You are in: eMedicine Specialties > Orthopedic Surgery > FOOT AND ANKLE Hallux ValgusArticle Last Updated: Mar 16, 2005AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: Crista J Frank, DPM, Surgeon, Department of Surgery, Landmark Medical Center Crista J Frank is a member of the following medical societies: American College of Foot and Ankle Surgeons and American Podiatric Medical Association Coauthor(s): Dan E Robinson, DPM, Chief, Section of Podiatry, Dwight D Eisenhower Veterans Affairs Medical Center Editors: John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director Designate, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri Author and Editor Disclosure Synonyms and related keywords: hallux abductovalgus, HVA, bunion deformity, metatarsus primus varus, metatarsus primus adductus, foot deformity, Reverdin procedure, Reverdin's procedure, hallux rigidus INTRODUCTIONSection 2 of 13
  History of the ProcedureIn the 19th century, the prevalent understanding of the bunion was that it was purely an enlargement of the soft tissue, first metatarsal head, or both, most commonly caused by ill-fitting footwear. Thus, treatment had varying results, with controversy regarding whether to remove the overlying bursa alone or in combination with an exostectomy of the medial head. These surgeries were considered to be beneath many surgeons, so the understanding of the pathology was gradual in its development. Surgeons slowly began to recognize that bunions could develop due to numerous different factors, that they tended to be familial, and that they were often associated with other foot deformities. As the school of thought began to shift, the first surgical treatment to address deforming pathology was developed and presented on May 4, 1881, when J. L. Reverdin gave a report to the Medical Society of Genfer concerning hallux abductovalgus. He described a procedure with a curved incision medial to the extensor hallucis longus followed by incision of the periosteum, chiseling off of the exostosis, removing a wedge of bone from behind the capitulum of the metatarsus, and suturing the bone with catgut. This operation is considered to be the predecessor of all operations that aim to correct hallux valgus via osteotomy. Since its inception, the Reverdin procedure has undergone many variations and modifications, including the addition of lateral releases and proximal osteotomies, in an effort to address deformity. Indeed, more than 100 procedures have been attempted and developed for the correction of hallux valgus, previously called a bunion. However, many of these variations have been ignorant or even repetitious of previous procedures, both failed and successful. Surgeons have continued to reevaluate the osteotomy in search of the most stable procedure with the fewest complications. ProblemHallux valgus is considered to be a medial deviation of the first metatarsal and lateral deviation and/or rotation of the hallux with or without medial soft tissue enlargement of the first metatarsal head. This condition can lead to painful motion of the joint or difficulty with footwear. FrequencyAlthough hallux valgus is a common occurrence that accounts for a significant number of office visits to foot and ankle specialists, the incidence has not been accurately documented. Relatively few studies are available, and much of the information consists of empirical data based on patient observations. According to the National Health Interview survey conducted by the National Center for Health Statistics, this condition affects 1% of adults in the United States. Gould et al found that the incidence increased with age, with rates of 3% in persons aged 15-30 years, 9% in persons aged 31-60 years, and 16% in those older than 60 years. Gould et al also reported a higher incidence in females versus males, with ratio of 2:1 to 4:1. Whether this finding indicate a truly increased incidence in the female population or whether it reflects differences in footwear remains to be determined. The role of genetic predisposition has also been noted, with evidence to suggest familial tendencies. No conclusive results have been reported to indicate racial predisposition. EtiologyContrary to common belief, high-heeled shoes with a small toe box or tight-fitting shoes are not etiologies of hallux valgus, but they do keep the hallux in an abducted position if hallux valgus is present, causing mechanical stretch and deviation of the medial soft tissue. In addition, tight shoes can cause medial bump pain and nerve entrapment. Hallux valgus is known to have numerous etiologies, including biomechanical, traumatic, and metabolic factors. Etiologies of hallux valgus include the following:
