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Hallux Varus

Hallux varus is a clinical foot condition characterized by the medial deviation of the great toe (hallux) at the metatarsophalangeal (MTP) joint. Essentially, the big toe points inward, away from the second toe, which is the opposite of a bunion (hallux valgus).

Causes

Hallux varus can be either congenital (present from birth) or acquired.

The most common cause of acquired hallux varus is iatrogenic, meaning it results as a complication of surgery to correct a bunion (hallux valgus). Factors in bunion surgery that can lead to overcorrection and hallux varus include:

  • Excessive release of the lateral soft tissues (ligaments and tendons).

  • Over-tightening of the medial soft tissues.

  • Aggressive removal of the medial "bump" (medial eminence).

  • Removal of the fibular sesamoid bone.

Other, less common acquired causes include:

  • Trauma to the big toe joint that disrupts the tendon and ligament balance.

  • Inflammatory arthropathies like rheumatoid or psoriatic arthritis.

  • Neuromuscular disorders.

Congenital causes are rare and may be associated with:

  • A tight or overactive abductor hallucis tendon.

  • Associated abnormalities like a delta phalanx (an extra bone in the toe) or metatarsus adductus (inward turning of the front part of the foot).

Symptoms

The most visible and primary symptom is the medial deviation (inward pointing) of the big toe. Other symptoms often arise due to this misalignment:

  • Pain and discomfort, most commonly from the toe rubbing against the inside of shoes.

  • Difficulty wearing standard footwear due to the toe's altered position.

  • Ingrown toenails (onychocryptosis) from pressure on the nail border.

  • Functional impairment, such as difficulty walking or a loss of propulsion during gait in severe cases.

  • In long-standing or severe cases, the MTP joint can become stiff and arthritic.

Diagnosis

Diagnosis is primarily made through a physical examination, which assesses the degree of toe deviation, joint flexibility, and muscle strength. X-rays are essential to evaluate the bony structure, measure the degree of the deformity, and check for signs of arthritis or previous surgical alterations.

Treatment

Treatment depends on the cause, the severity, and whether the deformity is flexible or fixed.

Non-Surgical Treatment

For mild, flexible, or early-stage deformities (especially mild post-operative varus), conservative management is often tried first:

  • Shoe modifications: Wearing shoes with a wide toe box to accommodate the toe without friction.

  • Splinting or taping: Using devices or techniques to hold the toe in a corrected, more neutral position to encourage soft tissue healing.

  • Stretching exercises: To loosen tight tendons, particularly the abductor hallucis.

  • Orthotic devices: Custom insoles to address any underlying biomechanical issues.

  • Anti-inflammatory medications: To manage discomfort and swelling.

Surgical Treatment

Surgery is typically recommended if the deformity is painful, rigid, progressive, or fails to respond to conservative treatment. Surgical goals are to achieve a straight, stable, pain-free toe. Procedures vary based on the specific pathology:

  • Soft Tissue Procedures (for flexible deformities): These aim to restore tendon and ligament balance.

    • Tendon Transfer: A common approach is to transfer the pull of a tendon (like the extensor hallucis brevis) to the side of the toe to act as a "check-rein" against the varus pull.

    • Capsular Release/Repair: Releasing the tightened medial joint capsule and tightening the lateral side.

    • Ligament Augmentation: Using sutures, tendon grafts, or specialized implants (like a Mini TightRope) to reconstruct the lateral collateral ligament for stability.

  • Bony Procedures (for fixed or severe deformities):

    • Osteotomy: Cutting and repositioning the bone of the proximal phalanx or metatarsal to realign the toe.

    • Arthrodesis (Joint Fusion): Fusing the MTP joint in a corrected position. This is often reserved for cases with severe, rigid deformity or significant arthritis, as it eliminates movement in the joint.

Correction of hallux varus, especially when it is iatrogenic, is often a complex and demanding reconstructive surgery.