Hallux valgus correction is a therapeutic foot surgery procedure used to treat hallux valgus (synonym: crooked toe). Hallux valgus is a combined deformity of the foot, which is characterized by the presence of both a malposition of the big toe in the metatarsophalangeal joint and a spreading of the metatarsus. Due to this change in the skeleton of the foot, the metatarsophalangeal joint of the big toe pulls laterally (away from the body) as the first metatarsal bone moves medially (towards the body).According to current scientific knowledge, the probability of the presence of hallux valgus depends on heredity, although no exact mode of inheritance has yet been discovered. The main cause of hallux valgus today is considered by doctors to be wearing improper footwear (high-heeled and tight shoes). As a consequence of wearing heels with a pointed front, the so-called valgus position of the big toe develops. The resulting reduced mobility of the big toe leads to the development of a manifest (permanent) deformity, the contracted hallux valgus. Due to this etiology (disease development), hallux valgus is a primarily degenerative phenomenon (wear and tear) that usually affects mainly middle-aged and elderly women. In order to cure the affected patient or reduce his pain, conservative (non-surgical) measures such as wearing orthopedic shoes, but also surgical interventions can be performed. Currently, various surgical methods are used for hallux valgus correction. The selection of the therapeutic procedure depends on the one hand on the clinical or diagnostic appearance, on the other hand also the activity and the age of the patient play an important role in the selection of the therapeutic option. Nowadays, more than sixty percent of people over 40 complain about painful feet. However, before therapy can take place, the treating physician must determine the severity of the deformity. The most important diagnostic procedure for the evaluation (assessment) of hallux valgus is X-ray diagnosis. Exclusively if a tumor or other atypical pathology is suspected, procedures such as magnetic resonance imaging (MRI) or sonography (ultrasound) should be used.
Indications (areas of application)
If symptoms are mild, conservative measures can often relieve symptoms. However, if the deformity is considered limiting and the clinical symptoms are permanent, surgical intervention should be performed. In contrast to the past, surgery is now performed for the present hallux valgus if no complex functional damage has yet occurred in the foot as a result of the deformity. Due to the fact that early surgery usually improves the prognosis, the patient suffering from painful hallux valgus should present to the orthopedist and find out about further therapeutic measures.
Contraindications
- Peripheral arterial occlusive disease (pAVK) – Patients suffering from peripheral arterial occlusive disease should usually not have surgical corrections performed on a hallux valgus, as this can massively aggravate the primary symptoms.
- Skin infections in the surgical area
- Thrombosis patients
Before surgery
- Because surgical treatment of hallux valgus is performed under either general or spinal anesthesia, the patient should remain fasting the evening before the procedure, although exceptions may be made in individual cases.
- In many cases, medications that inhibit blood clotting, such as acetylsalicylic acid (ASA), must be discontinued prior to surgery.
- Furthermore, prior to surgery, X-ray diagnostics must be used to determine which conservative or surgical procedure is suitable as a therapeutic measure and thus recommended.
The procedures
As a therapeutic measure for an existing hallux valgus, surgical and non-surgical procedures can be used. However, it is also possible to take preventive measures before the development of a manifest hallux valgus for prevention.In addition to refraining from wearing pointed and high-heeled shoes permanently, it is further indicated to perform foot gymnastics and to walk barefoot as far as possible. Conservative therapy for hallux valgus:
- Foot gymnastics – the benefit of this conservative procedure is now considered by most doctors to be relatively small, since the mobility of the big toe is only slightly improved and at the same time a slight strengthening of the muscles of the foot muscles.
- Orthopedic shoes – orthopedic shoes or insoles provide relief for the affected foot, as they allow forefoot softness due to their structure and shape, and significantly reduce the pressure discomfort on the big toe. With increasing age and permanent stress, an advanced stage of deformity is frequently reached, which can be treated conservatively by means of adjustments to the shoe in the sense of a roll cradle and support in the metatarsal region through precise foot bedding. In contrast to the advanced hallux valgus can be stopped at the juvenile hallux valgus by means of conservative treatment during skeletal growth a progression (advancement) of the deformity.
Distal soft tissue surgery with osteotomy (surgical bone transection).
