Hallux valgus, or bunion, is one of the more common orthopedic problems affecting mainly women. After the age of 50, bunion occurs in approximately 1 in 40 women.
The foot can be divided into 3 parts:
- Foot radius – consists of two phalanges forming the big toe, one metatarsal bone and two sesamoid bones at the base of the first metatarsal (i.e. small bones with a function similar to the kneecap in the knee). In the correct foot, all bones are positioned in one axis, which allows for efficient load transfer.
- Muscles – the muscles that move the big toe can be divided into two groups: the long muscles and the short muscles of the foot. Long muscles are involved in the movement of the big toe and forefoot during walking. Short muscles, on the other hand, act as stabilizers, ensuring the correct positioning of the toe and the entire forefoot. The most important long muscles are the long big toe flexor and the long big toe extensor, while the short muscles are: the short big toe flexor, the short big toe extensor, the big toe abductor, the transverse head and the oblique head of the big toe adductor.
- Ligaments – structures that stabilize the joints and protect against pathological excessive movement in the joint. In the metatarsophalangeal joint these are: the collateral ligaments of the metatarsophalangeal joint I, the intersesamoid ligament.
Hallux valgus deformation is an incorrect position of the first toe of the foot, it occurs due to genetic predisposition and as a result of chronic exposure to external factors – mainly too tight shoes and high heels. The pathology concerns the skeletal system, but the muscles and connective tissue play a key role in the formation of hallux valgus. The weakening of the short and long muscles of the foot and the abnormal structure of the connective tissue contribute to this deformity. Hallux valgus hinders walking, standing, causes chronic pain, and if left untreated, it can lead to the development of degenerative changes in the knee and hip joints.
The big toe is necessary when walking. Owing to this finger we are able to bounce off the ground properly, the correct bounce from the big toe allows us to make an efficient, springy step. A person takes about 1.5 million steps a year. The correct gait cycle consists of the phase of resting the foot on the ground (62%) and the phase of moving the limb in the air (38%). During the step, the weight of the body rests on the heel, and as the foot rolls over the ground, the pressure moves to the front of the foot so that the foot breaks off by pushing it out of the big toe. During this time, the entire body weight rests on it. In the case of bunion deformity, the weight of the body is transferred to the second finger, which leads to its overload and degenerative changes, revealed by the formation of painful calluses on the forefoot and dorsal subluxation of the second finger (hammer finger).
- hammer-toe deformity of the 2nd, 3rd, 4th and 5th finger;
- flat foot;
- Achilles tendon contracture;
- rheumatic diseases;
- neuromuscular diseases;
- rupture of the posterior tibial tendon;
Hallux valgus is considered a civilization disease. It appears much more often in populations wearing footwear. Shoes with a narrow toe and high heels as well as too tight footwear cause the formation of bunions.
Hallux valgus in some cases may also run in families – if that happens, changes may occur in adolescence.
The most common symptom that triggers a consultation with a doctor is pain in the forefoot. Often the ailments are caused by a conflict with worn shoes. The pressure of shoes in the area of the protruding head of the metatarsal bone causes painful calluses, i.e. skin thickening, which force the patient to seek help from specialists. For some patients, cosmetic aspects are also very important..
In addition to the characteristic appearance of the foot and accompanying symptoms, proper diagnosis and treatment planning requires a thorough examination by a doctor and diagnostic tests.
X-ray examination of the feet is the basic diagnostic tool. At CMC, we take photos in three projections: AP (from the top), side and tiptoe at an angle of 45 °. Radiologists and orthopedists carefully examine and evaluate X-ray images. They assess the position of all the bones of the foot, including the sesamoid. They then make accurate measurements of the angles of the foot to properly plan further treatment.
The correct IMA angle is less than 9°. The HVA angle should be up to 16°. Whereas DMAA (Distal Metatarsal Articular Angle) – up to 10°. Increasing values of these angles indicate a progressive deformation of hallux valgus. Accurate measurements enable correct and optimal treatment planning. In the future, computed tomography scanning may also be helpful.
Thanks to all these data, the orthopedic surgeon decides on the further course of treatment. The doctor issues referrals for rehabilitation or appropriate surgery. Often the doctor who issues a referral for surgery informs the patient about the need to correct other changes in the foot, e.g. hammer toes.
Treatment of hallux valgus
Conservative treatment may be effective in some patients with mild disease advancement. Appropriate lifestyle change, weight loss, physical exertion, shoe change and rehabilitation can give good treatment results. Unfortunately, when the changes in the foot are advanced, only surgical correction of the hallux valgus can be considered.
Surgical procedures performed at the Carolina Medical Center can be divided into operations performed on soft tissues (muscles, ligaments) and various types of correction of the first metatarsal bones. The treatment can be performed on one or both feet simultaneously.
Soft tissue surgery
This procedure is the basic procedure performed in patients suffering from hallux valgus. During the surgery, a 5 cm long cut is made on the inner edge of the foot and the transverse ligament of the metatarsus and the joint capsule are cut, thanks to which the displaced sesamoid can return to their place under the head of the first metatarsal bone.
Then the excess of the overgrown bone tissue is removed from the inside of the head of the first metatarsal bone and a part of the joint capsule, which is then sewn onto the overlap by tightening it. The procedure ends with sewing the skin on and applying a dressing. As a result, it is possible to obtain full correction of hallux valgus in the case of the beginning pathology, with a small angle of deformation.
