Hallux Valgus
Complaining of foot pains is very common. A “new bone” appears sometimes, at the basis of the great toe. Wearing the same shoes becomes difficult, and high heels shoes becomes unaffordable. We call this disease “Bunion”. Bunion disease occurs with a small deformity getting bigger or by a pain or both. In some cases, it starts by feeling that the shoes are not comfortable anymore.
Knowledge in 26 questions
1 – What is an « bunion » or what is it Hallux Valgus ?
It is a sometimes painful distortion of the foot called « hallux valgus », which means that the big toe is exaggeratedly outwards, oriented to the outside of the foot. With an enlarged forefoot. Why and where does this distortion come from? Because the first ray: which is made of the first metatarsal and 2 Phalanges: the 1st metatarsal. Diverges from the second metatarsal and the large toe, which consists of two phalanges, moves outwards, and that there is a partial relaxation of the tendons, capsules, and aponeuroses.
The « bunion » is not a new bone that has grown. This « bump » under the skin rubs against the shoe and creates a conflict at the origin of the pain, there is associated a redness called« bursitis ». Bursitis is therefore the term which designates the formation between the skin and the bone of a small pocket which can ignite, sometimes contain some liquid.
2 – Why there is formation of a bunion?
This divergence between the 1st and 2nd bone radius affects 10% of the population, especially women (the majority of cases). The cause of this deformation is multiple and complex, it is acquired in 60 to 70% of the cases and innate in 30%. The shoe can be incriminated in the acquired forms but it is not only because of the shoe.
It is also the shape and mobility of bone tissue and soft tissue that play a part and contribute to the creation of this deformity which becomes painful. The components that create or precipitate the creation of the deformity are: flat foot, big toe (Egyptian foot), hallomegaly, family history (30%) or overweight.
This can also occur on hollow feet. The shoe precipitates and / or aggravates the relaxation of the tendons and the capsule.
3 – What about the other toes: Should we operate the hallux ?
Operation of the hallux valgus does not necessarily prevent distortion of the other toes. A toe is independent and can endure relaxation and musculo-tendinous contractions.
Mechanically the big toe can clash with the 2nd and push it out, precipitating or aggravating the formation of a second toe grip. Once the hallux valgus is operated, the other toes can stabilize or continue the progression of the deformation, necessitating sometimes another specific intervention dedicated to this situation.
However, it should be noted that some surgical techniques re-balance the distortion of the forefoot better than others, which can stop or decrease preventively the deformation of the other toes called « laterals ».
4 – At what age should the intervention take place?
There is no definite rules. No precise age for surgery, we just have to wait, in the young, if possible, the end of growth. The extreme ages range from 15-16 to 86 -87 years, mostly around 50 -55 years of maximum discomfort. The indication of an operation does not depend on age. It depends on the embarrassment to the shoe and the pain that exists with the deformation of the big toe.
5 – How long does convalescence last after a foot surgery?
Indirectly answered in question 18. The partial support period of the forefoot lasts from 3 to 4 weeks, complete support is then allowed and bone consolidation usually occurs between the 6th and 8th week.
6 – And what about rehabilitation after surgery?
Unnecessary immediately after surgery, becomes useful after ablation of points and especially between the 3rd-4th week and the 6th-8th week.
For self-re-education which involves mobilizing oneself in flexion / extension several times a day the toes is highly recommended as well as an ascending massage between the thumb and the index of the root of the toes to the calf, but when stiffness occurs, the solution is rehabilitation and auto-rehabilitation by exercices like wolking in aquatic environment ( swimming pool).
7 – What are the post-surgery cares?
- a) The first dressing is done by the surgeon himself, between the 2nd and 3rd week then once every 2 to 3 days until healing.
- b) Preventive treatment of a thromboembolic complication is prescribed; It is not an obligation in the surgery of the foot especially if the patient walks the next day and especially if it supports. Nevertheless, it is usual to cover this risk by daily subcutaneous injection with HLMW (heparin of low molecular weight) for 10 to 20 days, maximum 30 days, in particular if the patient presents risk factors for phlebitis. Other treatments exist, in tablet form: PradaxaTM or XareltoTM.
- c) Control visit. It takes place between 1 and 3 weeks to check the wounds, by doing the fitsy dressing, and in any case, 6 -8 weeks later with a control radio, to appreciate the evolution of the bone callus of the or osteotomies.
- d) Wearing normal shoes?
