed with a
A biplanar chevron osteotomy, excising a medial wedge to allow
medial rotation of the metatarsal head as it is translated laterally;
internally ﬁxed with a single screw.
Moderate hallux valgus (IMA 14˚ to 20˚)
A scarf osteotomy with a distal soft-tissue procedure is used. A varus
osteotomy of the proximal phalanx (Akin procedure) is added if more
correction is desired. The Akin osteotomy is ﬁxed with a staple. If
there is any residual pronation of the hallux this can be reduced by
rotating the Akin osteotomy.
The same procedure is undertaken, but the DMAA is corrected by
rotating the scarf osteotomy
Severe hallux valgus (IMA > 20˚)
For intermetatarsal angles > 20˚ there are four principle options:
extend the indications for a scarf osteotomy, undertake a rotational
osteotomy (Ludloff, crescentic or chevron) or perform a fusion either
at the tarsometatarsal or metatarsophalangeal joint. Our preference is
to perform a scarf osteotomy in most cases.
Hallux valgus with ﬁrst tarsometatarsal hypermobility
A ﬁrst tarsometatarsal fusion (Lapidus) with a distal soft-tissue pro-
cedure may be undertaken
Hallux valgus with ﬁrst metatarsophalangeal joint degeneration
First metatarsophalangeal joint arthrodesis is performed
Hallux valgus interphalangeus
This is treated with an Akin osteotomy. Hallux valgus interphalangeus
in isolation is rare, and an Akin osteotomy is normally performed in
conjunction with other procedures which correct the intermetatarsal
* IMA, intermetatarsal angle
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satisfaction. Foot Ankle 1985;5:327-32.
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release. Foot Ankle Int 1994;15:59-63.
45. Jones KJ, Feiwell LA, Freedman EL, Cracchiolo A 3rd. The effect of Chevron
osteotomy with lateral capsular release on the blood supply to the ﬁrst metatarsal
head. J Bone Joint Surg [Am] 1995;77-A:197-204.
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