CHAPTER 37

POSTOPERATIVE HALLUX VARUS

Christolther R.D. Menke, DPMKieran T. Mahan, DPMHoward.l. Hilktrom, PhD

The first known case of hallux varus dates back to a 3.75million year old fossil from the Pliocene age in Africa.,Although this may imply that hallux varus is not exclusiveto surgery, most cases are reported as a postoperativecomplication associated with the surgical correcion ofhallux abducto valgus.'6 In looking for the mosr accurateestimate of hallux varus as a complication of hallux abductovalgus surgery, an extensive review of the literature is

presented. This article is the most comprehensive literaturereview to date regarding the occurrence rare ofhallux varusby procedure.

ANAIOMY

Four intrinsic muscles insert directly onro the base of theproximal phalanx. The extensor hallucis brevis insertsdorsally, the flexor hallucis brevis plantarly, abductorhallucis medially, and the common tendon of the obliqueand transverse head of the adductor hallucis tendoncombine with the lateral head of the flexor hallucis brevisto insert plantar laterally. These 4 muscles are importanrfor stabilizing the great toe into a neutral position, withno more than 15' of lateral deviation allotted.'r,7 Finally 2extrinsic muscles, the extensor hallucis longus dorsallyand the flexor hallucis longus plantarly, course over themetatarsophalangeal joint to insert distally on the distalphalanx. As the hallux drifts medially, the pull of thesemuscles can bow string and enhance the medial deviationof the hallux.

ETIOLOGIC FACTORS

Many etiologic factors in the developmenr of hallux varushave been presented throughout the literature. It is

believed that there is no one specific factor that acts alonein the advancement of this deformity and as stated byBanks and Ruch, usually several paramerers have to beviolated before the first metatarsophalangeal jointassumes an aberrant position.o The most common theoryis that interruption of the conjoined adductor tendonwith subsequent overpowering of the medial muscles of

the first metatarsophalangeal eventually leads to halluxvarus.e''. The foliowing list shows etiologic factors that are

believed to have a possible role in the progression of a

deviated hallux secondary to surgery: excessive plantar-lateral release/fibular sesamoidectomy; "staking" the firstmetatarsal head; excessive medial capsulorraphy/medialcapsule tightening; overcorrecrion osreoromy; excessivelylong first metatarsal; rounded first metatarsal head;elasticity of .joint capsule; and postoperative bandaging.

LITERATURE REVIEW'

Metatarsocuneiform pro cedures.

AIso know as the Lapidus, this procedure has been indi-cated in patients with a hypermobile first raf;degenerative changes of the first metatarsocuneiformjoint, and severe metatarsus primus varus (Thble 1).

Overall there was a 5.3o/o rate of hallux varus our of 453Iapidus procedures with 24 reported cases between 1980and 2004.In 1990 Mauldin reported a hallux varus rate

of L5.7o/o after performing a metararsocuneiformstabilization procedure along with a modified McBrideon 51 feet. It was concluded that an over-zealous lateralrelease was the underlying factor. In response ro rhe

encountered complications, the authors began to repairthe adductor tendon in an attempt to prevent a dynamicvarus from appearing postoperatively.li Mclnne in 2001reported a 12.5o/o hallux varus rate (4 cases) out of 32lapidus osteotomies with a total lateral release." In 2003Lombardi reported 2 hallux varus deformities afterperforming 20 lapidus osteotomies with an additionaiReverdin-Laird osteotomies and lateral release.'3 Theremaining studies depicted a low percentage of halluxvarus ranging berween 0 and 4oh.

Proximal osteotomies with soft tissue procedure.

One of the main advantages for using a proximalosteotomy is the ability to correct a larger intermetatarsalangle. Howeve! it was gathered from eighteen variousstudies between 1992 and 2001 that there was an overallhallux varus rate of 10.60/o (Table 2). This procedure

228 CFIAPTER 37

Thble 1

REPORTED HALLI.X VARUS AFTER METAIARSO CUNEIFORM PRO CEDURES

Procedure o/o # Feet Author (ref) Year

Lapidus & lateral release''''3

Lapidus & lateral releaseu

Lapidus & Reverdin-Laird, Iateral release''13

Lapidus & lateral releasett

Lapidus & Iateral releasel''3

Lapidus & Iateral release'

Lapidus & Iateral release3

Lapidus & lateral release''3

Lapidus & lateral release''l

TOTAL

15.7t2.510.0

4.3

5.8,<)51.5

0.0

5.3

199020012003199920041980

L98919922003

8l5t4132

2120

2t473l5r31119

tl40U670126

24t453

Mauldin"Mclnnet'

Lombardi"Catanzariti'a

Faber'5

Butson'n

Sangeorza'7

MyersonttCoetzee'e

fibular metatarsosesamoid ligament; lateral releaset = adductor transler after adductor tenotomyi lateral releasen = total release; Iateral release*t = not specified.

