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Hallux valgus surgery

If conservative treatment methods have already been exhausted and the pain of hallux valgus can no longer be alleviated, the level of suffering in everyday life is often high. In most cases, hallux valgus surgery helps to finally be free of pain again. In this article you will learn everything about hallux valgus surgery, what you should know as a patient and how you yourself can contribute to a successful surgery. In addition, we will inform you about the time after the hallux valgus surgery, when you are allowed to drive again and how long you might be unable to work. You can find out everything about the causes (development), bandages, physiotherapy splints and risk groups here, in our online guide.

Reading time: 6 min

Hallux valgus before and after image

Before and after images during hallux valgus surgery. These pictures show the surgical procedure of a mild hallux valgus, which was performed with a screw made of human bone.

When should a hallux valgus be operated on?

“Many patients try to relieve the pain caused by hallux valgus with conservative methods. However, this often only succeeds to a small extent. So whether a hallux valgus should be operated on or not always depends on the patient’s level of suffering,” says Dr. Klaus Pastl, hallux valgus expert from Linz, Austria. For surgeons, there are precise classifications here about the severity of hallux valgus. However, the severity or intermetatarsal (IM) angle tells only a limited amount about the patient’s pain. In mild to moderate malocclusions, the IM angle is 11°- 15° and one can often delay surgery. The angle can be accurately determined by X-ray examination. If the hallux valgus angle is over 15°, patients suffer from more severe pain in everyday life. In most cases, only surgery can help. When to have a hallux valgus surgery, however, must always be decided individually depending on the pain sensation.

Tip:
Visit a hallux valgus specialist near you for a consultation. You do not know which doctor you should go to? Ask us, we will be happy to recommend a hallux valgus specialist in your area.

The severity of hallux valgus

“The goal of hallux valgus surgery is to relieve the patient’s pain as quickly as possible. A large hallux valgus angle is often also an indication of more severe pain. However, this does not have to be the case. Patients often have severe pain even though the intermetatarsal angle is still well below 15°,” says Dr. Pastl. The following table shows the severity levels of hallux valgus.

Schweregrad

Hallux valgus Winkel (IM)

Symptome

Behandlung

|

Intermetatarsalwinkel (IM) unter 15°

gelegentliche Schmerzen im Alltag, Rötungen und verdickte Haut möglich

Physiotherapie, Fußgymnastik, Operation nach Austin, Schienen, Einlagen

||

Intermetatarsalwinkel (IM) zwischen 15° und 20°

häufige Schmerzen im Alltag, Rötungen, Druckstellen am Ballen, Schmerzen beim Tragen von Schuhen

Optimiertes Schuhwerk, Operation nach Scarf, Fußgymnastik

|||

Intermetatarsalwinkel (IM) über 20°

Schmerzen auch im Ruhezustand, sowie beim Gehen und Laufen

Operation nach Scarf oder Lapidus-Arthrodese, Fußgymnsatik

Hallux valgus pain is not always dependent on the severity of the hallux valgus angle. Pain in hallux valgus is always a purely subjective sensation and varies from patient to patient!

Materials used in hallux valgus surgery

“The majority of hallux valgus operations involve the use of screws or plates. I always discuss the various options with my patients and decide together with them on the best option in each case. As always, all systems have advantages and disadvantages,” says Dr. Klaus Pastl. Basically, screws made of human bone, screws and plates made of metal, and screws made of bioreactive plastics are available.

Screws from human bone

Screws made from human bone form a solid bone healing unit with the patient’s bone.1 “More and more of the body’s own cells migrate into the bone screw and eventually remodel it into its own bone tissue. So there is no metal removal after hallux surgery.” In addition, the surgeon can use these screws for mild, moderate and severe hallux deformities,” Dr. Klaus Pastl said. The Bone screws are sunk entirely into the patient’s bone. The surrounding tissue is therefore not irritated.

1Literatur: Elliot DS et al, (2016) Bone healing unit

Human bone screw Shark Screw® Hallux

Shark Screw® are screws made from human bone. Sie bilden eine stabile Knochenbrücke und dienen als Leitstruktur für alle Knochenzellen des Patientenknochens. It can be used for mild, moderate and severe hallux valgus deformities.

You can find a hallux valgus surgery with the Shark Screw® here. Attention in this video is also blood.

Metal screws and plates

Metal screws and plates have been in use for decades. Not only in hallux valgus surgery. These are tried and tested systems in orthopedics and trauma surgery. Unfortunately, however, screws and plates made of metal always bring with them a certain risk of metal removal that may be necessary. Depending on the severity of the deformity and depending on the study, the incidence of metal removal has been reported to range from 8.9% for Chevron (mild hallux valgus) to 32.3% for Lapidus arthrodesis (severe hallux valgus) within the first 21 months. Of the study participants who did not undergo metal removal, 18% considered future metal removal after the first 21 months.1

Metal plates are often used for severe hallux valgus deformities. These wear on and can cause pain when wearing shoes. You can find a hallux valgus surgery with a plate here. Attention in this video you can see real blood.

