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

Future Directions

Three-plane Correction

Recent literature indicated that a first metatarsal rotational deformity, such with increased DMAAs on AP radiography, may not be because of an anatomic finding, but rather pronation of the hallux. This finding suggests possible inaccuracy of the AP foot radiograph to evaluate the DMAA.[34] Surgical techniques have been described to address not only the translational but also the rotational component of the deformity through a metatarsal osteotomy and modified Lapidus procedure, in hopes of achieving a more anatomic correction.[35] Osteotomy guides and surgical techniques with intramedullary nails and orthogonal plating had recently been used to improve fixation. No long-term studies are available to demonstrate superior improvement in pain relief, reduction in recurrence, or nonunion rate. The role of triplane correction in the treatment algorithm is being defined.

Minimally Invasive Techniques

Minimally invasive techniques are gaining popularity in the hallux valgus correction because they are in general orthopaedics. Short-term outcomes demonstrate a trend for equivalent radiographic deformity correction over traditional open procedures.[36] Iannò et al[37] cautioned against using minimally invasive techniques in patients with severe subluxation of the MTPJ or sesamoid because the recurrence rate is high, contributing to an overall adverse event rate of 29.4%. There is considerable interest in defining the role of minimally invasive techniques in the hallux valgus correction.[38]

Adverse Events

Common adverse events after hallux valgus correction include transfer metatarsalgia and recurrence of the deformity at rates of 6.3% and 4.9%, respectively (Table 1).[39] Although many risk factors have been identified, late recurrence may actually be a natural progression of the deformity. Early recurrence has been linked to the incomplete initial correction from an inadequate translation or "underpowered" osteotomy technique, as evidenced by incomplete reduction of the metatarsal head about the sesamoids. Other factors may contribute to recurrence such as hypermobile joints, metatarsal head shape, severe preoperative deformity, and metatarsus adductus.[40] Inadequate corrective procedures result in higher recurrence rates. Although obesity has been identified as a risk factor for revision surgery, Visual Analog Scale and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Rating System scores were comparable between obsess and nonobese patients.[41] A recent review of pooled data from 16,273 hallux valgus corrective procedures reported the rate of metatarsalgia up to 17.4%, recurrence up to 4.9%, unresolved pain up to 4.6%, and nonunion up to 3.7%. The review also noted nonunion to be highest in first TMTJ arthrodesis, whereas hallux varus deformity was more frequent with proximal osteotomies. Patient satisfaction negatively correlated with large preoperative first-second IMA.[39] Chong et al[42] reviewed 118 patients, reporting that 25.9% were dissatisfied 5.2 years after hallux valgus operative management, regardless of severity of the initial deformity and type of surgical correction. Osteonecrosis of the metatarsal head has been implied to be a risk after distal osteotomies because of the disturbance of blood flow. Clinical and radiographic studies that followed question the application of this knowledge given that distal osteotomies with or without soft-tissue release had been demonstrated to be safe with very low rate of osteonecrosis.[9,43–45]

Most of the operations for the correction of hallux valgus have good clinical results based on the short-term outcomes. More critical analysis of the results with longer-term follow-up has improved our understanding of which operations will provide lasting relief of the pain and impairment associated with hallux valgus. As a consequence of more critical approach to examining patient outcomes, many of the operations which were considered standard practice in the past are no longer recommended. There is a need for well-designed prospective clinical studies and long-term follow-up results.