- Lateral release – In this surgical procedure, the skin of the great toe is opened through a dorsal incision (dorsal foot incision). Following the opening, scissors are used to spread the subcutaneous (underneath the skin) fat tissue down to the tendon of the adductor hallucis muscle (big toe muscle). After the spreading is done, a so-called Langenbeck hook is inserted. To expose the tendon, it must be stretched by forceful traction. This tendon stretching makes it possible to detach the displayed tendon from the outside of the sesamoid bone with the help of a scalpel. Once this is done, the tendon is then removed from the great toe directly on the bone. In order to be able to cut the metatarseum transversum ligament (metatarsal tendon), this must first be exposed by means of dissection with a curved clamp. In order to significantly reduce the risk of complications, the courses of the superficial nerves and vessels must be precisely observed and omitted. A subsequent step in this method is the multiple incision by scalpel into the lateral (side) portion of the joint capsule of the first metatarsophalangeal joint (metatarsophalangeal joint). Then, the entire capsule of the metatarsophalangeal joint can be torn after additional forceful manipulation.
- Medial capsular reefing – to perform this surgical method, a scalpel must be used to split the skin over the ball of the big toe. This incision forms the basis for the vertical opening of the joint capsule. Through this surgically created opening, the pseudoexostosis (synonyms: Overbone, bone bulge – represents an increase in bone substance for the layman, yet pseudoexostosis is exclusively the joint malposition, which gives the impression of a new bone formation) can be removed up to a defined point. Furthermore, a strip of capsule approximately seven millimeters wide is cut out of the anterior part of the joint capsule. Then, after the suture at the end of the operation, the big toe is held by the shortened capsule of the first metatarsophalangeal joint (metatarsophalangeal joint) in an axis-correct position, so that the prognosis for freedom from pain and discomfort can be described as satisfactory.
- Basic osteotomy of the metatarsal I – In addition to the surgical procedures already presented, there is also the therapeutic option of performing a surgical transection of the Os metatarsale I (first metatarsal bone). In this surgical method, the base of the Os metatarsale I is initially exposed through a skin incision starting from the dorsum of the foot in the first interdigital space (space between the toes). Then, the osteotomy (surgical bone cutting) is performed between the Os metatarsale I and the Os kuneiforme I (first sphenoid bone). A special arcuate saw blade is used to prevent length reduction of the Os metatarsale I and to increase the postoperative stability of the affected joints. The anterior portion of the transected metatarsal is guided into the correct position with the aid of a sharp clamp.The posterior portion of the bone can be positioned by compressing the forefoot to allow adequate adaptation to the physiological condition.
Chevron osteotomy
- In this relatively old surgical procedure, after osteotomy of the Os metatarsale I (metatarsal I) has been performed, the posterior bone fragment is displaced outward and the pseudoexostosis is removed. In principle, the procedure of the operation can be compared with the basic osteotomy.
Osteotomy of the proximal phalanx
- Although this method was first described in 1925, it is still relatively widely used nowadays because osteotomy of the proximal phalanx can be very well combined with other surgical procedures to correct hallux valgus. After spreading the skin and exposing the Os metatarsale I, the bone at the site of the intended osteotomy is prepared and exposed subperiosteally (below the connective tissue envelope of the bone). An oscillating (vibrating) saw is now used for the subsequent osteotomy. The bone material removed in this way is the deformity identified before surgery by radiological diagnosis.
After surgery
- Pain – as anesthesia (numbing) progressively wears off after surgery, pain may increase significantly as the procedure progresses, so taking an analgesic (pain-relieving medication), preferably a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen, is indicated. The substance to be taken and the dosage are selected by the attending physician
- Immobilize the affected foot – to reduce swelling and improve healing, the operated leg or foot should be spared for the time being.
- Mobilization of the patient with the help of hallux valgus shoes (HVS) for 6 weeks. These shoes have a rounded and stiffened sole or are forefoot relief shoes (VES), with which the forefoot is supported and relieved when walking. The hallux valgus wearer should refrain from driving a car during this time, because due to the wearing of the orthoses, the braking response is considerably prolonged.
Possible complications
- Wound healing disorders (2-4%)
- Bone or joint infections – surgical procedures on the skeletal system are always associated with a risk of infection.
- Nerve lesions – due to the surgical area, there is a possibility that an adjacent nerve is affected by the surgical intervention.
- Anesthesia – the procedure is performed under general anesthesia or after performing spinal anesthesia, resulting in various risks. General anesthesia can cause, among other things, nausea and vomiting, dental damage and possibly cardiac arrhythmia. Circulatory instability is also a feared complication of general anesthesia. Nevertheless, general anesthesia is considered a procedure with few complications.Spinal anesthesia is also relatively low in complications, but complications can also occur with this method.