Table 2

REPORTED HALLIIX VARUS AFTERPROXIMAL OSTEOTOMIES \UNTH LAIERAL RELEASE

Procedure o/o # Feet Author(ref) Year

Closing Base \7edge & lateral release'

Closing Base tWedge & lateral releaset

Closing Base tWedge & Iateral release'

Proximal Chevron & lateral release'''

Proximal Crescentic & lateral release5

Proximal Crescentic & lateral release'''''

Proximal Crescentic & Iateral releaset'''3

Proximai Crescentic & lateral release''''5

Proximal Crescentic & lateral release''3

Proximal Crescentic & lateral releaset'''t

Proximal Crescentic & lateral releaset''

Proximal Chevron & lateral release'

Proximal Chevron & lateral release''3'5

Proximal Crescentic & distal closing wedge & akinProximal Chevron & Iateral releaset

Proximal Crescentic & Iateral releaseu

Proximal Chevron & lateral release''3

Proximal Chevron & lateral release''3

TOTAL

26.518.0

17.4t2.012.0t2.010,710.0

10.0

9.0

7.1b..,

5.44.6

4.0

3.4t.40.0

5.3

16160

9150

t911095143

3125

t3lr0931284t464t4t8/861114

2132

2t371121

1t251t29U720151

24t453

Tinka'nZembsch''

Tlnka"Easlel

Markbreiter'3Mann'a

Dreeben"Thordarson'u

EaslelZettl'7

Okuda"Bortonte

Veri3')

Coughlin''Markbreiter"

Fox3'

Sammarco33

Sammarcora

r999200019971.995

199719921"996

199619962000200r19942001r9991997

19991 9981993

fibular metatarsosesamoid ligameni; lateral releaset = adductor transfer after adductor tenotomy; lateral releaseo = total release; lateral release*s = not specified.

CHAPTER 37 229

demonstrated the highest rate of hallux varus complicationin rhe lirerarure.

Interestingly it should be noted that Tlnka has

reported cases of a varus complication in multiplestudies.20'22'35" tnkas articles from 1999 and 1997reviewed patients that had undergone a closing base

wedge osteotomy in conjunction with an adductortenotomy.2.'35 All of the patients included in the 2 studies

underwent the surgeries berween 1974 and 1985, thusraising some question as to whether there was overlapamong the reported data.. Excessive medial eminenceresection was thought to be an underlying cause in 10 ofthe cases and it was specifically noted that excessive

medial capsulorraphy was the cause in 8 cases. The last

varus complication developed secondary to a Keller-Brandes procedure that was included in one of thepatients to relieve hallux rigidus symptoms. It was alsonoted in the article when reviewing hallux abducto valgus

surgery results; one should define every hallux abductovalgus angle iess than 0" as a hallux varus. ft could be forthis reason why Tinka has consistently reported higheroccurrences of hallux varus regardless if it was sympto-matic or not to the patient. Trnka concluded that onlyhallux varus deformities with higher degrees (16'-24")were clinica.lly troublesome and those to a lesser degree donot have any clinical relevance.

Excluding the data from Tinkat studies, the overallpercentage rate of hallux varus for a proximal osreotomydrops from 10.60/o down to 7.4o/o,which only covers theproximal chevron and proximal crescentic osteotomies.Easley conducted a study that compared the results ofthese 2 procedures.e At a minimum followup of 12

months, Easley observed hallux varus in 12o/o (5143) of

the proximal chevron and 70o/o (4141) in the proximalcrescentic osteotomies. In conjunction with the proximalosteotomies, was a lateral release consisting of an

adductor tenotomy and a lateral capsulotomy. Of thepatients with the deformity, there were no complaints ofpain or shoe modifications necessary. Furthermore oniyone patient in each group was disappointed with thecosmetic appearance of the great toe. Overall, Easley was

still in favor of the proximal chevron osteotomy because

he found there to be a statistically significant shorterhealing time as well as less shortening of the metatarsal. Healso concluded that postoperatively the tibial sesamoid was

shifted more medial in the proximal chevron osteotomy

and therefore aided in restoring the normal biomechanicsof the first metatarsophalangeal joint.e

Midshaft Osteotomy Procedures.

These procedures attempt to utilize the advantages ofboth proximal and distal metatarsal osteotomies in thatthey can correct higher intermetatarsal angles while at the

same time allowing an early return to postoperativemobilization (Table 3). Midshaft osteotomies or"compromise" osteotomies include the Mau, LudloflScarf-Meyer Z-osteotomy, Vogler offset V-osteotomy, and

the Kalish osreoromy.ao A total of 4.lo/o of 755 cases

reported, resulted in a varus deformity (3 1 feet).

Although Schoen reported a 20o/o complication rate ofhallux varus (10i56), he also stated that there were no

patient concerns regarding the appearance of the foot on

the long term study. Similar to the study by Trnka, thisreport also considered any hallux adductus measurement

less than 0" as a hallux varus deformity. Seven out of the

ten cases of hallux varus were no greater than 5" in varus

Thble 3

REPORTED HALLTIX VARUS AFTER MIDSHAFT OSTEOTOMY PROCEDURES

Procedure # Feet Author (ref) Yearo/o

Scarf & lateral release''3r

Mau & Iateral releaseo/ sesamoidectomyKalish & adductor transfer in IM" Iess than 15'Scarf & lateral releasea

Scarf & lateral release''3'a

Kalish & adductor transfer in IM'greater than 15'Kalish & lateral releasea''

Chevron osteotomy with a long plantar armTOTAL

20.09.t8.06.5

3.01.5

t.50.04.t

1.996

1998199420001989199419941994

10155

2122

5164

51752t66

31200

4t2560t t5

3u755

Schoen3t

Bar-David3e

Downefu\7ei1''

Zygmunt"DownefoKalisha'

Donnellf3

fibular metatarsosesamoid ligment; lateral releasei = adductor transfer after adductor tenotomyi lateral release6 = total releasei lateral release-t = not specified.

