Journal of Clinical Orthopaedics and Trauma 30 (2022) 101898

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Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

The Linear Hallux Valgus Offsete A novel way to measure Hallux

Valgus
A. Saad a, Karthikeyan P. Iyengar c, John Fitzpatrick b, C. Azzopardi b, H. Panchal d,
R. Botchu b, *
a
Department of Orthopaedics, Royal Orthopaedic Hospital, Birmingham, UK
b
Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
c
Southport and Ormskirk NHS Trust, Southport, UK
d
Sanyapixel Diagnostics, Ahmedabad, India

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Hallux Valgus (HV) is a complex deformity involving the first ray of the forefoot and a
Received 5 February 2022 common cause of forefoot pain. Several radiological measurements such as Hallux Valgus Angle (HVA),
Received in revised form First Metatarsophalangeal Angle (IMA) and Distal metatarsal articular angle (DMAA) exist to calculate the
29 April 2022
severity of HV and direct patient management. However, these are angular measurements are prone to
Accepted 11 May 2022
error with variable intra- and inter-observer reliability.
Available online 18 May 2022
Purpose: To describe a new radiological linear hallux valgus offset (LHVO) to measure HV deformity.
Patient and methods: We performed a retrospective cohort study looking at Antero-posterior, weight-
Keywords:
Hallux valgus
bearing foot radiographs of 100 consecutive patients with forefoot pain referred to our foot and ankle
Bunion clinic. Demographic details, clinical indication, HVA (hallux valgus angle) and LHVO were measured for
Radiography each patient and data were analyzed using the student t-test. Intraclass Correlation Coefficient (ICC)
Hallux valgus angle analysis was evaluated to assess the intra-class reliability between observers.
Intermetatarsal angle Results: There was a female predominance of approximately 2:1, with 51.3 years (range 13e86 years).
Reliability There was a statistically significant difference of LHVO between normal and hallux valgus cohorts with a
p-value of 0.0001. The LHVO gave moderate intra-observer and inter-observer reliability on ICC analysis
of 0.7.
Conclusion: The LHVO can be an additional measure of assessing severity of hallux valgus. In contrary to
the traditional angular measurements, this linear measure is easier to calculate and reproducible on
plain, weight bearing radiographs. LHVO measurement has shown a moderate inter-observer reliability
in the study to complement traditional radiological evaluation of hallux valgus alignment.
© 2022 Delhi Orthopedic Association. All rights reserved.

1. Introduction complaints and is commonly associated with flatfoot or hypermo-

Hallux Valgus (HV), either adult or adolescent, is a common,
complex deformity of the first ray of the forefoot.1 It is described by
medial angulation of the first metatarsal and the lateral deviation of
the proximal phalanx at the level of the first metatarsophalangeal
(MTP) joint.2,3 Adolescent or Juvenile HV is often bilateral, and
patients may present with significant angular deformities involving
the first ray at the articular level. This primarily leads to cosmetic
* Corresponding author. Royal Orthopaedic Hospital, Bristol Road South North-
field, Birmingham, UK.
E-mail address: drbrajesh@yahoo.com (R. Botchu).
bility features.4,5 Contrary to Adult HV, which is often insidious,
developing over a prolonged period of time, typically affecting
middle-aged and older women, and attributed to wearing
constrictive footwear.6
HV deformity, commonly referred to as a bunion, is a recognized
cause of forefoot pain and can lead to foot malignment, inability to
wear appropriate footwear, loss of function and disability in
affected patients.7
The aetiology of HV is multifactorial. The intrinsic factors such as
pes planus, generalised joint laxity, hypermobility of the first ray
articulations, arthropathies and neuromuscular disorders and
extrinsic factors such as footwear, hereditary predisposition have
been associated with the development of HV.8 The pathophysiology

