Operative Approach to Adult Hallux Valgus Deformity

Principles and Techniques

Glenn G. Shi, MD; Joseph L. Whalen, MD, PhD; Norman S. Turner III, MD; Harold B. Kitaoka, MD


J Am Acad Orthop Surg. 2020;28(10):410-418. 

In This Article


Mild (Hallux Valgus Angle < 20, Intermetatarsal Angle < 13)

Indications for simple medial eminence resection, medial capsulorrhaphy, with or without distal soft-tissue release are limited. Resection is an acceptable treatment in which the goal is to address the irritation over the medial eminence rather than realignment. This can be combined with either lateral capsulotomy alone or a modified McBride soft-tissue procedure, releasing the deforming adductor-conjoined tendon without lateral sesamoidectomy to rebalance the proximal phalanx. This operation was widely used until the early 1990s when evidence of its limitations in patients with hallux valgus emerged with progression of the deformity and significant patient dissatisfaction.[6]

Mild hallux valgus deformities are often corrected with distal osteotomies, laterally displacing the center of the metatarsal head. This translational corrective osteotomy does not, however, address rotational deformities. A distal chevron osteotomy is popular among orthopaedic foot and ankle surgeons for correction of mild deformities, partially because of its biomechanically stable design.[7] This osteotomy was originally described as translating no more than 50% of the metatarsal head, allowing for the correction of mild deformities (Figure 2A). Distal chevron osteotomy has been modified in many ways, such as performing the bony cuts at a more acute angle, a longer plantar arm, internal fixation, combination with Akin osteotomy, biplanar ability, and much greater osteotomy displacement. The degree of lateral displacement of the metatarsal head may be increased, the "extended chevron" with the initial results comparable with that of more proximal osteotomies.[8] The distal metatarsal osteotomy has been successfully applied for the correction of moderate deformities. Repositioning of the metatarsal head over the sesamoids may or may not correlate with the radiographic hallux valgus recurrence in the short term.[9] However, the preoperative severity of the deformity measured in IMA, HVA, and DMAA correlates with recurrence.[10] Distal soft-tissue release can be used as an adjunct procedure to distal osteotomies, improving radiographic alignment but not patient satisfaction.[11]

Figure 2.

Illustrations showing the (A) distal chevron osteotomy, (B) scarf osteotomy, (C) proximal osteotomy, (D) modified Lapidus, and (E) Akin osteotomy.

When hallux valgus interphalangeus is present, a closing wedge osteotomy of the proximal phalangeal osteotomy (Akin) can be performed (Figure 2E). As an isolated procedure, it is not advisable for the correction of hallux valgus. Vander Griend[12] reported success in using Akin osteotomy concurrently with other forefoot procedures in both primary and revision cases, with acceptable radiographic outcomes and low adverse event rates. When combined with the first metatarsal osteotomy, Akin osteotomy also reduces the deforming pull of the extensor and flexor hallucis longus.[8] Correction has been demonstrated to be effective in pain reduction, radiographic HVA and IMA, and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Rating System and Short Form-36 scores in both open and percutaneous techniques.[13]

Moderate (Hallux Valgus Angle 20–40, Intermetatarsal Angle 13–16)

Proximal osteotomy of the first metatarsal has greater potential of reducing the IMA. A variety of osteotomies have been described, each with their own unique characteristics and shortcomings.[4,14,15] Given that the sesamoid position on weight-bearing AP radiography does not change, reduction of the metatarsal head after proximal osteotomy has been shown to be an important factor in determining adequate intraoperative reduction and is associated with lower risk of recurrence.[5] Patients with increased DMAA, if not concurrently corrected, are at risk for a high recurrence rate after proximal osteotomy.[16]