230 CHAPTER 37

alignment and it was concluded that small amounts ofadductus are accepted by patients.3'

Kalish found that the rate of hallux varus secondary

to the Kalish osteotomy was directly related to the inter-metatarsal angle and concomitant adductor hallucistendon transfer. It is advocated to transfer the adductortendon only in intermetatarsal angles greater than 15"

while transecting the adductor tendon without transfer inintermetatarsal angles less than 15".a0 Hallux varus was

found to be the most common complication for the

Kalish osteotomy.

DISTAL OSTEOTOMY\T{TH LAIERAL RELEASE.

The distal chevron procedure, described by Austin in1981, has been written on in great detail and is one of the

most common distal metatarsal procedures performedtoday (Thble 4). As shown in Table 5, the occurrence ofhallux varus secondary to this procedure has relativelybeen 1ow in comparison with other first metatarsal

osteotomies. Austin does not clearly define the number ofpostoperative varus cases that he observed and only stated

in passing that there were a "few" cases.to Interestingly,

Austint original technique consisted of the V shaped

osteotomy along with an adductor tenotomy. Accordingto the techniques reported by the other surgeons in this

group, it appears that as additional structures are

incorporated in the lateral releases, the number of varus

cases substantially increased.

Distal Osteotomy without Lateral Release.

\fith the exception of the study by Loretz, there were few

hallux varus complications secondary to a lone distal

procedure. Loretz's hallux varus deformities ranged froman adducted hallux, to a more complicated triplane

deformity. Of the patients with the varus complication,the postoperative hallux abductus angle ranged from'1,7to -1. Five of the patients were categorized as a transverse

deformity and only one patient had a lack of toe

purchase. The final case was not identified within the

study as to the severiry of the deformity, however, it was

noted that the patient went on to have the adducted toe

surgically corrected.t5 Only 2 other studies in this groupof osteotomies demonstrated any varus complicationswhile nine other studies expressed no complications. As

stated by Sanders in her comprehensive review of hallux

varus, "the distal osteotomies as a group seem to be

entirely spared the complication of hallux varus."65

First Metatasophalangeal Joint Implant.

There has not been a great deal of literature written on the

first metatarsophalangeal implants with hallux varus as

a complication (Thble 6). Commonly reported

Trble 4

REPORTED HALLI.X VARUS AFTER DISTAL OSTEOTOMY I-{IERAL RELEASE

Procedure o/o # Feet Author (ref) Year

Distal Chevron / McBride / DSTP with Met OsteotomyDistal Chevron & lateral releaseu

Distal Chevron & extensive lateral release''''5

Distal Chevron & lateral release'

Distal Chevron & lateral release'

Distal Chevron & lateral release'''

Distal Chevron & lateral release''3

Distal Chevron & lateral release'

Distal Chevron & lateral release''a/ sesamoidectomy

Distal Chevron & lateral release'

Tiicorrectional & Iateral releasen

Distal Chevron & Iateral releaseu/ sesamoidectomy

Distal Chevron & lateral release'

Reverdin-Laird & lateral release'

TOTAL

r0.08.78.5

5.84.82.62.0

1.6

1.0

0.0

0.00.00.0

3.5

6160

2t23Bl94

7112r3162

tl38rl58U64

1/ 100

Few/30001121

0t t30176

0124

301854*

Coughlin"Pochatkoa5

TLnka36

Hetheringtona6Tinka'5

Stienstraaa

PetersonaT

Schneider"Feitae

Austinso

Selner5t

Oloff'Horne53

Becksa

\9951994r997199319972002t99420021997

1981

1999t99B1,984

t974

fibular metatarsosesamoid liga-eni; lateral releme' = adcluctor transfer after adductor ti.oto-y; lateral releasen - total release; lateral releasett = not specified.*total does not include 300 cases from Austin

CHAPTER3T 231

Thble 5

Procedure

REPORTED HALLI.X VARUSAFTER DISTAL OSTEOTOMY WITHOUT LAIERAL RELEASE

o/o # Feet Author (ref) Year

Reverdin-LairdWilsonHohmannDistal ChevronDistal Chevron\TilsonMitchellDistal ChevrontWilson

Distal ChevronMitchellMitchellTOTAL

71692142

1t500t950t230132

01204

0t450/1000t2250t960172

tolto53

Loretz5s

Klosok5o

Faber'3

Viehe'7Mannst

Pouliartsn

Blum6o

KlosoktuSchemitschu'

Hattrup6'Merkeln'Glynno'