https://doi.org/10.1016/j.jcot.2022.101898
0976-5662/© 2022 Delhi Orthopedic Association. All rights reserved.
A. Saad, K.P. Iyengar, J. Fitzpatrick et al.
is complex. It stems from a disruption in the balance between the
extrinsic and intrinsic muscles of the foot. The stronger lateral
structures (adductor hallucis muscle, collateral ligaments and
peronei) eventually displace the first metatarsal medially and the
hallux (big toe) laterally, leading to medial capsule strain, rupture
and deformity.8
Diagnosis of HV is made based on history and clinical exami-
nation. However, radiological imaging is crucial in confirming the
diagnosis, assessing the deformity's severity, and analysing joint
congruity to guide treatment.9
Plain radiography tends to be the primary imaging modality to
assess HV. Various radiological angles on weight-bearing ante-
roposterior (AP), oblique, lateral and sesamoid axial views of the
foot allow measurement of HV deformity, assess articular changes
in sagittal or coronal planes and aid clinicians in planning patient
management.10 (Table 1). Traditionally used radiological measure-
ments such as Hallux Valgus Angle (HVA), First Meta-
tarsophalangeal Angle (IMA) and Distal metatarsal articular angle
(DMAA) all involve measurements of angles between the bones of
the first ray or adjacent foot articulations. These angular mea-
surements are quantitative measures of hallux valgus. Conse-
quently, comparative inter-observer and intra-observer reliability
of these radiographic measurements in the estimation of symp-
tomatic HV can be variable.11,12
This article highlights a novel linear measurement- The Linear
Hallux Valgus Offset (LHVO) to evaluate HV deformity. The LHVO
we feel is easier to calculate on conventional weight-bearing plain
foot AP radiographs and reproducible with good intra-observer
reliability in the radiographic assessment of HV deformity in
patients.
2. Patients and methods
2.1. Study design and inclusion criteria
Following hospital ethical committee approval, we performed a
retrospective evaluation of our Radiology Information System (RIS)
and Picture Archiving and Communication System (PACS) to iden-
tify 100 consecutive cases of patients referred to our foot and ankle
clinics over a 3month period with forefoot pain and first ray
deformity. Amongst them, there was a female predominance of
approximately 2:1, with 69 females and 31 male patients. The mean
age of our patients was 51.3 years (range 13e86 years). The imaging
protocol included weight bearing, antero-posterior and lateral view
plain radiographs of the foot, where the requesting clinician had
stated 'bunion' or 'hallux valgus' evaluation as the indication in the
clinical details section. Patients with a previous surgical history
Table 1
Traditionally used radiological indices to assess and measure Hallux Valgus on Plain X-ray Antero-posterior
Weightbearing view.
Name Calculation
1 Hallux Valgus Angle The angle is formed by a line drawn through the longitudinal axis of the first metatarsal with that Less
(HVA) that of a line drawn through the longitudinal axis of the first proximal phalanx.
2 First The angle is formed by a line drawn through the longitudinal axis of the first metatarsal with that
Metatarsophalangeal that of a line drawn through the longitudinal axis of the SECOND metatarsal
Angle (IMA)
3 Distal metatarsal DMMA is formed between first metatarsal axis and line through base of distal articular surface
articular angle (DMAA)
AbbreviationsX-ray ¼ Radiographs; AP ¼ Antero-posterior; MTP ¼ Metatarsophalangeal joint.
2
Journal of Clinical Orthopaedics and Trauma 30 (2022) 101898
involving the HV, forefoot or midfoot region with or without
metalwork were excluded from our cohort group.
2.2. Image analysis
The radiographs were reviewed by the senior author (RB), a
fellowship-trained musculoskeletal radiologist with more than 10
years’ experience, another fellowship-trained musculoskeletal
radiologist, and a musculoskeletal Radiology fellow for analysis. In
addition, RB repeated the measurements after a week to assess
intra-observer reliability. Finally, the radiographs were evaluated
for features of alignment abnormalities, degenerative changes and
the 'Hallux Valgus Angle (HVA) was calculated using standard
technique.9,10
3. Calculation of the Hallux Valgus Angle (HVA)
The 'Hallux Valgus Angle (HVA) is calculated by determining the
angle between two lines - a line along the first metatarsal long axis
and a line parallel to the longitudinal axis of the first proximal
phalanx of the hallux.13 A normal angle is interpreted as
15 ,
whereas a greater value indicates the presence of a hallux valgus.14
3.1. Calculation of the Linear Hallux valgus Offset (LHVO)
The LHVO is calculated on an AP weight-bearing plain radio-