This can be done as early as the 4th week and if the foot remains swollen from the 6th week. Edema is the enemy of the shoe and the surgical incisions. It limits the return to normal heating. It is very specific, and so limited to the person herself, the state of his venous return and in general the state of his veins. The first shoes should be wide to rounded, with velcro or lace and one or a half sizes above the initial size. It should be noted that the old shoe reproduces the initial form of the foot , before surgery, because the foot deformation is reproduced by the shoes; and should no longer be worn in principle. High-heeled shoes after the operation of a hallux valgus ( and any other forefoot surgery, because surgery is performed when it is painfull and when there is a fixed deformity pf the foot or the toes)are allowed even if this type of shoe is very physiological. - e) Work stoppage:
The work stoppage takes into account the severity of the action, which depends on the amount of prre-operative deformity. Other criteria include the patient’s weight, the age, the type of activity, because the safety shoe is an essential part of this decision. The stop is from 1 month minimum to 2 months and a half. The operation of the two feet in the same time imposes an identical duration no more. - f) A) When to drive?
Driving is permitted as soon as the medical post operative shoe is abandoned after surgery and the recovery of a good mobility of the toes, that starts from the 25th day 4 weeks. - g) Recovery of sport?
After the 6-8th week of convalescence, it becomes possible to redo the sport but gradually and without force, by privileging sports that require little foot: bike on flat or swimming from healing. It is useful to wait at least 12 weeks (3 months to 4 months ) before getting back to hard sports that constrain the foot and suppose a support on the forefoot and a sporting walk. Swimming is proposed from the 3rd week. - h) The same sports as before?
The surgical operation does not change the capacity of the muscles and the bone touched during the gesture. It is supposed to consolidate completely (after 10 to 12 weeks), the patient can then resume the sporting activity before or even the competition. - i) The question of recidivism?
The question is legitimate and the risk of recidivism is real. It depends on the quality of the correction, the postoperative shoeing, the importance of the deformation. Some believe that if the correction is made at an advanced stage, it is unlikely that the distortion will return and, conversely, if it is performed at a very early stage or at a very young age, Still has a deformation potential and the deformation can recur. It is di cult to decide this debate but it exists and it is necessary to know that the recurrence exists and that the postoperative footwear is there for something. - j) Removal of equipment?
Beyond 3 months, bone consolidation is acquired and the orthopedic equipment put in place no longer serves anything. If it is rubbed in the shoe, it can be removed, but a one-year compliance period is recommended. Some use resorbable pins that do not need to be removed as they resolve within 9 to 18 months. - k) If material is removed, the risk of recurrence increases?
No, the osteotomies must be consolidated. After the 3-month period, bone consolidation is acquired and the orthopedic equipment is no longer used. If removed, the bone retains its place and its withdrawal does not increase the risk of recurrence.
Hallux Valgus
More answers…
There is no urgency to operate a hallux valgus and all those who do not are operated, obligatorily (except inflammatory bursitis, ulcerative, with serous or purulent discharge). An intervention can be justified only if the patient is embarrassed, functionally with a pain that becomes continuous and / or disabling, with a dilemma to put on. Surgery should never be performed for aesthetic reasons or for purely foot width reasons or aesthetic finesse or preventive. The intervention is always possible whatever the deformation.
One can delay the evolution and prevent the consequences of the imbalance with cloth or soft leather shoes, with rounded toe giving enough space for the toes avoiding the seams facing the zones of friction. The shape of the sole especially if the foot is flat can also be important. Wearing a small sole with inner arch support can make the footwear comfortable. By changing the load distribution on the other toes. It will be performed by a professional graduate in podiatry
There are protections called « toe separator » or « spreader » or silicone « spacer » that can temporarily alleviate. Just as there are « orthoplasty » or nocturnal reduction orthoses, which are protective silicone gel products, and which also can temporarily alleviate the pain, but this does not really change the evolution of the deformation of the fat toe. They can relieve, delay a little and in some cases prevent degradation and aggravation.
Il n’y a pas de traitement médical connu et validé qui corrige la déformation. Seule la chirurgie permet de traiter la douleur en diminuant la déformation et en replaçant les attaches tendineuses en place. Mais un hallux valgus n’est pas obligatoirement synonyme de chirurgie. La décision repose aussi sur le degré de la gêne, sur la tolérance et surtout sur l’importance de la douleur.
La déformation de la chaussure, l’état des sésamoïdes et leurs positions interviennent dans la décision. On n’opère pas une lésion, ni une radio, encore moins une déformation mais un patient avec ses antécédents, ses pathologies. Le bilan de ces antécédents, et la balance bénéfices/risques évaluée avec le chirurgien et l’anesthésiste sont le fondement de l’indication chirurgicale et de la nature de l’acte opératoire.