10.1

4.82.0

0.00.00.0

0.00.00.00.00.00.01.0

199319932004

2003199719961994t9931 989198519831980

Thble 6

Procedure

REPORTED HALLIIX VARUSAI'TER FIRST METATASOPHAI-A.NGEAL JOINT IMPLANT

# Feet Author (ref) Yearo/o

MTPJ ImplantClosing Base \Wedge & total implantTOTAL

9.33.26.8

4t437l3r5174

20031994

Fuhrmann66

Seiberg6T

complications included infections, metatarsalgia involvingthe lesser digits, cock-up hallux or abnormal rotations ofthe hallu-x with lack of toe purchase. Nevertheless, rhese

observations were of no use to this study. \7ith the studyby Seiberg,ot the total implant was 1 of only 3 implantsused in their study. As explained in their paper, the patientpreviously had bunion surgery in which a grear deal ofdegenerative changes affected the joint, ultimateiy leadingto the joint implant. Due to a lack of parient compliance,the hallux varus developed secondary to implant failure.Fuhrmann's study was the only other study involvingimplants that noted halh-x varus as a rrue complication.66

Phalangeal Procedures.

Like first metatarsophalangeal joint implants, there has

been little regarding hallux varus and procedures distal tothe joint (Table 7). This is not surprising as there are veryfew procedures described for correcting bunions based on

solely altering the proximal phalanx of the great toe. Theoccurrence of hallux varus was fairly consistent among thereported data, however, it should also be noted that of thefour studies listed, each procedure devised for halluxabducto valgus correction was different from the next.

Soft-Tissue Procedures.

The surgical procedure originally described by McBrideemphasized the importance of releasing the lateralcontractures of the first interspace to restore the normalalignment of the great toe (Table 8). "The conjoinedtendon ofthe base ofthe outer aspect ofthe first phalanxis released from its attachment and transplanted into thehead of the first metatarsal. The external sesamoid isremoved if it is eroded, abnormal in shape, or displaced.The bursa and prominence on the medial aspect of thehead of the metatarsal are then remoyed and an ideal yetconservative correction is obtained.""

232 CHAPTER3T

Table 7

Procedure

REPORTED HALLTIX VARUS AFTER PHAT-ANGEAL PROCEDURES

# Feet Author (ref) Yearo/o

Oblique Proximal Phalangeal OsteotomyKeller & lateral release3

Keller & sesamoidectomyKeller & lateral release'

TOTAL

5.65.42.02.0

3.2

2136

2t37tl502t97

71220

2003200020022002

Cohen6t

Zembsch''Donlef'

Schneider"

Thble 8

Procedure

REPORTED HALLI.X VARUS ATTER SOFT:TISSUE PROCEDURES

# Feet Author (ref) Yearo/o

Modified McBride (DuVries) & sesamoidectomyMcBride & sesamoidectomvModified McBrideModified McBrideMcBride & sesamoidectomyMcBride & sesamoidectomyMcBride & sesamoidectomyMcBride & sesamoidectomyMcBride & sesamoidectomyTOTAL

25.013.01 1.0

8.3

5.3t.61.1

1.0

Case)7

3lt2t8l 1391 1/1006172

2t3918/1 100

101878

31300

717

7U2640

Beck o

HansenT'

MannT'Mann'a

McBrideT3

JanisTa

Feinstein'

Hawkins5Mille16

t97t1974i 981

t99t1935\9751 980197 |1975

Although the percentage of hallux varus ranged

between lo/o and 25o/o, Ta6le B shows that there was an

overall complication rate of 2.7o/o for soft tissue

procedures. Other than the paper by Beck, who gave

very little discussion regarding his high rate of varus

complication, Hansen, Mann, and Janis all had differentopinions regarding the reason for the deformity. Hansenstated that due to injuring the lateral head of the flexorhallucis brevis, the medial head gained a mechanicaladvantage as an abductor, and subsequently initiated thevarus a1ignment.71 Mann credited his varus complicationsto "an over eagerness to correct a severely deformed footand that a hallux varus was rarely a complication of a

mild-to-moderate hallux valgus deformity."" Finally,

Janis, whose study encompassed over 1,100 McBride typecorrections, found only 18 cases of hallux varus as acomplication. He attributed the complication to the lengthof the first metatarsal, stating that the chances of a halluxyarus were increased when the first metatarsal head was

rounded as well as longer than the second metatarsal.Ta

MAIERIALS AND METHODS

A review of the literature was performed by manuallyinspecting the table of contents, online search engines,

and inspecting the reference section from previous articles

written. This study includes articles up to 2004. Thejournals extensively evaluated for this study included the

following: Clinics in Podiatric Medicine and Surgery ofNorth America, Clinical Orthopedics and Related

Research, Foot and Ankle Clinics, Foot and AnkleInternational, Journal of the American Podiatric MedicalAssociation, Journal of Bone and Joint Surgery, and the

Journal ofFoot and Ankle Surgery.

The data from reported cases of hallux varus were

broken down into B separate tables based upon the type

of surgical procedure performed. The surgical procedures

included metatarsocuneiform procedures, proximalosteotomies with a soft tissue procedure, midshaftosteotomies, distal osteotomies with a laterai release,

distal osteotomies without a lateral release, first metatar-

sophalangeal joint implants, phalangeal procedures, and

CFIAPTER 37 233

soft-tissue procedures. Only articles that specificallyadmitted to looking for hallux varus as a postoperarivecomplication were considered as reliable estimates andwere included for analysis in this study. After compilingthese data into the appropriate groupings, the percentage

of the reported cases was calculated. Lastly, chi-squareanalysis was utilized to evaluate if data differedsignificantly. The following null hypothesis was

formulated: (H1) If the incidence of hallux varusdeformity as a complication from hallux abducto valgus

correction is stratified across the types of surgicalprocedures then there will be no significant difference.The resulting proportions (ie, observed frequencies)of hallux varus complications by procedure weresummarized. Contingency tables were formed such thatthe pooled data is shown in Thble 9.

