WHAT IS IT?
Hallux valgus, more commonly known as a “bunion”, is a very common progressive deformity of the foot. It consists of the rotation of the first metatarsal around its base and of the shifting of the first toe towards the second. This results in the development of a painful bulge on the inside of the foot (= bunion). It is sometimes believed that this is a painful growth extending out of the edge of the foot. It is, in fact, a deformity between the metatarsal and phalanx that creates this lump. The lump is formed by the progressive pressure of the metatarsal head against the skin.
In all variants of hallux valgus, the first metatarsal fails to provide the necessary support. An important part of this stability is linked to the correct alignment of tendons in the feet and the hallux valgus, as a result of this deviation, alters the balance. In normal circumstances and in a standing position, the first metatarsal supports twice the load of the other metatarsals. When instability occurs, it tends to be noticed when walking or when putting weight on the foot and, in such cases, the metatarsal in question will only receive a fraction of the body’s weight. The remainder of the weight is supported by the next metatarsals along, which are not designed for such a load. For this reason, hallux valgus is often associated with pain under the forefoot, thereby revealing the chronic stress on the central metatarsals due to this compensation overload (see METATARSALGIA). This is even more obvious in patients presenting with significant instability of the internal column (unstable internal column, hypermobile flatfoot, etc.).
The main problem is usually at the bony projection on the inner edge of the foot (= pseudo exostoses). It causes a conflict in the shoe, especially when wearing high heels or narrow shoes.
As explained above, many hallux valgus cases involve a shifting of the load from the first metatarsal to the next ones along, causing pain under the forefoot (metatarsalgia). And this is a common complaint.
When the condition is advanced and as the deformity progresses, the big toe will come into contact with the second toe and this can also become a source of conflict.
WHEN SHOULD YOU CONSULT A SPECIALIST?
Although non-surgical treatment options exist (such as changing footwear, etc.), hallux valgus is a progressive disorder and the discomfort it causes will generally increase over time. For many years doctors believed that patients should wait until the pain became unbearable before consulting; however, this is not currently true. This approach was indeed the case when techniques were not very effective and particularly painful.
The situation has now changed and leaving a hallux valgus untreated for too long can trigger other conditions (such as arthritis, hammertoe, etc.) or involve the need for more complex corrective surgery.
We advise that a specialist should be consulted when the discomfort causes a change in the quality of life or usual activities, when putting on shoes becomes difficult or when the deformity progresses rapidly.
As it is mainly the bunion pressing against the shoe that causes the pain, changing the type of footwear is obviously the first step to be taken. Soft and wide shoes are preferable, as well as shoes with no localized and excessive pressure points. Wearing high heels should be limited as they increase the load placed on the forefoot and produce a conflict within the shoe.
Wearing customized insoles can help in the early stages of the condition.
Night splints to help straighten the big toe are available on the market; however, their efficacy has yet to be determined and their benefit seems to be limited only to pain relief and does not provide correction of the hallux valgus deformity.
When conservative treatment is inadequate, surgery should be offered.
Over 180 different procedures are available to correct a hallux valgus. Although some of these procedures have no place in the modern approach to this condition, most involve surgery on the first metatarsal bone. The main idea is to return the joint between the metatarsal and the phalanx to its original position, which realigns the toe and re-centers the surrounding tendons. The bone is usually cut (osteotomy) to move the metatarsal head to the desired position. Most of the techniques vary in terms of the specific action on the bone, the direction of the osteotomy, and its shape or length.
Surgery may be performed on both sides simultaneously. In such cases, recovery can be a little slower.
A technique called a Scarf procedure is one of the most popular. It consists of making a Z-step cut (Scarf) in the metatarsal, to realign the big toe. To maintain the position, the cut (the osteotomy) is attached with screws or using a special osteotomy technique without fixation. This procedure is usually performed by open surgery.
It is possible to perform this surgery using a percutaneous minimal invasive surgical technique. This is a new approach, and a small single incision of 1 mm is made. The osteotomy itself is identical to open surgery, but the minimal incision allows a faster recovery, near-invisible scars and limited pain. The fixation is carried out using either screws or a metal 2-mm diameter pin, which is removed 4-5 weeks after surgery. This removal is painless and carried out in the doctor’s surgery.
Finally, in cases involving a significant instability of the first metatarsal, during certain surgical revisions or in the presence of major deformity, the metatarsal osteotomy is not sufficient and the risk of recurrence high. In these cases, surgery carried out at the base of the metatarsal is the preferred option. The cartilage of the joint between the cuneiform and metatarsal bone is removed and the two bones are brought into close contact with a plate, allowing the fusion of this joint in an aligned position. This is an arthrodesis, that is a fusion of the joint (Lapidus arthrodesis).
In any event, your surgeon will discuss with you the best surgical option. Each foot is different and requires specific care to provide an optimal and sustainable correction.
POST SURGICAL FOLLOW-UP
Weight-bearing walking is permitted immediately, protected by a special shoe for six weeks. A cane may be used solely for comfort purposes.
In case of percutaneous surgery fixed with a pin, the latter is removed after 4-5 weeks. Regular checks (1week, 3weeks, 6weeks and 3 months) during this time possible ensure healing without complications.
Driving can resume after six weeks. When only one foot has been operated on, driving is allowed after a shorter time, on condition the car is an automatic one.
Returning to work is not possible for 3 weeks to 3 months, depending on the profession (sedentary or more active job, whether standing up or not, etc.).
In terms of sport, swimming or riding a bike can start after 6 weeks; running or contact sports will require up to a minimum of 3 months.
Wearing high heel shoes is generally permitted from the 4th month onwards.
RISKS AND COMPLICATIONS
Besides the possible complications after any type of surgery (thrombosis, infection <1%, algodystrophy <1%), it is recognized that the treatment of hallux valgus involves the following risks and complications:
- Recurrence of the deformity (4-10%). This may be due to a failure to analyze the problem, technical failure, an incorrect indication or the failure to follow post-surgical instructions.
- Non-union of the bone cut or arthrodesis (pseudarthrosis), rare
- Nerve damage (usually temporary and regressive)
- Persistence of swelling (oedema). Normal during the first 2-3 months, it may persist longer in some cases.
- Stiffness (frequent). Any procedure involving a joint causes stiffness, which requires mobilization after the operation by a physiotherapist or the patient.