Resorbable implants

In order to counteract problems arising from the provision of metal implants, various resorbable osteosynthesis materials (screws for the fixation of bone) have been developed in recent decades. In the group of resorbable (dissolving) screws, according to the literature, side effects occur, due to the resorption processes, (dissolution processes). Aseptic inflammation, fluid formation, fistula formation, cysts, and sustained bone, cartilage, and soft tissue damage may occur. Mild side effects, such as diffuse pain, may occur in up to 47% of cases. Period 60 days – 9.5 years after surgery.2

Conclusion:
A wide range of surgical materials are available to the surgeon and patient. Which is the best material for the patient is always on a mutual basis. Often, a second opinion from another specialist can also help.

Old and New Surgery Methods for Hallux valgus

If surgery is decided upon, it is important to clarify with the treating foot orthopedist how large the intermetatarsal angle (IM) is for hallux valgus and which surgical procedure offers the best chances of healing. The literature speaks of over 200 different surgical methods used in hallux valgus surgery. However, only a fraction of them are really practiced frequently.

The most common surgical methods for hallux valgus correction are: Austin hallux valgus correction, Scarf osteotomy, Akin, Lapidus arthrodesis (TMT I arthrodesis) Chevron osteotomy, modified Austin osteotomy, Keller Brandes surgery, minimally invasive hallux valgus surgery.

Hallux OP

The goal of hallux surgery is to correct the misalignment of the big toe using a special hallux surgical procedure. There are approximately 200 hallux surgical procedures worldwide. The most common hallux valgus surgeries are:

  • Hallux surgery according to Akin (additional correction)
  • Hallux surgery according to Austin (mild hallux valgus)
  • Hallux surgery after Scarf (Middle hallux valgus)
  • Hallux surgery with lapidus arthrodesis (severe hallux valgus)

Hallux-Chirurgie mit Lapidus-Arthrodese (schwerer Hallux valgus)

A new surgical method for mild to severe hallux valgus deformities is surgery and fitting with screws made from human bone. The advantage for patients: The screws are converted into the patient’s own bone tissue and no longer need to be removed. This new surgical method has been used for hallux valgus since 2016. Learn more about screws made from human bone here.

Austin / Chevron Osteotomy

The Austin or chevron osteotomy is performed for moderate and moderately severe hallux valgus deformities. This involves making a V or L-shaped incision in the first metatarsal. The Chevron osteotomy is a very effective surgical method to correct hallux valgus. Screws made of human bone, screws made of metal or metal wires can be used for fixation of the Austino or Chevron osteotomy. In the case of metal implants, the patient bears the risk of possible surgery to remove the metal.

X-ray images before and after hallux valgus surgery according to Austin with Shark Screw®.

X-rays before and after Austin hallux valgus surgery. Austin’s surgery used a screw made from human bone. The advantage: elimination of the possible metal removal.

Scarf osteotomy

Scarf osteotomy is a possible surgical method for hallux valgus. It is used for moderate hallux valgus deformities. At the Scarf, the surgeon cuts through the bone with a Z-shaped line (diaphyseal osteotomy). Then the shank and the metatarsal head are moved laterally (outward). For fixation of the Scarf Osteotomy, 2 screws made of human bone, metals or resorbable plastics are used.

Lapidus arthrodesis (TMT I arthrodesis)

Lapidus arthrodesis is performed for severe hallux valgus deformities or for osteoarthritis and instability in the TMT I joint. Correction by Lapidus arthrodesis involves removal of a small bone wedge and fusion of the TMT I joint.3 Screws made from human bone, or screws and plates made from metal can be used for fixation.

Als eine Methode beim schweren Hallux valgus gilt unter anderem die plantare Platte mit 6 Metallschrauben. Due to the invasive procedure (plantar medial approach, detachment of tendons & nerves), between 8% and 42% of patients complain of pain in daily life in the first two years postoperatively. In 32.6%, the plate is removed within the first 21 months.4 Due to the dorsal surgical approach with the Shark Screw®, and the location of the screws within the bone, this pain does not occur with the Shark Screw®. In most cases, the surgery is performed under general anesthesia. Physiotherapy after Lapidus arthrodesis can be started approximately 6 weeks after surgery.

X-ray images before and after hallux valgus surgery / lapidus arthrodesis with Shark Screw®.