RESULTS

Through chi-square analysis, it was found that there was a

significant difference in complication rates of hallux varus

when stratified across various surgical procedures (Thble

10). From this analysis the null hypothesis was rejected.

DISCUSSION

After reviewing the literature, it is still difficult ro con-clude what degree of deformity warrants the title of halluxvarus. By definition, hallux varus may range from a sim-

ple transverse plane hallux adductus to a triplane defor-mity consisting of a medially deviated hallux in a varus

rotation with a non purchasing contracted hallux.* Inaddition, some researchers define hallux varus if the hal-Iux abducto valgus angle is less than 0" on a dorsoplantarradiograph."'75 Yu discussed the relevance of first identify-ing all of the deformities involved, observing the patientboth weightbearing and non-weightbearing. After an

accurate assessment of the first metatarso-phalangeal joint, Yu defined a hallux varus as a term used

to describe only the transverse plane medial deviation ofthe great toe in respect to the first ray. He reserved thetitle of hallux malleus to describe the flexure contractionat the distal phalangeal joint and concomitant extensioncontracture at the first metatarsophalangeal joint. \fi4ren

both deformities exist simultaneousiy, this should be

referred to as an iatrogenic hallux varus with concomitanthallux malleus deformity."'

With these definitions in mind, a majoriry ofdocumented cases are incidental findings in that mostpatients have no difficulty with footwear and are

asymptomatic with the deformity." As stated byGranberry, this condition may be more common thanreported in the literature due to the benign nature ofsymptoms and Mann concluded that an 8" hallux varus

deformity is of little or no clinical significance.T''7' Thisraises the question should the postoperative diagnosis relysolely on radiographic views, or on the clinical appearance

and patient's satisfaction?

Thble 9

Procedure

TOTAL REPORTED HALLTX VARUS COMPLICAIION BY PROCEDURE*

7 8 Total

Hallux VarusNo ComplicationTotalPercentage

24

4294535l

93

78587810.6

3t7247554.1

3082485415

10

104310531.0

5

69

/46.8

7 71 27r213 2569 6656220 2640 69273.2 2.7 3.9

*1 =MetatarsocuneilormProcedures; 2=ProximalOsteotomieswithLateralRelease; 3=MidShaftOsteotomyProceduresi 4=Distal OsteotomywithLateral

Release;5=DistalOsteotomywithoutLateralRelease;6=FirstMetatasophalangealJointlmplant;7=PhalangealProcedures;8=Soft-TissueProcedures.

Thble 10

TOTAL REPORTED

Thble )G

HALLTIX VARUS EXPECTED

df Critical P ValueValue )G

FREQUENCIES

Statistical HypothesisSignificance

Data Set

9 143.965 7 14.067t <0.0001 Yes Reject H1

234 CHAPTE,R 37

There is a difference in the incidence of hallux varus

deformity as a complication from hallux abducto valgus

correction when stratified across various surgicalprocedures. Through chi-square analysis, the hypothesiswas rejected. The data from reported cases of hallux varus

was broken down into 8 separate tables based upon thetype of surgical procedure. After compiling these datainto the appropriate groupings, the percentage of thereported cases was calculated. Proximal osteotomies withsome form of lateral release ultimately resulted in havingthe highest varus complication rate at 10.5%. Distalosteotomies that did not include any type of lateral release

had the lowest occurrence rate at 1.0olo.

It is the author's opinion that a great deal ofpublished literature lack true representation of theoccurrence rate of hallux varus secondary to a lack ofpatient complaints. This makes it difficult to evaiuate anddevelop the most accurate estimate of hallux varus. In a

majority of the literature reviewed, the authors found thathallux varus complications were commonly eithermentioned in just a single sentence or in a brief statementregarding the occurrence rate for that procedure with littlefollow up or possible explanation. In some instances, data

from formulated tables expressing postoperatiye negative

intermetatarsal angles had no mention of hallux varus

anpvhere within the articles.Te''o This possibly could resultfrom the common presentation of patients who are

asymptomatic with the deformiq., regardless; this data was

not included in the current study. Only articles thatspecificaliy admitted to looking for hallux varus as a post-operative complication were considered as reliableestimates and were included for analysis in this study.

Unfortunately, a majoriry of articles reviewed had nomention of whether hallux varus was openly looked for,

which does have an affect on the overall incidence of thiscomplication. Obviously if all of the articles involvingsurgical correction of hallux abducto valgus could have

been used in this study, the occurrence rate ofhallux varus

as a postoperative complication could have been moreaccurately assessed.

