hallux abductovalgus


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hallux abductovalgus

; HAV biplanar first-ray deformity, where the tip of the hallux is deviated on the transverse plane (away from body midline) in conjunction with frontal-plane axial rotation of the hallux about its longitudinal axis (i.e. the medial nail sulcus approaches the support surface) and transverse-plane deviation of the first metatarsal head towards the midline of the body (i.e. secondary to metatarsus primus varus); HAV is associated with a range of forefoot pathologies (Table 1 and Box 1; Figure 1) and may require surgical correction Table 2
Table 1: Features that predispose to hallux abductovalgus
LocationFeaturePredisposing factor
Intrinsic to the foot and lower limbExcess STJ and MTJ pronationAnkle equinus
Pes planovalgus
Forefoot varus
Metatarsus primus elevatus
Metatarsus primus varus
Pes cavus
Long second metatarsal/short first metatarsal
Functional hallux limitus
Adductus foot
Structural anomalies within the lower limb that predispose to compensatory foot pronationExternal tibial torsion
Tibial varum
Genu varum/valgum, recurvatum
Femoral retroversion
Wide-based gait
Longer limb
TraumaFirst MTPJ intra-articular damage
First MTPJ sprain (turf toe)
Subluxed second toe
Soft-tissue tears
Extrinsic to the foot and lower limbInflammatory joint diseaseRheumatoid disease
Psoriatic arthropathy
Gout
Connective tissue disorders characterized by joint hypermobilityGeneralized hypermobility syndrome
Ehlers-Danlos syndrome
Marfan's syndrome
Down's syndrome
Osteogenesis imperfecta
Neuromuscular disease characterized by the development of pes cavus or pes planovalgusMultiple sclerosis
Hereditary sensorimotor neuropathy (Charcot-Marie-Tooth disease)
Cerebral palsy
Poliomyelitis
Friedreich's ataxia

STJ, subtalar joint; MTJ, metatarsal joint; MTPJ, metatarsophalangeal joint.

Box 1: Clinical features of hallux abductovalgus
  • Diamond-shaped forefoot (adduction of first metatarsal, abduction of hallux, abduction of fifth metatarsal, adduction of fifth toe)

  • Marked varus deviation of first metatarsal and valgus deviation of hallux (more marked in the weight-bearing foot)

  • Dorsiflexion or plantarflexion of the first metatarsal

  • Transverse-plane motion available at distal end of first metatarsal

  • Relatively long or relatively short first metatarsal, in comparison with the second

  • Subluxation of the hallux at the first MTPJ (hallux over- or underlies the second toe)

  • Pain in and around the first MTPJ area that is exacerbated by activity and shoe wear

  • Prominence of medial aspect of the head of the first metatarsal

  • Formation of large bursa overlying medial aspect of the first MTPJ

  • Marked 'bowstring' of the long extensor and flexor tendons

  • Apparent lateral drift of the first MTPJ sesamoids (the medial sesamoid approaches the lateral sesamoid groove on the plantar aspect of the first metatarsal head; the lateral sesamoid occupies the space between the heads of the first and second metatarsals)

  • Axial rotation of the hallux, so that the tibial (medial) sulcus approaches the support surface and the fibular (lateral) sulcus impinges against the medial aspect of the second toe, with resultant hallucal pain and onychophosis

  • Decreased range of sagittal-plane movement at the first MTPJ (hallux limitus)

  • Hyperextension of the hallux at the IPJ with 'roll-off' hyperkeratosis and/or corn formation

  • Reduced hallux purchase Table 3

  • Subluxation of the second MTPJ (second toe over- or underlies the hallux)

  • Lesser-toe deformities, such as hammered second, clawed third and fourth, varus fifth toes

  • Nail pathologies (onychophosis, onychocryptosis, onychauxis) secondary to lesser-toe positional deformities

  • Overload and metatarsalgia of second and third MTPJs

  • Degenerative changes at the first MTPJ with arthrosis, exostosis formation and crepitus

  • Hyperkeratosis (corn and callosity) of plantar skin overlying second and third MTPJs

  • Digital corns (apices of toes, dorsal aspects, PIPJs of second to fourth toes; interdigital corns (often between first and second, and fourth and fifth toes)

  • Focal plantar hyperkeratoses, second and/or fifth MTPJs, or diffuse plantar hyperkeratosis second to fourth MTPJs

  • Morton's (plantar digital) neuroma or neuritis of second (between second and third toes) and third (between third and fourth toes) interspaces

  • Paraesthesia and/or loss of sensation of medial aspect of hallux

  • Excess foot pronation from midstance to toe off

  • Feet abducted throughout gait and during stance

  • Difficulty in obtaining acceptable shoe styles that accommodate the forefoot deformity

Table 2: Classification of hallux purchase
GradeCharacteristics
GoodThe sheet of paper remains static and in situ when pulled
FairThe sheet of paper moves slightly when pulled, but tends to tear when greater traction is applied
PoorThe sheet of paper can be pulled out with minimum effort
AbsentThe paper slips out easily; it is not retained by the hallux as the pulp of the toe does not make ground contact

Hallux purchase is inferred by the ease with which a sheet of paper can be pulled out from beneath the pulp of the weight-bearing hallux.

Figure 1: Clinical features of hallux abductovalgus. HD, heloma durum; ID, interdigital; IDH, interdigital heloma. This article was published in Neale's Disorders of the Foot, Lorimer, French, O'Donnell, Burrow, Wall, Copyright Elsevier, (2006).
Table 3: Surgical options for the treatment of hallux abductovalgus
Surgical approachInterventionExample procedure
Joint-destructive proceduresExcision of base of hallux proximal phalanx
Arthrodesis
Keller
Screw arthrodesis
Joint-preserving proceduresClosing basal wedge osteotomy, first metatarsal
Distal metatarsal osteotomy
Basal wedge osteotomy
Wilson; Austin
Ray alignment proceduresZ osteotomy
Medial closing-wedge osteotomy, hallux
Scarf
Akin
Ray stabilization proceduresArthrodesis of first metatarsal/medial cuneiform jointLapidus
CosmesisExcision of medial eminence at head of first metatarsal (cheilectomy)Silver

There are over 100 named surgical techniques for the correction of hallux abductovalgus, most of which are modifications of a number of principles of approach.