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CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 396,

pp. 179–183 © 2002 Lippincott
Williams & Wilkins, Inc.
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Adult Hallux Valgus With Metatarsus

Adductus: A Case Report
Ryuzo Okuda, MD; Mitsuo Kinoshita, MD; Junichi Morikawa, MD;
Tsuyoshi Jotoku, MD; and Muneaki Abe, MD

It is difficult to surgically treat a hallux valgus deformity
with significant metatarsus adductus, because the space
between the first and second metatarsals is too narrow to
correct the metatarsals.
tarsus primus varus with a first metatarsal os-teotomy. A
55-year-old woman had severe hal-lux valgus with
significant adduction of the second and third metatarsals.
A distal soft tissue
procedure and a proximal crescent-shaped os-teotomy
of the first metatarsal combined with corrective
osteotomies of the second and third
metatarsals were done. The patient's symptoms
disappeared, and hallux valgus and adduction of the
second and third metatarsals were cor-
rected. To the authors' knowledge, there is no previous
description of surgical treatment in-cluding correction of
metatarsus adductus and hallux valgus for adult hallux
valgus with metatarsus adductus.
duction deformities of the lesser metatarsals on a
radiograph taken with the patient weight-bearing. An
adduction deformity of the second metatarsal associated
with a hallux valgus de-formity does not provide
adequate space be-tween the first and second
metatarsals because of medial deviation of the second
metatarsal and the first metatarsal.2,3,5,15 Therefore,
an os-teotomy of the first metatarsal only may lead to
incomplete correction of the metatarsus primus varus in
a hallux valgus deformity with significant adduction of
the second metatarsal.
A case of a patient with severe hallux val-gus
deformity with significant adduction of the second and
third metatarsals is reported. A distal soft tissue
procedure combined with a proximal osteotomy of the
first metatarsal and corrective osteotomies of the second
and third metatarsals were done.

In surgical treatment of a hallux valgus deformity with

metatarsus adductus, it is important to assess not only
the hallux valgus deformity but also the metatarsus
primus varus and adductus.
From the Department of Orthopedic Surgery, Osaka
Medical College, Osaka, Japan.
Reprint requests to Ryuzo Okuda, MD, Department of
Orthopedic Surgery, Osaka Medical College, 2–7
Daigaku-machi, Takatsuki-shi 569-8686, Osaka, Japan.
Received: December 29, 2000.
Revised: May 29, 2001; June 18, 2001.
Accepted: July 17, 2001.
CASE REPORT
A 55-year-old woman was seen because of a 3-year history of
progressively worsening pain at the right first metatarsophalangeal
joint, which interfered with activities of daily living, and painful
plantar callosi-ties at the second and third metatarsal heads.
The medical history of this patient was unremarkable.
This patient had no particular custom or style of footwear at a
younger age. There were no family members with hallux valgus
or metatarsus adductus.
Physical examination of the right foot revealed severe
hallux valgus deformity, valgus deformity

179
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Clinical Orthopedics
180 Okuda et al and Related Research

of the second and third toes, and plantar keratosis formity of the second and third metatarsals (Fig
at the second and third metatarsal heads. The ex- 1A). The axial radiograph of the right foot taken
tension and flexion of the first metatarsophalangeal with the patient weightbearing revealed lateral dis-
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joint were 90 and 50 , respectively. location of the sesamoids (Fig 1B). The hallux val-
The dorsoplantar radiograph of the right foot gus angle, the first and second intermetatarsal an-
taken with the patient weightbearing revealed a se- gle (the angle between the long axes of the first and
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vere hallux valgus deformity, a valgus deformity of second metatarsals), and the metatarsus primus
the second and third toes, and severe adduction of- varus angle 6 (the angle between the long axes of the

