Hallux Valgus

Introduction:
Hallux Valgus is the clinical deformity of the great toe when it is bent laterally producing a bunion or prominent lump medially. More information is available under the heading of Bunion. The condition is often associated with a bunion and the use of ill fitting shoes over many years. However the condition may be congenital due to a particular bone structure in the foot. It is unknown exactly how many people are affected by this condition, but it is more prevalent in the older population. More women than men are affected possibly because of the differing designs in footwear. Although footwear is thought to precipitate this condition, genetic factors, the alignment of the bones in the foot, loose ligaments, foot injuries and flat feet contribute to the biomechanical instability of the foot and the formation of Hallux Valgus.

Anatomy/ Physiology:
Hallux Valgus is considered to be a deviation of the big toe (Hallux) towards the other toes of the foot. It may also be associated with some added rotation of the toe and some nail deformities. It may result in a painful movement of the big toe. The joint affected is the 1st metatarsal phalangeal joint and this is used, primarily during propulsion, in the weight-bearing process.

Indications/Symptoms:
Hallux Valgus is usually characterised by a slow onset of a deep aching pain especially during activity. This may be followed by the appearance of a reddened and swollen area (bunion) on the inner side of the big toe and then deviation of the bones in the big toe. There may be decreased length in surrounding muscles and, coupled with over-stretched ligaments, this may lead to the big toe crossing over or under the 2nd toe.

Diagnosis: An x-ray will indicate the relative state of the 1st metatarsal phalangeal joint and inform the Orthopaedic Surgeon as to the usefulness of surgery. These are usually performed in a weight-bearing position.

Treatment:
The options available are non-operative intervention and surgical intervention. Non-operative management includes: orthotic inserts, wider shoes, exercises, taping and alterations in activity. Wearing good footwear may ease symptoms. It may also prevent a small bunion from getting worse. Ideally, get advice about footwear from a podiatrist or chiropodist. Advice may include:
Wear shoes, trainers or slippers that fit well and are roomy.
Don’t wear high-heeled, pointed or tight shoes.
Padding over the bunion may help.

Medication
Painkillers such as Paracetamol or ibuprofen may ease any pain. If the bunion develops as part of an arthritis then other medication may be advised. A course of antibiotics may be needed if the bunion becomes infected.

Surgery
An operation may be advised if a change of footwear does not ease the problem. The aim of the operation is to straighten the joint as much as possible. There are many different types of operation which can do this. The one chosen by the specialist depends on the severity of the bunion, the shape of your foot, and other factors such as if you have arthritis in the joint.
An operation is usually successful at easing the symptoms, providing some correction of the joint deformity, allowing the use of more normal footwear, but not in all cases. Your specialist will be able to advise on the pros and cons of surgery, and the success rate of the chosen operation.
Surgical interventions are dependent on the state of the tissues pre-operatively and the preferences of the Surgeon. There are over 100 different types of operations for Hallux Valgus, but they fall into 4 broad categories.
Removal of the part of the great toe joint i.e. Kellers Procedure. This is commonly used in the elderly population. One disadvantage is that when part of the joint is removed, the joint may become floppy, shortened and cosmetically unacceptable.
Alteration of the angle of the toe i.e. Osteotomy. Part of the joint is redirected into a better position and held firm for 4-6 weeks with a metal pin. This allows bony healing to take place.
Fusion of the great toe joint. Complete fixation, stiffening or arthrodesis of the great toe joint is commonly used for patients requiring a high level of joint stability. However, post-operative treatment involves the patient being non-weight bearing for 6-8 weeks, which some patients find difficult.
Implantation of a new joint into the great toes may be considered. There are various types of prosthesis available although there are limited studies as to their effectiveness. They are also subject to the same problems as other replacement joints such as infections and loosening of the prosthesis over time.

Complications:
The complications of surgery depend on the type of surgery performed. There may be under or over correction of the big toe, delayed union of the relevant bones, decreased strength of the toe musculature and a floppy or flail toe. In some cases there may be no reduction of the pain in the affected area. Remedial action may be in the form of ice packs and non weight-bearing exercise (to control swelling) and medication (to control post-operative pain). Additional corrective or remedial surgery may occasionally be necessary.

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