Operative Approach to Adult Hallux Valgus Deformity

Summary

Successful operative management of hallux valgus deformity may be achieved with an understanding of the pathophysiology and application of appropriate procedure. Future research would be beneficial such as large clinical trials, long-term follow-up studies, and multicenter investigations using foot specific registry data.

Table 1. Severity of Deformity, Procedure, and Adverse Events
Deformity	Corrective Procedure	Potential Complications	Pearls
Any	Arthrodesis ± osteotomies	Malunion, nonunion, hallux varus, transfer metatarsalgia	• To avoid malunion and nonunion, surgeons apply stable internal fixation with good bony contact. Confirm correct osteotomy and arthrodesis position intraoperatively. • To prevent hallux varus, avoid negative postoperative IMA and aggressive lateral release, and excessive removal of medial eminence. • Transfer metatarsalgia can occur with incomplete correction, elevation of the metatarsal head, or shortening
Mild (HVA < 20, IMA < 13)	Distal osteotomy (ie, chevron), with or without distal soft-tissue release	Osteonecrosis	• Limit plantar and lateral periosteal stripping and extensive lateral release • Meticulous technique with good osteotomy bony contact.
Moderate (HVA 20–40, IMA 13–16)	Proximal osteotomy, with or without distal soft-tissue release	Troughing (scarf), hallux varus, transfer metatarsalgia	• Extend scarf osteotomy to metatarsal head for greater cancellous bone contact • Avoid negative postoperative IMA • Avoid unintentional elevation or depression of the distal fragment to reduce risk of transfer metatarsalgia • Add lateral soft-tissue release if the deformity is incongruent
Severe (HVA > 40, IMA > 16)	Proximal osteotomy, modified Lapidus, with or without distal soft-tissue release First MTPJ arthrodesis	Malunion, nonunion, hallux varus, transfer metatarsalgia	• In arthrodesis, ensure neutral rotation, extension such that the fat pad of the great toe rests on the platform simulating weight-bearing, and 10–15 degrees of valgus. Adjustments are necessary in a simulated plantigrade position which is achieved using a platform such as a sterile surgical tray cover. Consider lateral soft-tissue release if the deformity is incongruent
DMAA (>10)	Biplanar closing wedge osteotomy, with or without distal soft-tissue release	Nonunion, transfer metatarsalgia	• Avoid removing excessively large wedge during joint preparation.
MTPJ arthritis	First MTPJ arthrodesis	Nonunion, malpositioning	• Arthrodesis should be considered in patients with spasticity and uncontrolled inflammatory arthropathy.
TMTJ arthritis	Modified Lapidus, with or without distal soft-tissue release	Nonunion, transfer metatarsalgia	• Consider when there is gross TMTJ instability
HV interphalangeus	Akin phalangeal osteotomy

Table 1. Severity of Deformity, Procedure, and Adverse Events

Deformity

Corrective Procedure

Potential Complications

Pearls

Any

Arthrodesis ± osteotomies

Malunion, nonunion, hallux varus, transfer metatarsalgia

• To avoid malunion and nonunion, surgeons apply stable internal fixation with good bony contact. Confirm correct osteotomy and arthrodesis position intraoperatively.
• To prevent hallux varus, avoid negative postoperative IMA and aggressive lateral release, and excessive removal of medial eminence.
• Transfer metatarsalgia can occur with incomplete correction, elevation of the metatarsal head, or shortening

Mild (HVA < 20, IMA < 13)

Distal osteotomy (ie, chevron), with or without distal soft-tissue release

Osteonecrosis

• Limit plantar and lateral periosteal stripping and extensive lateral release
• Meticulous technique with good osteotomy bony contact.

Moderate (HVA 20–40, IMA 13–16)

Proximal osteotomy, with or without distal soft-tissue release

Troughing (scarf), hallux varus, transfer metatarsalgia

• Extend scarf osteotomy to metatarsal head for greater cancellous bone contact
• Avoid negative postoperative IMA
• Avoid unintentional elevation or depression of the distal fragment to reduce risk of transfer metatarsalgia
• Add lateral soft-tissue release if the deformity is incongruent

Severe (HVA > 40, IMA > 16)

Proximal osteotomy, modified Lapidus, with or without distal soft-tissue release
First MTPJ arthrodesis

Malunion, nonunion, hallux varus, transfer metatarsalgia

• In arthrodesis, ensure neutral rotation, extension such that the fat pad of the great toe rests on the platform simulating weight-bearing, and 10–15 degrees of valgus. Adjustments are necessary in a simulated plantigrade position which is achieved using a platform such as a sterile surgical tray cover. Consider lateral soft-tissue release if the deformity is incongruent

DMAA (>10)

Biplanar closing wedge osteotomy, with or without distal soft-tissue release

Nonunion, transfer metatarsalgia

• Avoid removing excessively large wedge during joint preparation.

MTPJ arthritis

First MTPJ arthrodesis

Nonunion, malpositioning

• Arthrodesis should be considered in patients with spasticity and uncontrolled inflammatory arthropathy.

TMTJ arthritis

Modified Lapidus, with or without distal soft-tissue release

Nonunion, transfer metatarsalgia

• Consider when there is gross TMTJ instability

HV interphalangeus

Akin phalangeal osteotomy

Operative Approach to Adult Hallux Valgus Deformity

Principles and Techniques

Summary

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Operative Approach to Adult Hallux Valgus Deformity

Principles and Techniques

Summary

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Authors and Disclosures

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