Hallux Valgus – Prevention and Our Surgical Methods
The term “HALLUX VALGUS” comes from Latin and it symbolizes the rotation of the large toe towards the outside of the foot (in direction of the rest of the toes). When it rotates, the inside of the foot becomes more prone to constant mechanical irritation which causes the formation of new bone (exostosis) and localized inflammation which is the main cause of pain in case of this foot deformity.
What causes Hallux valgus?
The most frequent cause of the Hallux valgus deformity is wearing of inadequate, usually too tight shoes for many years. Such footwear squeezes the toes and puts them into an unnatural position.
This deformity can also be caused by chronic inflammation (arthritis) either because of overuse of joint cartilage or autoimmune disease. Rheumatoid arthritis is such a disease and it occurs most frequently in the population. In most cases, there is also a positive family medical history.
AOFS research has shown that 88% of women in the United States wear inappropriate footwear and 55% of them develop this large toe deformity. Therefore, it is not surprising that large toe deformity is nine times more common in women than in men.
Can the cause of inflammation be prevented?
This deformity becomes painful quickly and gout-like redness and pain appear on the inside of the foot. If the deformity is not identified in time and treatment is not provided immediately, soon both the second and the third toes become endangered – then, painful flexion of small joints develops which often causes larger problems than the ones caused by the large toe alone.
In the majority of cases, inflammation and pain can be successfully treated by wearing adequate footwear which does not put pressure on the toes. Different available orthoses are used to keep the large toe in a correct position during the night while during the day adequate orthopaedic insoles can maintain the foot in such position.
If this deformity is present, our advice for prevention is:
- Do not buy footwear based only on size which is indicated inside the shoes because sizes varies between different models; you should always try the shoes on and judge for yourselves whether they are comfortable
- Choose footwear which is adequate for the shape of your foot
- Be aware that the shape of your foot changes as you grow older
- Measure the length and width of your feet because many people have one foot larger or wider than the other; if that is your case, choose shoes in larger size
- When trying on the shoes, stand up and make sure that you have enough free space for the toes
- Do not buy tight footwear expecting that it will stretch a bit from the inside (however, keep in mind that footwear made of certain materials can stretch in the parts which are compressing the toes)
- Shoes also need to be comfortable around the heel and the heel should glide minimally around the back of the shoe
- Walk a bit and judge for yourselves whether you are comfortable
Medication for reducing pain and swelling are used for inflammations caused by arthritis.
Kome se preporučuje operativni zahvat?
Many studies have shown that 85-95% of patients who underwent surgery were satisfied with the result afterwards.
The reasons why patients should decide to undergo this surgery are the following:
- Pain which prevents you from performing everyday activities, especially when walking, i.e. wearing shoes
- Chronic inflammation and swelling which does not subside when resting or taking medication
- Toe deformity – rotation of larger toes towards the smaller ones, lifting of the second and third toe and alike
- Toe stiffness – impossibility of bending and straightening
- Constant pain which does not subside even when non-steroid anti-inflammatory drugs are used. Generally, the effect of such drugs varies from person to person
- Feeling of pain even when adequate shoes are worn
One should be careful when choosing the operation because terms such as “simple” and “minimal” surgeries can often do more damage than actually help. The aim of the operation is to eliminate pain and correct the deformity as much as possible.
Types of surgical procedures
Surgical procedure is chosen by orthopaedic surgeon based on the type and cause of foot deformity.
Orthopaedic surgery has numerous different procedures which we successfully perform at our Polyclinic:
- Surgical procedures on soft tissues (tendons and ligaments)
Since soft tissues are too tight on one side and too loose on the other, an imbalance develops between them what causes the rotation of the large toe towards other toes. This procedure consists of releasing the structures which are too tight and strengthening the loose ones. It is often combined with removing exostosis and with a procedure called osteotomy.
- Removing exostosis
This procedure consists of removing new formations on the foot joint. It is not performed independently because exostosis itself does not cause deformities but it is their consequence and it is frequently recurring. Removing exostosis is combined with other procedures, either on soft tissues or bones.
In the Etela Polyclinic, two surgical procedures are combined and the method is very successful. The choice of osteotomy type depends on the place of origin of deformity. Usually, proximal or distal osteotomy is performed. Basically, we “cut through” the metatarsal bone and place it into correct and regular position. After osteotomy, the foot is not immobilized using a plaster cast but is maintained in a required position by performing soft tissue procedures or using small implants which meet the size of bone in the foot. Our Polyclinic keeps up with the latest studies worldwide; therefore, “scarf osteotomies” have been among the procedures that we perform for some time.
A procedure used to remove damaged joint surface on both joint bodies. These are brought closer together and the physiological position of the toe is maintained by using screws, wires and plates until the bone has healed. This procedure is applied to patients who have several toes affected by this deformity, what is the case in arthritis, and conditions where other surgical procedures have proved unsuccessful.
A surgery which removes the damaged part of the joint and is used mostly in elderly patients, in patients who have already had some operation on their foot joint, or in those who have toe arthritis.
Orthopaedic examination includes three components:
- Medical history
Physicians get general information about patients’ health condition from their medical history, especially information about the severity of pain. The doctor will ask questions related to other medical conditions because some of them can affect the outcome of the operation. For example, diabetes and rheumatoid arthritis can increase the risk of infection and impede the normal healing process while circulation problems can increase postoperative pain and prevent healing.
- Clinical examination
Clinical examination is used to determine the degree of damage inflicted to soft tissues and whether there are other deformities such as hammer toes.
- X-ray examination
X-ray is used to determine the degree of damage and joint deformation.
Based on the above and depending on the severity of damage, prim. Mladen Miškulin, MD, PhD will explain which surgical procedure is indicated in your particular case. He will also provide information on possible risks and complications of the procedure.
