Hallux Valgus: Demographics,Etiology,and Radiographic Assessment

Abstract

Background

The purpose of the study was to preoperatively evaluate the demographics, etiology, and radiographic findings associated with moderate and severe hallux valgus deformities in adult patients (over 20 years of age) treated operatively over a 33-month period in a single surgeon's practice.

Methods

Patients treated for a hallux valgus deformity between September, 1999, and May, 2002, were identified. Patients who had mild deformities (hallux valgus angle < 20 degrees), concurrent degenerative arthritis of the first metatarsophalangeal joint, inflammatory arthritis, recurrent deformities, or congruent deformities were excluded. When enrolled, all patients filled out a standardized questionnaire and had a routine examination that included standard radiographs, range of motion testing, and first ray mobility measurement. A chart review and evaluation of preoperative radiographs were completed on all eligible patients.

Results

One-hundred and three of 108 (96%) patients (122 feet) with a diagnosis of moderate or severe hallux valgus (hallux valgus angle of 20 degrees or more)⁷⁰ qualified for the study. The onset of the hallux valgus deformity peaked during the third decade although the distribution of occurrence was almost equal from the second through fifth decades. Twenty-eight of 122 feet (23%) developed a deformity at an age of 20 years or younger. Eighty-six (83%) of patients had a positive family history for hallux valgus deformities and 87 (84%) patients had bilateral bunions. 15% of patients in the present series had moderate or severe pes planus based on a positive Harris mat study. Only 11% (14 feet) had evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that 86 of 122 feet (71%) had an oval or curved metatarsophalangeal joint. Thirty-nine feet (32%) had moderate or severe metatarsus adductus. A long first metatarsal was common in patients with hallux valgus (110 of 122 feet; 71%); the mean increased length of the first metatarsal when compared to the second was 2.4 mm. While uncommon, the incidence of an os intermetatarsum was 7% and a proximal first metatarsal facet was 7%. The mean preoperative first ray mobility as measured with Klaue's device was 7.2 mm. 16 of 22 (13%) feet were observed to have increased first ray mobility before surgery.

Conclusions

The magnitude of the hallux valgus deformity was not associated with Achilles or gastrocnemius tendon tightness, increased first ray mobility, bilaterality or pes planus. Neither the magnitude of the preoperative angular deformity nor increasing age had any association with the magnitude of the first metatarsophalangeal joint range of motion. Constricting shoes and occupation were implicated by 35 (34%) patients as a cause of the bunions. A familial history of bunions, bilateral involvement, female gender, a long first metatarsal, and an oval or curved metatarsophalangeal joint articular surface were common findings. Increased first ray mobility and plantar gapping of the first metatarsocuneiform joint were more common in patients with hallux valgus than in the general population (when compared with historical controls).

Keywords

Bunion Hallux Valgus Metatarsus Primus Varus

Get full access to this article

View all access options for this article.

References

Bacardi

B.E.

; Boysen

T.J.

: Considerations for the Lapidus operation. J. Foot Surg. 25: 133–138, 1986.

Banks

; Hsu

Y S

; Mariash

; Zirm

: Juvenile hallux abducto valgus association with metatarsus adductus. J. Am. Podiatr. Med. Assoc. 84: 219–224, 1994.

Barnett

C.H.

: Valgus deviation of the distal phalanx of the great toe. J. Anat. 96: 171–177, 1962.

Barnicot

N.A.

; Hardy

R.H.

: The position of the hallux in West Africans. J. Anat. 89: 355–361, 1955.

Bednarz

P.A.

; Manoli

II : Modified Lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int. 21: 816–821, 2000.

Blum

J.L.

: The modified Mitchell osteotomy-bunionectomy: indications and technical considerations. Foot Ankle Int. 15: 103–106, 1994.

Bonney

; Macnab

: Hallux valgus and hallux rigidus; a critical survey of operative results. J. Bone Joint Surg. 34-B: 366–385, 1952.

Bordelon

(ed.): Surgical and conservative foot care. A unified approach to principles and practice., Slack, Inc., Thorofare, NJ, pp 13–14, 1988.

Brahm

S.M.

: Shape of the first metatarsal head in hallux rigidus and hallux valgus. J. Am. Podiatr. Med. Assoc. 78: 300–304, 1988.

10.

Bryant

; Tinley

; Singer

: A comparison of radiographic measurements in normal, hallux valgus, and hallux limitus feet. J. Foot Ankle Surg. 39: 39–43, 2000.

11.

Cathcart

: Physiological aspect: nature of incapacity. The feet of the industrial worker: clinical aspect; relation to footwear. Lancet 2: 1480–1482, 1938.

12.

Chi

; Davitt

; Younger

; Holt

; Sangeorzan

B.J.

: Intra-and inter-observer reliability of the distal metatarsal articular angle in adult hallux valgus. Foot Ankle Int. 23: 722–726, 2002.

13.

Clark

; Veith

R.G.

; Hansen

S.T.

Jr. : Adolescent bunions treated by the modified Lapidus procedure. Bull. Hosp. Jt. Dis. Orthop. Inst. 47: 109–122, 1987.

14.

Cleveland

; Winant

: An end-result study of the Keller procedure. J. Bone Joint Surg. 32-A: 163–175, 1950.

15.

Coughlin

M.J.

: Hallux valgus. J. Bone Joint Surg. 78-A: 932–966, 1996.

16.

Coughlin

M.J.

: Hallux valgus. Causes, evaluation, and treatment. Postgrad. Med. 75: 174–178, 183, 186–187, 1984.

17.

Coughlin

M.J.

: Hallux valgus in men: effect of the distal metatarsal articular angle on hallux valgus correction. Foot Ankle Int. 18(8): 463–470, 1997.

18.

Coughlin

M.J.

: Juvenile hallux valgus. In Coughlin

M.J.

; Mann

R.A.

(eds): Surgery of the foot and ankle, 7th edition, Mosby Yearbook, St. Louis, pp. 270–319, 1999.

19.

Coughlin

M.J.

: Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 16: 682–697, 1995.

20.

Coughlin

M.J.

; Carlson

R.E.

: Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies. Foot Ankle Int. 20: 762–770, 1999.

21.

Coughlin

M.J.

; Freund

: Roger A. Mann Award. The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int. 22: 369–379, 2001.

22.

Coughlin

; Grebing

; Jones

: Arthrodesis of the metatarsophalangeal joint for idiopathic hallux valgus: intermediate-term results, Foot Ankle Int. 26: 783–792, 2005.

23.

Coughlin

; Richardson

; Myerson

; Hansen

: The distal metatarsal articular angle: a debate. A symposium at the Annual Winter Meeting of the American Orthopaedic Foot and Ankle Society, New Orleans, March 22, 1998.

24.

Coughlin

; Saltzman

C.L.

; Nunley

II : Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot and Ankle Society on angular measurements. Foot Ankle Int. 23: 68–74, 2002.

25.

Coughlin

M.J.

; Shurnas

P.S.

: Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 24: 731–743, 2003.

26.

Coughlin

M.J.

; Shurnas

P.S.

: Hallux valgus in men. Part II: First ray mobility after bunionectomy and factors associated with hallux valgus deformity. Foot Ankle Int. 24: 73–78, 2003.

27.

Coughlin

M.J.

; Thompson

F.M.

: The high price of high-fashion footwear. Instr. Course Lect. 44: 371–377, 1995.

28.

Coughlin

; Jones

; Villadot

: Hallux valgus and first ray mobility: a cadaveric study. Foot Ankle Int. 25: 537–544, 2004

29.

Creer

W.S.

: The feet of the industrial worker: clinical aspect; relation to footwear, Lancet 2: 1482–1483, 1938.

30.

DiGiovanni

; Kuo

; Tejwani

: Isolated gastrocnemius tightness. J. Bone Joint Surg. 84-A: 962–970, 2002.

31.

Dreeben

; Mann

R.A.

: Advanced hallux valgus deformity: long-term results utilizing the distal soft tissue procedure and proximal metatarsal osteotomy. Foot Ankle Int. 17: 142–144, 1996.

32.

Durman

D.C.

: Metatarsus primus varus and hallux valgus. Arch. Surg. 74: 128–135, 1957.

33.

DuVries

: Surgery of the foot. C.V. Mosby Co. St. Louis, pp. 346–442, 1959.

34.

Easley

; Kiebzak

; Davis

W.H.

; Anderson

R.B.

: Prospective, randomized comparison of proximal crescentic and proximal chevron osteotomies for correction of hallux valgus deformity. Foot Ankle Int. 17: 307–316, 1996.

35.

Engle

; Morton

D.J.

: Notes on foot disorders among natives of the Belgian Congo, J. Bone Joint Surg. 13: 311, 1931.

36.

Faber

; Faber

; Kleinrensink

: Mobility of the first tarsometatarsal joint in relation to hallux valgus deformity: anatomical and biomechanical aspects. Foot Ankle Int. 20: 651–656, 1999.

37.

Giannestras

: The Giannestras modification of the Lapidus operation. In Giannestras

(ed): Foot disorders: medical and surgical management, Lea & Febiger, Philadelphia, pp. 366–373, 1973.

38.

Glasoe

; Allen

M.K.

; Saltzman

C.L.

: First ray dorsal mobility in relation to hallux valgus deformity and first intermetatarsal angle. Foot Ankle Int. 22: 98–101, 2001.

39.

Glasoe

; Grebing

; Beck

; Coughlin

; Saltzman

: A comparison of device measures of dorsal first ray mobility. Foot Ankle Int. 26: 957–961, 2005

40.

Goldner

J.L.

; Gaines

R.W.

: Adult and juvenile hallux valgus: analysis and treatment. Orthop. Clin. North Am. 7: 863–887, 1976.

41.

Grebing

; Coughlin

: Evaluation of Morton's theory of second metatarsal hypertrophy. J. Bone Joint Surg. 86-A: 1375–1386, 2004

42.

Greenberg

G.S.

: Relationship of hallux abductus angle and first metatarsal angle to severity of pronation. J. Am. Podiatry Assoc. 69: 29–34, 1979.

43.

Griffiths

T.A.

; Palladino

S.J.

: Metatarsus adductus and selected radiographic measurements of the first ray in normal feet. J. Am. Podiatr. Med. Assoc. 82: 616–622, 1992.

44.

Haines

R.W.

; McDougall

: The anatomy of hallux valgus. J. Bone Joint Surg. 36-B: 272–293, 1954.

45.

Hansen

S.T.

: Functional reconstruction of the foot and ankle, Lippincott, Williams & Wilkins, Philadelphia, p 221, 2000.

46.

Hansen

S.T.

Jr. : Hallux valgus surgery. Morton and Lapidus were right! Clin. Podiatr. Med. Surg. 13: 347–354, 1996.

47.

Hardy

R.H.

; Clapham

J.C.

: Hallux valgus; predisposing anatomical causes. Lancet 1: 1180–1183, 1952.

48.

Hardy

R.H.

; Clapham

J.C.

: Observations on hallux valgus; based on a controlled series. J. Bone Joint Surg. 33-B: 376–391, 1951.

49.

Harris

; Beath

: Hypermobile flat-foot with short tendo Achilles, J. Bone Joint Surg. 30-A: 116–138, 1948.

50.

Harris

; Beath

: The short first metatarsal: its inclination and clinical significance, J. Bone Joint Surg. 31-A: 553–565, 1949.

51.

Hawkins

; Mitchell

; Hedrick

: Correction of hallux valgus by metatarsal osteotomy, J. Bone Joint Surg. 27-A: 387–394, 1945.

52.

Hohmann

: Der hallux valgus und die ubrigen Zehenverkrum-munger. Ergeb. Chir. Orthop. 18: 308–376, 1925.

53.

Inman

V.T.

: Hallux valgus: a review of etiologic factors. Orthop. Clin. North Am. 5: 59–66, 1974.

54.

Ito

; Shimizu

; Miyamoto

; Katsura

; Tanaka

: Clinical significance of increased mobility in the sagittal plane in patients with hallux valgus. Foot Ankle Int. 20: 29–32, 1999.

55.

James

C.S.

: Footprints and feet of natives of Soloman Islands, Lancet 2: 1390–1393, 1939.

56.

Jones

; Coughlin

; Pierce-Villadot

;: The validity and reliability of the Klaue device. Foot Ankle Int. 26: 951–956, 2005.

57.

Jordan

H.H.

; Bordsky

A.E.

: Keller operation for hallux valgus and hallux rigidus. An end result study. Arch. Surg. 62: 586–596, 1951.

58.

Joseph

: Range of movement of the great toe in men. J. Bone Joint Surg. 36-B: 450–457, 1954.

