Bradley Castellano, D.P.M.

Recurrence of deformity is one of the more commoncomplications in hallux valgus surgery (1-3). The deform-ity may have been undercorrected with an inadequateprocedure or spuriously repaired with an inappropriateprocedure. At times the recurrence may present despiteapparently adequate correction. ln any case, the manage-ment of the recurrent deformity is an unpleasant taskrequiring good doctor-patient relationships and carefuldeliberation to revise the procedure appropriately.

ln assessing recurrent hallux valgus deformity, atten-tion to the patient's complaint should take precedenceover the surgeon's dissatisfaction with the result. Thesurgeon often concentrates on the recurrence of the dor-somedial prominence of the first metatarsal head. Thepatient may only be describing painful limitation of jointmotion and be completely satisfied with the amount ofcorrection. Defining the patient's complaint is animportant consideration in revisional surgery.

ETIOTOGY AND TREATMENT

Even seemingly appropriate surgery with satisfactoryintra-operative correction can result in recurrence. Ascer-taining the etiology of recurrent hallux valgus can be dif-ficult. Several factors must be considered whenevaluating the deformity. Efforts to discover the causeof recurrence may be aided by dividing recurrences intothree types (Table 1.).

Type I recurrences consist of those deformities inwhich structural correction was never obtained. Under-corrections are usually the easiest to evaluate. Theincreased intermetatarsal angle and/or hallux abductusangle was never adequately repaired. Type ll recurrencesinclude those deformities which appeared satisfactorilycorrected intra-operatively but recurred shortly after thesurgery. Finally, type lll recurrences are comprised ofthose deformities which for one reason or another, in-sidiously recur after a substantial period of time.

Treatment may then be based on the type of recur-rence and should be aimed at alleviating the deformingforce.

REVISIONAT HAttUX VATGUS SURGERY

Type I Recurrent Hallux Valgus

Deformities which have had an attempt at surgical cor-rection that did not adequately reduce the intermetatar-sal and/or hallux abductus angle are classified as type I

recurrent hallux valgus. Ricurrent is probably amisnomer for this form of surgical failure since the de-formity was never actually corrected. Residual halluxvalgus may be a more appropriate term.

Type I recurrences may result from performing aninadequate procedure such as a simple exostectomy ina patient with a significantly increased intermetatarsalangle (Fig. 1). lnsufficient capital fragment displacementor base wedge resection are other likely causes. ln eitherform of osteotomy the lack of fixation or fixation failurecan result in displacement and recurrence of deformity.Failure to recognize and address associated deformitiessuch as hallux valgus interphalangeus may be anothercause of type I recurrence (4).

Treatment of type I recurrences is directed toward thestructural deformity which continues to exist. Undercor-rection of hallux valgus deformity may simply be theresult of improper intra-operative assessment. While per-forming the surgical revision the forefoot should be load-ed to simulate weightbearing while assessing the degreeof correction. Special consideration may be requireddepending on the osseous integrity remaining followingthe previous surgery. Realignment of displaced distalosteotomies will often require careful application ofinternal fixation such as stainless steel wire loop, crossedKirschner-wires (K-wire), or even screws (5, 6). The useof intra-operative x-rays is another grossly neglectedtechnique of evaluation.

Type ll Recurrent Hallux Valgus

Hallux valgus deformities which recur after a briefperiod of apparently adequate correction are termedtype ll. In this type recurrence the deformity reappearswithin weeks to a few months following surgical repair.Displacement of osteotomies can be an early cause oftype ll recurrences, especially if delayed union developsor internal fixation is removed prematurely.

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Table 1.