PathophysiologyDuring the gait cycle, the hallux and digits generally remain parallel to the long axis of the foot, regardless of the degree of forefoot abduction (or pronation) occurring (see Image 3). This is because of the pull of the conjoined adductor tendon, extensor hallucis longus, and flexor hallucis longus tendons. The tendons gain greater mechanical advantage the further displaced the joint becomes, with tension created for the medial aspect of the joint and compression laterally. Medial tension causes the medial collateral ligaments to pull on the dorsomedial aspect of the first metatarsal head, causing the bone to proliferate. Lateral tension causes the sesamoid apparatus to fixate in a laterally dislocated position. Remodeling also occurs laterally in addition to medially, as evidenced by the increase of the proximal articular set angle or structural remodeling of the cartilage. Therefore, without correction of the biomechanical etiology, excessive pronation continues, with propagation of the deformity. ClinicalHistory Patients can present initially in several ways; therefore, evaluation of their history is extremely important. A patient may present with a nonacute onset of deep or sharp pain in the first metatarsophalangeal joint during ambulation, with exacerbation during particular activities. This presentation indicates degeneration of the intra-articular cartilage. Patients may also describe aching pain in the metatarsal head secondary to shoe irritation that is relieved when the shoes are removed. This presentation is indicative of superficial bump pain. Often, both forms of pain are progressive and have been present for many years. The frequency or duration of pain may have recently begun to increase, and activity may exacerbate the pain. Patients may even describe a recent notable increase in the size of the deformity or medial bump. Limitation of physical or daily living activities is also a valuable aid in understanding the severity of the patient's pain. Ascertaining what relieves the pain and what past treatments (eg, surgery) is also important. Occasionally, trauma or inflammatory arthritis can be an associated finding. Another possible presentation is burning pain or tingling in the dorsal aspect of the bunion, which indicates entrapment neuritis of the medial dorsal cutaneous nerve. The patient may also describe symptoms caused by the deformity, such as a painful overlapping second digit, interdigital keratosis, or ulceration to the medial metatarsal head, without complaint of the bunion deformity itself. Physical examination The physical examination includes an assessment of the vascular, dermatologic, neurologic, and musculoskeletal systems. The musculoskeletal assessment can be divided into 2 components: determination of the causative etiology and evaluation of the resultant pathology (or presenting deformity). It is essential to understand both components to determine the most satisfying and successful treatment plan, whether conservative or surgical. The workup for the causative etiology is tailored according to the patient's history. If a neurologic complaints, systemic arthritis, or collagen vascular disease are mentioned, they should be further addressed in detail. If none of these are present, the focus then turns to the biomechanical examination, which includes assessment of the following measures, any or all of which can contribute to hallux valgus:
Assessment of resultant pathology can be divided into weight-bearing and non–weight-bearing evaluations, as both yield important information for determining the appropriate treatment protocol (see Image 4). With the patient in a non–weight-bearing position, examine the following.
Often, the pathology or severity of deformity is not as apparent when the patient is not bearing weight as it is when the patient is bearing weight. Therefore, weight-bearing examination is an important part of the physical evaluation. In the weight-bearing examination, assess the following aspects:
INDICATIONSSection 3 of 13
Indications for repair of hallux valgus include painful joint ROM, deformity of the joint complex, pain or difficulty with footwear, inhibition of activity or lifestyle, and associated foot disorders that can be caused by this condition. Associated foot disorders include the following:
RELEVANT ANATOMYSection 4 of 13
See Images 6-7. CONTRAINDICATIONSSection 5 of 13
Contraindications to surgery include the following:
WORKUPSection 6 of 13
Lab Studies
Imaging Studies
StagingRoot et al described the pathomechanical development of hallux valgus in 4 stages.