The conclusions obtained in this paper are

considered to be the "best case scenario" as far as theoccurrence rate of hallux varus deformity. The datacollected to formulate these opinions were derived fromclinicians considered at the top of the podiatric andorthopedic fields of medicine with their complication rates

considered as the preeminent standards. Since the literatureis a source of continual education that consistently shapes

our practice and acknowledging the reviewed articles as ourmost reliable source, it can only be hypothesized thathallux varus is occurring more commonly in the typicalpodiatric and orthopedic office.

A great deal of literature has been publishedregarding hallux varus as a post operative complication ofhallux abducto valgus surgery. This article involved a

comprehensive evaluation of the literature and specifically

analyzed the results from a variery of long term follow upstudies. It was found that proximal metatarsalosteotomies in con.junction with some form of distal softtissue release were the most likely of procedures to acquire

a hallux varus deformity.

REFERENCES

i. Day MH, \(ickens EH. Laetoli pliocene hominid footprints andbipedalism. Nature 19 85 ;286:38 5 -7 .

2. Donley BG. Acquired hallux varus. Foat Ankle Int 1997:18:586-92.3. Feinstein MH, Brown HN. Hallux adductus as a surgical complication.

J Faot Surg 1 980;1 9:207- 1 1 .

4. Greenfogel SI, Glubo S, -Werner J, Sherman M, Lenet M. Halluxvarus - surgical correction and review of the literature. J Foot Surg198423:46-50.

5. Harvkins FB. Acquired hallux varus: cause, prevention and correction.C lin Orth op 197 I ;7 6:1 69 -7 6.

6. Miller J\tr. Acquired hallux varus: a prevenrable and correctable disorder.

J Bone Joint Surg Am 7975;57:183-8.7. Juliano PJ, Meyerson MS, Cunningham B\fl. Biomechanical assessment

of a new tenodesis for correction of hallux vxrs. Foot Ankle Int1996;17:17-20.

8. Banks AS, Ruch JA, Kalish SR. Surgical repair of hailu varus. / lzPodiatry Med Asoc 1988;8:339-47.

9. Easley ME, Kiebzak GM, Davis \(H. Prospective, randomizedcomparison ofproximal crescentic and proximal chevron osteotomies forcorrection of hallux valgus deformity . Foot Ankle Int 1 996;1 7: 1 - 1 0.

10. Langford ]H, Mmell JR. A treatment of post surgical hallux varus.

J Am Podiatric Med Asoc 198272:142-4.11. Mauldin DM, Sanders M, -Mhitmer -W\(. Correction of hallux valgus

with metatarsocuneiform stabilization. Foot Ankle Int 1990;ll:59-66.12. Mclnnes BD, Bouche RT. Critical evaluation of the modified lapidus

procedve. J Foot Anlile Surg2001;40:71,-90.l3. Lombardi CM, Silhanek AD, Connolly FG. First metatarsocrureilorm

arthrodesis and reverdinlaird osteotomy for treatment of hallux valgus:

an intermediate-term retrospective olltcome study. / Foot Anlele Surg200342:77 -85.

14. Catanzariti AR, Mendicino R\W, Lee MS, Gallina MR. The modifiedlapidus arthrodesis: a retrospective analysis. J Foot Ankk Surg1999:38:322-32.

15. Faber FWM, Mulder PGH, Verhaar JAN. Role of first ray hyper-mobiliry in the outcome of the hohmann and the lapidus procedure: a

prospective, randomized trial involving one hundred and one feet. J Bone

J o i n r S urg,lu 200+r8b:48b-q5.Butson ARC. A modification of the lapidu operation for hallux valgus.

J Bone Joint Surg Br 1980;62:350-2.Sangeorzan BJ, Hansen St. Modified lapidus procedure for hallux valgus.

Foot Ankle Int 19899:262-6.18. Myerson M, Allon S, McGravey \fl. Metatarsocuneiform arthrodesis for

management of hallux valgus and metatarsLls primus varus. Foot AnkleInt ).992:1.3:107-15.

19. Coetzee JC, Resig SG, Koskowski M, Saleh KJ. The lapidus procedure as

salvage after failed surgical treatment of hallux valgus: a prospectivecohart study.,/Bone Joint Swrg Am 2003;85:60-5.

20. Trnka HJ, Muhlbauer M, Zembsch A, Hungerlord M, Ritschl P. Basal

closing wedge osteotomy for correction of hallux valgus md metatarsus

primus varus: 1.0- to 22- Year Follow-up. Foat Anble Int 1999;20:17 l-7 .

21.. Zembsch A, Trnka HJ, futschl P. Correction of hallux valgus: metatarsal

osteotomy versus excision arthroplasty. Clinical OrthoP 200037 6:183-94.22. Trnka HJ, Zettl R, Hungerford M, Muhlbauer M, futschl P. Acquired

hallux varus and clinical tolerabiliw. Foot Anble Int 1997 18:593-7.23. Markbreiter La, Thompson FM. Proximal metatarsal osteotomy in hallu

valgus correction: a comparison ofcrescentic and chevron procedures. -Foof

Ank le [nt 1 99 8 :1 8:7 1 -7 6,

16.

1.7.

CHAPTER 37 235

)<

27

24.

45

46.

4t.

43.

51.