graph of the foot. The calculation method involves drawing a
straight vertical line from the tip of the distal phalanx down to the
lateral edge of the base of the first metatarsal (LINE A). A second 90
horizontal line is drawn from line A to the lateral border of the
metatarsophalangeal joint of the first Metatarsal (LINE B). The
distance between lines A and B is measured and corresponds to
LHVO. (Fig. 1).
3.2. Calculation of the Linear Hallux valgus Offset (LHVO) index
To explore the clinical significance of LHVO further, we
measured the first ray metatarsal head width and correlated it with
LHVO to produce a LHVO Index.
The first ray metatarsal head width was measured at the
broadest part (Fig. 2) The corresponding LHVO was divided by this
measure C (Metatarsal head width) to derive the LHVO Index. LHVO
index measurement would guide whether a distal metatarsal
osteotomy such as Chevron or Scarf osteotomy would adequately
correct the HV deformity, or a proximal based osteotomy would be
needed.
Normal Hallux Valgus severity/ References
Value Significance Cited
Identifies first MTP 9, 10
than deformity
15 Anything greater than
15  indicates hallux
valgus
Severity Classification
Less
than 9
Less Signifies first MTP
than Incongruity
10
A. Saad, K.P. Iyengar, J. Fitzpatrick et al.
Fig. 1. Schematic showing calculation of Linear Hallux Valgus Offset: Weight-bearing
anteroposterior x-ray showing line A(formed by joining the middle of the tip of
distal phalanx of the great toe and lateral part of the base of the first metatarsal) and
line B (distance between the lateral part of the 1st MTPJ and line A).
4. Methodology
4.1. Data collection
Our data included patient demographics details, clinical indi-
cation for imaging, the standard radiological measurement of the
HVI and an LHVO measurement calculated for every patient within
our cohort. Data was recorded on a Microsoft Excel data spread-
sheet and using SPSS 24.0 software (SPSS Inc. Chicago, Illinois, USA).
The data was analysed using the student's t-test, and an Intraclass
Correlation Coefficient (ICC) analysis to assess the reliability. The
ICC usually falls between 0 and 1. The reliability value is as follow:
below 0.5 indicate poor, between 0.5 and 0.75 moderate, between
0.75 and 0.9 good, and above 0.9 indicate excellent reliability.15
5. Results
Amongst 100 consecutive cases in our cohort, there was a fe-
male predominance of approximately 2:1, with 69 females and 31
male patients. The mean age of our patients was 51.3 years (range
13e86 years) (Table 2).The LHVO measurement was calculated for
all the cases and described in Table 3. There was a statistically
significant difference of LHVO between normal and hallux valgus
cohorts with a p-value of 0.0001. There was moderate intra and
interobserver reliability with an ICC of 0.7, suggesting moderate
3
Journal of Clinical Orthopaedics and Trauma 30 (2022) 101898
Fig. 2. Schematic showing calculation of LHVO Index: line A(formed by joining the
middle of the tip of distal phalanx of big toe and lateral part of the base of the first
metatarsal) and line B (LHVO- distance between the lateral part of the 1st MTPJ and
line A). Width of metatarsal head is line C. LHVO index is calculated as B/C.
MT- Metatarsal, PP- proximal phalanx, DP- distal phalanx.
reliability. The LHVO was proportionately increased with an in-
crease in the degree of hallux valgus (0.7 for mild hallux valgus, 1
for moderate and 1.6 for severe hallux valgus).
Linear Hallux valgus Offset (LHVO) Index calculation is depicted
in Table 4.Table 4.
6. Discussion
Radiographic parameters have played a critical role in assessing
the severity and guiding clinicians in the surgical management of
HV. Commonly used methods are based on angular measurements
and include; the hallux valgus angle (HVA), Intermetatarsal angle
(IMA) and distal metatarsal articular angle (DMAA).16
These are often measured by direct visual estimation based on
weight-bearing foot plain radiographs.17e19 The accuracy of these
measurements for clinical and research purposes is debatable in the
literature. As a result, many attempts have been instigated to
improve the reliability of these angles. Nonetheless, these mea-
surements must be reliable and reproducible.11,12,18,19
The HVA is the traditionally used measurement obtained by
joining a line between the midline axis of the proximal phalanx and
first metatarsal. An angle of <15 is thought to be within normal
limits, whilst an angle of >40 represents a severe deformity.20
Although many studies have shown a high test-retest reliability
of the HVA,11,12,19,21 it lacks a standardised approach for measuring
A. Saad, K.P. Iyengar, J. Fitzpatrick et al. Journal of Clinical Orthopaedics and Trauma 30 (2022) 101898