Expectations after surgery
When you decide to undergo a surgery, it is important that you understand its realistic outcomes and what can be achieved with this particular procedure.
The majority of patients who undergo this procedure feel significant decrease of pain after surgery, with a toe that is evidently straightened. After surgery, you will get instructions on what kind of shoes to wear for the rest of your life so that the deformity of the large toe would not return.
Preparation for Operation
When you decide to undergo surgery, you should have your general practitioner do a complete examination in order to determine your general health condition. If you have heart, lung or any other chronic problem, additional preoperative examinations will be necessary. Before operation, you need to do your blood and urine tests, ECG, lung X-ray and foot X-ray. You should also let your surgeon know which drugs you are using, if any.
The Course of Operation
On the day of surgery, you should come to the hospital one to two hours before the operation. After you are admitted, a team of anaesthesiologists will examine you. Most operations are done in local anaesthesia which means that you are awake during surgery. General or spinal anaesthesia are rarely used. The course of operation will be monitored by your anaesthesiologist. The procedure lasts for about an hour. After surgery, you will be taken to recovery room and one to two hours afterwards your doctor will release you from hospital.
Considering low invasiveness of our surgical techniques, we perform the procedure on both feet at once in young patients.
Complications of the procedure
In a smaller percentage of patients, complications can include local infection, recurring of hallux valgus and chronic pain.
The success of operation partially depends on how much patients adhere to the instructions their physicians give them in the weeks following the surgery. During recovery, several check-ups need to be done which will serve your surgeon for monitoring the normal healing process of wound.
Before leaving the hospital, the physician will apply special dressing to your wound which will keep your toes in a correct position. You will also get special post-operative shoes. Ten days after surgery, the doctor will take out the stitches. You will need to wear an orthopaedic shoe for five weeks. A normal healing process requires that this part of the foot is kept clean and dry, thus, it is recommended to wrap the foot into waterproof plastic material during showering as long as the stitches have not been taken out.
Posture and Gait
In the first days after surgery, your doctor will recommend using crutches when standing and walking. Under surgeon’s supervision, when walking, you will gradually begin bearing weight on the operated foot.
Less walking is recommended in the first several weeks.
Swelling and Shoes
For a few days after surgery it is necessary to put ice compression and keep the foot elevated several times a day in order to reduce swelling and pain. The swelling on the foot sometimes does not recede for as long as six months after surgery. After taking off your orthopaedic shoes and bandages, the shoes you wear in the next couple of months have to be sports, soft and comfortable in order for the tissue to heal completely and properly. Three to four months need to pass before you will be able to wear higher heel shoes.
Exercises for strengthening the foot
After surgery, physical therapy will be necessary for returning the full range of motion and strength to foot muscles. Your orthopaedic surgeon will recommend using some aids during exercising in order to improve mobility and gain strength in the foot and toe joints.
After surgery, the doctor will prescribe painkillers and antibiotics to prevent infection.
Possible problems after surgery
Complications after surgery are rare; however, certain situations can cause problems and if that happens you are required to report to your doctor immediately. These situations include:
- The bandage compressed the wound or got wet
- The bandage is soaked with blood
- Side effects to drugs prescribed after surgery
- Fever and shivering
- The skin around the wound dressing is red and hot when touched
- The pain is getting worse
- Legs above the foot are swelling
In order for the recovery to be fast and complete, patients need to practice every day to increase the mobility of the large toe, fingers and ankle. Your orthopaedic surgeon or physical therapist will teach you how to exercise and recommend that you practice three to five times a day, 20-30 minutes.
Early post-operative rehabilitation phase
Moving – normal gait and wearing orthopaedic shoes is very important. After surgery, crutches are used for walking and post-operative shoes which you will get enable that all weight bearing during walking is on the back of the foot. The surgeon will determine how much and when you can bear weight on the treated foot. When walking with crutches it is important that you do not move them too far away from your body. When walking, first move the crutches in front of the body, then make a step with the operated leg so that only your heel touches the floor and finally make a step with your healthy leg. You will be allowed to walk without crutches only when your surgeon determines.
Ankle exercises – move the foot front and back. Do this exercise continuously, two to three minutes, two to three times per hour. Then rotate your feet to the one and then to the other side.
These can be practiced only when your surgeon allows it.
Folding a towel – put a small towel on the floor in front of you and fold it using only your toes. Repeat this exercise five times.
Lifting onto your toes, retracting the toes underneath the foot, standing on the heels – stay in each of these positions for five seconds, repeat the exercise ten times.
Lifting sponges from the surface – put fifteen small sponges on the floor, take each sponge with your toes and place it into a box. Repeat the exercise until you have moved all the sponges into the box.
Exercises for strengthening the ankle muscle with an elastic band – put the band around the front of the foot and pull the band towards you while pushing the front of the foot away from you .
Pulling tight rubber band using your toes – put a tight rubber band around both your large toes and pull them away from each other. Hold them in this position for five minutes and repeat the exercise ten times.
Pulling tight rubber band using all your toes – put a tight rubber band around all your toes, spread it and hold in this position for five seconds, repeat ten times.
Squeezing your toes – put a small, sponge plug between each toe, squeeze them with your toes and keep in this position for five seconds, repeat this exercise ten times.
After surgery, when the doctor determines that the crutches are no longer necessary, walking and doing everyday activities is recommended. When the pain subsides completely and when your large toe and other toes become completely mobile and gain strength, you can start jogging and doing sport activities.
After exercising, or engaging in sports activities, mild pain and swelling might appear. In that case, lift your leg and apply ice compression. Exercising every day is recommended in order to increase mobility and strength in muscles.