This protocol applies to patients with symptomatic hallux valgus and persistent forefoot pain at the first metatarsophalangeal (MTP) joint who have not achieved adequate pain relief or improved foot function following an initial course of conservative management.
The patient presents with hallux valgus and forefoot pain at the first MTP joint. Deformity severity meets at least one radiographic threshold: hallux valgus angle (HVA) of 20° or greater, or first intermetatarsal angle (IMA) of 14° or greater.
Symptomatic patients typically present with a gradual onset of sharp pain at the metatarsophalangeal joint that is worse on weight bearing. The HVA and intermetatarsal angle are used to sub-classify deformity severity; patients must meet at least one angular criterion to be placed in this group.
Conservative measures were the first-line approach. These included analgesia, footwear assessment and modification, offloading orthotics for the first metatarsophalangeal joint, and physiotherapy targeting balance, proprioception, and core stability. Therapeutic injection of the first MTP joint was considered when inflammation or arthritis was suspected, or when the patient was unfit for surgery.
This protocol is indicated when those measures failed to achieve resolution of forefoot pain at the first metatarsophalangeal joint and improved foot function.
For moderate to severe hallux valgus meeting the angular thresholds above, a surgical intervention is indicated. The evidence-based approach involves osteotomy procedures of the first metatarsal, which may be performed as open surgery or via a minimally invasive percutaneous technique with internal fixation. The specific procedure selection and combination are detailed in the full protocol.
The clinical goals are resolution of forefoot pain, restoration of proper hallux alignment, and correction of both the hallux valgus angle and first intermetatarsal angle into normal ranges.
Symptomatic patients typically present with a gradual onset of sharp pain at the metatarsal phalangeal (MTP) joint that is worse on weight bearing.
NICE uses the HVA and intermetatarsal angle (IMA) to sub-classify the severity of the deformity. Patients must meet at least one of the criteria in the rows to be diagnosed.
In moderate to severe cases, proximal MT osteotomy is preferred and is often performed in combination with distal MT osteotomy.
A Scarf osteotomy, also known as a Z osteotomy, is another popular method used to treat moderate to severe HV.
An Akin osteotomy used in moderate to severe HV is a closing medial wedge osteotomy of the proximal phalanx of the great toe. It is rarely used in isolation, more commonly utilized in conjunction with a scarf osteotomy procedure.
They concluded that minimally invasive and open procedures have a similar efficacy and risk profile, with comparable patient-reported outcomes and recovery times for all severities of deformity.
Surgical correction of HV aims to alleviate pain and improve foot function through restoration of the proper alignment of the hallux.
View source ↗