Surgical Treatment of Mild Hallux Valgus Deformity: The State of Practice among Academic Foot and Ankle Surgeons

INTRODUCTION

Hallux valgus is a common problem characterized by lateral deviation of the great toe and prominence of the medial eminence. Generally, initial conservative treatment is successful. Patients in whom conservative treatment fails to relieve symptoms may be candidates for operative correction. The spectrum of deformity of hallux valgus is wide, ranging from mild to severe, and, accordingly, over 100 different operative procedures have been described in the literature. ^15,16 The purpose of this study was to assess the current state of practice among academic foot and ankle surgeons for operative treatment of mild hallux valgus deformity.

MATERIAL AND METHODS

A database of academic orthopaedic foot and ankle surgeons was identified. ⁸ This database was expanded by contacting the administrative coordinator at each of the 152 orthopaedic residency programs in the United States by telephone. They were asked to identify the orthopaedic surgeons who were responsible for teaching foot and ankle surgery to the residents. The final study group was restricted to surgeons who were directly responsible for teaching orthopaedic residents and devoted 50% or more of their clinical practice to treating foot and ankle problems. These criteria were chosen to allow us to study a discreet, easily definable group of orthopaedic surgeons.

A hypothetical case study was created, consisting of a patient with mild hallux valgus deformity (Figure 1). The patient was an active 60-year-old woman with right medial forefoot pain and a bunion deformity. She continued to be symptomatic despite flat accomodative shoewear. Her physical examination was consistent with a mild hallux valgus. Weightbearing anteroposterior radiographs demonstrated a first intermetatarsal angle of 11 degrees and a hallux valgus angle of 22 degrees (Figure 2). The patient desired operative correction.

The case was sent to the 153 surgeons who had been compiled in the database. Each surgeon received a cover letter explaining the nature of the study and an outline of the case including the information shown in Figure 3. They also received a questionnaire and a request to indicate the procedure or combination of procedures that represented their standard operative treatment for the hypothetical patient (Figure 4). The surgeons were given an opportunity to list additional procedures that were not on the original survey. Each surgeon also was sent a stamped return envelope. The return envelope was number coded to our database. The surgeons who did not respond to the survey within 6 weeks received a second identical survey. A total of 128 surgeons completed the survey for a response rate of 83.7% (128 of 153).

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Fig. 1:

A and B, Clinical photographs of a patient with mild hallux valgus.

Twenty-three respondents were excluded because less than 50% of their clinical practice was devoted to foot and ankle problems. This left a study group of 105. Invalid responses were noted; for example, if part of the questionnaire was left blank or there were multiple conflicting responses. There were two invalid responses, and the study group was defined as 103.

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Fig. 2:

A, Weightbearing anteroposterior radiograph. B, Lateral radiograph.

RESULTS

The survey results are listed in Table 1. Eighty-seven percent (90 of 103) reported that they would use a distal chevron osteotomy as their primary surgical treatment. Ten respondents reported that they would perform an Akin osteotomy in addition to the chevron osteotomy. Two respondents reported that they would perform an isolated Akin osteotomy. Eight respondents stated they would add an Akin osteotomy if the correction with the chevron osteotomy was not adequate. Eleven described treatment approaches other than a distal chevron osteotomy. In addition to the two isolated Akin osteotomies these included a proximal metatarsal osteotomy in five, a medial eminence resection in two, and soft-tissue procedure only in two.

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Table 1:

Results of the survey for procedure of choice for treatment of mild hallux valgus, 103 respondents

Distal chevron osteomy	90 (87%)
Akin osteotomy, total	12 (12%)
Isolated Akin	2 (2%)
Akin + chevron	10 (10%)
Add Akin (if chevron correction inadequate)	8 (8%)
Other	11 (11%)
Proximal metatarsal osteotomy	5 (5%)
Medial eminence resection	2 (2%)
Soft-tissue only	2 (2%)
Other	1 (1%)
“No surgery”	1 (1%)

DISCUSSION

Hallux valgus is one of the most common foot and ankle deformities treated by orthopaedic surgeons. It is a complex deformity involving the first metatarsophalangeal joint, and there are numerous surgical treatment options. ^15,16 Because not all bunions are equal, there is no single operation to treat all bunions. An algorithm has been developed as a guideline for treatment of this complex deformity. ^18,21 Nonetheless, operative correction of hallux valgus is one of the most common elective procedures done on the foot. ²⁷ This study evaluated the state of practice of academic orthopaedic foot and ankle surgeons in the United States for treatment of a mild hallux valgus deformity.

