2. Introduction
Hallux valgus means lateral deviation of great toe
Commonest of foot deformities
Not a single disorder; but a complex deformity of the first ray
Frequently accompanied by deformity and symptoms in lesser toes
3. Spectrum of hallux valgus
Varus deformity of first metatarsal
Valgus of great toe
Great toe bunion formation
Arthritis of 1st MP joint
Hammer toe
Toes corn
Calluses
Metatarsalgia
Stress fractures of lesser metatarsals
4. Anatomy
The head is grooved inferiorly
by medial and lateral sesamoid
bones in the tendons of Flexor
hallucis brevis
The proximal phalynx is round
on three sides but flat
inferiorly, even concave
inferiorly for the flexor hallucis
longus tendon
5. Causes of Hallux Valgus
Congenital Hallus valgus :
Very rare
Metatarsus primus varus is common at birth
Concealed supernumerary phalynx may be the cause
Shortened second metatarsal
Hereditory :
Johnston(1956) : Transmitted as autosomal dominance with incomplete
penetration
Age:
14-16 in girls and little later in boys
Symptomatic hallux valgus is more common after 40 years of age, mostly
bilateral.
6. Causes of Hallux Valgus
Sex:
Women > Men
Women : Men = 50: 1
Predisposed by pointed compressive high heeled shoes
7. Causes of Hallux Valgus
Shoes:
Has been considered as extrinsic cause of Hallux Valgus
In Chinese population, Hallux valgus was more common due to special
compressive shoe wearing habits.
Tight fitting show at toes have been proven as cause of bunion, corns.
“Shoes as at present worn, serve but to
deform the toes and cover the feet with
corns” – Camper (1781)
8. Causes of Hallux Valgus
Intrinsic Factors:
Pes Planus
Articular surface of 1st MP joint
Advanced position of great toe and its metatarsal.
Metatarsus primus varus
9. Causes of Hallux Valgus
Intrinsic Factors:
Pes Planus
Articular surface of 1st MP joint
Advanced position of great toe and its metatarsal.
Metatarsus primus varus
10. Causes of Hallux Valgus
Intrinsic Factors:
Pes Planus
Articular surface of 1st MP joint
Advanced position of great toe and its metatarsal.
Metatarsus primus varus
11. Causes of Hallux Valgus
Intrinsic Factors:
Pes Planus
Articular surface of 1st MP joint
Advanced position of great toe and its metatarsal.
Metatarsus primus varus
12. Causes of Hallux Valgus
Miscellaneous causes:
Muscular imbalance: Poliomyelitis, Spastic CP
Trauma : Malunited # - secondary deformity
Congenitally absent, Amputated or hammered second toe
13. Pathogenesis
1st metatarsal inclines medially
Proximal phalynx deflects in opposite direction
Joint knuckles towards the midline –
prominence of forefoot at the tibial border
Great toe pronates – Nail and hallux slants
medially, pulp towards second toe
Great toe may ride over 2nd digit or slip under
it
Lesser toe – crowded together, clawed,
hammered
Bunionette:- deformity at outer border of
forefoot
Forefoot is splayed
14. Anatomical changes in foot
In a full blown hallux valgus, several changes take place in and around
the first metatarso-phalyngeal joint. They Involve
1. Articular Bones
2. Capsular and ligamentous structure
3. Muscle and tendon
4. Bursa
5. Skin
15. Anatomical changes in foot
1. Articular bones
Mild cases: Outward deviation of proximal phalynx is the sole feature
Severe deformity: Axial rotation of proximal phalynx
: Subluxation of MP joint.
Crista on the undersurface of 1st Metatarsal smoothens out, effaced due
to migration of sesamoid.
16. Anatomical changes in foot
In more advanced cases, the interior of metatarsal head is
cystic due to proliferation of marrow connective tissue in
response to denuded hyaline surface
Sesamoids: Lateral migration of Sesamoids is evidence of
Hallux valgus
In these new incongruent location, sesamoids wear out, loose
hyaline cartilage, become mushroomed, forms spurs and
fragments
Incarcerted in the first inter metatarsal space, the fibular
sesamoid may serve as a wedge and push the 1st metatarsal into
greater varus
Rarely, there is bony union between sesamoids and the
metatarsal head.
17. Anatomical changes in foot
2. Capsular and ligamentous structures
Capsule on the tibial side show elongation and on the fibular
side show shortening
Extent of these contractions depend on the degree of deviation
and displacement of sesamoids
18. Anatomical changes in foot
3. Muscles and tendons:
With axial rotation:
Abductor halluces – NO Abduction, works as flexor
Short flexors – Aid in adductor pull’
Bowstringed extensors and laterally displaced
flexors further accentuste the valgus deformity
19. Anatomical changes in foot
4. Bursa:
Adventitious bursa occurs on the dorsal, plantar
and medial aspect of 1st metatarso phalyngeal
joint.