Opérer un hallux valgus est une décision qui ne doit jamais être prise à la légère, des complications peuvent survenir, telle que cette hypercorrection entraînant un hallux varus post opératoire (photo ci-dessus).
The criteria are numerous, the taking into account of the antecedents is essential, but the specific decision rests on essentially 3 criteria:
- The functional discomfort to the heating which is paramount in the decision (motivates half of the decision).
- Pain on the level of the onion or on the lateral toes which is a key element of the surgical indication. Is it disabling? Does it impotence?
- The importance of the deformation which is an element but secondary (15%).
According to the American Orthopedic Foot and Ankle Society (AOFAS) criteria, plastic or aesthetic motivation should not be included in the components of a surgical decision.
There are three types of anesthesia: general anesthesia, rachiesthesia (or epidural equivalent), and loco-regional anesthesia, also known as nervous or neurological peripheral anesthesia, or so-called truncular anesthesia. It is an anesthesia often advised because the patient is asleep only from the knee to the foot. This anesthesia does not disrupt the body and has a post-surgical analgesia lasting several hours. If bilateral surgery is performed, general anesthesia or spinal anesthesia will be more readily available.
It is recommended to operate one foot after the other. The pain is less and it is easier to move when one foot is limited and the other is normal or functional (postoperative shoes being unbalanced).
It also depends on the size of the deformations and the type Intervention. In the case of bilateral simple hallux valgus, Possible to operate both feet at the same time. But the experience patients attests that this is more challenging. If the deformation is Complex with many operative gestures on several toes and metatarsal rays, it is recommended to operate one foot then the other with 2 weeks to 3 months of delay, depending on the case.
The surgical field is never visible. For the sounds, patients are offered individual headphones or a personal music player that isolate phonetically from the room. Otherwise the anesthesiologist may propose a so-called sedation product which causes somnoler during the procedure.
The duration varies according to the operating method, the importance of the deformation and the number of toes to be operated. For a simple hallux valgus, the duration of the gesture is 30 to 45 minutes. On a complex foot, it is twice as long, but the absence of the patient from his room lasts 2 to 4 hours because there is preparation and passage in the recovery room.
The bad reputation (the surgery of the foot is said to be very painful and trying) emanates from the heavy and wide techniques with an analgesia post-operative ine cace, or even absent. At present, anesthesia has a range of analgesic protocols, but most often, by offering locoregional anesthesia, there is an e and analgesic which lasts several hours after surgery and which can, if requested by the surgeon, and patient accepts it, leave a catheter to inject analgesics and anesthetics in situ for 24 to 48 hours.
And since the really painful phase lasts only 48 hours, the problem is solved, but each one does not react similarly to this analgesia and this type of anesthesia. Then analgesia is supplemented by powerful analgesics such as morphine drugs or their equivalents.
There is no age ideal, nor an ideal time even less an ideal season. The intervention is feasible at all times. It is determined by functional discomfort and pain. There is no more risk of nosocomial infection at a time
It has been said above that surgical indications can range from 15-16 to 85-86 years, it is obvious that not all techniques are equal. Some will be more suitable than others. Osteoporosis when it exists complicates the choice of a precise technique before a type of indication. The quality of the bone intervenes a little in the result, the osteoporosis does not prevent the good consolidation of the bone.
The answer is NO. There is not one univocal technique for all hallux valgus, because there are several types of interventions:
- Bone gesture only,
- gesture on the soft parts only,
- a mix, of the 2,
- In the open surgery, or
- With closed hearth,
- With a wide osteotomy, over the entire length of the metatarsal,
- oblique or in Z called SCARF
- or limited : in « bevel » or in « chevron », with acute angle or not,
- Seated at the proximal metaphysis (Lapidus) or distal, respecting the articulation or not (Keller-Lelièvre), associated or not with a gesture on the phalanx (Atkin).
The type of intervention must depend on:
- The value of the angle M1-M2 (which is normally from 6 to 8 °, maximum 10 °), and The value of the angle M1-P1 (which is normally from 10 to 12 °, maximum 15),
- The morphotype of the foot,
- The patient’s general condition like age, bone status, presence of diabetes or not, insulin-dependent or not, distal vascular state
- the practice of the operator.
And each of the criteria can present alone or together, affecting the choice.
Most of these techniques are to re-center the bone and to reduce the value of the angle M1-M2. And the value of angle M1-P1 must also be reduced.