59.

Kato

; Watanabe

: The etiology of hallux valgus in Japan. Clin. Orthop. 157: 78–81, 1981.

60.

Kelikian

: Hallux valgus, allied deformities of the forefoot and metatarsalgia, W.B Sanders Co., Philadelphia, pp 27–68, 1965.

61.

Kilmartin

; Barrington

R.L.

; Wallace

W.A.

: Metatarsus primus varus. A statistical study. J. Bone Joint Surg. 73-B: 937–940, 1991.

62.

Kilmartin

T.E.

; Wallace

W.A.

: The significance of pes planus in juvenile hallux valgus. Foot Ankle 13: 53–56, 1992.

63.

King

D.M.

; Toolan

B.C.

: Associated deformities and hypermobility in hallux valgus: an investigation with weightbearing radiographs. Foot Ankle Int. 25: 251–255, 2004.

64.

Klaue

; Hansen

S.T.

; Masquelet

A.C.

: Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. 15: 9–13, 1994.

65.

Lake

: The foot. Williams and Wilkins, Baltimore, pp. 184–185, 1939.

66.

Lane

: The causation pathology and physiology of several of the deformities which develop during young life. Guy's Hosp. Reports 44: 241, 1887.

67.

La Reaux

R.L.

; Lee

B.R.

: Metatarsus adductus and hallux abducto valgus: their correlation. J. Foot Surg. 26: 304–308, 1987.

68.

Maclennan

: Prevalence of hallux valgus in a neolithic New Guinea population. Lancet 1: 1398–1400, 1966.

69.

Mancuso

; Abramow

; Landsman

; Waldman

; Carioscia

: The zero-plus first metatarsal and its relationship to bunion deformity. J. Foot Ankle Surg. 42: 319–326, 2003.

70.

Mann

R.A.

; Coughlin

M.J.

: Adult hallux valgus. In Mann

R.A.

Coughlin

M.J.

(eds): Surgery of the foot and ankle, 7th edition, C.V. Mosby, St. Louis, pp 159–269, 1999.

71.

Mann

R.A.

; Coughlin

M.J.

: Hallux valgus – etiology, anatomy, treatment and surgical considerations. Clin. Orthop. 157: 31–41, 1981.

72.

Mann

R.A.

; Pfeffinger

: Hallux valgus repair. DuVries modified McBride procedure. Clin. Orthop. 272: 213–218, 1991.

73.

Mann

; Rudicel

; Graves

S.C.

: Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up. J. Bone Joint Surg. 74-A: 124–129, 1992.

74.

Markbreiter

L.A.

; Thompson

F.M.

: Proximal metatarsal osteotomy in hallux valgus correction: a comparison of crescentic and chevron procedures. Foot Ankle Int. 18: 71–76, 1997.

75.

Mauldin

; Sanders

; Whitmer

W.W.

: Correction of hallux valgus with metatarsocuneiform stabilization. Foot Ankle 11: 59–66, 1990.

76.

Mayo

C.H.

: The surgical treatment of bunion. Ann. Surg. 48: 300–302, 1908.

77.

Mitchell

; Fleming

; Allen

; Glenney

; Sanford

: Osteotomy-bunionectomy for hallux valgus. J. Bone Joint Surg. 40-A: 41–58; discussion 59–60, 1958.

78.

Morton

: Hypermobility of the first metatarsal bone: the interlinking factor between metatarsalgia and longitudinal arch strains. J. Bone Joint Surg. 10: 187–196, 1928

79.

Morton

: The human foot. Its evolution, physiology, and functional disorders. Columbia University Press, New York, 1935.

80.

Myerson

: Foot and ankle disorders, hallux valgus. WB Sanders Co., Philadelphia, pp. 213–289, 1999.

81.

Myerson

; Allon

; McGarvey

: Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle 13: 107–115, 1992.

82.

Myerson

M.S.

; Badekas

: Hypermobility of the first ray. Foot Ankle Clin. 5: 469–484, 2000.

83.

Piggott

: The natural history of hallux valgus in adolescence and early adult life. J. Bone Joint Surg. 42-B: 749–760, 1960.

84.

Pinney

; Hansen

; Sangeorzan

: The effect of ankle dorsiflexion on gastrocnemius recession. Foot Ankle Int. 23: 26–29, 2002.

85.

