What is the recommended treatment for hallux valgus deformity?

Treatment of Hallux Valgus Deformity

Begin with conservative management using specialized footwear and orthoses, but proceed to surgical correction when conservative measures fail to control symptoms, as surgery provides superior pain relief and functional outcomes compared to non-operative treatment.

Conservative Management (First-Line Approach)

Conservative treatment cannot correct the deformity but can effectively control symptoms and should be attempted initially. 1, 2

• Footwear modification is the cornerstone of conservative management, requiring shoes that accommodate the deformity and avoid tight fitting at the metatarsophalangeal joints 1
• Patients should be referred for specialized footwear if standard shoes cannot accommodate the deformity or if signs of abnormal loading are present 1
• Orthoses and nocturnal splints combined with appropriate footwear can help manage symptoms 3, 2
• Insoles and physiotherapy in combination with proper footwear provide symptomatic relief 2

When Conservative Treatment Fails

Surgery is indicated when conservative measures do not adequately control pain and functional limitations. 4, 3

Surgical Management

Distal chevron osteotomy of the first metatarsal is more effective than conservative treatment for pain reduction, with a mean difference of -15.00 points (95% CI -22.79 to -7.21) in the first year following surgery. 4

Surgical Decision-Making Algorithm

Classify the deformity severity first (mild/moderate versus severe), as this determines the surgical approach 5, 2:

• Mild to moderate deformity: Distal metatarsal osteotomies (chevron-type procedures) 4, 2
• Severe deformity: Proximal metatarsal osteotomies or modified Lapidus fusion 2
• Concurrent degenerative changes of the first metatarsophalangeal joint: Consider arthrodesis 2

Expected Surgical Outcomes

All common surgical techniques achieve comparable correction of the bony deformity and functional improvement. 5

• The AOFAS score improves by an average of 33.8 points (95% CI: [30.5; 37.0]) across all surgical techniques 5
• Postoperative AOFAS scores range from 81.4±7.7 to 90.1±4.8 points depending on the technique used 5
• The choice of specific surgical technique and duration of follow-up have no significant effect on subjective treatment outcomes 5
• Differences between various osteotomy types are minimal in terms of clinical outcomes 4

Common Surgical Complications

The overall complication rate after surgical correction is 18.5%. 5

The most frequent complications include:

• Metatarsalgia (transfer pain to adjacent metatarsals) 5
• Recurrent deformity (occurs in approximately 29% of patients in some series) 1, 5
• Stiffness of the first metatarsal joint 5
• Wound-healing disorders 5
• Hallux varus (overcorrection) 5

Post-Operative Management

Functional support with bracing is preferred over immobilization in post-operative management. 1

• Corrective dressings of the great toe are applied post-operatively 2
• Weight-bearing protocols vary by procedure: partial or full weight-bearing in a post-operative shoe or cast immobilization 2
• Serial radiographs should be obtained at regular intervals until osseous healing is achieved 2

Special Considerations for Diabetic Patients

In diabetic patients with hallux ulcers and limited range of motion of the first metatarsophalangeal joint:

• Metatarsal-phalangeal joint arthroplasty combined with non-removable offloading devices should be considered when non-surgical offloading interventions have failed 6
• This approach is specifically indicated for hallux ulcers with limited joint motion, not for other deformities 6

Key Clinical Pitfalls

• Do not expect conservative treatment to correct the deformity—it only manages symptoms 2
• Recurrent deformity is common (29% in some series), emphasizing the importance of careful patient selection and meticulous surgical technique 1
• Patients with more severe deformities and greater impairment have higher potential for improvement in functional scores 5
• Women are disproportionately affected (83% of cases), with typical onset between ages 30-60 years 3, 5