May Undergo
1. Suppurative bursitis with regional cellulitis
2. Sinus formation
3. lymphangitis
20. Anatomical changes in foot
5. Skin:
Skin on the medial and plantar aspect of toe
undergoes cornification
Repeated pressure on the skin causes callosity
formation
21. Anatomical changes in foot
6. Changes affecting the lesser toes
Relative or real plantar descent of the central
metatarsal heads
Proximal phalynx subluxates dorsally with PIP
joint in flexion
Skin over these knuckled IP joint develops
callosities
2nd toe is usually hammered.
Splaying of foot: Side to side span of foot is
increased.
5th metatarsal inclines fibularwards, with its
head presenting as lateral eminence
Bursa over this eminence is known as
Bunionette.
22. Clinical features
Symptoms:
Pain in foot
Difficulty in being fitted with shoes
Gait changes
Corns
Keratosis
Cosmetic deformity
23. Pain in foot
Bursitis:
Bursa develops between skin and medial eminence
Complications like inflammation result in regional cellulitis,
Rupture and pus discharge through sinus
May also lead to osteomyelitis of the adjacent bones
Arthritic pain:
Movement of toes are limited with crepitus and painful movement
Metatarsalgia:
Most distressing and disabling
Frequently associated with hallux valgus
24. Investigations:
Xrays:
3 views:
1. AP view
2. Oblique views
3. Axial exposure of Sesamoid.
Xray of opposite foot for comparison
should be taken
25. Angle between 1st and 2nd metatarsal
Usually less than 8 degree
More than 10 degree – Metatarsus varus
26. Valgus angle
Usually between 10-15 degree
Depending on angle
Mild- 20 degree
Moderate -30 degree
Marked- 40 degree
27. Classification of hallux valgus
Pigott (1960) classified HV into 3 types based on congruity of 1st MP
joint
Type 1: Congrous joint
Type 2: Deviated non congruous joint
Type 3: Subluxated joint
28. Classification of hallux valgus
Mann and conghlin(1993) classified HV into 3 types based on Hallux
valgus angle
Mild: Angle < 20 degree, intermetatarsal angle usually less than 11 degree
Moderate: Angle 20 - 40 degree, intermetatarsal angle between 11 and 18
degree
Severe: Angle > 40 degree, intermetatarsal angle > 16-18 degree
29. Classification of hallux valgus
From surgical point of view , it can be classified as
1. Simple hallux valgus
1. Without sagittal groove
2. With sagittal grove
2. Hallux valgus with axial rotation
1. Reducible
2. Irreducible
3. Hallux valgus with metatarsus primus varus
1. Mobile/ hypermobile first metatarsal
2. Fixed varus
4. Hallux varus with degenerative arthritis of joint
5. Hallux valgus with mixed deformities
30. Treatment of hallux valgus
Conservative Management:
Young and asymptomatic patients
• Proper fitting shoes with wide deep toe boxes
• Night splinting and other orthosis
Once the deformity is established, it is difficult
to check the progression of disease by
conservative measures.
31. Surgical Treatment
Indications of operative treatment
Failure of non operative measures
Persistent pain that interferes with daily work
Severe deformity and pain unlikely to respond to conservative
measures
41. Mann Algorithm for selection of appropriate
operative procedure in treatment of hallux
valgus
Hallux valgus < 25 degree
Congruent joint
Chevron osteotomy
Mitchell Osteotomy
Incongruent joint
Distal soft tissue realignment
Chevron osteotomy
Mitchell Osteotomy
42. Mann Algorithm for selection of appropriate
operative procedure in treatment of hallux
valgus
Hallux valgus 25 - 40 degree
Congruent joint
Chevron osteotomy with akin procedure
Mitchell Osteotomy
Incongruent joint
Distal soft tissue realignment with proximal metatarsal osteotomy
Mitchell Osteotomy
43. Mann Algorithm for selection of appropriate
operative procedure in treatment of hallux
valgus
Severe Hallux valgus >40 degree
Congruent joint
Double osteotomy
Akin and chevron osteotomy
Akin and 1st metatarsal proximal osteotomy
Akin and 1st cuneiform opening wedge osteotomy
Incongruent joint
Distal soft tissue realignment with Proximal osteotomy
First metatarsal crescentic osteotomy
1st cuneiform open wedge osteotomy
Hypermobile 1st Metatarso-cuneiform joint
Distal soft tissue realignment and fusion 1st metatarso-cuneiform joint
44. Conclusion
Hallux valgus is the most common deformity of foot
Commonly seen an adolescent females and becomes symptomatic in
middle age
Can be treated conservatively if diagnosed early
Surgery is the only option after the deformity develops.
The first metatarsal is large and strong and plays an important role in supporting the weight of the body
Pes planus: Owing to eversion of calcaneus , the Abductor hallucis shifts towards the outer border of the foot
Plantarly depressed tarsal bones bear down on the AbH muscle , and causes it to stretch and lose its tone.
Weakened abductors no longer counterbalance the adductors halluces
Pes planus causes the abductirs to be non functional