CIASSIFICATION OF RECURRENT HAttUX VALGUS

TYPETIME IAPSE BEMEEN

SURGERY AND RECURRENCEPOSSIBTE REASONS FOR THE RECURRENCE

Immediate 1. lnadequate exostectomy

2. Exostectomy only with increased intermetatarsal angle

3. Failure to assess the correction obtained intra-

operatively with the foot in loaded position

4. Poor choice of procedure

5. Displacement of osteotomies

II Weeks To Few Months 1. Reliance on soft tissue procedures to correct

structu ral deform ities

2. Late displacement of delayed or non-union fragments

3. Failure to perform muscle-tendon balance

about the first metatarsophalangeal joint

4. Inappropriate or inadequate osteotomy utilization

ilt Several Months To Years 1. Failure to control pronatory forces such as equinus

2. Rheumatoid arthritis - progressive disease

3. Spasticity of lower extremity muscles

4. Ligamentous laxity

Another possible cause is seen when soft tissuemanipulations such as capsulotomy, capsulorrhaphy, ortendon transfer are relied upon to maintain a structurallyuncorrected deformity. This should not be misconstruedto imply that muscle-tendon balance is unimportant inhallux valgus repair. In fact, failure to alleviate the aber-rant lateral direction of pull of the flexor hallucis longusby adductor hallucis release and sesamoid relocationmay be another significant cause of type ll recurrence(Fig. 2).

Probably the most typical cause of type ll recurrentdeformities is related to the choice of osteotomy per-formed on the first ray. Correction of hallux valgus withmedial cuneiform, first metatarsal, and proximalphalangeal osteotomies have all been described. The suc-

cess or failure of each of the techniques will depend onmany factors. ln general, the degree of correction is

related to the realignment of the first metatarsal with suf-

ficient decrease of the intermetatarsal angle and decrease

in the hallux abductus angle. Procedures which tend toneglect either of the above deformities are at a greaterrisk of failure. The classic example of this is the use ofthe Akin phalangeal osteotomy as an isolated procedureto repair the entire complex deformity of hallux abduc-to valgus with associated metatarsus primus adductus(Fig. 3).

The Akin procedure does not decrease the inter-metatarsal angle and when performed alone results ina significant incidence of recurrence of hallux valgusdeformity (7).

Decreasing the intermetatarsal angle by osteotomy ofthe first metatarsal has proven to be an effective meansof hallux valgus repair. Choosing the level of the

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Fig. 1. This hallux valgus deformity was treated with minimal incisionaltechnique. Simple exostectomy is destined to failure in this conditionsince neither muscle-tendon balance nor structural realignment wasobtained in this moderately severe deformity.

Fig. 3. Basilar phalangeal osteotomy with metatarsal head exostectomywas used in this failed attempt to correct moderately severe deformity.Level of deformity is clearly at metatarsal segment and appropriate cor-rection with osteotomy of first metatarsal will be required to revise thisrecurrent deformity.

Fig. 2. Recurrence of hallux valgus despite distal first metatarsal displace-ment osteotomy with fixation and proximal phalangeal wedgeosteotomy. Muscle-tendon balance about first metatarsophalangealjoint was apparently neglected or inadequately treated as evidencedby lateral subluxation of sesamoid apparatus.

osteotomy has generally been related to the severity ofthe deformity. Most authors feel that distal first metatar-sal osteotomies should be restricted to use in mild tomoderately severe deformities. The deformity with alarge intermetatarsal angle is best corrected byosteotomy or perhaps arthrodesis at the first metatarsalbase region. Although guidelines for the proper use offirst metatarsal osteotomies have been suggested basedon the intermetatarsal angle few objective reports havebeen presented to support these criteria (8). The surgeonmust often rely on his own experience to determine therealistic parameters of each osteotomy procedure.

Treatment of the type Il recurrence is directed at cor-rection of the structural deformity, as was the case intype I recurrences. When performing the revisionalsurgery the osseous integrity and alignment should becarefully assessed prior to surgery. Careful attention is

given to joint congruity and muscle-tendon balanceabout the first metatarsophalangeal joint.