TREATMENTSection 7 of 13
Medical therapyAdequate physical examination is required to determine the contributing etiology and resultant deformity to know how to approach treatment. Medical therapy can be used to address the etiology, but it cannot change the deformity, as this is irreversible because of cartilage, bony, and soft tissue adaptation. Therefore, most medical therapies are aimed at assuaging symptoms. Adapting footwearSpot-stretching shoes or using of shoes with wider and deeper toe boxes might be considered. Padding and strapping have limited success, other than to relieve footwear or digital pressure in long-term management. However, in the elderly population, padding and strapping may be the best options if contraindications to surgical correction are present. Pharmacologic or physical therapyNonsteroidal anti-inflammatory drugs and physical therapy can also be offered to relieve acute, episodic inflammatory processes. Corticosteroid injections can also be offered in the management of acute inflammatory conditions to the first metatarsophalangeal joint. No evidence supports prolonged physical therapy for hallux valgus. Functional orthotic therapyFunctional orthotic therapy might be implemented to control the biomechanics. This approach can relieve symptomatic bunions, though the foot and first metatarsophalangeal joint must still have some degree of flexibility. For example, the joint cannot be clinically found to be laterally track bound, and on radiograph, the sesamoid position cannot be greater than 4. These 2 findings indicate a nonreducible deformity, or one that cannot be manipulated to a neutral pain-free position. Flexibility is necessary, as it allows the orthotics to manually manipulate the joints and foot and reduce the deformity. It provides stability and thus relief. A rigid deformity can only be corrected surgically, as it can no longer be manipulated. If orthotics are to be manufactured for a patient, the physician must be familiar with the orthotic prescription form to control the patient's deformity, though this form varies among different manufacturers. In addition, a sufficient understanding of what the patient requires may enable the physician to use simple over-the-counter devices instead of more costly custom-molded devices. The physician should be aware of the following issues: the patient's activities and weight, the top cover of the orthotic, the rearfoot/forefoot post, the biomechanical examination, and the possible modifications. These are discussed in more detail next. Activity When prescribing orthotics, the physician should ask questions such as these: "When will the patient primarily be using the orthotics? In dress shoes? During sports activities? During the day at work?" Generally, dress shoes afford the patient the option to wear smaller devices, but these lack the control as larger orthotics. Patients participating in sports require more shock-absorbing capability from the orthotic; therefore, a more pliable material should be used. Furthermore, the type of material used for the shell or orthotic can vary. A rigid material, such as graphite, is thin and lightweight, it does not deform, and it is durable. However, graphite has a tendency to crack; therefore, it should not be used for sports applications. Another option is polypropylene, a type of durable, flexible plastic that is resistant to breakage. It can easily be altered by grinding or heat molding in the office, whereas graphite cannot. One disadvantage of polypropylene is its tendency to deform over time and with use. Some physicians use leather or cork with success. Weight The material used can be ordered in varying thicknesses. The heavier patient need a material that is thicker in to enable it not to bend, crack, or deform under the patient's weight. As well, the bulkier the patient's shoe, the thicker the shell material that can be used without causing the orthotic to fit uncomfortably. A thicker material can add control. Top cover Orthotics generally have liners on top of the shell, either for shock absorption or cushioning or to act as the shoe liner. Choices include but are not limited to leather, vinyl, Spenco, ethylene vinyl acetate (EVA), Poron, and Pelite. Top covers do not contribute to the control of the orthotics and are not functionally needed. Rearfoot/forefoot post Applying a post, or exterior material that is either molded with the shell or added on later from a different material can increase the stability and control of the orthotic. A rearfoot post is under the heel cup, which does not extend into the midfoot region. A forefoot post may be added for biomechanical control for a patient with a rigid deformity, such as rigid forefoot valgus, which cannot be satisfactorily or comfortably controlled with the orthotic due to the nonmaneuverability of the patient's foot. Therefore, the patient with rigid forefoot valgus requires a piece of material added extrinsically, or under the orthotic on the lateral aspect, to balance the forefoot to the rearfoot. Biomechanical examination The physician must determine what type of deformity the patient has and obtain angular measurements to prescribe for the correction. A plaster non–weight-bearing mold is made of the foot in a neutral position (rear foot neither everted or inverted), with the forefoot loaded to simulate weight bearing. From this cast, the orthotic manufacturer creates an orthotic with corrections built into the orthotic. For example, if the patient has a 4° flexible forefoot varus, the rear foot is likely compensating for this deformity in order to allow the forefoot to bear weight evenly across all metatarsal heads. A well-built orthotic compensates for this inconsistency and allow the foot, both in the forefoot