Authors

1. Klugarova, Jitka PhD
2. Hood, Victoria PhD
3. Bath-Hextall, Fiona
4. Klugar, Miloslav PhD
5. Mareckova, Jana
6. Kelnarova, Zuzana PhD

Abstract

Objective: To establish the effectiveness of surgery compared to conservatory management for adults with hallux valgus.

Background: Hallux valgus (HV) is a complex progressive triplanar forefoot deformity, characterized by a valgus deviation of the big toe, a metatarsus primus varus and a medial prominence on its head. It develops gradually due to interaction of biomechanical factors, structural anomalies, systemic diseases, hereditary predispositions and wearing of inappropriate footwear.1

Hallux valgus is common foot deformity. One published systematic review with meta-analysis on this topic reported the wide variation in prevalence of HV in analyzed primary studies and confirmed higher prevalence of HV in woman and older adults. They found that HV deformity affects on average 23% of adults aged 18-65 years and 35.7% of older adults aged over 65 years.2

The patients usually complain about pain, difficulties during walking and problems with footwear. Nix et al.3 found in a systematic review that there are biomechanical changes in the gait of patients with HV. These included reduced peak of dorsiflexion and rear foot supination during terminal stance. In older patients with HV they described a less stable gait pattern with reduced velocity and stride length during walking on irregular surface.

Over the past 80 years, HV problems have been dealt primarily by surgeons specialized in orthopaedics. In the available literature more than 130 surgical procedures have been described, correcting the axis of the first ray.4 Although the most effective therapy is generally prevention, in clinical practice many patients with foot disorders visit a healthcare professional at a more advanced stage of their problem.

In mild stages of HV, conservative treatment is recommended and this usually involve the use of different type of orthoses, e.g. night splints, or taping. Other options are physical therapy, including manual therapy, mobilization, foot exercise, sensomotoric training, thermotherapy, hydrotherapy and ultrasound therapy. Brantingham et al.5 found that a progressive mobilization of the first metatarsophalangeal joint had positive effects on pain and Foot Function Index (FFI). Du Plessis et.al.6 tested the effect of a modified structured protocol of manual and manipulative therapy (the Brantingham protocol) on HV related pain (visual analog scale), FFI and range of hallux dorsiflexion (goniometry) and compared to orthotic therapy using a night splint. They did not find any significant differences between these two interventions after three weeks in patients with mild to moderate HV. Bayar et.al.7 reported that eight-weeks taping of the first ray and forefoot combined with foot exercise decreased hallux valgus angle (goniometry), foot pain (visual analog scale), and improved walking ability (the walking ability scale) by at least one grade in the patients with HV. Radovic and Shah8 demonstrated that use of botulinum toxin A injection reduced the hallux abducto valgus deformity clinically and radiographically and also its associated pain in a 43-year-old woman presented with a chief complaint of bilateral bunion pain.

In severe stages of this condition surgery is often used. The aim of HV surgery is either to correct the bony or soft tissues or both tissues.9 Surgical procedures for HV include simple bunionectomy, various soft tissue procedures, metatarsal and phalangeal osteotomies, resection arthroplasty and metatarsophalangeal arthrodesis.10 Bunionectomy is a simple procedure based on shaving off the medial prominence on the medial side of the first metatarsophalangeal joint. Arthroplasty is combination of bunionectomy and removal of part of the proximal phalanx; this procedure is indicated in severe stages of HV and leaves a flexible joint, but shorter first ray. Arthrodesis is more radical procedure than arthroplasty and is based on excision of head of first MTPJ and fusion of the operated segment. Osteotomy of the first metatarsus includes proximal and distal procedures. Distal osteotomy, e.g. Chevron osteotomy, is indicated in patients with mild HV and proximal osteotomy, such as scarf osteotomy, in severe stages of HV deformity. Soft technique procedures often complement the bony procedures.9,11,12

The effectiveness of HV treatment is verified in clinical practice, in most cases by radiological examination (Hallux valgus angle and 1,2-intermetatarsal angle), visual analog scale (pain), assessment scoring system developed by American Orthopaedic Foot and Ankle Society (pain, satisfaction, range of movement), FFI, etc.9 In 1979, Stokes et al.13 did the first evaluation of the effect of HV surgery using biomechanical analysis of gait. During the last 30 years, many other researchers have used different type of motion analysis software to evaluate the impact of HV surgery on dynamic and kinematic parameters of gait.13-17

Many primary studies have evaluated effect of treatment of HV surgery, however to date there is no systematic review which has studied the effect of HV surgery or conservative management on gait, pain or function.