Pouliart

; Haentjens

; Opdecam

: Clinical and radiographic evaluation of Wilson osteotomy for hallux valgus. Foot Ankle Int. 17: 388–394, 1996.

86.

Richardson

; Graves

; McClure

J.T.

; Boone

R.T.

: First metatarsal head-shaft angle: a method of determination. Foot Ankle 14: 181–185, 1993.

87.

Sammarco

G.J.

; Russo-Alesi

F.G.

: Bunion correction using proximal chevron osteotomy: a single-incision technique. Foot Ankle Int. 19: 430–437, 1998.

88.

Sangeorzan

B.J.

; Hansen

S.T.

Jr. : Modified Lapidus procedure for hallux valgus. Foot Ankle 9: 262–266, 1989.

89.

Sangeorzan

; Mosca

; Hansen

: Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle Int. 14: 136–141, 1993.

90.

Saragas

N.P.

; Becker

P.J.

: Comparative radiographic analysis of parameters in feet with and without hallux valgus. Foot Ankle Int. 16: 139–143, 1995.

91.

Schemitsch

; Horne

: Wilson's osteotomy for the treatment of hallux valgus. Clin. Orthop. 240: 221–225, 1989.

92.

Schoenhaus

H.D.

; Cohen

R.S.

: Etiology of the bunion. J. Foot Surg. 31: 25–29, 1992.

93.

Schweitzer

; Maheshwari

; Shabshin

: Hallux valgus and hallux rigidus: MRI findings. Clin. Imaging 23: 397–402, 1999.

94.

Silver

: The operative treatment of hallux valgus, J. Bone Joint Surg. 5: 225–232, 1923.

95.

Sim-Fook

; Hodgson

A.R.

: A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J. Bone Joint Surg. 40-A: 1058–1062, 1958.

96.

Sorto

L.A.

Jr ; Balding

; Weil

L.S.

; Smith

S.D.

: Hallux abductus interphalangeus. Etiology, x-ray evaluation and treatment, 1975. J. Am. Podiatr. Med. Assoc. 82: 85–97, 1992.

97.

Tanaka

; Takakura

; Kumai

; Samoto

; Tamai

: Radiographic analysis of hallux valgus. A two-dimensional coordinate system. J. Bone Joint Surg. 77-A: 205–213, 1995.

98.

Thompson

; Coughlin

M.J.

: The high price of high-fashion footwear. J. Bone Joint Surg. 76-A: 1586–1593, 1994.

99.

Thordarson

D.B.

; Krewer

: Medial eminence thickness with and without hallux valgus. Foot Ankle Int. 23: 48–50, 2002.

100.

Truslow

: Metatarsus primus varus or hallux valgus. J. Bone Joint Surg. 7: 98–108, 1925.

101.

Veri

; Pirani

S.P.

; Claridge

: Crescentic proximal metatarsal osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up study. Foot Ankle Int. 22: 817–822, 2001.

102.

Viladot

: Metatarsalgia due to biomechanical alterations of the forefoot. Orthop. Clin. North Am. 4: 165–178, 1973.

103.

Vittetoe

; Saltzman

; Krieg

J.C.

; Brown

T.D.

: Validity and reliability of the first distal metatarsal articular angle. Foot Ankle Int. 15: 541–547, 1994.

104.

Volkmann

: Ueber die sogennante exostose der grossen Zehe. Virchow's Archiv fur pathologische Anatomie. 10: 297, 1856.

105.

Wanivenhaus

; Pretterklieber

: First tarsometatarsal joint: anatomical biomechanical study. Foot Ankle 9: 153–157, 1989.

106.

Wells

L.H.

: The foot of the South African native. Am. J. Phys. Anthropol. 15: 185–189, 1931.

107.

Westbrook

; Subramanian

; Monk

; Calthorpe

: Best foot forward. Proceeding of the British Orthopaedic Foot Surgery Society. J. Bone Joint Surg. 85-B(Supp III): 249, 2003.

108.

White

; Lucas

; Richards

; Purves

: Cerebral asymmetry and handedness. Nature 368: 197–198, 1994.

109.

Wynne-Davis

: Family studies and the causes of congenital clubfoot talipes equinovarus, talipes calcaneovalgus and metatarsus varus. J. Bone Joint Surg. 46-B: 445–476, 1964.