We found the procedure of choice among the respondents to be interesting. With all the operations described for hallux valgus deformities, our survey results show there was general agreement on the treatment of the hypothetical patient with a distal chevron osteotomy. Radiographic characteristics of mild hallux valgus are a first intermetatarsal angle of less than 13 degrees and a hallux valgus angle of less than 30 degrees. ^18,21 It can be argued that this is a somewhat arbitrary definition and that interobserver reliability in assessing the intermetatarsal angle is not perfect. ²³ However, this approach does differentiate a mild hallux valgus deformity from moderate and severe ones. Also, this definition of a mild hallux valgus deformity appears to be generally accepted and widely used. ¹⁸

Patients with a mild deformity often complain of pain, deformity, shoewear problems, and activity limitations. Often, their perception of the pain is similar to patients with a more severe deformity. ²⁶ These patients can continue to be symptomatic despite optimal nonoperative management. A number of procedures have been described as treatment options for patients with mild hallux valgus. Silver ²⁵ described resection of the medial eminence, plication of the medial capsule, and release of the lateral capsule and adductor tendon. McBride ¹⁹ described a soft-tissue procedure that is a modification of the Silver operation. The Keller bunionectomy involves resection of the base of the proximal phalanx. ^13,22 In addition, there are numerous types of osteotomies to correct mild deformities, such as the Akin, ^1,4 Mitchell, ²⁰ and scarf. ^5,12

The distal chevron osteotomy was described in 1968, by Austin and Leventen ² and was popularized by Leventen ¹⁴ and Johnson et al. ^7,10,11 The operation consists of a medial exostectomy and a V-shaped osteotomy centered in the first metatarsal head. The capital fragment is translated laterally by 3 to 5 mm, or one-third the width of the head. The fragment is impacted and fixed with a screw or Kirschner-wire. The prominent proximal medial cortex is resected, and the medial capsule is plicated.

Clinical results of the chevron osteotomy have been consistently good to excellent for improvement of symptoms, cosmesis, and function in patients with mild and moderate deformities. ^9,17,24 The longest study evaluated 112 feet in 73 patients with a minimum followup of 10 years. Excellent clinical results were found to be consistent and further improvement occured with time. ²⁴ However, although consistently good to excellent results have been reported for distal chevron osteotomy, these studies are retrospective case series and therefore represent Level IV evidence. ^9,17,24 Nevertheless, the consistently good results warrant a Grade B treatment recommendation (treatment option supported by fair evidence) for this approach.

The Akin osteotomy involves a medial closing wedge osteotomy of the base of the proximal phalanx. This osteotomy has been described as an isolated procedure. After removal of the medial eminence and the base of the proximal phalanx, a 3-mm wedge is removed from the medial aspect, the cut surfaces are coapted, and fixation is completed with a small screw, Kirschner-wire, or suture. It has been described as a useful adjunct to a first metatarsal osteotomy for bunion correction. ^3,5,6,12

The results of this study show that most orthopaedic foot and ankle surgeons (87%) use the chevron osteotomy as their primary procedure for treatment of a mild hallux valgus deformity. The second most common approach was a more proximal metatarsal osteotomy, reported by five surgeons. An isolated Akin osteotomy of the proximal phalanx, a medial eminence resection, and an isolated soft-tissue procedure were chosen by two surgeons. One surgeon stated that he believed there was no indication for surgery in a patient with this mild deformity. An interesting result was that 10% (10 of 103) reported that they would augment their correction with an Akin osteotomy. Eight respondents wrote in the comment section that they would add an Akin osteotomy if they were not satisfied with the intraoperative corrected appearance of the deformity with only the chevron osteotomy.

It is important to emphasize what this study can, and cannot, conclude. This study looked at the present state of practice among a discrete group of orthopaedic surgeons practicing in the United States. The results suggest a high-degree of consistency with which they approach the operative management of mild hallux valgus deformity. However, this study was not designed to assess whether this is the most effective way to treat this problem. Therefore, we can only conclude that a distal chevron osteotomy is the most common approach among this group. The results do not allow us to make any specific comments on the effectiveness of this procedure.

This study has limitations. First, the study method employed a hypothetical case and not an actual patient. It is possible that the case used may not have accurately portrayed a typical patient with a mild deformity. Second, it is possible that all academic orthopaedic foot and ankle surgeons were not included in this study. Attempts were made to contact each orthopaedic residency program, but some surgeons who are actively involved in teaching foot and ankle surgery to residents may not have been surveyed. However, we do think that the large survey size and relatively high response rate permits useful information to be extracted from this study. A third limitation is the decision to define the study group as those surgeons with more than 50% of their practice devoted to foot and ankle surgery. This decision was made at the commencement of the study in an effort to ensure that all members of the study group had the care of foot and ankle patients as the primary component of their clinical practice. By defining the study group in this manner, the study results may not be an accurate representation of how hallux valgus is treated by general orthopaedic surgeons. Nevertheless, by defining the study group as above, we think the results offer an accurate assessment of the state of practice for operative treatment of mild hallux valgus among a distinct group of subspecialist orthopaedic foot and ankle surgeons.