A hallux valgus, also known as a bunion, is a deformity of the first metatarsophalangeal joint.
It is characterized by medial inward deviation of the first metatarsal
and outer lateral deviation with or without rotation of the big toe.
the surgery is indicated if the symptoms are severe or persistent.
If you have trouble walking,
and the symptoms do not improve with conservative management.
plain radiography: Radiographic measurements should be performed on anteroposterior weightbearing view.
the hallux valgus angle (HVA):
The angle created between the longitudinal axis of the first metatarsal and the longitudinal axis of the hallux.
Contemporary research suggests an angle of 20 degrees or greater is abnormal.
Intermetatarsal angle (IMA).
The angle determined by the bisection of the longitudinal axes of the first and second metatarsals.
An angle less than 9 degrees is considered normal.
the distal metatarsal articular angle (DMAA):
is the angle formed between the line perpendicular to the line drawn at the base of the articular surface of the metatarsal head
and the longitudinal axis of the metatarsal.
An angle less than 10 degrees is considered normal.
Hallux valgus interphalangeal (HVI).
Between longitudinal axis of proximal phalanx and distal phalanx.
An angle less than 10 degrees is considered normal.
surgical procedures:
bunionectomy:
In a bunionectomy, a surgeon shaves off the excess bone on the outside of your first metatarsal bone.
This procedure is always done in conjunction with all other procedures.
Modified McBride:
Includes release of adductor from lateral sesamoid
and from the base of proximal phalanx,
and lateral capsulotomy.
Chevron procedure:
a ‘V shaped’ osteotomy of the distal first metatarsal is created,
allowing the first metatarsal to be shifted laterally back into a normal alignment,
then fixed by pins and screws.
Commonly used for mild to moderate deformities.
I M A less than 13.
HVA less than 40.
osteotomy can be performed in two planes (Biplanar distal Chevron) to correct increased DMAA.
Scarf procedure:
a longitudinal osteotomy is made within the shaft of the first metatarsal,
for the distal portion to be moved laterally and fixed with screws.
it is useful for when the deformity is moderate to severe.
Ludloff osteotomy:
Oblique osteotomy of the proximal two thirds of the first metatarsal in a proximal dorsal to distal plantar direction,
and lateral rotation of the distal fragment around a proximally placed screw. and fixation with a screw or a plate.
it is useful for when the deformity is moderate to severe.

The proximal osteotomy of the first metatarsal is done and the bone is moved to its normal position and fixed with a plate and screws.
This procedure is used in severe cases
and may be accompanied by a distal osteotomy in very severe cases
or if the DMAA articular angle is greater than 15°.
The osteotomy can be made in a V shape and is called a proximal chevron osteotomy,
or an open osteotomy and fixed with a special plate.
Akin Osteotomy:
In this procedure, your surgeon makes a small cut in the proximal phalanx,
and removes a wedge of bone to straighten the big toe. The bony fragments are then stabilized.
This procedure may be performed as a single procedure if the primary deformity at the level of the interphalangeal joint,
as if HVI is greater than 10.
or combined with other procedures in moderate to severe cases.
metatarsophalangeal joint arthrodesis.
the surgeon fuses the proximal phalanx and the first metatarsal by removing the MTP joint surfaces,
then stabilizes the bones with screws and plate.
This procedure is used for severe MTP osteoarthritis.
rheumatoid arthritis.
Gout.
Down's syndrome.
cerebral palsy.
and EhlerDanlos.
Lapidus procedure:
the surgeon fuses the base of the first metatarsal and medial cuneiform.
Often used when the underlying cause is tarsometatarsal joint hypermobility,
or in very severe cases when the IMA angle is too large,
or in the case of degeneration of the first tarsometatarsal joint.
First Cuneiform Osteotomy.
in severe deformity in young patient with open physis.
Fixation with plate or staplers, and bone grafting may be required.
Keller procedure:
the surgeon resects the base of proximal phalanx of the big toe.
Indicated only in older patients with reduced functional demands.
recovery and post op rehabilitation.
Elevate the foot to minimize swelling as much as possible for the first 6 weeks.
It is common to have some swelling in your foot for 3 months
but sometimes up to six months following surgery.
Fortunately, however with modern techniques available, you will not need a plaster cast and you can walk on your foot from day one.
Generally, the time taken for the bone to heal is around six weeks.
In this time, you will use a special forefoot relief shoe,
where the weight is taken on the heel rather than the forefoot.

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