and rear foot, to stand in a neutral position, removing increased pressures and deforming forces caused by the compensation. Modifications Modifications include measures such as increasing the height of the heel cup (for more control), creating a wider medial arch (for a collapsed, flat foot), providing plantar fascial groove (for a tight, painful plantar fascia), and using a metatarsal pad (for pain under second metatarsal head secondary to overloading due to the hallux not bearing weight appropriately). If the etiology is determined to be a metabolic or systemic condition, it is best to work with a rheumatologist, neurologist, or primary care physician to stabilize, manage, and slow the progression of disease and to choose therapy for the hallux valgus deformity. Surgical therapySurgical treatment can be offered when conservative therapy is impractical or fails to relieve the patient's symptoms. The goals of surgical treatment are to relieve symptoms, restore function, and correct the deformity. The clinician must consider the patient's history and physical and radiographic findings before selecting a procedure. On occasion, the final procedure is determined intraoperatively when the physical appearance of the joint, bone, and tissue can be directly observed. The following features of the surgical repair allow for successful correction of the deformity:
The actual procedures vary depending on the surgeon's preference, the nature of the deformity, and the particular needs of the patient, though the surgeon can follow a simple algorithm based on clinical and radiographic findings to determine the procedure of choice (see Image 17). The procedure is chose to reduce the patient's symptoms most effectively and prevent reoccurrence. The selections are based on particular components of the hallux valgus, which can include positional and structural deformities of the metatarsophalangeal joint, adaptive changes of the first metatarsophalangeal joint, and the position and condition of the sesamoid apparatus. The classes of surgical procedures include capsulotendon balancing or exostectomy, osteotomy, resectional arthroplasty, resectional arthroplasty with implant, first metatarsophalangeal joint arthrodesis, and first metatarsocuneiform joint arthrodesis. Capsulotendon balancing or exostectomy This procedure can be performed independently, but it is usually performed in conjunction with an osteotomy. It is designed to restore the integrity of the first metatarsophalangeal joint and reduce the medial osseous prominence of the metatarsal head. Indications include a painful osseous medial prominence of the metatarsal head, deviated or subluxed first metatarsophalangeal joint, adequate, pain-free ROM, and reducible deformity. The patient's postoperative course includes limited-to-full weight bearing in a surgical shoe immediately following the procedure. Osteotomy Osteotomy (see Images 18-19) is performed to correct structural deformities associated with the cuneiform, metatarsal, and phalanges of the first ray and typically includes a lateral release and capsulorraphy. These procedures should be performed at the level of the deformity. Akin first proposed osteotomy of the hallux in 1925 for the correction of hallux valgus. However, experience has shown that this is not a primary procedure to be used for the repair of hallux valgus deformity, as it does not directly restore the sesamoid position, address adaptive changes of the cartilage of the metatarsal phalangeal joint, or correct metatarsal deviations. Instead, hallux osteotomies are used to address deformity of the proximal phalanx, correct an abnormal hallux abductus interphalangeus angle, long proximal phalanx, abnormal distal articular set angle (DASA), or frontal plane rotational position of the hallux. The common proximal phalanx osteotomy performed is the Akin procedure, in which a medial wedge is removed from the proximal phalangeal shaft. This procedure is often performed concomitantly with a procedure that does address hallux valgus, should deformity of the proximal phalanx also be present. It is best evaluated intraoperatively once the primary surgical procedures have been performed. Should an Akin operation be performed independently for correction of hallux valgus, the surgeon may anticipate an even greater lateral subluxation of the first metatarsophalangeal joint that leads to rapid recurrence of the original condition despite the initial clinical improvement. Metatarsal/cuneiform osteotomies address deformities occurring along the metatarsal/cuneiform complex. Indications include an increased intermetatarsal angle, metatarsus primus elevatus, or increased proximal articular set angle with articular adaptation of the first metatarsal head. The levels at which they are performed include the distal, diaphyseal, and proximal levels along the metatarsal shaft. Distal osteotomies are performed in the metaphyseal region and achieve only a relative correction of the intermetatarsal angle. They are inherently stable and are associated with fewer occurrences of head displacement/rotation or shaft elevation. The joint congruency is corrected primarily with this osteotomy. They may be performed for both a congruent joint as well as an incongruent joint with an intermetatarsal angle less than 15°. Following distal osteotomies, the patient typically has 2-6 weeks of limited weight-bearing in a surgical shoe. Common complications include shortened first metatarsals, second metatarsalgia, restriction of motion, and recurrence of deformity. Common distal or head osteotomies include the following: (1) the Reverdin-Laird procedure, which is a medially based wedge resection with lateral transposition of the metatarsal head; (2) the Austin or