Hallux Valgus is the most common foot pathology or deformity. The big toe (hallux) is bent laterally (valgus) toward the second toe. This creates a lump or bunion on the medial side. It is this unsightly and painful lump that causes discomfort and handicap.
Some statistics :
Number of cases of cases of Hallux Valgus treated
Average surgery time
3 à 6
Number of weeks to recover
We do not exactly know the origin of this pathology. It may perhaps be a congenital bone or joint deformity. People with hyperlaxity are more liable to develop it or to suffer recurrence. Gender seems to be an important factor; women are more at risk, but it would be quite wrong to blame them for wearing pointed shoes or high heels: these kinds of shoes heighten the pain, but are in no way involved in onset. Women are not the perpetrators of hallux valgus – they are the victims. Indeed, 10% of the patients are women under 18 years of age who have never worn anything except sports shoes; and 5% are men, who rarely if ever wear high heels.
Don’t blame yourself!
The patient very quickly becomes aware of the problem – first just by noticing the deformity, then by experiencing pain in the lump, which gets red and troublesome in footwear. This is “bursitis”.
Hallux valgus deformity is not a very severe condition in itself, but unfortunately incurs two types of complication.
Pain: The lump rapidly becomes problematic in shoewear: friction causes inflammation in the summit of the bunion, which is liable to swell in what is known as “bursitis”. The pain handicaps the patient, who can no longer easily wear shoes, which have to be wide and sometimes even open.
Secondary associated deformities: The big-toe deformity may in time cause two other pathologies:
- claw-toe deformity in the lesser toes;
- and plantar calluses or metatarsalgia.
A - Surgical treatments
The standard treatment for hallux valgus is surgery. The big toe has to be realigned by bone cuts (osteotomies) to set the bones in the right axis and sometimes, to be safe, fixing them with screws, staples, pins or plates. While doing this, stiff joints need freeing (arthrolysis) and retracted tendons have to be lengthened (tenotomy). Various well-honed and scientifically proven techniques are available for this, which the surgeon can choose between according to his or her own habits, to the patient and to the deformity. Techniques can be combined, to achieve an optimal result.
Classical open surgery
A few videos to better understand
EVOLUTIVE history of HALLUX VALGUS & complications
THE OSTEOTOMY OF THE FIRST PHALANGE OF THE BIG TOE
THE CHEVRON OSTEOTOMY
THE SCARF OSTEOTOMY
The so-called “classical” open techniques (which are not in fact as classical as all that, as they were first described only between the 1970s and the 1990s) are controlled visually under the surgeon’s eyes. The deformed bone is sectioned and repositioned, then fixed by screws or other material (plates, pins, etc.). All this can be planned in advance of the operation. These techniques have been validated in scientific studies with long follow-up, and are certainly very reliable.
Minimally invasive or percutaneous technique
Doctors have always tried to achieve good results while avoiding the unpleasant effects of large incisions. This is the spirit of minimally invasive or percutaneous surgery. The aim is to achieve the same result with a smaller opening and less material. This kind of technique has been known for a good while, but only recently became truly reliable. Scientific comparative studies now show that results are equivalent – although the follow-up for these more recent techniques is inevitably shorter.
It should be borne in mind that minimally invasive or percutaneous surgery requires more frequent radiological control during surgery, subjecting the patient to a higher dose of X-rays.
A few videos to better understand
But it should be borne in mind that most surgeons now combine the two techniques, in what is known as “mixed” surgery. The two supplement one another easily. On other words, very few specialists dogmatically use only open or only minimally invasive/percutaneous surgery.
B - Non-surgical (medical) treatments
Medical treatment plays a small role in hallux valgus. It can be suitable for the early stages, for very advanced age, periods in which surgery is absolutely contraindicated, or if the patient refuses surgery.
Rigid orthoses neither prevent nor reduce hallux valgus, but just relieve the worst pain. They are to be worn at night or at home, as they cannot be incorporated into any kind of footwear.
Insoles or plantar orthoses
Here again, insoles do not reduce hallux valgus; but they do relieve plantar pain and can reduce a deformity such as flat foot that is aggravating the hallux valgus.
Obviously, producing and wearing made-to-measure orthopedic shoes is only for patients with longstanding deformity, in very particular situations (mental illness, advanced diabetes, etc.).
Why does the big toe get deformed?
No-one really knows; but what is sure is that shoewear, sport or sedentary lifestyle have nothing to do with it. There is clearly a predisposition regarding female gender and certain families. Perhaps it is a congenital or hereditary abnormality? – perhaps one day we’ll know… But at all events, metatarsal head deformity is quite common, especially in young people; and surgical correction does realign the big toe.
The deformity cascade
It all seems to start with a lump on the inner side of the big toe. The deformity then destabilizes the forefoot. The big toe swings to the side. The lesser toes tend to follow suit or curl up in claw- or hammer-toe. Meanwhile, pain sets in under the foot, and we can speak of metatarsalgia. Next come plantar calluses, which are often very painful. And finally the second toe crosses over the big toe…
A few videos to better understand
Who needs surgery, and when?
Hallux valgus needs operating on when it hurts. There is no place for preventive not to mention cosmetic surgery. If the patient is suffering, cannot wear shoes or play sports or work, then and only then should surgery be considered, after specialist advice.
There is never any rush for this kind of operation. It’s best to take one’s time to get things organized at home and at work.
Can both feet be operated on at once?
Technically, yes; but in fact it’s a bad idea. Operating on both feet in one step, for example:
- increases surgical risk (of infection, phlebitis …);
- delays getting out of bed and beginning to walk again;
- increases operative time;
- rules out same-day-discharge and simple locoregional anesthesia, which has been a real progress in terms of both complications and postoperative pain;
- and means operating on the second foot, which is rarely at the same stage of deformity as the painful foot.
What kind of anesthesia is recommended?
Locoregional anesthesia has transformed the procedure and is perfectly adapted to outpatient surgery and modern pain management.
Is foot surgery, and hallux valgus surgery in particular, painful?
Limb surgery is classically painful, and this is especially true for the foot. However, the advent of minimally invasive surgery and above all of locoregional anesthesia has transformed the situation. After coming round from general anesthesia, patients used to report severe pain. Now, we put the organ (the foot) to sleep, and operate on it while it is sleeping. When, several hours later, it wakes up, analgesics are there to alleviate pain, and excruciating awakening is a thing of the past. Moreover, we now have very effective postoperative drugs, including morphine tablets. So, yes – it is painful, but nothing like it was, thanks to the new anesthesia techniques and powerful pain killers in tablet form.
Outpatient or classical inpatient surgery?
Outpatient care used to seem unsuited to foot surgery, because the patient would have to walk out of the hospital the same day. Here in France, we were slow to come around to the new techniques, even when they had become widespread in the rest of the world. Under pressure from the health authorities, however, we adopted day surgery – with excellent results for all concerned. What could be better for the patient than to go back home for the night? – especially with at least one foot on the ground. Modern locoregional anesthesia has transformed postoperative course: less pain, and less of the side effects of general anesthesia.
When can you start walking?
That depends on the type of deformity and on the surgical technique.
Generally, you can put your foot on the ground immediately or at least within a few days. But be careful: after the operation you need to plan for a quiet period at home, with your foot up to limit bleeding, edema, pain and displacement of the surgical assembly.
When can you put your shoes back on?
To be reasonable, you can wear comfortable sports-type shoes as soon as your dressings have been removed: i.e., at the end of the first month.
When can you get back to work?
French national health insurance guidelines restrict working time for the first 42 days after surgery for a foot with only slight deformity and a job that does not involve heavy lifting. But you can always go back to work earlier if your job permits.
When can you start driving again?
In principle and usually, at the end of the first month, to be on the safe side. Operating the brake pedal requires complete recovery of strength and a consolidated assembly.