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1038


THE JOURNAL OF BONE AND JOINT SURGERY

 

 



"

"

"



"

 

ASPECTS OF CURRENT MANAGEMENT

 

Modern concepts in the treatment of 

hallux valgus

 

A. H. N. Robinson, 

J. P. Limbers

 

From Addenbrooke’s 

Hospital, Cambridge, 

England

 

"



 

A. H. N. Robinson, BSc, 

FRCS(Orth), Consultant 

Orthopaedic Surgeon

 

"

 



J. P. Limbers, FRACS(Orth), 

Fellow


Department of Trauma and 

Orthopaedics

Box 37, Addenbrooke’s 

Hospital, Cambridge CB2 

2QQ, UK.

Correspondence should be 

sent to Mr A. H. N. Robinson; 

e-mail: fredrobinson@

uk-consultants.co.uk

 

©2005 British Editorial 



Society of Bone and

Joint Surgery

doi:10.1302/0301-620X.87B8. 

16467 $2.00



 

J Bone Joint Surg [Br] 

 

2005;87-B:1038-45.



 

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-

priate techniques.



 

Aetiology and pathogenesis

 

The wearing of constricting and high heel



shoes are extrinsic factors which are important

in the development of hallux valgus.

 

1,2


 

 Hered-


ity is likely to be a major predisposing factor in

some patients, with up to 68% of patients

showing a familial tendency.

 

3



 

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

neuromuscular disorder.

 

4



 

 The presence of pes

planus does not reduce the rate of success of

operations for hallux valgus.

 

5,6


 

Hypermobility of the first tarsometatarsal

joint is thought by some

 

7,8



 

  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-

lux valgus,

 

8-10



 

 and a higher incidence of hyper-

mobility at this site causes a hallux valgus

deformity which is painful.

 

8,11


 

  The accurate

clinical assessment of hypermobility of the first

ray is difficult.

 

9

 



  However, a recent cadaver

study


 

12

 



  has shown that correction of a hallux

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.

 

13

 



 Weakening of the

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-

tional.


The resultant reduction in plantar pressure

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-

locate.


 

Clinical assessment

 

Mann, Rudicel and Graves



 

14

 



 have shown that

patients present with restriction in the wearing

of their shoes in 80%, pain over the medial


 

MODERN CONCEPTS IN THE TREATMENT OF HALLUX VALGUS

1039

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.

 

8



 

  The patient should also be

examined for signs of generalised ligamentous laxity.

 

Radiological assessment

 

Weight-bearing anteroposterior (AP) and lateral radio-



graphs of the foot are taken to help assess the deformity

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

AbH

FHB


AdH

EHL


EHB

LC

TL



LS

FHL


MS

Fig. 1


Anatomy of the structures around the first metatarsophalangeal joint (AbH, abductor hallucis; FHB, flexor hal-

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).



 

1040


A. H. N. ROBINSON, J. P. LIMBERS

THE JOURNAL OF BONE AND JOINT SURGERY

 

progression than one which is incongruent. The DMAA is



difficult to measure, with high inter- and intra-observer

variability.

Hallux valgus interphalangeus deformity is present if

there is significant angulation between the proximal and

distal phalanges.

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.

 

Non-operative treatment

 

Hallux valgus can be treated with accommodative foot-



wear. The provision of a soft leather shoe with extra width

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-

mise.

The provision of orthoses is often discussed but there is



little evidence to substantiate the use of these devices which

are often expensive. A support for the medial longitudinal

arch has been shown to relieve symptoms for approxi-

mately six months only.

 

15

 



 There is no evidence to show that

orthoses prevent progression of hallux valgus.



 

Surgical treatment

 

The indication for surgery is pain which is not adequately



controlled by non-operative means. The pain may be over

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.

 

16



 

 If


transfer lesions are present before operation, it may be

necessary to wear cushioned shoes or even insoles following

operation.

The surgical procedures available are numerous and dis-

cussed in detail here.

 

The Keller’s procedure. 

 

This is a simple operation in which



approximately one-third of the proximal phalanx of the

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.

 

17,18


 

The procedure reduces the function of the first ray with one

study

 

19



 

 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

cases.