Recurrences following isolated Akin or Akin-McBrideprocedures will require careful attention to hallux align-ment since decrease in the intermetatarsal angle bymetatarsal osteotomy may result in an adductus positionof the hallux. ln cases in where a distal metatarsalosteotomy has resulted in recurrence sesamoid displace-

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Recurrences following isolated Akin or Akin-McBrideprocedures will require careful attention to hallux align-ment since decrease in the intermetatarsal angle bymetatarsal osteotomy may result in an adductus positionof the hallux. ln cases in where a distal metatarsalosteotomy has resulted in recurring sesamoid displace-ment one should carefully evaluate the lateralaspect ofthe joint to ascertain adequate release. Failure to performadductor tendon and fibular sesamoidal ligament releaseis a common cause of recurrence (Fig. 4).

Caution should be used to prevent overcorrection dur-ing management of recurrences, since simple muscle-tendon balance may be all that is needed to reduce andmaintain correction. This would be true only in instanceswhere adequate structural correction was previouslyobtained.

Type lll Recurrent Hallux Valgus

The last type of recurrent hallux valgus occurs after a

signif icant period of apparent lasting correction. This istermed type lll recurrent hallux valgus. The conditionswhich result in type lll recurrence include extraneousforces such as pathologic pronation or muscle spasticity(9, 10). Patients with undiagnosed rheumatoid arthritismay have continued expression of their disease resultingin fibular drift of all digits including the hallux. Panmetatarsal head resection with or without implant ar-throplasty of the first metatarsophalangeal joint will oftenbe required in the rheumatoid patient with recurrenthallux valgus secondary to the disease.

Discerning the etiology of the type lll recurrent halluxvalgus condition will require ruling out the above men-tioned causes. Pronatory forces should be controlledfollowing the surgical revision if that is found to be thecause of the recurrence. The influence of equinus shouldnot be underestimated and tendo Achillis orgastrocnemius lengthening may be performed as an ad-junct to the hallux valgus revisional surgery. ln otherinstances the patient may be placed in a raised heel shoeto compensate for equinus.

Failure to recognize or alleviate spasticity of leg andfoot musculature can also result in late recurrence ofhallux valgus (Fig. 5). The deforming influence of spasticmurscles is sometimes difficult to predict and even typell recurrences may occur in the presence of severeinstances of spasticity. Tendon transfer and/or ar-throdesis procedures will usually be required to preventfurther recurrence or additional deformity in thepresence of spasticity.

Fig. 4. Dissection of first intermetatarsal space of left foot is shown.Note attachment of adductor hallucis tendon remains intact in thisrecurrent hallux valgus deformity. Release of fibular sesamoidal liga-ment and adductor hallucis from their insertion into fibular sesamoidwill be necessary to complete surgical revision.

SPECIAT CONSIDERATIONS IN REVISIONALHALTUX VATGUS SURGERY

Each individual case of recurrent hallux valgus is

unique and challenging. The surgeon performing therevision must be able to objectively evaluate the recur-rent deformity. At times objectivity can be difficult if thesurgical failure is ones own. Occasionally, it may be wisefor the surgeon to seek the opinion of a peer to insurerational decision making. Realistic expectations on thepart of the surgeon and the patient should delineate notonly the means of surgical intervention but also the ex-tent to which conservative methods shou ld beexhausted.

Although it is difficult to categorize recurrent halluxvalgus cases there are a few special considerations andcircumstances which may be common among thesedeformities. The timing, osseous and soft tissue integrity,and patient's complaint all play an important role in thetreatment.

Tissue plane dissection is important in revisionalsurgery. Delamination of soft tissues and lysis of adhe-sions will often be necessary to adequately mobilize thefirst metatarsophalangeal joint. ldentification ofpathologic and iatrogenic anatomic relationships is bestaccomplished through anatomic dissection techniques.Surgical hemostasis although usually obtained easily withcareful anatomic dissection may in some instances war-rant the use of a tourniquet.

