1. Hallux
Valgus
Dr. E. M. Regis Jr.
Orthopaedic Dept.
S.G.P.H
16/5/16

2. Overview
• History
• Definition
• Incidence
• Aetiology
• Anatomy
• Pathology
• Signs/ Symptoms
• Investigation
• Diagnosis
• Treatment
• Conclusion

3. History
• “Hallux Valgus" was define as static subluxation of
first Metatarsophalangeal Joint with lateral deviation
of great toe.
• This term was introduced by Carl Hueterto.
• The first surgical procedure to address the
deformity was described by Reverdin in May, 1881.

4. Definition
• deformity resembling abduction contracture in
which great toe turned away from mid-line of
body.
• commonly referred to as “Bunion”

5. Lateral deviation of Great Toe
Medial deviation of 1st
Metatarsal
Progressive subluxation of 1st
MTP joint

6. Incidence
• 1% adults in US
Gould et al studies
• increased incidence with age (3% 15-30 yrs, 9%
31-60 yrs & 16% >60yrs)
• F > M {2:1 - 4:1}

7. Aetiology
• Extrinsic Factors;
shoes with narrow toe/ high heels
occupational factors

8. • Intrinsic Factors;
Hereditary {60-90%}
Arthritic/metabolic
• Gouty arthritis, RA, Connective tissue
disorders {Marfan, Ehlers- Danlos, Down}
Neuromuscular Disease
• Cerebral Palsy, Multiple sclerosis

9. Traumatic Conditions
• malunions, Dislocations, Intra-articular
damage
Structural Deformities
• malalignment of articular surface,
abnormal metatarsal length

10. Anatomy
Groups Encircling 1st MTP joint
1. Extensor hallucis longus & brevis
2. Flexor hallucis longus & brevis
3. Abductor
4. Adductor

11. Pathology
• with a valgus deformity of >30 degrees, the great
toe rotates into pronation (nail face medially)
• the sesamoids bones of FHB are displaced
laterally
• also FHL & EHL tendons bowstring on the lateral
side adding to deformity forces
• the contracted adductor hallucis & lateral capsule
contribute further to the fixed deformity

13. Signs/Symptoms
• Asymptomatic
• Pain/ Tenderness
• Skin calluses/ areas of redness
• Increased/Decreased 1st MTP joint R.O.M
• Pronation of great toe

15. Investigation
• Radiographs
weight bearing AP, lateral & oblique views
Findings;
lateral displacement of sesamoids
joint congruency & degenerative changes

16. • Hallux Valgus Angle (HVA)
intersection of longitudinal axis of 1st MT and
proximal phalanx (normal <15)

17. • Intermetatrsal Angle (IMA)
Intersection of 1st & 2nd MT (Normal <9)

20. Classification
Piggott (1960) based on x ray appearance
1. MTP joint is centred but the articular surfaces
though congruent, are tilted towards valgus
2. articular surfaces are not congruent, the
phalangeal surface being tilted towards valgus
3. the joint is both incongruent and slightly
subluxated

22. • Labs
Uric acid
ESR
C-reactive protein
ANA
RF

23. Diagnosis
Root et al (pathomechanical devlopment of hallux valgus)
• Stage 1 - excessive pronation causes hypermobility of 1st ray,
causing the tibial sesamoid ligament to be stretched and the
fibular sesamoid ligament to contract; lateral subluxation of the
proximal phalanx occurs
• Stage 2 - hallux abduction progresses, with the flexor hallucis
longus and flexor hallucis brevis gaining lateral mechanical
advantage

24. • Stage 3 - Further subluxation occurs at the 1st
MTP joint, with formation of metatarsus primus
adductus
• Stage 4 - The 1st MTP joint finally dislocates

25. Treatment
Medical
cannot change the irreversible cartilage, bony & soft tissue adaptions of the deformity
• Adapting footwear - shoes with wider & deeper toe box. Extra padding &
strapping

26. • Pharmacologic/ Physical Therapy - NSAIDS in acute episodic
inflammatory process. No evidence to support prolong physical therapy.
• Functional orthotic therapy

27. Surgical
Indications; persistent pain (not cosmetic)
progression of deformity
failure of non operative treatment
Goals; correct all pathologic elements and maintain
biomechanically functional forefoot.
Combination of soft tissue procedures with bony
procedures in almost all cases

28. • SOFT TISSUE PROCEDURES
NB. Medial & Lateral procedures done together are
contraindicated

30. • BONY PROCEDURE
Distal MT: {IM angle 12-15 degrees)
Mitchell
Wilson
Chevron
Proximal MT: {IM angle >15 degrees}
Medial opening wedge
Lateral closing wedge

31. Mitchell
Chevron

32. Phalangeal:
Proximal Phalanx Osteotomy {Aiken}
Combination osteotomies
Keller’s excision for arthritis of MTP joint
Arthrodesis .. {eg. Lapidus)

36. Complications
• Recurrent deformity
• Hallux Varus
• Pronation deformity
• Pain
• Neurologic Injury
• Osteonecrosis
• Nonunion/ malunion

37. Conclusion
• Hallux Valgus is abduction contracture deformity
resembling big toe displaced laterally.
• Women have a higher incidence which is directly
proportional with increase age.
• Aetiology is divided into extrinsic & intrinsic factors.
• Treatment usually non surgical first, then if failed surgical
option is advised.
• Surgery most often involves a combination of soft tissue
and bony procedures.

38. References
• Apley’s System of Orthopaedics & Fracture, 9th
Edition
• Campbell’s Operative Orthopaedics: 12th
Edition, Vol.1
• J Maheshwari (1997), Essential Orthopaedics
2nd Edn. New Delhi, Interprint
• www.orthobullets.com/halluxvalgus