HALLUX VALGUS (part II)

Custom made medial arch support insole

Flat foot (obliteration of the medial arch)
Bunion (swelling at the base of the big toe)

PRECAUTIONARY MEASURES

In the early stages, certain measurements can delay the evolution of Hallux Valgus:

• To avoid the high-heeled shoes
• To avoid the pointed shoes with the front one
• For those with the flat feet: a plantar orthosis with a support of arch.

However in the later stages, there is side luxation of the tendons. This results in a gradual pull leading to the deviation of the big toe.

For comfort, it goes without saying a rather broad shoe which corresponds to real width of the forefoot is recommended. Shoes made of soft leather will be most comfortable. Shoes can also be stretched to enlarged the shoebox. It is also necessary to avoid if possible shoes which have a seam right in the vicinity of the bunion.

In early Hallux Valgus, the pain may be due to stretching of the joint capsule. This can be partly relieved by a toe separator worn in the evening. In the advanced cases, the capsule is stretched so much that it is not sensitive any more.

Occasionally the bunion becomes inflammed. This is mainly due to it rubbing with shoewear. In such cases a change of shoewear and application of ice may releave it.

Current surgical methods have had excellent result. It corrects the deformity, alleviates the pain and allows for the application of normal shoe ware again.

SURGICAL TREATMENT

The surgery for Hallux valgus has had a bad reputation in the pass. There are over 150 different types of surgery for Hallux valgus. SOme have had better results than others.

Multiple variables must be taken into account for an effective surgery with less chance of recurrence. This includes:

• The clinical stage
• The age of the patient
• The degree of deviation of the big toe
• The angle between the 1st and the 2nd metatarsal bone
• Relative lengths of 1st and 2nd metatarsal
• The slope of the head of 1st metatarsal (DMAA) and particular anatomy of the head of this metatarsal
• Osteoarthritis, arthritis.
• Hypermobility of the 1st ray
• Lesser toe deformities
  
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Essentially, the principles of surgery involves correction of soft tissue imbalances causing the deforming forces to deviate the toe and osteotomies to realign the metatarsal. One example of the surgery is the Scarf Osteotomy.

Pre operative radiographs

Post operative radiographs
(The Scarf Procedure has been performed to the 1st metatarsal with soft tissue release to correct the Hallux valgus deformity. A Weil Osteotomy was performed to the lesser toes to realign the toes and correct the deformities)

Two weeks - post operative appearance

Six weeks - post operative appearance

(correction of the Hallux valgus deformity. The bunion has been excised. Surgical scar well healed)

COMPLICATIONS

• Swelling and Stiffness: This is usually temporary. The swelling will resolve after a period of approximately 8 weeks and physiotherapy will be started as soon as 2 weeks to prevent stiffness.

• Poor fixation and fractures: rare if the osteotomy is fixed in a solid way, but more frequent if fixation is doubtful or non-existent. The rate is higher if the patient is osteoporotic.

• Infections: rare (approximately 1 per cent). This for patients not-diabetics with a good peripheral circulation. Diabetic patients have a higher rate of infection but this is minimized with pre operative preparation and antibiotics.

• Non-union and avascular necrosis: This is very rare but may occur if overzealous soft tissue release is performed.

• Chronic regional pain syndrome: very rare. This can occur after any type of surgery or fracture. The foot becomes overtly sensitive and goes through changes in temperature. This condition requires physiotherapy and patience because it lasts several months.