Fig 1A–C. (A) A dorsoplantar radiograph obtained

before surgery with the patient weightbearing
shows severe hallux valgus and metatarsus
adductus. (B) An axial radiograph obtained before
surgery with the patient weightbearing shows
lateral dislocation of the sesamoids. (C) A drawing
of the dorsoplantar radiograph obtained before
surgery with the patient weightbearing shows the
measurements: a hallux valgus angle; b first
and second intermetatarsal angle; c metatar-
AB
sus primus varus angle; d second metatarsal
angle; and e metatarsus adductus angle.
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Number 396
March, 2002
medial cuneiform and the first metatarsal) were
62, 14, and 35, respectively (Fig 1C). Metatarsus
adductus was assessed by measurements of the sec-
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ond metatarsal angle13 and the metatarsus adductus
angle4.8 (Fig 1C). The second metatarsal angle was
68 (a normal mean value, 96 13), indicating meta-
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tarsus adductus. The metatarsus adductus angle
was 37 (a normal mean value, 134) indicating
metatarsus adductus. The longitudinal axis of the
metatarsal was defined as a line connecting the cen-ter of
the articular surface of the metatarsal head
with the center of the proximal joint.
A distal soft tissue procedure combined with a
proximal crescent-shaped osteotomy of the first
metatarsal was reported previously.11 That procedure
was similar to the procedure of Mann et al,10
and the corrective osteotomies of the second and
third metatarsals were done in October 1997. The
release of the distal soft tissues, excision of the
medial eminence, and proximal crescent-shaped
osteotomy of the first metatarsal were done. Next, to
3-cm dorsal longitudinal incision was made be-tween the
base of the second and third metatarsals.
Proximal oblique osteotomies of the second and
third metatarsals were done at an angle of approxi-
mately 60 to the long axis of the metatarsal using
an oscillating saw (Fig 2A). After completion of the
osteotomies, the distal fragment of the second
metatarsal was rotated laterally so that the second
metatarsal angle13 became nearly the normal mean
value and was fixed with a bone screw (Fig 2B).
The distal fragment of the third metatarsal was rotated
laterally so that the long axis of the distal fragment of
the third metatarsal was parallel to that of
Fig 2A–B. (A) A drawing of the lateral
aspect of the metatarsal shows
a proximal oblique osteotomy of the
second and third metatarsals. An
oblique osteotomy at the proximal
metatarsal is done at an angle ap-
proximately 60 to the longitudinal
axis of the metatarsal. (B) A draw-ing of
the dorsoplantar aspect of the
metatarsal shows the correction of
the adduction of the metatarsal after an
oblique osteotomy. The dis-tal fragment of
the second meta-tarsal was rotated laterally. TO
Hallux Valgus With Metatarsus Adductus 181
the distal fragment of the second metatarsal and
It was fixed with a bone screw. Then, the metatarsus
primus varus deformity was corrected, and the medial
part of the capsule of the first metatarsopha-langeal
joint was plicated.
A short-leg cast was worn for 3 weeks. A short-
leg plaster shell was worn for 2 weeks. Range of
motion exercises were started 4 weeks after surgery.
Nonweightbearing walking was done for 5 weeks.
Full weightbearing walking was allowed 9 weeks
after surgery, and the patient was instructed to wear
ready-made shoes with an arch support.
Thirty-four months after surgery, the patient had
no pain at the first metatarsophalangeal joint, and
plantar callosities at the second and third metatarsal
heads were asymptomatic and diminished. The ex-
tension and flexion of the first metatarsophalangeal
joints were 75 and 5, respectively. The hallux
metatarsophalangeal-interphalangeal score according
to the system of the American Orthopedic
Foot and Ankle Society7 was 44 points before
surgery and 100 points after surgery. The patient
was satisfied with the result of this procedure.
A radiograph obtained 34 months after surgery
revealed that the valgus deformities of the great, sec-
ond, and third toes and the adduction of the second
and third metatarsals were corrected (Fig 3A). Os-
theophytes on the lateral margin of the first metatar-
socuneiform joint and cortical thickening at the lat-
eral side of the proximal third of the first metatarsal,
neither of which were shown preoperatively, were
seen (Fig 3A). These findings did not change be-
tween 2 years after surgery and the latest followup.
The hallux valgus angle, the first and second inter-
b
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182 Okuda et al
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TO
metatarsal angle, the second metatarsal angle, and the
metatarsus adductus angle measured 12 87 and 20 , ,
,
respectively. The axial radiograph showed the sesamoids in