 

20-22



 

  A cock-up deformity and a reduced range of

movement of the first metatarsophalangeal joint is com-

mon.


 

20,23


 

The salvage of a failed Keller’s procedure is difficult.

Machacek et al

 

23



 

 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.

 

24,25


 

  Consequently, a

Keller’s procedure should only be considered in an elderly

person with extremely low functional demands who would

not tolerate a larger procedure.

 

17,20,21



 

 In essence, a Keller’s

procedure is not an operation for hallux valgus.

DMAA


IMA

HVA


Fig. 2

Radiological assessment of hallux valgus (HVA, hallux valgus angle; IMA,

intermetatarsal angle; DMAA, distal metatarsal articular angle).


 

MODERN CONCEPTS IN THE TREATMENT OF HALLUX VALGUS

1041

VOL. 87-B, No. 8, AUGUST 2005



 

The distal soft-tissue procedure. 

 

Usually through an inci-



sion in the first dorsal webspace, the adductor hallucis and

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

joint capsule.

Mann and Coughlin

 

26



 

 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˚.

 

15,16


 

Johnson et al

 

27

 



 showed that a Chevron osteotomy resulted

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.

 

28



 

 The patients were dissatisfied

in 41% of cases.

 

Osteotomies of the first metatarsal. 

 

Osteotomy may be under-



taken proximally or distally. Proximal osteotomies allow a

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-

ular.


There are a number of important principles that should

be remembered when selecting a first metatarsal osteotomy:

1. The technique should be technically easy to undertake

and reproducible.

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.



 

Distal metatarsal osteotomies

 

The Wilson procedure. 

 

This is an oblique metaphyseal osteo-



tomy from distal medial to proximal lateral, allowing dis-

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%

of patients.

 

29



 

 Pouliart, Haentjens and Opdecam

 

30

 



 found an

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

metatarsalgia.

 

31



 

 Due to these shortcomings this operation

is not recommended.

 

The Mitchell osteotomy. 

 

This involves a double cut through



the first metatarsal neck, leaving a step in the lateral cortex.

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

patient satisfaction.

 

32

 



 It is recommended for an IMA up to

15˚ and HVA up to 35˚. Good correction of the deformity

has been reported.

 

33,34



 

 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.

 

33,35


 

 Loss of


correction can also occur. Some authors have reported a

decrease in these complications by the use of internal fixa-

tion in order to increase stability.

 

32,34



 

The distal Chevron osteotomy. 

 

This is a V-shaped osteotomy



through the metatarsal neck followed by lateral displace-

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-

ties.

 

36



 

 Excellent clinical results have been reported

 

31,37


 

 with


little or no transfer metatarsalgia when the procedure has

been used within limits of correction of the IMA of 4˚ to 8˚

and the HVA of 11˚ to 18˚.

 

31,37



 

  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.

 

31,38



 

 Some authors maintain that

the results are not as good in patients > 60 years.

 

6



 

 However,

others have not found this to be the case.

 

20,37



 

 The operation

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.

 

31

 



 This

is termed a biplanar Chevron osteotomy.



 

Complications with distal osteotomies. 

 

A concern with the



Chevron and other distal osteotomies is the development of

avascular necrosis of the first metatarsal head with a

reported incidence of between 0% and 20%.

 

38-41



 

  Some


authors have noted a higher incidence when a concomitant

lateral release is performed

 

41,42


 

 and have cautioned against

such a combined procedure. Others have not found this to

be the case.

 

37

 



A number of studies

 

43-45



 

 have described the blood supply

of the head of the first metatarsal. Laterally it is derived


 

1042


A. H. N. ROBINSON, J. P. LIMBERS

THE JOURNAL OF BONE AND JOINT SURGERY

 

from the first dorsal and first plantar metatarsal artery and



medially from the superficial branch of the medial plantar

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.

 

44

 



 If the sawblade passes too far beyond

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

 

Diaphyseal osteotomies have been recommended if the



IMA is between 14˚ and 20˚.

 

46,47



 

 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

performed simultaneously.



 

The modified Ludloff osteotomy 

 

(Fig. 3)



 

 

This osteotomy



consists of a bone cut extending distally and inferiorly from

the dorsal cortex, 2 mm distal to the metatarsocuneiform

joint, to the plantar cortex.

