Hallux valgus is a static deformation of the foot, more precisely it is the deformation of the big toe and the front part of the foot. We find that, in urban people, it is becoming more and more common, in 30% of the population on average, more common in women between 40-50 years of age.

The basic characteristics of this deformation are valgus position of the big toe, increased first metatarsal angle, non-union with our without bursitis in the area of the medial side of the big toe and big toe rotation. Hallux valgus in most cases is not a separate deformation of the entire foot, most often it comes associated with deformations of flattened longitudinal and/or transversal arch of the foot. Pronation of the back part of the foot and valgus position of the heel can be noticed as well.

Fig. 1 Hallux valgus. The characteristics of big toe deformation are that the big toe is moving towards the other toes, there is painful protuberance of the head of the first metatarsal bone (bone structure on the big toe is its continuation) and there is a disturbance in the foot structure.

Causes

The causes of Hallux valgus can be internal factors such as an inflammation in the area of the first metatarsophalangeal joint, or deformations in the front part of the foot, for instance if the first metatarsal bone is too long or too short, disturbance in the sezamoid bones or weakness of the muscles and ligaments in the front part of the foot. External factors are life and work style of a civilized person, this includes standing for long times, inappropriate footware, walking on a flat, hard surface, whereby overloading the front part of the foot.

 

Diagnostics

Hallux valgus is diagnosed by x-ray where the hallux valgus angle is to be measured, then the first intermetatarsal angle, metatarsal index must be determined and the position of the sesamoid bones. The angle of hallux valgus is the angle closed by the longitudinal axis of the first metatarsal bone with the longitudinal axis of the proximal phalange of the big toe. Normal value is 10 +/-2 degrees. The first intermetatarsal angle is the angle closed by the longitudinal axis of the first and second metatarsal bones. Normal value is up to 9 degrees. Metatarsal index is the difference in length between the first and the second metatarsal bones. If these bones are of the same length, then we talk about plus-minus index. If the first metatarsal bone is longer than the second, then we have a plus metatarsal index; while if the first metatarsal bone is shorter than the second, then we speak about a minus metatarsal index.The position of sesamoid bones can be divided into four degrees. The degree is higher if the head of the first metatarsal bone is more medial from both sesamoid bones. The forth degree is when both sesamoid bones are lateral from the central line of the metatarsal bone.

Fig. 2 Radiological imaging important in the estimation of the level of deformity and deciding upon the type of surgery. MTF – metatarsophalangeal angle is closed by the longitudinal axis of the big toe and of the first metatarsal bone. IMTT – intermetatarsal angle is closed by the longitudinal axis of the first and second metatarsal bones

Treatment

Treatment of Hallux valgus is surgical only. There are five types of surgical procedures: osteotomy, procedures performed on soft tissues, arthroplastics, aloarthroplastics and arthrodesis.
Osteotomy can be performed at the level of proximal phalange, first metatarsal bone, cuneiform bone and there can be combined procedures.

Surgeries performed on soft tissues can be divided to relaxing the external soft tissue structures, strengthening the structures on the medial side and closing.
In case of a surgical treatment the valgus position of the big toe must be corrected as well as the varus position of the first metatarsal bone, then the non-union must be eliminated. The position of the sesamoid bones must be corrected as well as the shift of the grasp and the direction of tendons and muscles, and the rotation of the first metatarsal bone.

The factors which impact the selection and results of the surgical procedure are age, sex and profession of the patient, type and degree of deformatian, type of the surgical procedure and surgical aptitude of the operator.

Type and duration of post-operational immobilization impact the results, as well as possible compliations and recidives. Counterindications and expected bad results of the surgery are arthrosis of the distal joint of the big toe, angle of Hallux valgus higher than 40 degrees and intermetatarsal angle larger than 20%.

Complications

Possible complications of surgical procedures are too extensive shortening of the first metatarsal bone, luxation or fracture of the first metatarsal bone, aseptic necrosis of the head of the first metatarsal bone, decreasing the scope of motions, hipercorrection and metatarsalgia.

Rehabilitation

The patient is required to wear an orthopaedic shoe 5 weeks after the surgery which allowed him to put his weight on the heel without the front part of the foot touching the floor. Walking with the help of two elbow crutches.

After 5 weeks the patient takes the orthopaedic shoe off and gradually in the next 4 weeks burden the foot fully.

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