Modern concepts in the treatment of hallux valgus

Abstract

More than 130 operations have been described for the treatment of hallux valgus. The plethora of techniques indicates that no single operation 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 appropriate techniques. Aetiology and pathogenesisThe wearing of constricting and high heel shoes are extrinsic factors which are important in the development of hallux valgus. 1,2 Heredity 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 planus 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 tarsometatarsal 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 hallux valgus, 8-10 and a higher incidence of hypermobility 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 procedure and a basal crescentic osteotomy significantly reduces hypermobility of the first ray, implying that the hypermobility maybe a secondary 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 metatarsophalangeal 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 prominence. As the soft tissues on the medial side become further attenuated, the metatarsal head moves medially so that the medial sesamoid lies under the eroded metatarsal ridge and the lateral sesamoid articulates with the lateral side of the metatarsal head in the first intermetatarsal space. The tendons of extensor hallucis longus and flexor halluci...

Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

“…However, it illustrates the need for further prospective comparative studies. Basically, proximal osteotomies are recommended for the treatment of moderate to severe deformities [3,[5][6][7]. The studies included in this meta-analysis also contained patients who suffered from mild to moderate hallux valgus deformity.…”

“…The severity of deformity is classified by radiological criteria [5]. Mild deformity has less than 15°intermetatarsal 1-2 angle (IMA), moderate deformity has 15-20°IMA and severe deformity has more than 20°IMA [6].…”

Validity and Reliability of Hallux Valgus Angle Measured on Digital Photographs

“…Our study investigated HV angle as a primary indicator of HV severity; however, it should be noted that a thorough preoperative assessment of HV includes measurement of other radiographic angles, such as intermetatarsal angle and distal metatarsal articular angle, 31 in addition to noting the presence of sesamoid displacement and degenerative change. 21 Therefore, radiographs would still be required in individuals with HV for whom surgical correction is being considered.…”

Long-term results of the retrocapital metatarsal percutaneous osteotomy for hallux valgus

“…Over 130 different surgical techniques [1][2][3][4] to correct hallux valgus deformity have been proposed, although choosing the most appropriate treatment option continues to generate controversy [5][6][7][8][9][10][11]. The current trend is directed toward percutaneous procedures with the potential benefits of minimally invasive surgery [2], e.g.…”