Chevron procedure in which a horizontally directed V displaced osteotomy with lateral transposition of the metatarsal head; and (3) the Mitchell procedure, which is a lateral transpositional transverse osteotomy with preservation of a lateral cortical block of bone. Diaphyseal osteotomy is associated with a decreased blood supply and is less stable than a distal procedure, but it can achieve a greater correction of the deformity and address a true proximal articular set angle (PASA) deviation. It can lengthen the first metatarsal after rotation or translocation to correct the intermetatarsal angle; therefore, it is a good procedure of choice for short metatarsals. The midshaft osteotomy is performed for mild-moderate hallux valgus deformities, with an intermetatarsal angle greater than 15° but a hallux valgus angle <40°, though large degrees of correction can also be achieved with greater rotation of the fragments. In addition, this can be performed as an alternative to a base procedure. This procedure is best used in patients with good bone quality without significant osteopenia. Common midshaft or diaphyseal osteotomies include (1) the Scarf procedure in which a Z-shaped osteotomy in the transverse plane extends from the metatarsal head to the base with lateral rotation of the distal fragment, and (2) the Ludlof procedure in which an oblique osteotomy is oriented dorsal and proximal to plantar distal from the head to the base with distal bone fragment transposed laterally. The proximal osteotomy is considered to be the least stable, with the greatest risk for metatarsal elevation and fixation failure, but it achieves an actual instead of relative correction of the intermetatarsal angle. Base osteotomies are considered for hallux valgus deformities with an intermetatarsal angle greater than 15° and a hallux valgus angle greater than >40, in which the first metatarsocuneiform joint does not demonstrate hypermobility. Proximal procedures necessitate the use of a non–weight-bearing cast for 4-8 weeks until complete ossification occurs to prevent elevation of the metatarsal. Common base or proximal osteotomies as follows: (1) In the crescentic method, a crescentic blade is used to transect the first metatarsal, resulting in a dome-shaped osteotomy. The distal segment can be rotated in the transverse and sagittal planes for correction of the deformity. (2) The closing abductory wedge (Loison/Balacescu type) procedure is a transverse osteotomy with the lateral wedge removed and the medial hinge kept intact. (3) The closing abductory wedge (Juvara) procedure is a long, oblique osteotomy extending proximal-medial to distal-lateral with the lateral wedge removed and medial hinge left intact. Resectional arthroplasty Resectional arthroplasty (see Images 20-21) is a joint-destructive procedure that is most commonly reserved for elderly patients with advanced degenerative joint disease with significant limitation of motion. The typical resectional arthroplasty that is performed is known as a Keller procedure. It is performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected. The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups. The technique is inherently unstable and should be used judiciously. The postoperative course includes limited to full weight bearing in a surgical shoe immediately after the procedure. Resectional arthroplasty with implant Resectional arthroplasty with implant (see Images 22-24) is the same procedure as the resectional arthroplasty, with similar indications, yet with the addition of the total implant the stability is markedly improved. However, this operation is not without the complications inherent to implants, which include foreign-body reactions, synovitis, lysis of the bone, and implant failure. First metatarsophalangeal joint arthrodesis First metatarsophalangeal joint arthrodesis (see Images 25-26) is a joint-destructive procedure, yet it offers a higher degree of stability and functionality and is considered the definitive procedure for degenerative joint disease. It results in complete loss of motion at the first metatarsophalangeal joint and is reserved for patients with high activity levels and functional demands. This is a difficult procedure to perform in elderly persons because of the need for non–weight-bearing status for 4-8 weeks postoperatively. Indications include painful or severely limited first metatarsophalangeal joint ROM, significant degenerative arthritis, revision or repair of prior arthroplasty with implant or osteotomy (salvage procedure), extensive trauma to the first metatarsophalangeal joint not reparable with osteotomy, ligamentous laxity, and neuromuscular disease. First metatarsocuneiform joint arthrodesis Significant and/or hypermobile hallux abductovalgus may be reduced with arthrodesis of the first metatarsocuneiform joint (see Images 27-28.) Indications include metatarsus primus varus, hypermobility of the first ray, metatarsalgia of the lesser metatarsals, and degenerative joint disease of the metatarsocuneiform joint. Preoperative detailsA complete history and physical examination are required for surgical correction. The evaluation may include an electrocardiography; chest radiography; and laboratory workup, including a complete metabolic panel, complete blood count, coagulation studies, and urinalysis if warranted. The history should include allergies, complications with anesthesia, bleeding disorders, use of anticoagulants, immunocompromise status, and tobacco use. The patient should be well informed of the etiology, course, and prognosis of the deformity, as well as the risks and benefits of conservative and surgical options. Hallux valgus can generally be surgically corrected on an outpatient basis. Situations that