This radiograph shows a severe hallux valgus deformity treated with Lapidus Arthrodesis (TMT I) and Shark Screw®. After 12 months, the human bone screw is barely visible.

Akin osteotomy - surgery

In the Akin procedure, a small wedge of bone is harvested distally (away from the body) from the metatarsophalangeal joint. By removing a small bone wedge in an Akin osteotomy, the crooked position of the big toe can be corrected. Akin osteotomy is often performed in addition to another hallux valgus surgery. E.g. Akin osteotomy in addition to Chevron or Austin osteotomy, Lapidus arthrodesis or TMT I arthrodesis, Scarf osteotomy, etc. A screw is used for fixation.

The best doctors for hallux valgus surgery

Is there a best hallux valgus doctor and how to find the best hallux valgus foot orthopedist? The good thing up front is that hallux valgus surgery is a low-risk operation that many orthopedic surgeons can perform. Ranking the best hallux valgus orthopedists is therefore difficult, as there are a great many surgeons who are masters of their craft. To find the best hallux valgus doctor, a search on the Internet often helps. However, we would also be happy to recommend specialists in your area. Due to our close cooperation with hallux valgus specialists, we can recommend clinics, foot centers and foot specialists with a clear conscience, from whom we would also have ourselves operated.

The right preparation for hallux valgus surgery?

Hallux valgus surgery begins well before the incision is made on the operating table, namely with the preparation for the operation. But how do you properly prepare for an operation? Since one is always restricted in movement for a few weeks after surgery due to the pain and the forefoot relief shoe, it is advisable to prepare for the time afterwards. This includes activities such as rescheduling appointments, completing important tasks at work, scheduling physical therapy or even lymphatic drainage.

Tip: Get a “compensatory shoe” even before the operation. This shoe helps you compensate for the height difference between your non-operated leg and the operated leg with forefoot relief shoe.

Procedure of hallux valgus surgery

Hallux valgus surgery usually proceeds without complications. Without complications, a hallux valgus operation lasts approximately between 30 and 120 minutes. Depending on the severity of the hallux. If you suffer from a severe hallux valgus, the operation usually takes a little longer than for a mild deformity. The surgery can be performed either as an outpatient or as an inpatient procedure. Whether an operation is performed on an inpatient or outpatient basis, under general or local anesthesia, can only be determined in consultation with your physician.

Driving, foot gymnastics, shoes, unable to work - this is what happens after hallux surgery

Once you are finally out of the operating room after the surgery, the post-surgery treatment continues. But how long is one actually unable to work after hallux valgus surgery? “It varies by patient and severity. As a rule, however, it is 4 – 6 weeks in which one must wear a forefoot relief shoe. During this time, working and driving are not recommended. The foot needs rest to heal in the best possible way. A lot of stress on the foot, such as running or walking without the forefoot relief shoe, is absolutely counterproductive here and jeopardizes an optimal surgical result for the patient,” says Dr. Klaus Pastl.

Important: Listen carefully to your doctor’s recommendations during follow-up treatment. Loading the operated foot too early can lead to risks such as a new operation!

Hallux valgus surgery experience - forum and testimonials

Before an operation, patients often want to know what experiences other patients who have already had hallux surgery have had. Experiences on this topic are often summarized in clinical medical studies. Often you can also read about patients’ experiences in a hallux valgus forum. According to a 2015 study by Feldmann et al. on the topic: “Patient satisfaction and medium-term results of various surgical procedures in hallux valgus and hallux rigidus surgery”, 82% of patients were satisfied with the surgical result, or with the surgical experience gained as a result. Depending on the study, between 5% and 33% are not completely satisfied with the result. The reasons for negative experiences are in most cases, too little correction of the hallux valgus angle, too much correction of the hallux valgus angle, necessary removal of metal implants and nerve injuries. However, these risks can be largely eliminated by choosing the right surgeon and proper surgical materials. Even though this can greatly increase the chances of a satisfied patient, there is still no 100% guarantee of satisfaction.

Literature

1 Literatur: Ruden, J. (2019). Operative Korrektur des 1. Strahls am Fuß – Evaluation des verwendeten Implantats und des klinisch funktionellen Outcomes. Marburg: Philipps-Universität Marburg.

2 Literatur: Pisecky, D. L. (2020). Bioresorbierbare Implantate in der Vorfußchirurgie: Materialien, Möglichkeiten und Nachteile. Linz: JATROS Orthopädie & Traumatologie Rheumatologie.

3 Literatur: Literatur: Kajetan Klos et al. Foot Ankle Surg2013 Dec;19(4):239-44.doi: 10.1016/j.fas.2013.06.003. Epub 2013 Jul 3.

4 Literatur: Kajetan Klos et al. (2013). Modified Lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: A preliminary report. Elsevier.

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