Mann RA, Rudicel S, Graves SC. Repair of hallu valgus with a distalsoft-tissue procedure and proximal merararsal osteotomy. J Bone JointSurg Am 1992;74:124-9.Dreeben S, Mann RA. Advanced hallu valgus deformiry: Long-termresults utilizing the distal soft tissue procedure and proximal metararsalosteotomy. Foot Ankle Int 1996 17:142-4.Thordarson DB, Leventen EO. Hallux valgus correction with proximalmetatarsal osteotomy: rwo year foilow-up. Foot Ankle 1992;13:321-6.Zettl R, Trnka HJ, Easley M, Salzer, futschl P. Moderate to severe hal-Iux valgus delormiry: correction with proximal crescentic osteotomy anddistal soft-tissue release. Arclt Ortho|, Trdurua Surg 2000 \20:397 -402.Okuda R, Kinoshita M, Morikawa J. Surgical treatment for hallux vaiguswith painlul plantar callosities . Foot Ankle Int 2001;22:203-8.Borton DC, Stephens MM. Basal metatarsal osteotomy lor hallux valgus.

J Bone Joint Surg Br 1980;76:204-9.Veri JP, Pirani SP, Claridge R. Crescentic proximal metatarsal osteotomyfor moderate to severe hallux valgus. Foot Ankle Int 2001;22:817-22.Coughlin MJ, Carlson RE. Treatment of hallux valgus with an increaseddistal metatarsal articular angle: evaluation of double and triple first rayosteotomy. Foot AnJile Int 1999:20:762-70.Fox IM, Caffiero L, Pappas E. The crescentic first metararsal basilarosteotomy lor correction of metatarsus primus varus. J Foat Ankle Surg199938:203-7.Sammarco G], Russo-A1esi FG. Bunion correction using proximalchevron osteotonry. Foot Ankle Inr 1998;19 :430-7.Sammarco GJ, Brainard BJ, Sammarco VJ. Bunion correction usingproximal chevron osteotomy: a single-incision technique. Foot Ankle Int199314:8-14.Trnka HJ, Hofirann S, Salzer M, futschl P. Clinical and radiologicalresults alter austin bunjonectomy for treatment of hallux valgts. FootAnkle Int 1997 :18:7 55-6.Trnka HJ, Zembsch A, \Tiesauer H et al. Modified ausrin procedure forcorrection ofhallux valgts. Foot Ankle Int 1997:18:119-27.Zygrnunt KH, Gudas CJ, Larus GS. Z-bunionectomy with internalscrerv fixation. ,I,4 m Podiatry Med Asoc 1989;79:322-9.Schoen NS, Zygmunt KH, Gudas C. Z-bunionectoml.: retrospectivelont-term study. J Foot Ankk Surg 1996;35:312-7.Bar-David T, Greenberg PM. Retrospective analysis of the mauosteotomy and effect of a fibular sesamoidectomy. J Faot Ankle Surg1998:37:212-5.Downey, MS. Complications of the Kalish bunionectomy. J AmPo diatri c M ed As s o c l)9 4;84:243 -9.\X/eil LS. Scarf osteotomy lor correction of hallux valgus: historicalperspecriye, surgical technique, and results. Foot and Ank/e Clinics.Hallux 2000:5: 559-80.Kalish SR, Spector JE. The kalish osteotoml: a review and retrospectiveanalvsis of 265 Cases. J Am Podid*ic Med Asoc 1994:84:237-42.Donnelly RE, Saltzman CL, Kile TA, et al. Modified chevron osteotomylor haliux valgus. Foot Ankle Int 1994:15:642.Stienstra JJ, Lee JA, Nakadate DT. Large displacement distal chevronosteotomy for the correction of hallux valgus delormity. J Foot AnlekSurg 2002;41:213-20.Pochatko DJ, Schlehr FJ, Murphey MD. Distai chevron osteotomy withlateral release for treatment of hallux valgus deformity. Foot Ankle Int1994;15:457-61.Hetherington VJ, Steinbock G, Laporta D, Gardner C. The austinbunionectomy: a follow-up sudy. J Foot Ankle Surg 1993;32:162-6.Peterson DA, Zilberfarb JL, Greene MA. Avascular necrosis of the firstmetatarsal head: incidence in distal osteotomy combined with lateral sfottissue release. Foot Anl<le Int 1994 15:59-63.Schneider 1X/, Knahr K. Keller procedure and chevron osteotomy in hal-lux valgus: five-year results of different surgical philosophies incomparable collectives. Foot Ankb Int 2002;23:321 -9.Feit EM, Scherer P, De Yoe B, Gerbert J, Patel V. The nonfixated austinbunionectomy: a retrospective study of one-hundred procedures

J Foot Ankb Surg 1997;36:347 -52.Austin D, Leventen E. A new osteoromy for hallux valgrs. ClinicalOrthop 1981 157:25.Selner Al, King SA, Samuels DI, Selner MD, Riley J. Tricorrectionalbunionectomy for hallux abducto valgus. a comprehensive outcomestudy. J Am Podiatry Med Asoc 1999;89:1.74-82.Oloff LM, Bocko AP. Application of distal metaphyseal osteotomy fortrearment of lrigh intermetatarsal angle bunion deformities. J Foot AnkleSurg 37:487-9, 7998.