Mau and Ludloff osteotomies are variations of the long proximal-oblique osteotomy, rotating the distal metatarsal laterally, reducing the IMA, and these are usually fixed with compression screws (Figure 2C).[17] Proximal opening wedge osteotomy is a single-plane osteotomy that has gained favor in recent years for moderate and severe deformities because of its easy-to-understand concept and stable fixation with procedure-specific plates.[18] The scarf osteotomy is an anatomically stable metatarsal shaft z-osteotomy with both corrective and first metatarsal lengthening powers that can be used in both primary and revision cases (Figure 2B).[19] Choi et al[20] evaluated functional and radiographic parameters of patients who underwent scarf osteotomy, demonstrating a reduction in Visual Analog Scale pain scores from 5.8 to 1.1 and an improvement in IMA from 13.6° to 5.6°. Bock et al[21] evaluated the long-term outcomes of scarf osteotomy, reporting a 30% radiographic recurrence rate at 124 months. Jeuken et al[7] compared the long-term outcomes of distal chevron and scarf osteotomies, reporting that no significant difference existed in recurrence rate and Visual Analog Scale pain score or subjective scores, including SF-36 and Manchester-Oxford Foot Questionnaire. Although radiographic recurrence can occur after both distal chevron and scarf osteotomies (73% and 78%), pain was not found to correlate with deformity recurrence at a mean of 14 years.[7]

Severe (Hallux Valgus Angle > 40, Intermetatarsal Angle > 16)

In patients with severe deformities, proximal osteotomy can be effective in reducing the deformity.[22] Some severe deformities are due to combined deformities, such as those with both increased IMA and DMAA. Braito et al[23] demonstrated that these severe deformities can be corrected with a double osteotomy, which has the potential for more correction, but with a 30% adverse event rate. In cases of severe hallux valgus deformity, especially those associated with first TMTJ instability or arthritis, a modified Lapidus procedure can be used (Figure 2D). Controversy regarding TMTJ hypermobility diagnosis and treatment exists in the literature.[2]

Ellington et al[24] found the modified Lapidus procedure to be a viable MTP joint-preserving option in revision surgical treatment after recurrence, with improved HVA, IMA, and DMAA from 36.2°, 13.6°, and 18.6° to 15.2°, 7.5°, and 11.7°, respectively. Similarly, Coetzee et al[25] reported short-term improvements at 24 months in radiographic HVA and IMA from 37.1° and 18° to 18° and 8.6°, with a patient satisfaction rate of 81%.

Recent long-term follow-up of a prospective randomized trial of distal osteotomy versus modified Lapidus showed no differences in radiographic outcomes, regardless of the clinical findings of preoperative hypermobility.[26]

Although some advocate that the improved implants and techniques allow for early weight-bearing in postoperative shoe, this is not universally accepted.[27–29]


MTPJ arthrodesis is applicable in the setting of arthritis, joint hypermobility, spasticity, previously failed operations, and severe hallux valgus deformities to reduce pain and recurrence. Pydah et al[30] examined 69 feet (13 bilateral feet) that underwent primary arthrodesis of the first MTPJ, demonstrating not only correction of the HVA and IMA but also improvement of the sesamoid position on AP radiography. McKean et al[31] reported a series of 19 first MTPJ arthrodesis procedures in 17 patients, showing improvements in IMA from 19.2° to 10.8° and HVA from 48.5° to 12.3°. Arthrodesis may also be used after failed osteotomies, osteonecrosis, progressive neurologic hallux valgus deformity, salvage of failed great toe implant arthroplasty, and salvage of failed resection arthroplasty. It is not always necessary in well-controlled inflammatory arthropathy with a functional joint.[32] When applied in the setting of hallux valgus versus hallux rigidus deformities, the hallux valgus group had a markedly higher nonunion rate, 14.3% versus 0%.[33] Extra-articular deforming forces and contractures may need to be balanced intraoperatively, and choice of implant maximizing stability should be considered to reduce the risk of nonunion in patients with hallux valgus deformity. In the past, MTPJ implant arthroplasty was successfully applied to rheumatoid arthritis patients with hallux valgus, but today it has a limited role in patients with hallux valgus.