Hallux valgus

Last evidence check March 2010

Is surgery any use?

The only study to examine this question is a RCT by Torkki (2003).

Patients who were suitable for surgery were randomised to no treatment, a functional foot orthosis or a distal chevron osteotomy. Great toe pain was the main outcome measure

After one year the best pain relief was in the surgical group. The orthotic group had temporary improvement in the first 6 months.

At one year the orthotic and non-treatment groups underwent chevron osteotomies. At two years from study entry there were no differences in outcome in any group.

Surgery was the best method of treating great toe pain in eligible patients. However, delaying surgery had no adverse effects.

Principles of surgical technique

As noted earlier, most of the evidence suggests the metatarsal head is pushed medially as the phalanx moves into valgus. Therefore, by removing the pressure from the phalanx, the metatarsal head may move naturally into the corrected position. This is the goal of soft tissue procedures such as the Silver or McBride, and may occur after excision arthroplasty (Keller or Mayo procedures) or fusion of the 1st MTP joint.

Unfortunately, realignment of the first metatarsal is often partial after these procedures, and inadequate correction of first metatarsal alignment is the commonset cause of failure of the Silver bunionectomy.

Therefore, most hallux valgus corrections incorporate a first metatarsal osteotomy to realign the head over the sesamoids. The osteotomy may be made through the distal, diaphyseal or proximal part of the metatarsal. It may incorporate additional correction of the DMAA.

An alternative method of realignment is to fuse the first tarsometatarsal joint with reposition of the first metatarsal (Lapidus procedure).

The other pages in the surgical section review some common procedures and their results. Many procedures have been described, mostly variants around those described here. We have chosen procedures UK orthopaedic trainees are likely to come across, or need to be aware of.