 

48



 

 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.

 

48,49



 

 There


is minimal shortening of the metatarsal and it is bio-

mechanically more stable than the proximal chevron and

proximal crescentic osteotomies.

 

49-51



 

The scarf osteotomy 

 

(Fig. 3)



 

 

This is a Z-shaped step-cut



osteotomy and is named after its woodworking equivalent.

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

Scarf

Ludloff


Fig. 3

Lateral view of the osteotomy cuts for the scarf and Ludloff osteotomies.

Fig. 4

A post-operative view of hallux valgus treated with scarf and Akin osteot-



omies.

 

MODERN CONCEPTS IN THE TREATMENT OF HALLUX VALGUS

1043

VOL. 87-B, No. 8, AUGUST 2005



 

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.

 

50,52


 

 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-

rected.


 

46,53


 

  This osteotomy has a high degree of inherent

biomechanical stability and is more stable than the basal

osteotomies.

 

54,55


 

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%.

 

46,47,56



 

  However, other

studies have reported less favourable results with a much

higher incidence of complications,

 

57

 



 indicating that it is a

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˚

 

46,47



 

 but with experience it can be

used for more severe deformities.

 

52,58,59



 

  The corrective

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.



 

Basal osteotomies

 

The final group of procedures are the proximal (basal)



osteotomies. Opening wedge, closing wedge, crescentic and

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

 

60

 



  over-

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-

ening.


 

Proximal wedge osteotomy. 

 

An opening wedge osteotomy



causes elongation and stretching of the medial soft-tissues

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

metatarsal.

 

17,50



 

  It is inherently unstable and dorsal

malunion occurs in up to 38%, leading to the potential for

post-operative transfer lesions.

 

17

 



 Distraction plates are now

available to fix opening wedge osteotomies and these may

improve the results.

 

The crescentic osteotomy. 

 

This osteotomy is associated



with Mann and Coughlin.

 

4



 

 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.

 

14,61


 

  However,

some have found it technically difficult and its instability

has led to dorsal malunion in up to 17% of patients with

consequent transfer metatarsalgia.

 

62,63



 

The proximal Chevron osteotomy. 

 

This is technically easier



and intrinsically more stable to dorsiflexion than the cres-

centic osteotomy. It has been shown to cause less transfer

lesions.

 

63-65



 

  Good results have been described.

 

65,66


 

  It


involves a medial approach to the metatarsal and creation

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

desired.


 

Arthrodeses

 

First metatarsophalangeal joint arthrodesis. 

 

This procedure



is indicated for hallux valgus in the rheumatoid patient and

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-

cated.


 

67

 



First tarsometatarsal joint arthrodesis (Lapidus). 

 

This is indi-



cated in combination with a distal soft-tissue procedure in

the patient with hypermobility of the first tarsometatarsal

joint, especially if associated with generalised ligamentous

laxity. Mann and Coughlin

 

4

 



  estimate this to occur in

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-



 

1044


A. H. N. ROBINSON, J. P. LIMBERS

THE JOURNAL OF BONE AND JOINT SURGERY

 

tarsophalangeal joint. The procedure is technically demand-



ing and associated with a prolonged period of recovery and

increased morbidity when compared to metatarsal oste-

otomies.

 

68,69



 

 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

90%.


 

68-70


 

Conclusion

 

Surgery for hallux valgus, while technically demanding, has



a high rate of success in appropriately selected patients.

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

score.


Our preferred methods of treatment are shown in Table I.

 

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 The etiology of hallux valgus in Japan. 



 

Clin Orthop

 

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Table I. The authors’ preferred methods of treatments

Type

Description

Mild hallux valgus (IMA

*

 up to 14˚)



Normal DMAA

Chevron osteotomy with a long inferior limb; internally fixed with a 



single screw.

Increased DMMA

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˚)

Normal DMAA

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.

Increased DMMA

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 

angle.

* IMA, intermetatarsal angle



† DMMA, distal metatarsal articular angle

MODERN CONCEPTS IN THE TREATMENT OF HALLUX VALGUS

1045


VOL. 87-B, No. 8, AUGUST 2005

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