• Academy of Ambulatory Foot and Ankle Surgery. Hallux abductovalgus. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 9 p. [50 references]

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Hallux abductovalgus. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 21 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

Hallux abductovalgus (bunion)

Diagnosis
Treatment

Podiatry

Podiatrists

To provide recommendations for the diagnosis and treatment of hallux abductovalgus

Patients with hallux abductovalgus

Diagnosis

1. History, including chief complaint (duration, onset, anything that improves or exacerbates symptoms, previous treatment) and general medical history (allergies, medications, surgical history, family history, social history)
2. Physical exam, including vascular evaluation; and neurology, orthopedic, biomechanical, dermatological exams
3. Diagnostic procedures, including radiographic and laboratory examination

Treatment

1. Nonsurgical treatment, such as padding the area with bunion pads, injections, shoe modifications, analgesics, physical therapy, orthotic treatment
2. Surgical treatment, such as partial removal of the medial side and/or dorsal aspect of the first metatarsal head or correcting the osseous deviation or subluxation of the joint
3. Postoperative management, such as x-rays and immobilization

Not stated

Searches of Electronic Databases

The guideline development process began with a thorough MEDLINE search as well as a "call for papers" from the membership of the Academy of Ambulatory Foot and Ankle Surgery at large.

Not stated

Not stated

Not applicable

Review

Not applicable

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Drafts of the guidelines were reviewed in detail by each member of the Board of Trustees.

1. Diagnosis

   Hallux Abductovalgus diagnosis is made by completion of the history and physical exam and a lower extremity exam, subjective and objective findings, radiological evaluation and other diagnostic procedures.

   1. History: This may include any of the following:
      1. Chief complaint
      2. Duration
      3. Onset
      4. Anything that improves or exacerbates
      5. Any previous treatment
      6. General medical history
      7. Allergic condition
      8. Medication taken
      9. Surgical history
      10. Family history
      11. Social history

      The patient may be asymptomatic with a small bump, but some patients with mild deformities may have severe pain. Their lifestyle may be altered to the point that they may be unable to perform the activities that they would normally perform. Hallux abductovalgus may be caused by biomechanical abnormalities, and may be an inherited condition. Pressure from the shoe may also cause pain or neuritis and ulceration in the area.

   2. Physical examination may include:
      1. Vascular evaluation
      2. Neurology exam
      3. Orthopedic exam
      4. Biomechanical exam
      5. Dermatological exam

      With a hallux abductovalgus deformity the great toe may or may not be deviated laterally. Hallux abductovalgus may be caused by biomechanical abnormalities that may lead to dysfunction in the first ray. There are numerous conditions associated with hallux abductovalgus, and sometimes it is necessary to treat these associated conditions while treating the hallux abductovalgus deformity.

   3. Concomitant conditions may include:
      1. Overlapping or under lapping second toe
      2. Metatarsalgia
      3. Pain in the lesser digits
      4. Contracture of the lesser digits
      5. Plantar grade position of the adjacent metatarsal heads
      6. Sesamoiditis
      7. Dorsal Exostosis
      8. Arthritic degeneration
      9. Neuritis and/or Neuroma
      10. (Extensor hallucis longus) EHL tendon contraction
   4. Diagnostic procedure
   1. Radiological examination: X-rays must be taken. They may be used to evaluate the type of deformity: soft tissue, osseous position deformity, structure deformity, joint destruction, sesamoid position. X-rays may be weight bearing, partial weight bearing, or non-weight bearing.
   2. Laboratory testing may be used to rule out inflammatory disease, degenerative joint disease, systemic illnesses, etc.
2. Types of Treatment
   1. Nonsurgical treatment
      1. Padding the area with bunion pads
      2. Injection of local anesthetic, anti-inflammatory injections, cortisones, oral anti-inflammatories
      3. Shoe modifications (i.e., wider shoes, molded shoes)
      4. Analgesics
      5. Physical therapy
      6. Orthotic treatment
   2. Surgical treatment
      1. Partial removal of the medial side and/or dorsal aspect of the first metatarsal head. This is done with or without a soft tissue release.
      2. Correcting the osseous deviation or subluxation of the joint. This may be performed with or without single or multiple osteotomies, or may be done with a Keller procedure.
3. Surgical Procedures for the Correction of the Hallux Valgus Deformity
   1. A soft tissue release with an ostectomy of the first metatarsal head
   2. Osteotomy at the proximal phalanx
   3. One or more osteotomies of the metatarsal
   4. A joint destruction procedure whereby an arthroplasty of the proximal phalanx is performed, with or without an implant
   5. A fusion along with the removal of the bump of the first metatarsal. At this time it may be necessary and indicated to surgically correct other deformities such as hammertoes, metatarsalgia, flexion deformities, and/or sesamoid pain.
4. Fixation

   Fixation may be used at the discretion of the surgeon, and may be internal or external or not at all.

5. Site of Surgery

   The surgical procedure is primarily performed in the doctor's office, but may also be done in the hospital or an ambulatory surgical center.

6. Anesthetic

   Local anesthetic is sufficient unless there are extenuating circumstances. Intravenous (IV) sedation may or may not be utilized with this.

7. Hemostasis

   Absence of bleeding via tourniquet is not required and is not recommended with minimal incision surgery.

8. Surgical Preparation

   Antiseptic preparation usually consists of antiseptic scrub pre-op, and sterile draping and technique.

9. Preoperative Lab

   Need based on patient's past medical history and current medical status.

10. Prophylactic Antibiotics

    May be given at the discretion of the surgeon.

11. Bilateral or Multiple Surgery

    May be performed at the same surgical session or in different surgical sessions.

12. Postoperative Management
    1. X-rays are necessary to access the progress of osseous healing. They should be taken immediately postoperatively and may be indicated at intervals throughout the postoperative follow-up period, depending on the type of procedure performed and the wishes of the doctor. Non-weight bearing (NWB) x-rays, weight-bearing (WB) x-rays taken at the angle and base of gait, or semi-weight bearing (SWB) x-rays are acceptable. NWB, SWB, or (WB) x-rays are taken at the discretion of the surgeon.
    2. Postoperative immobilization may consist of casting, a splint, surgical shoe, a rigid sole shoe, or external splinting via gauze, tape, etc.
    3. Internal fixation of fixating devices are not required when doing bunion surgery, but may be used at the discretion of the surgeon when it is appropriate.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Treatment may reduce symptoms and the deformity, which will allow the patient to maintain or return to a relatively normal activity level.

Complications

• The deformity may reoccur or worsen
• Hallux varus
• Hallux elevatus (toe may not touch ground)
• Sesamoiditis
• Fusion of the joint
• Limited dorsiflexion and/or plantar flexion of toe
• Prolonged healing
• Metatarsalgia/transfer of weight
• Non-union/delayed union/malunion
• Vascular failure (gangrene)
• Nerve damage/Reflex sympathetic dystrophy
• Shortening of metatarsal and/or toe

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Academy of Ambulatory Foot and Ankle Surgery. Hallux abductovalgus. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 9 p. [50 references]

Not applicable: The guideline was not adapted from another source.

2000 (revised 2003 Sep)

Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Preferred Practice Guidelines Committee

The committee consisted of five (5) members who were board certified, had a minimum of ten (10) years of clinical practice experience, and a minimum of five (5) years of teaching experience.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Hallux abductovalgus. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 21 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

None available

None available

This summary was completed by ECRI on October 12, 2000. The information was verified by the guideline developer as of December 8, 2000. This summary was updated by ECRI on December 19, 2003. The information was verified by the guideline developer on December 29, 2003.

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer.