HALLUX VALGUS (BUNION)

What is?

A bunion is a deformity of the base joint of the big toe. The problem is lateral deviation of the great toe so as to put a valgus deformity on the first metatarso-phalangeal joint. A deviation of 15 to 20° is considered abnormal.

This deviation upsets the biomechanics of the foot. It may cause subluxation of the first MTP joint and the great toe may even overlap the second toe.

Lateral subluxation produces a prominence on the metatarsal head (bunion) often followed by the development of a fluid filled bursa. This becomes painful as it rubs against the shoe.

Hallux valgus and bunion (red area) inflamed.


Hallux Valgus right foot.  The great toe deviated laterally and the 2nd toe is on of the first toe.  The bunion is obvious in the medial side of the great toe.


Typical deformation of shoes from being hallux valgus (bunion)

What causes Hallux Valgus?

Contrary to common belief, high-heeled shoes with a small toe box or tight-fitting shoes do not cause hallux valgus.

However, such footwear does keep the hallux in an abducted position if hallux valgus is present, causing mechanical stretch and deviation of the medial soft tissue. In addition, tight shoes can cause medial bump pain and nerve entrapment.

Hallux valgus is known to have numerous etiologies, including biomechanical, traumatic, and metabolic factors. There is higher incidence of hallux valgus in women. Footwear may account for this.

Ballet dancers spend much time up on blocks, dancing on their toes, and so they may be expected to have a high prevalence of the condition, but this is apparently not so.
Age.

Incidence increased with age, with rates of 3% in persons aged 15-30 years, 9% in persons aged 31-60 years, and 16% in those older than 60 years.

In some cases it is associated with a joint problem such as osteoarthritis, rheumatoid arthritis, psoriatic arthropathy, gout etc.  
Genetic factors have been cited with evidence to suggest familial tendencies.

Symptoms

• Pain. You may then have difficulty walking due to pain.

• Inflammation and swelling at the base of the toe. This sometimes becomes infected.

• The foot may become so wide that it can be difficult to find wide enough shoes.

• You may get arthritis in the big toe.

• The second toe can become deformed.

• In severe cases, the big toe can push your second toe up out of place.

X-ray


The X-rays determine the extent of damage and deformity in your toe joint.


MRI is a highly accurate tool to measure the deformation of the toes and matatarsal of the foot

CONSERVATIVE TREATMENT
THERAPY: 

Conservative treatment

Hallux Valgus pain can be successfully managed in the vast majority of cases by switching to shoes that fit properly and don't compress the toes.

Left = wrong,                            Right = correct

Photo by AAOS

Drugs

Analgesics, including NSAIDs, may reduce pain and make the condition more bearable.
Steroid injection into the joint may give some relief of pain and inflammation.

Physical therapy

There is no evidence of long term benefit from physiotherapy.

Orthotics

Orthotics may provide some relief by tending to correct some of the other associated deformities.

Special orthotic device for hallux valgus deformity.

OPERATIVE TREATMENT
THERAPY: 

Operative treatment

Both intermetatarsal angle and hallux valgus angle must be corrected during the operative procedure.  In hallux valgus disease both angles are abnormal.  Intermetatarsal angle is consider abnormal when it is greater than 9 degrees.  Normal metatarsophalangeal joint angle is 9 degrees on average but definitely less.

Τhe intermetatarsal angle is 25 degree and hallux valgus angle is 35 degree. Both are not normal.

Τhe intermetatarsal angle is 13 degrees and hallux valgus angle is 62 degrees.  Both are not normal.

Indications

Indications for repair of hallux valgus include painful joint ROM, deformity of the joint complex, pain or difficulty with footwear, inhibition of activity or lifestyle, and associated foot disorders that can be caused by this condition. Associated foot disorders include the following:

• Neuritis/nerve entrapment

• Overlapping/underlapping second digit

• Hammer digits

• Ulceration

• Inflammatory conditions (bursitis, tendinitis) of first metatarsal head

Information about Surgery

The patient will most likely be asked to arrive at the hospital or surgical center two hours prior to surgery.
After admission, you will be evaluated by a member of the anesthesia team.