could warrant inpatient hospitalization include the need for parenteral medications, the presence of perioperative complications or anesthetic complications, an inability to functioning independently, and the presence of coexisting medical condition. Patients undergoing complex surgical procedures may also require hospitalization. Hallux valgus can be corrected surgically by using a variety of anesthetic techniques depending on the surgeon's, patient's, or anesthesiologist's preference. The choices include general anesthesia, spinal anesthesia, or monitored anesthesia with local blocks. The block is typically performed with a short- and/or long-acting local anesthetic. It should be administered prior to the initial incision for maximum benefit and preemptive analgesic effect. A pneumatic ankle tourniquet is generally advised to achieve hemostasis for better intraoperative visualization. Prophylactic antibiotics are generally not warranted unless the surgery is anticipated to last longer than 2 hours, the patient is immunocompromised, or an implant is being inserted. Intraoperative detailsA linear dorsomedial longitudinal incision, extending from the mid shaft of the first metatarsal distally to the mid shaft of the proximal phalanx medial to the extensor hallucis longus tendon, is created. The incision is deepened through skin and soft tissue, with care taken to identify and retract all vital neurovascular structures. Cauterization is used as needed for bleeding. The lateral release is then performed in stepwise fashion to achieve release of lateral contractures, with the hallux able to reduce without restriction (see Image 29). Capsulotomy is then performed and the periosteum is reflected to expose the metatarsal head. The initial goals of the anatomic dissection are to provide access to the surgical area, to establish hemostasis, to identify and release any soft tissue contractures, and to prepare the site for the osteotomy. Once this is accomplished, the predetermined osteotomy is performed. Fixation is achieved by using the lag technique described by the Arbeitsgemeinschaft für osteosynthesefragen–Association for the Study of Internal Fixation (AO-ASIF). Once fixed, the capsule, subcutaneous tissue, and skin are reapproximated, with capsulorraphy performed if warranted. Dressings consist of nonadherent gauze with dressings to splint the hallux in its newly corrected position. Postoperative detailsThe type of procedure performed and its inherent stability determine postoperative management of the osteotomy. Dressings applied at the time of the surgery should supply corrective forces, such as derotation, plantarflexion, and adduction, while the soft tissue remodels with mild compression to control postoperative edema. Pain should be well controlled postoperatively. The patient's weight-bearing status is determined on the basis of the procedure performed, but it is generally limited during the first 2 weeks to prevent deviation or displacement and to minimize edema. The patient may begin ROM exercises on a daily basis after the sutures are removed, and weight-bearing is advocated to prevent limitation of joint motion from excessive scarring. Radiographs are obtained immediately after surgery and when a change in activity level is anticipated to assess alignment, fixation, and progression of ossification. Follow-upOnce the immediate postoperative period has passed, ensuring that the deformity does not recur is important. Therefore, the etiology must again be reconsidered and addressed properly. If the practitioner is can control such factors, he or she should do so at this time to optimize the surgical results. Patients may require functional orthotic control. Several studies have shown that orthotic devices are beneficial, especially in patients with diseases such as rheumatoid arthritis in which excessive forces accelerate degeneration. Control of these forces may postpone further destruction to the joints and provide the best long-term results after surgery. COMPLICATIONSSection 8 of 13
Complications can include delayed healing of the incision, osseous malunion or nonunion, numbness or tingling, hematoma, hardware failure, displacement of the osteotomy, delayed suture reaction, cellulitis, osteomyelitis, avascular necrosis, elevation of the metatarsal, transfer lesions, limitation of joint motion, hallux varus, and recurrence. These complications can vary depending on the surgical technique and procedure. Preoperative education and realistic patient expectations can help in minimizing or managing these sequelae. OUTCOME AND PROGNOSISSection 9 of 13
Hallux valgus is a complex deformity, and various approaches are available. To date, no satisfactory studies have been performed to compare the various procedures and their success rates. If the deformity and etiology are successfully addressed, the benefits of treatment far outweigh the risks. For excellent patient education resources, visit eMedicine's Foot Care Center. Also, see eMedicine's patient education article Corns and Calluses. FUTURE AND CONTROVERSIESSection 10 of 13
In the future, surgeons and patients will benefit from prospective randomized studies to actively compare various procedures, their success rates, and their indications. The surgeon must continually search for the most stable procedure that offers the greatest degree of correction with the fewest complications. Surgeons must first be familiar with what has been attempted previously to avoid the mistakes of the past. ACKNOWLEDGMENTSSection 11 of 13
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Dale Dalenberg to the development and writing of this article. MULTIMEDIASection 12 of 13
REFERENCESSection 13 of 13
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