Surgical procedures on bone
If the abnormality is advanced, with a high deformation angle, the only treatment method is bone tissue surgery supplemented with soft tissue surgery. The skin incision is similar to that of soft tissue surgery
During procedures on bone tissue, we perform intraoperative X-ray pictures. They allow the doctor to assess the correct alignment of the bones.
- Scarf Osteotomy – after performing soft tissue surgery, the surgeon cuts the first Z-shaped metatarsal bone, then shifts both bone fragments accordingly to give the correct shape of the foot, and connects them with the help of selected screws. A control X-ray image is performed during the procedure to confirm that the first metatarsal bone is properly fixed.
- Chevron osteotomy – following this method, we cut the first metatarsal bone by making two incisions at an angle of approximately 80° in the area of the head of the first metatarsal bone. Then we move the fragments and stabilize them against each other, after obtaining the correct position. We take a control X-ray image and stabilize it with a screw.
- Open wedge osteotomy — within the first metatarsal bone, we make a cut perpendicular to the long axis of the bone and then separate both bone fragments, obtaining the correct position. We stabilize the foot using the appropriate plate and screws.
- Closed wedge osteotomy – in this method, two incisions are made within the first metatarsal bone, which allow for the removal of the bone wedge and the correct positioning of the fragments.
- Akin osteotomy – this procedure is performed as a supplement to the first metatarsal osteotomy, as well as a stand-alone procedure. The main indication for this procedure is incorrect (valgus) position of the phalanx of the proximal toe. This procedure consists in removing a bone wedge from the phalanx and fusing the bones with a screw.
- Lapidus procedure – involves the excision of the bone outgrowth from the area of the head of the 1st metatarsal and then the fusion of the 1st metatarsal bone with the wedge bone.
- Accompanying treatments – correction of hammer fingers, Weil osteotomy.
Hallux valgus is often accompanied by pathologies of fingers II, III, IV and V. Most often they are hammer fingers. Incorrect setting of fingers is adjusted by cutting the tendon of the short extensor muscle of the fingers and extending the tendon of the long extensor muscle of the fingers. We also deal with the proximal interphalangeal joint. If necessary, we stabilize the finger with Kirchner wire inserted below the nail plate.
In the case of severe pain located under the heads of the 2nd and 3rd metatarsal bones and the shortening of the 1st metatarsal bone, the considered procedure is 2nd, 3rd and 4th finger Weil osteotomy. It consists in shortening the bones and stabilizing the fragments with cannulated screws. On account of this method, we move the final point of dislocation while walking towards the big toe and first metatarsal bone.
Indications for surgery:
- Significant pain, making it impossible to wear shoes or even walking are the main indications for surgery.
- Deformation of the big toe and other toes, making it impossible to put on standard footwear.
- Subsequently, cosmetic reasons are also indication for surgery.
Before the surgery, the patient is consulted by an anesthesiologist with whom the issues related to anesthesia are discussed, and a set of additional tests is performed.
Systemic diseases: poorly controlled diabetes mellitus, diseases resulting in reduced or no vascular flow in the lower extremities, active skin infections. In young people with ungrown metatarsal epiphyses, osteotomies are also not recommended.
After receiving a referral for surgery, the patient is directed to the reception where he sets the date of the surgery, receives a quote and all information on how to prepare for the surgery.
Before the surgery, it is necessary to perform recommended tests and consult an anesthesiologist. On the day of the procedure, the patient must be fasting (for at least 8 hours without food and for at least 6 hours without drinking). The patient is obliged to bring complete medical documentation obtained at the Carolina Medical Center for the surgery. Before the procedure, the patient is admitted to the ward and prepared for anesthesia. The medical team performs anesthesia and maintains it throughout the surgery.
Hospitalization usually lasts for 2 days. After few hours, the patient can walk with the use of crutches and special footwear. These shoes will be worn for a period of about 6 weeks, i.e. until the follow-up visit with the attending physician. On the first day after surgery, the patient begins the rehabilitation process with the appointed physiotherapist. During the first 24 hours, due to the possible pain symptoms, intensive analgesic treatment is continued. He receives all postoperative instructions on the day of discharge.
The patient should come to the CMC for a dressing change, and after 2 weeks – to remove the stitches. 6 weeks after the procedure, the patient has a follow-up visit with the attending physician, before which he is obliged to take a current X-ray of both feet. During the visit the doctor evaluates scar healing, the appearance of the feet, bone union and bone alignment on X-rays. In the event of a positive test result, the doctor allows the orthopedic footwear to be removed and allows normal functioning. Most patients may have slight swellings in the operated area for 4-5 months after the procedure.
Rehabilitation after surgery
The patient is assigned his personal physical therapist who guides him throughout his recovery. The physiotherapist is appointed by the attending physician and is in constant contact with him. Sessions are held 2-3 times a week for 1 hour. As soon as the physiotherapist decides that the patient is able to exercise individually, he reduces the number of meetings.
Complications after the correction of hallux valgus surgery are relatively rare. They can be divided into acute and chronic. Acute complications most often include a skin healing disorder. It should be noted, however, that this applies to elderly patients and patients with systemic comorbidities. Bone union disorders were also observed, as well as persistent pain in the foot area. A chronic complication observed in some patients is the deformity recurrence.
It should be noted that a good cosmetic effect can be obtained primarily in younger patients. In older, mainly postmenopausal women, the main result of the operation is the permanent relief of pain – a good cosmetic effect in these patients is much more difficult to achieve.