Thick toe down the wrong track

21. February 2011

One of the most common cases presented to podriatic surgeons – hallux valgus, known as inward misalignment of the big toe – is associated with severe pain. Treatments aim to restore functionality.

Not just an affliction of our time: hallux valgus deformities can be found in the art of antiquity as well. Much points to genetic factors – in two thirds of cases, specialists find frequent incidence in families, especially with women. It is likely that genetic influences lead to abnormalities of the muscles and tendons in the big toe. Exactly which genes have been altered, however, is still unknown.

With a meta-analysis of over 78 publications and nearly 500,000 patients, researchers at the University of Queensland, Australia, went further into the question of the frequency of the condition. Their conclusion: Its frequency in the population aged between 18 and 65 adds up to 23 percent, among people over 65, the measure rises to slightly less than 35 percent. Women were, with a frequency of 30 percent, significantly more often affected than men – in their case the figure was only about 13 percent. Wearing pointy, narrow shoes over years also happens to lead to hallux valgus. Subsequently, other toes can also become deformed, resulting in hammer toes.

Little children, big worries

Incorrect footwear is not merely an adult problem: children’s shoes that are too short also cause harm to feet, according to study results from the Vienna University of Medicine. For this research doctors studied 858 children aged three to six years. Around 70 percent of them wore what were undersized street shoes. In regard to the shoes they wore at home they were found to be in as many as 90 percent of cases measured too small. From the measured angular positions of the great toe it becomes apparent: The more the shoe presses, the more pronounced the hallux valgus. Children do not sense when shoes are too short and so squeeze their feet obediently into them, orthopaedist Dr. Christian Klein of the Emco Klinik Bad Dürrnberg near Salzburg, points out. His recommendation to all parents: Feet in their growth phase need about 12 to 17mm wiggle space.

Diagnosis at first glance

In the doctor’s clinic, a first glance is usually sufficient to diagnose a hallux valgus. An X-ray examination then clarifies the extent of the disease. Of particular relevance are the angle between the first and second metatarsal bone (intermetatarsal angle) and the degree of deformity (hallux valgus angle), which describes the deviation of the large toe at the first metatarsal. Here too, technology has entered the picture: in comparison to manual evaluation of X-ray images, computer-based methods deliver more accurate results, says a method comparison at the UK-Staffordshire University. The severity of the deformation ultimately decides as to which therapeutic method promises the most success.

var dcmv = new DcMediaViewer(); dcmv.embed({“slider”: ” MSJNzZCdDSYfm7pQH64mdg”, “view”: “max”, “tooltips”: false });

Treat or wait?

Left untreated, in the majority of cases hallux valgus worsens. Does this mean however that therapy should of necessity commence immediately? This is the question that Orthopaedists from England’s Arthritis Research UK Primary Care Center have pursued. Their findings: in quite a number of cases the life quality of hallux valgus sufferers is reduced, for instance, due to pain. The flexibility of the foot worsens, which is a problem at any age. The primary goal of therapy, in addition to controlling symptoms, is to restore the functionality of the foot. For many patients aesthetic issues are also inextricably linked, which likewise can lead to psychological stress – a matter of wearing ‘conspicuous balls’ versus wearing fashion shoes.

Always nice to stay mobile

Previously, the common practice was to remove parts of the big toe base joint as per Keller-Brandes, now only necessary in rare cases. In particular it is the altered biomechanics after surgery that has a negative effect in younger, physically active patients. Alternatively, orthopaedists stiffen the joint between the tarsus and metatarsal using lapidus arthrodesis.

Modern techniques however rely on the restoration of functionality. In mild cases an abrasion of the protuberances of bone, along with an additional corrective treatment of the soft tissue, is sufficient. In almost all other methods surgeons cut through the first metatarsal bone and fix it after correction using screws, wires or plates. One advancement is a synthetic slowly-reabsorbable nail, made of a material based on polydioxanon. Several studies, considering both medical and economical aspects, rate the material well. A correction of the respective tendons and ligaments of the joint capsule is needed too. The treatment success of various interventions is not dependent on the age of the patients, say the results of an investigation by the Department of Podiatric Surgery in Derbyshire, United Kingdom. The doctors ascertained two years after their respective surgery the extent of mobility as well as patient satisfaction. They found between the two groups, under and over 50 years, no significant difference.

Numerous methods have been established

There is now a number of surgical techniques described in literature. An operation for instance as per Austin/Chevron will help in moderately severe cases. An adjustment can be made via a V-shaped cut through the bone. However, surgeons can also intervene and make a correction as per Meyer/Scarf to the shaft of the first metatarsal bone with a Z-shaped incision. For particularly severe cases of deformity, an osteotomy as per Myerson/Ludloff, with an oblique division of the first metatarsal, was designed.

As in all areas of surgery, surgeons are also working on hallux valgus correction using minimally invasive methods. British scientists studied the literature and made comparisons between the success and effectiveness of the respective procedures. Minimally invasive methods would be offered, according to the authors, in particular to patients who might be running the risk of delayed healing. The soft tissue especially in this case would be able to regenerate more quickly. Nevertheless, due to the small number of cases, no clear recommendations for routine procedures could be given.

Getting away from pain step by step

Despite the success of surgical techniques, pulling out a scalpel is not always necessary – in the mean time, surgeons lament the often uncritical presentation of new surgical procedures in the literature. After all, orthopedics also often lead to very good results, as Prof. Dr. Klaus A. Milachowski and his colleagues were able to demonstrate.

He has corrected mild to moderate deformities with special orthotics. The angle of deformation in question has been reduced by an average of fifteen degrees using a splint. In addition, contrary to popular opinion, axial correction was also achieved with this conservative method of treatment. The authors emphasise that the Hallufix® Rail splint represents an alternative to performing surgery in mild and moderate cases and also effectively puts a halt on osteoarthritis. The most important requirement, however, is that the patients be motivated to put on the brace.

An innovation in orthopedics is the computer-aided measurement of foot pressure, i.e. pedobarography. Electronic sensors within a disc analyse the pressure of the foot when standing or walking and provide an accurate picture of the distribution of forces to a PC. Because of its digital capture and good reproducibility, the method is also used to verify the success of therapy, such as before and after surgery.

5 rating(s) (4.4 ø)

Copyright © 2019 DocCheck Medical Services GmbH
Follow DocCheck: