isolated background of foot deformity called bunion deformity or hallux valgus

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HALLUS VALGUS

WHAT IS HALLUX VALGUS?

Hallux valgus is a complex deformity of the entire forefoot. Strictly speaking, the term “hallux valgus” merely refers to a deviation of the big toe (hallux) in the metatarsophalangeal joint outwards, i.e. into the valgus position. However, in addition to this deformity, there is usually also a widening of the forefoot and often also a deformity of the little toes.

HOW COMMON IS HALLUX VALGUS?

Hallux valgus affects around 2 to 4% of the total population, making it the most common clinically relevant forefoot deformity. Women are around nine times more likely to suffer from hallux valgus deformity than men. The deformity probably occurs on both sides in >80% of cases, although often to varying degrees.

WHAT IS THE CAUSE OF A HALLUX VALGUS DEFORMITY?

The commonly held idea that hallux valgus deformity is typically caused by excessive use of high-heeled shoes (high heels) is outdated. High, tight shoes can certainly favour the development of hallux valgus, but only an absolute minority of patients who regularly wear high-heeled shoes are seen in the consultation. From today’s perspective, “idiopathic” hallux valgus (without a clearly identifiable cause) is multifactorial, i.e. numerous causes, some of which are unknown, play a role. In most cases, a certain muscular imbalance, bony structural changes or functional instabilities can be identified as triggers or at least favouring factors. A positive family history can usually be established, whereby experience has shown that individual generations can be skipped over.

In rare cases, a direct cause such as trauma (amputation of neighbouring toes, fractures that have not healed properly), tumour disease or previous surgery can lead to hallux valgus.

HOW DOES THE MALPOSITION DEVELOP?

The disease begins with a slight malrotation of the big toe. This can be recognised simply by observing that the toenail points slightly more inwards. Increasing decentration of the extensor and flexor tendons exacerbates the malposition of the big toe as the disease progresses. A supposedly simple outward deviation of the big toe often develops into a complex deformity of the entire forefoot:

– Deviation of the 1st ray inwards, i.e. the forefoot becomes wider and an increasing splayfoot develops. In most cases, a painful bunion (pseudoexostosis) now also develops over the metatarsophalangeal joint of the big toe

– Displacement of the small ankles, the so-called sesamoid bones, outwards as an expression of the decentration of the small flexor tendons

– Possible instability of the 1st ray

– metatarsalgia due to overuse and increasing small toe deformities such as hammer and claw toes

WHAT SYMPTOMS DOES HALLUX VALGUS CAUSE?

Initially, those affected often complain of unpleasant aesthetics or shoe problems due to mechanically induced irritation over the prominent metatarsophalangeal joint with redness and tenderness. As the condition progresses, the forefoot area becomes wider, the neighbouring toes are increasingly displaced and the metatarsophalangeal joint degenerates prematurely due to malalignment. This leads to increasing pain and restricted movement. At an advanced stage, the big toe can overgrow or undergrow the neighbouring toes (hallux valgus superductus/subductus) and further small toe deformities develop.

HOW IS HALLUX VALGUS DIAGNOSED?

During the inspection, excessive discolouration of the foot allows conclusions to be drawn about incorrect and excessive strain. Typical hallux valgus symptoms such as a prominent metatarsophalangeal joint, widening of the forefoot, redness and tenderness can be seen.

Following a medical history and inspection, the functional examination should pay particular attention to possible instability of the metatarsophalangeal joint and shortening of the calf muscles. The mobility and backward displacement of the metatarsophalangeal joint should be checked. Examination of the healthy and unaffected opposite side (if there is no hallux valgus) can provide a helpful comparison for all tests.

IS AN X-RAY REQUIRED FOR FURTHER ASSESSMENT?

An X-ray must be taken specifically before a planned operation. The diagnostic imaging generally consists of images of the affected foot in a standing position, both from above and strictly from the side. Oblique images (fracture images) are not required for the assessment and surgical planning of hallux valgus, in fact they are unnecessary. There are also some special images depending on the problem.

HOW CAN HALLUX VALGUS BE TREATED WITHOUT SURGERY?

Hallux valgus surgery for purely aesthetic reasons should be viewed with caution and should not be performed, as the risk of problems after surgery can never be ruled out.

Non-surgical therapy can slow down or ideally even stop the progression of a mild deformity, although there is still no high-quality scientific evidence to date. Although special forms of manual therapy (e.g. spiral dynamics) offer interesting approaches, they have not yet been able to provide scientific proof that they can correct a hallux valgus deformity.

Conservative therapy involves the use of orthopaedic aids (e.g. hallux splints, toe spreaders, insoles), stretching and strengthening exercises in the foot and calf area and the use of suitable footwear. Sometimes it is easier and more sensible to adapt the shoe to the foot than vice versa. Not every symptomatic hallux valgus deformity needs to be operated on immediately!

WHAT METHODS ARE THERE TO OPERATE ON HALLUX VALGUS?

Despite a variety of non-surgical treatment options, surgery is the only way to permanently straighten the toe. Many different surgical methods (>100) for hallux surgery are known, although most techniques are very similar.

The surgical procedures are generally divided into soft tissue and bony procedures, as well as joint-preserving and joint-resecting/joint-stiffening procedures. In the case of hallux valgus, a combination of soft tissue procedures at the level of the metatarsophalangeal joint and bony correction is generally always necessary in order to achieve sufficient correction of the deformity and minimise the recurrence rate.

The extent of the soft tissue intervention depends on the existing conditions and the surgeon’s experience.

The bony interventions depend largely on the location and extent of the deformity. Common joint-preserving procedures (corrective osteotomies) are

– Akin osteotomy: correction by removing a bone wedge and rotating the toe
– Chevron (Austin) osteotomy: correction via a V-shaped bone incision
– Scarf osteotomy: correction via a Z-shaped bone incision
– Metatarsal 1 base osteotomy: correction by removing a bone wedge or spreading the bone
– Lapidus arthrodesis: stabilisation of the first joint between the midfoot and forefoot
– Minimally invasive correction has become a very popular procedure. In this case, a correction is only achieved via very small incisions in the skin.

WHAT IS THE FOLLOW-UP TREATMENT AFTER HALLUX SURGERY?

Aftercare depends mainly on the type of operation, the material used and the bone quality.

In general, full weight bearing is possible for approx. 6 weeks if a special bandage shoe is used. The bandage shoe only allows the operated foot to sit up, but not to roll.

In order to maintain the corrective result achieved in the long term and prevent a recurrence, special bandaging must be applied for a further 4 weeks after the wound has healed (takes approx. 2 weeks; crutches should also be used during this time). It is then advisable to wear a splint at night for a further 6 weeks. Driving is usually possible again after 6 weeks and a normal shoe can then be worn. Sporting activities such as jogging are possible again after 3 months.

YOUR SPECIALIST FOR HALLUX VALGUS AND OTHER COMPLAINTS

“Numerous deformities and wear and tear disorders of the foot and ankle can also be treated excellently using minimally invasive techniques.”

ADVICE AND CONTACT FOR QUESTIONS ABOUT HALLUX VALGUS

Do you have questions about treatment and therapy for hallux valgus complaints? Our foot specialist Prof. Dr Norbert Harrasser* will be happy to provide you with detailed information and advice in a personal consultation. Simply make an appointment. We look forward to hearing from you.