Finally, the importance of careful dissection and preser-vation of blood supply to the first metatarsal head has

been stressed by many authors. Previous surgery aboutthe first metatarsal creates an increased risk of avascular

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Fig. 5. A" This 20 year old male presented with severe hallux valgusdeformity and spastic paralysis of tibialis anterior muscle. B. Correc-tion of the severe hallux valgus deformity was obtained with proximalfirst metatarsal wedge resection and modified McBride Procedure.

necrosis of the first metatarsal head. This simply rein-forces the need for meticulous dissection.

The osseous integrity is often compromised byprevious bunionectomy. Staking of the metatarsal headwithout true correction of the hallux valgus deformityis unfortunately a commonly seen complication. Manage-ment of this situation may require joint realignment withcapital fragment wedge resection such as a Reverdinosteotomy. However, in some cases exostectomy mayhave been too extensive to allow joint realignment. lnsuch instances, metatarsal head resection with orwithoutimplant arthroplasty may be required. Allogenicosteochondral grafting had been suggested but not yetproven as useful in this situation (personal communica-tion, E. Dalton McClamry, D.P.M., 19BB).

CONCTUSION

A discussion of recurrent hallux valgus deformity hasbeen presented. A classification of the types of recurrenthallux valgus has been suggested as a tool for determin-ing the etiology and possible techniques for revision.Since prevention is usually the best medicine, anunderstanding of the etiology of the recurrence is sug-gested as crucial in preventing similar surgical failures.

C. Profound recurrence of deformity is seen secondary to continuedinfluence of spastic muscle pull. Hindsight suggests arthrodesis at firstmetatarsocuneiform joint may have been more appropriate.

Fig. 6. Delamination and release of adhesions will often be necessaryin revisional hallux valgus surgery. McCIamry metatarsal elevator is

shown releasing fibrous adhesions about sesamoid apparatus whichwere causing limitation and motion.

It is the objective of this chapter to aid the foot surgeonin anticipating possible pitfalls with various proceduresand to avoid their occurrence. Prevention is still the besttreatment for complications of any type.

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References

1. Meier P, Kenzora J: The risks and benefits of distal firstmetatarsal osteotomies. Foot Ankle 6:7-17, 1985.

2. Das De S, Hamblen D: Distal metatarsal ostetomy forhallux valgus in the middle-aged patient. Clin Orthop218:239-246, 1987.

3. Hattrup S, Johnson K: Chevron osteotomy: analysis offactors in patient's dissatisfaction. Foot Ankle5:327-332,1985.

4. Duke H, Newman L, Bruskoff B, Daniels R: Hallux ab-ductus interphalangeus and its relationship to halluxabducto valgus. J Am Podiatry Assoc 72:5s625-628,

1982.5. Ruch J, Banks A, Weeber K: Surgical procedures of the

hallux in hallux abducto valgus. In McGlamry ED (ed):

Comprehensive Textbook of Foot Surgery, vol 1.

Baltimore, Williams & Wilkins, 1987, pp 185-194-

6. Ruch J, Banks A: Proximal osteotomies of the firstmetatarsal in the correction of hallux abducto valgus.

In McGlamry ED (ed): Comprehensive Textbook ofFoot Surgery, vol 1. Baltimore, Williams & Wilkins,1987, pp 195-211.

7. Coldberg l, Bahar A, Yosipovitch Z: Late results aftercorrection of hallux valgus deformity by basilarphalangeal osteotomy. J Bone Joint Surg 69A:6L67,1987.

B. A methcd of predicting the degree of functional cor-rection of the metatarsus primus varus with a distallateral displacement osteotomy in hallux valgus. FootAnkle 5:322-326,1985.

9. Root M, Orien W, Weed J: Forefoot deformity causef,by abnormal subtalar joint pronation. /n Normal andAbnormal Function of the Foot, ClinicalBiomechanics, vol 2. Los Angeles, ClinicalBiomechanics Corp, 1977, pp 349-462.

10. Rochelle J, Bowen J, Ray S: Pediatric foot deformitiesin progressive neuromuscular disease. ContempOrthop 8:41-50,1984.

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