normal position (Fig 3B).
DISCUSSION
There are few reports on the relationship be-tween
hallux valgus and metatarsus adductus in adults.8,13 La
Reaux and Lee 8 reported that the incidence of
metatarsus adductus in the group of patients with adult
hallux valgus was significantly larger than that in the
group of patients without hallux valgus and suggested
that metatarsus adductus contributes to the formation of
hallux valgus. However, Scott et al13 reported that there
was no significant difference in the second metatarsal
angle be-
Clinical Orthopedics
and Related Research
Fig 3A–B. (A) A dorsoplantar radiograph obtained 34 months
after surgery with the patient weightbearing shows the
correction of valgus de-formities of the great, second, and
third toes and adduction deformities of the second and third
metatarsals. Osteophytes on the lateral margin of the first
metatarsocuneiform joint (arrowhead) and cortical thickening
at the lateral side of the proxi-mal third of the first metatarsal
(arrows) were seen. (B) An axial radiograph obtained 34
months after surgery with the patient weightbearing shows
the normal position of the sesamoids.
tween the group of patients with adult hallux valgus and
4 , the control group and stated that no evidence was found
to support any concept of second metatarsal deviation
from normal.
Therefore, the relationship between hallux valgus and
metatarsus adductus in adults is controversial. When
surgery was done for adult hallux valgus associated with
metatarsus adductus, an underlying metatarsus adductus
generally was not recognized or evaluated.12 The first
and second intermetatarsal angle in hallux valgus
generally increases because of metatarsus primus
varus.1,13,14 However, this angle in hallux valgus with
metatarsus adduc-tus increases little because of the
medial incli-nation of the second metatarsal.2,5,15 In
this study, the preoperative hallux valgus angle and the
metatarsus primus varus angle were in-
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Number 396
March, 2002
creased considerably, but the first and second
intermetatarsal angle was not large.
Consequently, an osteotomy of the first metatarsal
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alone may lead to incomplete correction of the
metatarsus primus deformity even if the first
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and second intermetatarsal angle was properly
corrected. Therefore, it is difficult to surgically
treat a hallux valgus deformity associated with
significant metatarsus adductus.2,5,15 Corrective
osteotomies for adduction deformities of
the lesser metatarsals are required to correct
the metatarsus primus varus deformity in hal-
lux valgus associated with metatarsus adduc-
tus. The current authors think that the primary
deformity of the foot in this patient is not hal-
lux valgus but rather the metatarsus primus
varus and metatarsus adductus.
In valgus deformities of the second and
third toes, the extensor digitorum longus and
flexor digitorum longus tendons displace
laterally and increase valgus force. In the current
patient, valgus deformities of the second and
Third toes were corrected without surgical intervention
of the second and third metatar-sophalangeal joints.
Therefore, the correction
of adduction deformities of the second and
third metatarsals might reduce or eradicate the
deforming force of the extensor and flexor on
the second and third toes.
The dorsoplantar radiograph at the latest fol-
lowup showed osteophytes at the first metatar-
socuneiform joint and cortical thickening at the
lateral side of the proximal third of the first
metatarsal, which were not seen preoperatively.
These findings suggested that the mechanical
stress, especially compression stress, on the
lat-eral side of the first metatarsocuneiform joint
increased after surgery. Symptomatic osteo-
arthritis may develop in the first metatarso-
cuneiform joint. Although the patient had no
symptoms at the latest followup, additional fol-
lowup is necessary to assess the long-term ef-
fects on the first metatarsocuneiform joint.
Mahan and Jacko9 reported on a 9-year-old
girl with hallux valgus with metatarsus adduc-
tus in which closing wedge abductory os-
teotomies of metatarsals one through five and
modified McBride bunionectomy were done.
Hallux Valgus With Metatarsus Adductus 183
However, an adult hallux valgus deformity as-associated
with severe adduction deformities of
the second and third metatarsals in which a dis-tal soft
tissue procedure combined with a prox-imal osteotomy
of the first metatarsal and corrective osteotomies of
the second and third
metatarsals were done has not been reported.
The surgical procedure reported in this study is
effective for treatment of severe hallux valgus
deformity associated with severe adduction de-formities
of the second and third metatarsals.
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