Hallux Valgus is the deviation of the big toe towards the other toes with the formation of a bony prominence at its base. Although it refers specifically to the great toe, it is often a complex deformity that is associated with deformities of the second and often the third toe as well. These complex foot deformities cause varying degrees of pain during weight-bearing and friction with footwear, affecting walking and reducing functionality, especially in elderly patients.
The forces exerted on the big toe joint during walking gradually push the great toe towards the second toe. Over time, the normal position of the toe changes, leading to deformity. In the early stages, pain may be reduced with wider shoes and orthopedic aids, but when pain persists and walking becomes difficult, surgical intervention is required to correct the deformity and remove the bony prominence.
The prevalence of Hallux Valgus in the general population is estimated between 10% and 30%, with twice the incidence in women, and first manifestations often occurring before the age of 20. Furthermore, 70% of people who develop Hallux Valgus have a positive family history.
The great toe consists of two bones called phalanges. The first phalanx forms a joint with the metatarsal bone, the first long bone of the foot, known as the metatarsophalangeal joint. In Hallux Valgus, the metatarsal deviates inward (varus metatarsal), while the phalanx of the toe deviates outward, towards the second toe. The metatarsophalangeal joint often becomes inflamed, swollen, and red, and a bony prominence develops at the head of the metatarsal. Pressure from the big toe causes deformities of the second and often the third toe, which remain permanently flexed. This results in painful calluses at pressure points with footwear, between the toes, and on the sole.
Several theories have been published regarding the etiology of Hallux Valgus. Footwear is often cited as the most significant factor, with the classic explanation being that tight and high-heeled shoes force the toes out of alignment. This explains why Hallux Valgus is more common in women and rare in populations that do not wear shoes. There is also evidence that the later in life footwear is introduced, the less likely it is for Hallux Valgus to develop, or at least its onset is delayed. A typical example is the significant increase in Hallux Valgus in Japan in the second half of the 19th century, when Western-style shoes replaced traditional Japanese footwear. However, this does not explain why deformity can occur in individuals who wear wide shoes or why it may affect only one foot. Ultimately, footwear seems to act as a triggering factor in a foot already predisposed to develop the deformity. The primary cause is biomechanical, involving disruption of the balance of forces applied to the first metatarsophalangeal joint during walking, combined with anatomical variations, leading gradually to the deformity. The most common anatomical variation is when the great toe is longer than the second toe while the first metatarsal is shorter than the second. Other contributing factors may include rheumatologic conditions, osteoarthritis, and trauma.
Clinically, Hallux Valgus is characterized not only by the obvious deformity of the great toe but also by symptoms that vary in severity, including pain and stiffness of the metatarsophalangeal joint, hammer toes, and painful calluses on the toes and sole. In the early stages, pain is absent, and only the deformity is visible. Gradually, pain develops at friction points with footwear, at the bony prominence, at the smaller toes due to hammer toe deformities, and under the metatarsal heads due to increased pressure. Over time, wearing shoes becomes increasingly difficult.
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Radiological evaluation provides important information for both diagnosis and preoperative planning and must be performed under weight-bearing conditions with the patient standing.
In the early stages, management is conservative. Anatomical shoes with arch support and silicone orthotic aids can reduce pain at pressure points and make walking easier. Exercises to maintain joint flexibility and nighttime splints that hold the big toe in alignment may also provide relief.
When footwear modifications no longer improve symptoms and walking is severely impaired, surgical treatment is indicated.
Since 1876, more than 200 different surgical methods have been proposed. The basic principle in all techniques involves removal of the bony prominence, release of contracted soft tissues on the lateral side of the first metatarsophalangeal joint, and corrective procedures for the lesser toes when necessary.
Modern surgical correction of Hallux Valgus is achieved through minimally invasive techniques. These are usually performed under regional anesthesia, with incisions no longer than 2–3 mm. Using small instruments, corrective osteotomies and removal of the bony prominence are performed under radiographic guidance. Deformities of the other toes can also be corrected simultaneously. The osteotomies are stabilized with special titanium screws that do not need to be removed. The patient walks immediately using a special postoperative shoe, without crutches, and is discharged the same day. This approach minimizes soft tissue trauma, resulting in faster recovery and minimal postoperative pain.
This method can be used in the majority of cases, with the exception of very severe deformities.
Surgical correction of Hallux Valgus (bunions) is performed at the Athens Medical Center by Dr. Tsarouchas and his team, following international standards in foot surgery across all age groups.
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