What are the treatment and management options for hallux valgus deformity?

Hallux Valgus Deformity: Treatment and Management

Conservative treatment should be the initial approach for hallux valgus, but surgery (specifically distal chevron osteotomy) is definitively more effective than conservative management or no treatment for reducing pain and improving function in symptomatic patients. 1, 2

Conservative Management

Conservative treatment is the first-line approach for hallux valgus, though evidence for its effectiveness is limited:

• Orthoses and night splints show no significant benefit over no treatment in improving clinical outcomes 3
• Conservative measures may include appropriate footwear modification, with shoes that accommodate the deformity and avoid tight fitting at the metatarsophalangeal joints 4
• Patients should be referred for specialized footwear if standard shoes cannot accommodate the deformity or if there are signs of abnormal loading 4

Important caveat: The evidence base for conservative treatments is weak, with multiple trials showing no advantage over no treatment 3. This should inform realistic patient expectations.

Surgical Management

When to Operate

Surgery is indicated when:

• Conservative treatment has failed to adequately control symptoms 1, 2
• Patients have significant pain interfering with daily activities 1
• There is documented functional impairment 2

Surgical Outcomes

Surgery demonstrates clear superiority over conservative management:

• Distal chevron osteotomy reduces pain significantly more than conservative treatment (mean difference -15.00,95% CI -22.79 to -7.21) in the first year 1
• AOFAS scores improve by an average of 33.8 points across all surgical techniques, reaching postoperative values between 81.4 and 90.1 points 2
• Patients with more severe deformities and greater preoperative impairment show higher potential for improvement 2

Choice of Surgical Technique

The specific surgical technique matters less than the decision to operate:

• Various osteotomy techniques (chevron, proximal, distal) achieve comparable correction of bony deformity with no significant differences in clinical outcomes 1, 3
• Distal chevron osteotomy is more effective than Lindgren osteotomy for walking speed (MD -0.24,95% CI -0.43 to -0.05) 1
• When comparing chevron osteotomy to Keller's arthroplasty, the osteotomy better preserves joint range of motion and improves intermetatarsal angle 3
• Minimally invasive techniques (such as SERI osteotomy) are effective for mild to moderate hallux valgus (HVA ≤40°, IMA ≤20°) with AOFAS scores improving from 46.8±6.7 to 89±10.3 at mid-term follow-up 5

Complications and Realistic Expectations

Patients must be counseled about surgical risks:

• Overall complication rate after surgical correction is 18.5% 2
• Common complications include metatarsalgia, recurrent deformity, first metatarsal joint stiffness, wound-healing disorders, and hallux varus 2
• Recurrent deformity occurs in approximately 29% of patients in some series 4
• Notably, 25-33% of patients remain dissatisfied at follow-up even when hallux valgus angle and pain have improved 3

Post-operative Management

Early mobilization improves outcomes:

• Continuous passive motion appears to improve range of motion and promote earlier recovery 3
• Early weightbearing is not detrimental to final outcomes 3
• Functional support with bracing is preferred over immobilization 4

Clinical Algorithm

1. Initial presentation: Begin with conservative management including appropriate footwear modification 4
2. If symptoms persist or worsen: Consider surgical consultation, particularly if pain interferes with daily activities 1, 2
3. Surgical planning: Any standard osteotomy technique is acceptable; choice can be based on surgeon expertise and deformity severity 1, 2, 3
4. Post-operative care: Implement early mobilization with functional support rather than rigid immobilization 4, 3

Critical pitfall: Do not overestimate the effectiveness of conservative treatments—the evidence shows they provide minimal benefit over no treatment 3. Conversely, do not oversell surgery, as patient dissatisfaction rates remain substantial despite objective improvement 3.