119

Downloaded from www.ajronline.org by 89.45.207.202 on 07/01/21 from IP address 89.45.207.202. Copyright ARRS. For personal use only; all rights reserved

Pictorial Essay

H . . . . ... . . . . . -

Hallux Valgus Deformity: Preoperative Radiologic

Assessment
David Karasick1 and Keith L. Wapner

An estimated 40% of the American adult population expe- to better differentiate normal from abnormal measurements
riences foot problems, especially bunions with hallux valgus on radiographs. Hallux valgus deformity consists of lateral
and hammer toes. The noted predominance among females deviation of the proximal phalanx on the metatarsal head with
usually is attributed to a choice of footwear. Hallux valgus is accompanying medial deviation of the first metatarsal. As the
defined as static subluxation of the first metatarsophalangeal deformity progresses, the first metatarsal head slides medially
joint with lateral deviation great toe and medial deviation
ofthe off the sesamoids, which are anchored to the second meta-
of the first metatarsal. With more than 1 00 surgical proce- tarsal by the transverse metatarsal ligament. Enlargement of
dures developed for the repair of hallux valgus and the the medial bony eminence of the first metatarsal head and
increasingly sophisticated techniques available, a thorough attenuation of medial capsular tissues occurs. Bursal thick-
understanding of the radiologic criteria involved in the assess- ening or inflammatory bursitis overlying the first metatarsal
ment of these foot deformities is needed. head can accentuate this medial eminence. The pressure of
Proper technique consists of obtaining radiographs while the great toe against the second toe may lead to abnormal
the patient is standing erect and bearing weight on the foot. alignment, subluxation, or dislocation of the second metatar-
An anteroposterior or a dorsoplantar view is obtained with sophalangeal joint [1].
1 5#{176}
of cephalic angulation of the tube at exposure factors of Given these pathologic developments in hallux valgus, cer-
6 mAs and 50 kV. A lateral view is obtained without angulation tam measurements made on radiographs of the weight-bear-
of the tube at 9.5 mAs and 55 kV; this view enables proper ing foot are essential for proper surgical correction [2-4].
evaluation of pes planus, or flatfoot. An accompanying oblique These include the hallux interphalangeus angle, hallux valgus
radiograph is obtained without tube angulation; exposure angle, metatarsus primus varus angle, and first intermetatar-
factors are similar to those for the anteroposterior view. The sal angle (Fig. 1). The other important measurements are the
source-to-image distance is 40 in. (1 01 .6 cm). At our institu- tibial sesamoid position (Fig. 2) and the relative lengths of the
tion, DuPont Quanta detail screens (Du Pont, Clifton, NJ) are first and second metatarsals (Fig. 3). Additional criteria con-
used with Agfa Gevaert MR 4 film (Agfa-Gevaert Rex, Secau- cern congruency of the first metatarsophalangeal joint (Fig.
cus, NJ). 4), shape of the first metatarsal head (Fig. 5), orientation of
A thorough knowledge and understanding ofthe pathologic the first metatarsal-cuneiform joint (Fig. 6), existence of a
conditions present with hallux valgus deformity are essential lateral facet (Fig. 7), size of the medial eminence (Fig. 8),

Received January 23, 1990; accepted after revision February 27, 1990.
I Department of Radiology, Jefferson Medical College, Thomas Jefferson University Hospital, 1 1 1 5. 11th St., Ste. 3607, Philadelphia, PA 191 07. Address reprint
requests to D. Karasick.
2 Department of Orthopedic Surgery. Jefferson Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107.

AJR 155:119-123, July 1990 0361-803X/90/1 551 -01 19 © American Roentgen Ray Society
 120 KARASICK AND WAPNER AJR:155, July 1990

degree of degenerative joint disease (Fig. 9), degree of pro-

nation of the hallux (Fig. 10), subluxation or dislocation of the
lesser metatarsophalangeal joints (Fig. 10), and presence of
crossover second toe deformity (Fig. 1 1).
The radiologist’s role in the basic decision-making process
for selecting the corrective procedure for hallux valgus is
Downloaded from www.ajronline.org by 89.45.207.202 on 07/01/21 from IP address 89.45.207.202. Copyright ARRS. For personal use only; all rights reserved

important. The surgical treatment can be divided into seven

categories [1]: (1) Simple exostectomy is indicated for a large
medial eminence without significant valgus deformity. (2) Soft-
tissue repair is indicated for mild to moderate hallux valgus
less than 35#{176}with an intermetatarsal angle less than 1 5#{176}.
(3)
Proximal first metatarsal osteotomy (Mann crescentic osteot-
omy) is indicated for moderate to severe hallux valgus when
the first metatarsal cannot be reduced to the second meta-
tarsal (intermetatarsal angle greater than 1 5#{176}).(4) Distal first
metatarsal osteotomy (Mitchell procedure) is indicated for
moderate hallux valgus, when the first metatarsal is not
shorter than the second metatarsal. Metatarsalgia, especially
of the second metatarsal, may develop postoperatively if this
surgery is performed on a short first metatarsal. (5) Resection
arthroplasty (Keller proximal phalanx resection) is indicated in
older patients for whom extensive surgery is contraindicated
or in whom hallux rigidus is not amenable to treatment by
cheilectomy, arthrodesis, or Silastic implant. It also is mdi-
cated as a salvage procedure for failed bunion surgery. (6)
Proximal phalangeal osteotomy (Akin procedure) is indicated
for hallux valgus interphalangeus and for mild to moderate
hallux valgus with a congruent joint. (7) Metatarsophalangeal
joint arthrodesis is indicated for advanced degenerative or
Fig. 1.-Normal (N) angles in anteroposterior erect foot as measured
rheumatoid arthritis with hallux valgus deformity. It also is
on radiographs.
1, Hallux interphalangeus angle: angle between long axes of first prox- indicated with failed implant or as a salvage procedure for
imal phalanx and first distal phalanx (N < 8#{176}). recurrent hallux valgus.
2, Hallux valgus angle: angle between long axes of first proximal phalanx
and first metatarsal(N < 15#{176}).
Hallux valgus can be mild(16-25#{176}),moderate
In summary, hallux valgus deformity is not difficult to diag-
(26-35#{176}),
or severe (>35#{176}). nose, but it must be evaluated carefully on radiographs to
3, Metatarsus primus varus angle: angle between long axes of medial ensure use of the most efficacious surgical procedure for
cuneiform and first metatarsal (N < 25#{176}).
4, First intermetatarsal angle: angle between long axis of first and each patient.
second metatarsals (N < 10#{176}).

