What is hallux valgus?

Hallux valgus, commonly known as bunions, is a complex deformity of the big toe. It is characterised by a protuberance, or bunion, of varying size between the first and second metatarsal (the first metatarsophalangeal joint) and an abduction of the big toe towards the second toe. It is frequently accompanied by a rotation, with the big toe bending towards the second toe. In many cases hallux valgus is also accompanied by additional deformities in the other toes, such as hammer or claw toe.

This complex deformity often causes considerable discomfort. A common complaint is pain or inflammation of the prominent big toe joint or under the soles of the feet. The pain is not only felt under the big toe, but also under the ball of the forefoot, especially under the second and third metatarsal because of the shift of weight. It is often painful to wear normal shoes and ladies' high-heeled shoes are completely out of the question. The hallux ball and the sac, or bursa, that lies over the joint often become inflamed. At advanced stages patients may develop an abnormal gait because of the pain level.

Initially the complaints caused by bunions are treated using conservative methods. First of all suitable shoes must be worn, i.e. heels on ladies' shoes should not be too high (max. 3 – 4 cm). Insoles may also help reduce pain. Bunion night-splints, designed to correct the position of the big toe, unfortunately do not lead to the desired results.

Surgical treatment of hallux valgus is considered if the conservative therapies have not alleviated or eliminated the pain satisfactorily. Forefoot surgery is not done for purely cosmetic reasons.

Hallux valgus should be treated surgically if it causes pain (with or without shoes), if the deformity increases, if other foot anomalies occur such as hammer toes or increasing cornification of the sole of the foot below the second metatarsal. It should also be operated on if the patient has difficulty finding shoes that fit without causing pain.

In the past, surgery used to involve removal of part of the big toe joint (a resection arthroplasty according to Keller-Brandes"). Although this usually corrected the deformity in the big toe, the joint itself was basically destroyed during the operation so that it was no longer fully functional. Frequently, weight could no longer be put on the big toe could when walking so that the adjoining toes and forefoot started to cause pain as weight was shifted. From a functional viewpoint, this operation was tantamount to a "functional amputation" and should therefore only be used in exceptional cases.

Modern foot surgery aims to correct the deformity while preserving the joint so that the foot regains all its functions and the big toe joint is fully mobile with no restrictions or impediments. A primary goal of modern day surgical techniques is to restore the strength of the entire first metatarsophalangeal bone so that it can bear weight when walking. After modern surgery many patients nowadays can do sports without any trouble, even point work in ballet.

A wide range of surgical techniques are now available, depending on the type and, more especially, the extent of the deformity. In the past results were often unsatisfactory because the procedure chosen did not take into consideration the peculiar characteristics of the deformity. Failure was more or less "programmed in".

Modern surgical procedures normally involve two steps. Firstly the surgeon will loosen the tissue (tendons and joint capsule) on the outside (in the direction of the second toe) so that the angle of the big toe joint can be corrected . The second step is to correct the varying degrees of bone deformity of the first metatarsophalangeal bone. This involves cutting through the metatarsal with a miniature motor saw (osteotomy). The separated parts of the bone are then pushed together so that the first metatarsal is more or less parallel to the second. This corrects the metatarsal splaying. Finally the surgeon will fix the bone with wires or mini screws so that it heals correctly in the new position, which takes around 4 to 6 weeks. Depending on the deformity, the metatarsal may be cut through either in the form of a V or Z or by cutting off the bony wedge.

Immobilisation in a plaster cast is normally not necessary and patients can usually put weight on their foot immediately after the operation. A special shoe has to be worn at the beginning (pressure relief shoes or post-op shoe). By putting weight on the foot from the very beginning the danger of thrombosis is reduced.

At the Emma Klinik modern forefoot surgery is performed under a combination of general anaesthesia with additional regional anaesthesia (local anaesthesia in the foot). This has the advantage that when patients wake up from the operation, they do not feel any pain, even after several hours.

Physiotherapy to restore the mobility of the big toe joint is an important aspect of post-operative care, as well as lymph drainage to treat any swellings that typically appear after the operation. If the operation to correct the hallux valgus goes to plan, patients can normally wear ordinary shoes after 6 weeks. Sports can be taken up again after 3 months.

As a result of surgery the pain is eliminated. The foot becomes fully functional again. Once the big toe has been straightened the foot will be narrower so that normal shoes can be worn.