Hallux ValgusDr. E. M. Regis Jr.

Orthopaedic Dept.S.G.P.H16/5/16

Overview• History

• Definition

• Incidence

• Aetiology

• Anatomy

• Pathology

• Signs/ Symptoms

• Investigation

• Diagnosis

• Treatment

• Conclusion

History• “Hallux Valgus" was define as static

subluxation of first Metatarsophalangeal Joint with lateral deviation of great toe.

• This term was introduced by Carl Hueterto.

• The first surgical procedure to address the deformity was described by Reverdin in May, 1881.

Definition

• deformity resembling abduction contracture in which great toe turned away from mid-line of body.

• commonly referred to as “Bunion”

Lateral deviation of Great Toe

Medial deviation of 1st Metatarsal

Progressive subluxation of 1st MTP joint

Incidence• 1% adults in US

Gould et al studies

• increased incidence with age (3% 15-30 yrs, 9% 31-60 yrs & 16% >60yrs)

• F > M {2:1 - 4:1}

Aetiology

• Extrinsic Factors;

shoes with narrow toe/ high heels

occupational factors

• Intrinsic Factors;

Hereditary {60-90%}

Arthritic/metabolic

• Gouty arthritis, RA, Connective tissue disorders {Marfan, Ehlers- Danlos, Down}

Neuromuscular Disease

• Cerebral Palsy, Multiple sclerosis

Traumatic Conditions

• malunions, Dislocations, Intra-articular damage

Structural Deformities

• malalignment of articular surface, abnormal metatarsal length

Anatomy

Groups Encircling 1st MTP joint

1. Extensor hallucis longus & brevis

2. Flexor hallucis longus & brevis

3. Abductor

4. Adductor

Pathology• with a valgus deformity of >30 degrees, the

great toe rotates into pronation (nail face medially)

• the sesamoids bones of FHB are displaced laterally

• also FHL & EHL tendons bowstring on the lateral side adding to deformity forces

• the contracted adductor hallucis & lateral capsule contribute further to the fixed deformity

Signs/Symptoms • Asymptomatic • Pain/ Tenderness• Skin calluses/ areas of redness• Increased/Decreased 1st MTP joint R.O.M• Pronation of great toe

Investigation• Radiographs

weight bearing AP, lateral & oblique views

Findings;

lateral displacement of sesamoids

joint congruency & degenerative changes

• Hallux Valgus Angle (HVA)

intersection of longitudinal axis of 1st MT and proximal phalanx (normal <15)

• Intermetatrsal Angle (IMA)

Intersection of 1st & 2nd MT (Normal <9)

ClassificationPiggott (1960) based on x ray appearance

1. MTP joint is centred but the articular surfaces though congruent, are tilted towards valgus

2. articular surfaces are not congruent, the phalangeal surface being tilted towards valgus

3. the joint is both incongruent and slightly subluxated

• Labs

Uric acid

ESR

C-reactive protein

ANA

RF

DiagnosisRoot et al (pathomechanical devlopment of hallux valgus)

• Stage 1 - excessive pronation causes hypermobility of 1st ray, causing the tibial sesamoid ligament to be stretched and the fibular sesamoid ligament to contract; lateral subluxation of the proximal phalanx occurs

• Stage 2 - hallux abduction progresses, with the flexor hallucis longus and flexor hallucis brevis gaining lateral mechanical advantage

• Stage 3 - Further subluxation occurs at the 1st MTP joint, with formation of metatarsus primus adductus

• Stage 4 - The 1st MTP joint finally dislocates

TreatmentMedical

cannot change the irreversible cartilage, bony & soft tissue adaptions of the deformity

• Adapting footwear - shoes with wider & deeper toe box. Extra padding & strapping

• Pharmacologic/ Physical Therapy - NSAIDS in acute episodic inflammatory process. No evidence to support prolong physical therapy.

• Functional orthotic therapy

Surgical

Indications; persistent pain (not cosmetic)

progression of deformity

failure of non operative treatment

Goals; correct all pathologic elements and maintain biomechanically functional forefoot.

Combination of soft tissue procedures with bony procedures in almost all cases

• SOFT TISSUE PROCEDURES

NB. Medial & Lateral procedures done together are contraindicated

• BONY PROCEDURE

Distal MT: {IM angle 12-15 degrees)

Mitchell

Wilson

Chevron

Proximal MT: {IM angle >15 degrees}

Medial opening wedge

Lateral closing wedge

Mitchell

Chevron

Phalangeal:

Proximal Phalanx Osteotomy {Aiken}

Combination osteotomies

Keller’s excision for arthritis of MTP joint

Arthrodesis .. {eg. Lapidus)

Complications• Recurrent deformity• Hallux Varus• Pronation deformity• Pain• Neurologic Injury• Osteonecrosis• Nonunion/ malunion

Conclusion• Hallux Valgus is abduction contracture deformity

resembling big toe displaced laterally.• Women have a higher incidence which is directly

proportional with increase age. • Aetiology is divided into extrinsic & intrinsic

factors.• Treatment usually non surgical first, then if failed

surgical option is advised.• Surgery most often involves a combination of soft

tissue and bony procedures.

References• Apley’s System of Orthopaedics &

Fracture, 9th Edition

• Campbell’s Operative Orthopaedics: 12th Edition, Vol.1

• J Maheshwari (1997), Essential Orthopaedics 2nd Edn. New Delhi, Interprint

• www.orthobullets.com/halluxvalgus