Fig. 2.-Tibial sesamoid position

(four-grade classification).
A, Grade 0: no displacementof ses-
arnold relative to reference line, which
bisects long axis of first metatarsal
shaft.
B, Grade 1: overlap of less than 50%
of sesamold to reference line.
C, Grade 2: overlap of greater than
50% of sesamold to reference line.
0, Grade 3: complete displacement
of tiblal sesamoid beyond reference
line laterally.
 AJR:155, July 1990 HALLUX VALGUS DEFORMITY 121

Fig. 3.-Relative lengths of first and

second metatarsals: bisecting vertical
line is drawn in second metatarsal bone
and connected to perpendicular hori-
zontal line drawn from second metatar-
sal head to first metatarsal head.
A, Short first metatarsal (minus rat-
ing): horizontal line extends distal (>2
Downloaded from www.ajronline.org by 89.45.207.202 on 07/01/21 from IP address 89.45.207.202. Copyright ARRS. For personal use only; all rights reserved

mm) to first metatarsal head.

B, Equal metatarsal lengths: hon-
zontal line intersects first metatarsal
head within 2 mm.
C, Long first metatarsal(plus rating):
horizontal line extends proximal (> 2
mm) to first metatarsal head.

Fig. 4.-Congruence of first meta-

tarsophalangealjoint: two straight lines
are drawn representing effective artic-
ulating surface of first metatarsal head
and effective articular cartilage at base
of first proximal phalanx.
A, Congruent joint: proximal and dis-
tal articulating surfaces are aligned
(parallel lines).
B, Deviated joint: distal articulating
surface is deviated lateral to proximal
articulating surface, leaving medial
border of proximal surface exposed
(lines converge outside joint).
C, Subluxed joint: base of proximal
phalanx is subluxed laterally with re-
spect to metatarsal head (lines inter-
sect within joint). An incongruous artic-
ulation appears to be at significant risk
for later metatarsophalangeal decom-
pensation.

Fig. 5.-Shape of first metatarsal

head.
A, Flat head: resists hallux valgus
deformity.
B, Round head: predisposes to hal-
lux valgus deformity.
C, Dome-shaped head with central
bulge: exhibits stability postopera-
tively.
 122 KARASICK AND WAPNER AJR:155, July 1990
Downloaded from www.ajronline.org by 89.45.207.202 on 07/01/21 from IP address 89.45.207.202. Copyright ARRS. For personal use only; all rights reserved

A B C
Fig. 6.-First metatarsal-cuneiform joint orientation. Fig. 7.-Lateral facet at base of first meta-
A, Flat or horizontal joint: resists increase in intermetatarsal angle. tarsal bone: its presence (arrowheads) can
B, Oblique joint less stable and prone to deformity. mechanically impair successful realignment
c, Round joint: enhances mobility of joint and medial deviation of metatarsal. unless an osteotomy of first metatarsal is
performed.

Fig. 8.-Large medial eminence:

size of this bony outgrowth on medial
aspect of first metatarsal head can
range from 1 to more than 5 mm in
width. Degree of hallux valgus does not
necessarily correlate with size of this
medial eminence.

Fig. 9.-Degenerative joint disease

at first metatarsophalangeal joint: de-
gree of joint-space narrowing, osteo-
phytic spurs, and rigidity can determine
surgical corrective procedure. Patients
with hallux valgus and significant de-
generativejoint disease may be treated
with arthrodesis.
 AJR:155, July 1990 HALLUX VALGUS DEFORMITY 123

Fig. 10.-Severe hallux valgus with

pronated hallux and dislocations of
second and third metatarsophalangeal
joints: with increasing hallux valgus,
lateral shift of lesser toes occurs as
well as pronation of great toe. This can
result in subluxation or dislocation of
adjacent metatarsophalangeal joints,
Downloaded from www.ajronline.org by 89.45.207.202 on 07/01/21 from IP address 89.45.207.202. Copyright ARRS. For personal use only; all rights reserved

especially the second.

Fig. I 1.-Crossover second toe do-

formity: with severe hallux valgus, sec-
ond toe can overlap great toe, resulting
in significant deformity.
10 11

REFERENCES deformity. J Am Podiatr Med Assoc 1974;64:544-566

3. Spinner SM, Lipsman 5, Spector F. Radiographic criteria in the assessment
1 . Mann RA, Coughlin MJ. Hallux valgus and complications of hallux valgus. of hallux abductus deformities. J Foot Surg 1984:23:25-30
In: Mann RA, ed. Surgery of the foot, 5th ed. St. Louis: Mosby, 1986: 4. Smith RW, Reynolds JC, Stewart MJ. Hallux valgus assessment: report
65-131 of research committee of American Orthopaedic Foot and Ankle Society.
2. LaPorta G, Melillo T, Olinsky D. X-ray evaluation of hallux abducto valgus Foot Ankle 1984:5:92-102