WHAT IS HALLUX VALGUS?

Hallux valgus is a complex deformity of the entire forefoot. Strictly speaking, the term “hallux valgus” only refers to a deviation of the big toe (hallux) in the metatarsophalangeal joint outward, i.e. into the valgus position. As a rule, however, in addition to this deformity, there is also a widening of the forefoot and, not infrequently, a deformity of the small toes.

HOW COMMON IS HALLUX VALGUS?

Hallux valgus affects about 2 to 4 % of the total population and is thus the most common clinically relevant forefoot deformity. Women suffer from hallux valgus deformity about nine times more often than men. The deformity probably occurs bilaterally in >80% of cases, although often to varying degrees.

WHAT IS THE CAUSE OF HALLUX VALGUS DEFORMITY?

The common perception that a hallux valgus deformity is typically caused by excessive use of high-heeled shoes (high heels) is outdated. High, tight footwear can certainly promote the development of hallux valgus, but only an absolute minority of patients who regularly wear high heels are seen in the clinic. From today’s perspective, “idiopathic” hallux valgus (without a clearly assignable cause) develops multifactorially, i.e. numerous causes, some of which are unknown, play a role. In most cases, a certain muscular imbalance, bony structural changes or functional instabilities can be identified as triggers or at least promoting factors. A positive family history can usually be elicited from anamnesis, whereby experience has shown that individual generations can be skipped, interestingly enough.Rarely, a direct cause such as trauma (amputation of neighboring toes, mishealed fractures), tumor disease, or even previous surgery can lead to hallux valgus.

HOW DOES THE DEFORMITY DEVELOP?

The disease begins with a slight misrotation of the big toe. This can be detected simply by observing that the toenail points slightly more inward. Increasing decentering of the extensor and flexor tendons intensifies the malposition of the big toe as the disease progresses. A supposedly simple outward deviation of the big toe often develops into a complex malposition of the entire forefoot:

Deviation of the 1st ray inward, i.e. the forefoot becomes wider and an increasing splayfoot develops. Usually, a painful bunion (pseudoexostosis) also forms above the metatarsophalangeal joint at this point
Outward displacement of the small bones, the so-called sesamoid bones, as an expression of decentering of the small flexor tendons
a possible instability of the 1st beam
overuse-related metatarsal pain and increasing small toe deformities such as hammer and claw toes

WHAT COMPLAINTS DOES A HALLUX VALGUS CAUSE?

Initially, affected individuals often complain of disturbing aesthetics or shoe problems due to mechanically caused irritation over the prominent metatarsophalangeal joint with redness and pressure pain. In the course of time, there is a widening of the forefoot area, increasing displacement of the neighboring toes and premature degeneration of the metatarsophalangeal joint due to malposition. This leads to increasing pain and restricted movement. In the advanced stage, the big toe can overlap or underlap the neighboring toes (hallux valgus superductus/subductus) and further small toe deformities develop.

HOW IS HALLUX VALGUS DIAGNOSED?

During inspection, excessive calluses of the foot allow conclusions to be drawn about incorrect and excessive strain. Hallux valgus typical symptoms such as a prominent metatarsophalangeal joint, widening of the forefoot, redness and pressure pain are evident.After history and inspection, the functional test should pay particular attention to possible instability of the metatarsophalangeal joint of the big toe and shortening of the calf muscles. The mobility and backward displacement of the metatarsophalangeal joint of the big toe should be checked. Examination of the healthy and unaffected opposite side (if there is no hallux valgus here) can provide a helpful comparison for all tests.

IS AN X-RAY REQUIRED FOR FURTHER EVALUATION?

An X-ray must be performed specifically before a planned operation. Diagnostic imaging basically consists of images of the affected foot in the standing position, both from above and strictly laterally. Oblique radiographs (fracture radiograph) are not necessary, or even unnecessary, for the assessment and surgical planning of hallux valgus. In addition, depending on the problem, there are still some special images.

HOW CAN HALLUX VALGUS BE TREATED WITHOUT SURGERY?

Hallux valgus surgery for purely aesthetic reasons should be evaluated with caution and should not be performed because the risk of problems after surgery can never be ruled out.

Non-surgical therapy can slow down or ideally even stop the progression of a mild deformity, although to date there is no high-quality scientific evidence on this. Special forms of manual therapy (e.g. spiraldynamics) have interesting approaches, but have not yet been able to provide scientific proof that they can correct a hallux valgus deformity.

Conservative therapy includes the use of orthopedic aids (e.g., hallux splint, toe spreader, insoles), stretching and strengthening exercises in the foot and calf area, and the use of appropriate footwear. Sometimes it is easier and more sensible to adapt the shoe to the foot than vice versa. Not every symptomatic hallux valgus deformity requires immediate surgery!

WHAT METHODS ARE THERE TO OPERATE THE HALLUX VALGUS?

Despite a variety of non-surgical treatment options, surgery is the only way to permanently straighten the toe. Many different surgical methods (>100) for hallux surgery are known, although most techniques are very similar.Surgical procedures are generally divided into soft tissue and bony procedures as well as joint preserving and joint resecting/stiffening procedures. In hallux valgus, a combination of soft tissue surgery at the level of the metatarsophalangeal joint and bony correction is usually always necessary to achieve adequate correction of the deformity and the lowest possible recurrence rate.The extent of soft tissue intervention depends on the conditions encountered and the experience of the surgeon. The bony interventions are largely determined by the location and severity of the deformity. Common joint-preserving procedures (corrective osteotomies) are:

Akin osteotomy: correction by removal of a bone wedge and rotation of the toe
Chevron (Austin) osteotomy: correction via a V-shaped bone incision.
Scarf osteotomy: correction via a Z-shaped bone incision
Metatarsal 1-base osteotomy: correction by removal of a bone wedge or spreading of the bone
Lapidus arthrodesis: stabilization of the first joint between the midfoot and forefoot
A procedure that has become very popular in the meantime is the minimally invasive correction. Here, a correction is achieved only through very small skin incisions.

WHAT IS THE AFTERCARE AFTER HALLUX SURGERY?

The aftercare depends mainly on the type of surgery, the material used and the bone quality.

In general, full weight-bearing is possible for about 6 weeks with the use of a special bandage shoe. The bandage shoe only allows the operated foot to sit up, but not to roll down.

In order to maintain the achieved corrective result in the long term and to prevent recurrence, special bandaging must be applied for a further 4 weeks after completion of wound healing (takes approx. 2 weeks; crutches should also be used during this time). Afterwards, it is recommended to wear a splint at night for another 6 weeks. Driving a car is usually possible again after 6 weeks, and normal shoes can then be worn. Sports activities such as jogging are possible again after 3 months.

ADVICE AND CONTACT FOR QUESTIONS ABOUT HALLUX VALGUS

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