HALLUX VALGUS

SARTIKA PRADHIPTA CAHYA

20204010030
HALLUX
VALGUS
Hallux valgus is a deformity at the
first MTP joint with abduction and
valgus rotation of the great toe
combined with a medially
prominent first metatarsal head.
PREVALENCE

23% in adults aged 18-65

35.7% in elderly people

aged over 65 years
Prevalence increased
with age and was higher
in females 30% males
13%
HALLUX VALGUS ANGLE
The angle created between the
lines that longitudinally bisect the
proximal phalanx and the first
metatarsal

< 15° → normal.

≥ 20° → abnormal.

45-50° → severe.
 ➢ 1st metatarsal inclines medially
PATOGENESIS ➢ Proximal phalynx deflects in opposite
direction
➢ Joint knuckles towards midline –
prominence of forefoot at the tbiial
border
➢ Great toe may ride over 2nd digit or slip
under it
Potential Intrinsic and
Extrinsic Factors
Intrinsic Extrinsic
Ligamentous laxity High-heeled narrow shoes
Metatarsus primus varus Genetics Excessive weight-
Pes planus bearing
Functional hallux limitus
Sexual dimorphism
Age
Metatarsal morphology
First-ray hypermobility
Tight Achilles tendon
 CLASSIFICATION OF HV
Piggott (1960) Based on congruity of 1st MP joint

1. The lines across the articular surfaces are still parallel and the joint is centred,
but the articular surfaces are set more obliquely to the long axes of their
respective bones

2. The lines are not parallel and the articular surfaces are not congruent

3. The surfaces are neither parallel nor centred

 • Foot evaluation in both a seated and standing
Clinical position.
Evaluation • Inspection for any skin changes or lesions, toenail
changes, and general position of the first ray
• Neurovascular examination is important to rule out
neurovascular insufficiency.
• Pain on the medial
aspect of the forefoot.
• Noticeable bump or prominence on the
medial aspect of the forefoot. Physical
• Difficulty with shoe wear due to medial
eminence Examination
• Compression of digital nerve may cause
symptoms
 X RAYS
New anatomical-based hallux valgus classification

Type 1 panels A and B involves

increased hallux valgus angle
(HVA) and intermetatarsal angle
(IMA), no metatarsal pronation,
and no sesamoid subluxation.
Type 2 involves the addition of
metatarsal pronation either
without sesamoid subluxation
as in panels C and D or with
sesamoid subluxation as in
panels E and F.
Type 3 incorporates metatarsus
adductus > 20 degrees as in
panels G and H.
Type 4 incorporates
degenerative changes at the
first metatarsophalangeal (MTP)
joint as in panels I and J.
 TREATMENT
Non Operative Management

SHOE MODIFICATION SPACERS ORTHOSES

 oFailure of non operative measures
oPersistent pain that interferes with daily work
oSevere deformity and pain unlikely to respond to conservative measures

TREATMENT
Operative Management

INDICATIONS

▪ Failure of non operative measures

▪ Persistent pain that interferes with daily work

▪ Severe deformity and pain unlikely to respond to conservative

measures
 Surgical Indications for Various Techniques
to treat Hallux Valgus
HVA IMA Modifier Procedure
< 25° <13° Distal osteotomy Chevron osteotomy. Biplanar if
Mild

DMAA > 10° usually with mod

McBride
26-40° 13-15° Proximal osteotomy +/- Chevron/mod McBride + Akin
Moderate

distal osteotomy osteotomy

Proximal MT osteotomy and
mod McBride
41-50° 16-20° Double -Proximal MT osteotomy +
osteotomy DMAA > biplanar chevron, mod McBride
15°
Severe

Lapidus procedure + Akin

Elderly/very low Keller
demand patient
Juvenile/Adolescent Double osteotomy of first ray
with DMAA > 20
 Procedure Technique Indications Complications

Modified Includes release of adductor from lateral 30-50 y/o female withHVA 15-25 -Recurrence
McBride sesamoid/proximal phalanx, lateral IMA <13 -Hallux varus
capsulotomy, medial capsular imbrication IPA < 15
Chevron Distal 1st MT osteotomy (intra-articular). Can reserved for mild to moderate -AVN of MT head
perform in two planes (Biplanar distal Chevron) deformities in adults and children, -recurrence
biplanar chevron-->correct increased -dorsal malunion with
DMAA transfer metatarsalgia
First Cuneiform Opening wedge osteotomy (often requires autograft) -children with ligamentous laxity, flatfoot, Nonunion (may or may not be
Osteotomy and hypermobile first ray symptomatic)
- adolescent with an open physis
 Procedure Technique Indications Complications

Mitchell Distal 1st MT osteotomy (extra-articular). same as Chevron. reserved for mild to moderate -recurrence
More proximal than Chevron) deformities, rarely utilized -malunion
-transfer
metatarsalgia
Akin proximal phalanx medial closing wedge -combined with Chevron in moderate to severe
osteotomy deformities
-hallux valgus interphalangeus
Scarf / Ludloff / Mau Metatarsal shaft osteotomies. -IMA 14-18° -dorsal malunion
-DMAA is normal or increased with transfer
metatarsalgia
-recurrence
 Procedure Technique Indications Complications
Proximal Proximal metatarsal Severe deformity -hallux varus
crescentric or osteotomies. (plus modified IMA > 20 -dorsal malunion with
Broomstick McBride) HVA > 50 transfer metatarsalgia
-recurrence
Keller resection Include medial eminence largely abandoned due to -cock-up toe deformity
arthroplasty removal and resection of base of complications. indicated only -poor potential for
proximal phalanx in older patients with reduced correction of deformity
functional demands
Lapidus first TMT joint arthrodesis with -moderate or severe Nonunion (may or may
procedure distal soft tissue procedures deformity not be symptomatic)
(medial eminence removal, first -hypermobility of first ray
dorsiflexion of the first
web space release of AdH, lateral
metatarsal with transfer
capsule release)
metatarsalgia
COMPLICATION
• Recurrent infection and
ulceration
• Transfer metatarsalgia
• Complex regional pain
syndrome
Reference
➢ Apley, G.A and Solomon, L. 2010. Apley’s System of Orthopaedics and Fractures.
9th ed. London: Hodder Arnold.
➢ Jason Mckean, Joseph Park. Hallux Valgus. [Updates 2020 November 9th]. In:
OrthoBullets. Lineage Medical Inc; 2020. Available from
https://www.orthobullets.com/foot-and-ankle/7008/hallux-valgus retrieved on
November 15 2020 at 08.30 p.m.
➢ A, Leah., Vitale, Mark., & Franko, Orrin. Distal Radius Fractures. [Updated 2020
October 22nd]. In: OrthoBullets. Lineage Medical Inc; 2020. Available from
https://www.orthobullets.com/trauma/1027/distal-radius-fractures retrieved on
November 11 2020 at 08.30 p.m.
➢ D'Arcangelo, P. R., Landorf, K. B., Munteanu, S. E., Zammit, G. V., & Menz, H. B.
(2010). Radiographic correlates of hallux valgus severity in older people. Journal
of foot and ankle research, 3, 20. https://doi.org/10.1186/1757-1146-3-20
➢ Justin J. Ray, MD1 , Andrew J. Friedmann, MD1 , Andrew E. Hanselman, MD1 ,
Justin Vaida, MD1 .(2019). Hallux Valgus. Foot & Ankle Orthopaedics.