Horne G, Tanzer'I', Ford M. Chevron osteotomy for the treatment ofhallux valgus. Clinical Orthop 1984;183:32-6.Beck EL. Modified Reverdin technique lor hallux abducto valgus (withincreased proximal articular set angle of the first metatarsophalangealjoint). J Am Podiatry Med Asoc 1974;64:657-66.Loretz L, Devalentine S, Yamaguchi K. The fimt metatarsal bicorrec-tional head osteotorny (distal "L"/rer.erdin-laird procedure) forcorrection of hallux abducto valgus: a retrospective strdy. J Foot Ank/eSurg 1993;32:554-68.Klosok JK, Pring DJ, Jessop JH, MatTulli N. Chevron or \flilsonmetatarsal osteotomy for hallux valgus: a prospective randomized trial.J Bone Joint Surg Br 1993;75:825-9.Viehe R, Haupt DJ, Heaslet M\(, \(alston S. Complications ofscrerv-fixed chevron osteotomies for the correction of hallux abductovalgrs. J Am Podidtry Med Assoc 200393:499-502.Mann RA., Donatto KC. The chevron osteotomy: a clinical andradiographic antlysis. Foot Ankle Int 1997 18:255-61.Pouliart N, Haentjens P, Opdecam P. Clinical and radiographicevaluation ol Wilson osteotomy for hallux valgts Foot Anklc Int1996;17:388-94.Blum JL. The modified Mitcheil osteotomy-bunioectomy: indicationsand technical considerations. Foot Anhle Int 1994 15:103-6.Schemitsch E, Horne G. \Milson's osteotorn), for the treatment of halluvalgrs. C lin Ort h op 1 9 89 :240 :221 -5.Hattrup SJ, Johnson KA. Chevron osteotomy: analysis of factors inpatient's dissatisfaction. Foot Ankle Int 1985 5:327 -32.Merkel KD, Katoh Y, Johnson E\X/, Chao EYS. Mitchell osteotomy forhallux valgus: long-term follow up and gait analysis. Foor Ankle Int1 993;3:1 89-96.Glynn MK, Dunlop JB, Fitzpatr:ick D. The Mitchell distal metatarsalosteotomy for hallu valgus. / Bone Joint Surg Br 1 980;62:1 88-9 1.

Sanders M. Complications of hallux valgus surgery:iatrogenic halluxvaurs, soft tissue reconstruction. Foot Ankle Clin 1998,3:1-18.Fuhrmann RA., Wagner A, Anders JO. First metatarsophalangeal jointreplacement: the method ofchoice for end stage hallux rigidus? Foot andAnkle Clinics: Innovations in foot and ankle surgery in Europe2003;8:711-21.Seiberg M, Felson S, Colson JP, Barth AH, Green RM, Green DR. 1994\William J. Stickel Silver Award. Closing base wedge versus Austinbunionectomies for metatarsus primus adductus. J An Podiany MedAsac 1994:84:548-63.Cohen MM. The oblique proximal phalangeal osteotomy in the correc-tion of hallux valgts. J Foot Ankle Surg 2003;42:2824.Donley BG, Vaughn RA, Stephenson K{, fuchardson EG. Keller resec-

don arthroplasty for treatment of hallux valgus deformiry: increased

correction rvith fibular sesamoidectomy. Foot Ankle Int 2002:22:699-703.Beck EL. An evaluation of the DuVries modification of the McBridehallux abducto valgus correction. A preoperative, immediate postopera-tive, and longterm xudy. J Am Podidtry Med Asoc l97l 61:445-56.Hansen CE. Hallux valgus treated by the McBride operutiot. ActdOrth op Scand 1 97 4;45 :7 7 8 -92.Mann RA, Coughlin MJ. Hallux valgus - etiologyi anatomyi treatmentand surgical consideration. Clinical Orthop l98l 157 :3L-4L.McBride ED. The conservative operation for "bunions": end results andrefinements of technic. J Am Podiany Med Asoc 1935:lO5:1164-8.

Janis LF, Donick II. The etiology of hallux varus: a revtew. J Am PodiatryAsoc 1975:65:233-7.Edeiman RD. Iatrogenically induced hallux varus. Clin Podiatr Med Surg19918:367 -82.Yu GV, Sellers CS, ShookJE, Karlock LG. The first ray: iatrogenic defor-mities of the first ray. Clin Podid*ic Med 1996:13:367-422.Lehman DE. Salvage of complications of hallu valgus surgery. Foot andArkle Clinics: complications offoot and ankle surgery 2003;8:15-35.Granberry \WM, Hickey CH. Idiopathic adult hallux varrs. Foot AnkleInt 1994;15:197-205.Mvers SR, Herndon JH. Silastic irnplant arthroplasry with proximalmetatarsal osteotomy for painful hallux valgus. Foot Anhle Int1990;10:219-23.

'Wanivenhaus AH, Feldner-Busztin H. Basal osteotomy of the firstmeatarsal for the correction of meratarsus primus varur associated withhallux valgus. Foot Ankle Int 1)88;8:337 -43.

53.

55.

56

57

58

26

54.

59.

60.

61.

62.

63

67

71

72.

73

75.

76.

77.

64.

65.

66.

28.

29

30

31

32

33.

34

35

36.

37

38.

39.

40.68

69

70

Q,

44

74

78

79

47.

48.

49

50

52

80