It is possible to proceed by what we call an osteoclasy (bone fragilisation) or directly with an osteotomy (section of the bone, with a saw). That is to say, in order to correct the axis, one proceeds in various ways. In fact, it is necessary to weaken the bone by several perforations, to leave a bone bridge, and it is by manually supplementing the osteoclasis that the axis of the bone is raised. This can be done by a mini-approach (known as « buttonhole » or « punctiform » or « fly » giving scars 2 to 8 mm long, (this is the so-called « percutaneous » technique) Or by incising to minima (ie mini-approach), also called mini-invasive. This action lasts from 30 to 70 minutes depending on the case and will allow by small cutaneous openings to introduce surgical instruments and to use tools that will allow thanks to the control obtained by the amplifier of brilliance (which is a kind of » Screen television equipped with a radiological source that shows the bone as a cliché, it is also called Fluoroscopy), to carry out the intervention without large incision of the skin
By this means, contraction of the tendons can be severed and the bones of the foot can be affected: the metatarsal and the phalanges, (of the big toe and of the other toes if they are deformed too).
Si la déformation est conséquente et s’associe à une atteinte latérale des autres orteils, on réalisera peut être u
If an « arthrodesis » (blockage) of the MTP (metatarsophalangeal) joint of the big toe is required because there is subluxation or advanced osteoarthritis, the incision may be wider. Some surgeons are able to do this « blocking » percutaneously as well. Finally, this blocking may be necessary because of age, osteoporosis or recurrence of deformation (iterative surgery, also called surgery of recovery) or by stiffness.
These surgical approaches are based on the same principles, they will be adapted to the morphotype of the foot, the presence of a flat or hollow foot, the orientation of the back foot, age, the presence of a front – anterior round foot (APRA: deformation of the forefoot in convex form instead of being concave). To the importance of the deformation, to the association of several deformations of the other toes adjacent, also called lateral.
Not really because the answer is YES and NO. Because surgery is always possible no matter how important the deformation. The time of consolidation (that is, the time of healing of the gesture made on the bone) is roughly the same regardless of the nature of the act. And the convalescence period is almost always the same: 4 to 6 weeks. But more limited deformation and more the surgical procedure is simple. The surgeon adapts his technique to deformation. But it should not be Operating a hallux valgus early, the operation will prevent the other toes from deforming. Moreover, a recurrence of the distortion of the big toe remains possible further.
No. The quality of the bone does not really intervene in the result and the osteoporosis does not prevent bone consolidation
Non, les déformations du pied ne peuvent pas être corrigées par une autre méthode que chirurgicale telle que le laser. Il existe peut-être une méprise car depuis quelques années a été introduite en France des techniques mini-invasives dite « percutanées » où on opère par des mini-cicatrices. Ces méthodes sont utilisées depuis plus de 25 ans aux Etats-Unis et bien plus récemment en France. Pour pratiquer cette chirurgie on n’utilise pas de « laser » mais des instruments spécifiques plus petits, de petites fraises qui ressemblent à celles utilisées en stomatologie et en dentisterie, et des méthodes de travail particulières sous amplificateur de brillance (ou fluoroscopie : appareil visualisant l’os comme une source radiologique).
The duration of hospitalization varies according to the technique, the deformations corrected and according to the practices of the operator. The procedure can be performed in ambulatory surgery (without hospitalization) if the gesture is simple or minimally invasive and / or percutaneous. The hospitalization may last 24 hours sometimes 48 for certain techniques, maximum 3 for complex feet covering all the radii of the foot or recurrences.
The rising takes place the following day with mobilization in the chair. With some rare exception, it is also the day after the intervention that you can take the first steps, with a shoe that allows partial support of the forefoot.
At the beginning, with the help of a shoe that completely discharges the forefoot (BaroukTM shoe type) or better that which allows partial support (with a so-called buffer Blotting, SOBER® brand or PODALUX®) which allows to preserve a good autonomy. The use of a cane can be advised to maintain balance if there is total discharge of the forefoot.
Pour conclure
En conclusion, l’hallux valgus est une affection bénigne fréquente, qui peut devenir très douloureuse et invalidante et qui peut être soignée par un acte chirurgical à foyer ouvert (incision de 6 à 12 cm, notamment pour la technique dite du SCARF) ou par chirurgie mini-invasive ou par chirurgie per cutanée ou par un mix des deux.
La chirurgie percutanée ou mini-invasive n’utilise pas le laser, mais des instruments spécifiques et se pratique sous fluoroscopie (amplificateur de brillance). Les résultats des 2 techniques sont comparables, avec un discret avantage à la chirurgie percutanée, car les incisions étant plus petites , elles cicatrisent plus vite, et parce que l’hospitalisation peut être plus courte et que la récupération peut se faire un peu plus rapidement. Mais l’habitude du chirurgien reste un caractère important dans la décision et le choix d’une technique.