Table 2
The ‘Linear Hallux Valgus Offset’ (LHVO) linear measurements in the study group of 100 patients (n ¼ 100).

HVA in patients Number of patients ¼ n Average LHVO Maximum LHVO Minimum LHVO

Normal 39 0.6 cm 0.9 cm 0 cm

Hallux Valgus patients 61 0.9 cm 2.1 cm 0.4 cm
Total 100

Abbreviations: Hallux Valgus Angle ¼ HVA; Linear Hallux Valgus Index ¼ LHVI.

Table 3 our simple technique may be used in the future research and
Descriptive statistics of the normal and hallux valgus cohorts. clinical settings. We suggest that the overall improvement in the
normal hallux valgus reliability of the measurements of the HV are best achieved by
Number of cases 39 61
adopting a standardised technique, evaluating the measurements
Average age (years) 48.49 52.76 as a minimum of two calculations and estimating the results.
Maximum age(years) 79 86
Minimum age(years) 13 24 6.1. Limitations of the study
Male 15 18
Female 24 43
Mean (cm) 0.6 0.95 Our study has certain limitations. This is a retrospective study
Standard deviation (cm) 1.24 0.34 with a small sample size subject to confounding factors. There was
Standard error of mean 0.2 0.04 lack of appropriate length of follow-up. Moreover there was no
95% confidence interval 0.2e1.17 0.86e1.04
documented communication of the findings between the MSK ra-
Median (cm) 0.3 0.9
diologists and surgeons undertaking the procedure to consolidate
the findings. However, our LHVO had moderate reliability with an
ICC of 0.7, and this reinforces our confidence in this measurement.
Table 4
LHVO index calculation in normal and hallux valgus cohorts.
7. Conclusion
HVA in patients Average LHVI Minimum LHVI Maximum LHVI

Normal 0.42 0.3 0.58
Hallux Valgus patients 0.65 0.36 1.1
Abbreviations: Hallux Valgus Angle ¼ HVA; Linear Hallux Valgus Offset
Index ¼ LHVI.
these angles, with various methods mentioned in the literature.
Moreover, some clinicians, especially those in early specialty
training, are challenged by complexities in identifying the long axis
of the metatarsus, drawn between either the center of the proximal
or distal metaphyseal bone. Therefore, depending on the method
utilised, the outcomes may not be as reliable, and hence, confound
the approach to surgical management.18,19
The IMA is another commonly used measurement for HV. It is
calculated by angle between longitudinal axes of the first and
second metatarsal shaft on an axial weight-bearing view of the foot.
A normal value is under 9 .22,23 The IMA, like the HVA, can similarly
be affected by the measurement method and subjected to potential
risk in error. However, studies have shown no improvement in
reliability based on experience.24 Furthermore, the IMA can be
mistakenly increased due to metatarsal deviation during the pro-
gression of HV or due to metatarsal rotation, and therefore, deemed
only reliable in the late stages of disease progression.25,26
Linear measurements used to evaluate the HV are generally
easier than angular measurements.19 The LHVO is a novel, more
simplified method that can be utilised to assess the severity of HV,
with an ICC of moderate reliability. We also found that the pro-
portionate increase in the LHVO has allowed us to categorise HV
into mild, moderate, and severe objectively. Moreover, we feel that
the LHVO can be an additional method to measure the HV, aid with
surgical planning, and use other measurements to improve reli-
ability outcomes and simpler to calculate for junior trainees.
To consolidate the results of our study and evaluate the clinical
significance of the LHVO, we measured the first ray metatarsal head
width and correlated it with LHVO to produce a LHVO Index. A
LHVO Index less than 1 suggests that a distal metatarsal osteotomy
such as Chevron or Scarf osteotomy would adequately correct the
HV deformity and as such guide clinical management. We hope that
This study describes a novel linear measurement that can be
used to assess the severity of hallux valgus. Compared to the
traditional angular measurements of HV, the LHVO is easier to
calculate and has good inter-observer reliability to complement the
current radiological evaluation of HV. Further larger, multi-center
collaborative cohort studies will be helpful to reinforce our find-
ings and applicability of the LHVO in routine assessment of hallux
valgus deformity to guide management decisions.
Funding
No funding to declare.
Declaration of competing interest
No conflicts of interest.
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