Most bunion surgery is performed under ankle block anesthesia.

General or spinal anesthesia is used occasionally. The anesthesiologist will stay with the patient throughout the procedure to administer other medications, if necessary. The surgery takes about one hour each foot. Afterwards will be moved to the recovery room.

The patient stay at hospital for 24 hours to take the anti-inflammatory, antibiotic treatment, medical and nursing total care.

Surgical Procedure

Operative technique (1st metatarsal osteotomy).

Bunionectomy of 1st metatarsal.

Corrective osteotomy of 1st metatarsal.  The mechanical and anatomical bone axis is corrected.

The Kirchner wire stabilize temporarily the bone.

The bones stabilized with special titanium screws. This procedure reduce the postoperative pain.

The final cut of bone prominence optimize the cosmetic result. 

Wound closure.


Special orthotic shoe that permit full weight bearing of the operated foot immediately post op

Case 



Female 42 years old with Hallux valgus problem bilaterally.


Angle measuring




Two months post op

 

Case


Female 39 years old with Hallux valgus problem.  The deformity of the 1st toe create a difficulty to wear the high heel shoes and generarly pain during walking.  The cosmetic problem additionally  exist.


Three months after the operation.  The funcional and Cosmetical results are excellent as consider by the patient.

 

Case 


Female 75 years old with great deformity of the feet.  She couldnt walk without assistive devices.  The pain and disability are the main symptoms.



Great deformity of first and second toes both of the feet.

  

Two months after the operation.  The mechanical and anatomical axis of the feet corrected.  The patient is satisfied because she can walk without pain and assistive devices. 
 

Case

Female 32 years with hallux valgus and varus 5th metatarsal deformity bilaterally, presents severe pain in the feet when walking due to intense skin hyperkeratosis (calluses).


Skin incision drawing just before operation.


Three months post op. The hyperkeratosis (callus), have subsided gradually improving the symptoms  of the patient as regards the pain and mobility.


X-ray, 3 months post op

CASE REPORT

A 30 years old suffering from hallux valgus on both feet, and deformation of the shafts to the other toes. The osteoplasty surgery was aimed at correction of the mechanical axis of the fingers and the aesthetic balance of these.


Before osteoplasty


After surgery. The fingers have acquired new aesthetic balance as mechanics axes have been corrected


Post-op


Pre-op


Post-op


Pre-op


Post-op


REHABILITATION: 

The success of the surgery will depend in large part on how well the patient follows the orthopaedic surgeon's instructions at home during the first few weeks after surgery. The patient must see the Orthopaedic surgeon regularly for the next several months to make sure the surgical wound heals properly.

The patient will be discharged from the hospital with bandages holding the toe in its corrected position. The patient also will wear a special postoperative surgical shoe to protect the foot. The sutures will be removed about 10-15 days after surgery, but the foot requires continued support from dressings or a brace for 4 weeks.

To ensure proper healing, it is very important not to disturb the dressings and to keep the wound dry. Interference with proper healing could cause a recurrence of the bunion. The patient can use plastic bag over operated foot (feet) while showering.

The bandage is removed and reapplied daily.

The patient is allowed to walk fully weight bearing from the beginning, using a forefoot relief shoe for 4-5 weeks; after that a comfortable walking shoe is recommended for another 4–6 weeks.

The patient is instructed to increase the duration of walking activities according to the residual amount of pain and swelling.

Four and 8 weeks following surgery, radiographs are taken to confirm maintenance of fixation and sufficient consolidation of the osteotomy .

The patient is instructed to actively exercise the great toe in plantar flexion.  Range-of-motion and strengthening exercises are to be continued for a total of 8 weeks.