Hallux valgus prevention and treatment


02. 11. 2021

The Canadian Medical Clinic in Prague 5 – Waltrovka offers premium care in one-day surgery. One of the issues that patients often visit the clinic with is a foot deformity called a bunion (hallux valgus). Orthopedist and podiatrist, Rastislav Hromádka, M.D., Ph.D., is here to answer our questions in this regard.

What actually is a bunion?

It is a forefoot deformity where the big toe deviates from its axis and bends towards the other toes. Interpreting the correct big toe position can differ between individuals, but you could define this deformity more accurately as the deviation of the big toe from the axis of the foot of more than 15 degrees. On the inner side, where the base joint of the big toe is located, a painful callus may form and the big toe can even start rotating. It is important to realize that the issues do not concern just the big toe – it is more of a consequence or a victim of the changes going on in the entire forefoot. The cause of big toe axis deviation is, in most cases, the incorrect shape or mobility of the first metatarsal bone. That is why the majority of bunionectomies are focused on the first metatarsal bone, either adjusting its shape or position. Excessive pronation can cause increased pressure on the big toe and surrounding joint surfaces, leading to the joint cartilage becoming damaged and developing painful bone protuberances.

What are the treatment options?

We can separate treatment into nonoperative (conservative) and operative. The first uses physical therapy methods that focus not just on the area of the big toe, but also the entire lower extremity. The methods used are mostly joint manipulation, soft tissue techniques, exercises meant to redistribute the use of lower leg muscles, and so on. Patients can use special insoles or plaster fixation of the big toe and forefoot. Nevertheless, according to studies, conservative care only leads to alleviating pain but does not remove the cause or the deformity itself. If the patient does not feel improvement, or they do not like the positioning of their big toe, it is time to choose and schedule a surgery. There are many different types of operations that have good results. Currently, the operations that the patients should go with are those that change the shape of the bone through osteotomy (bone cutting), the correct position is then locked in with screws. When firm fixation with screws or a splinter is used, the patient feels less pain because there is no movement between the bone fragments, and the result of the surgery is easier to predict.

What are the causes of a bunion?

There are internal and external causes. The internal ones are mostly genetic. The deformity forms due to mismatched lengths of metatarsal bones, misaligned joint surfaces, or the decreased firmness of ligaments and muscles holding the bones in their correct position. Unfortunately, diseases leading to changes in soft tissue and bones are also among the internal causes. For instance, rheumatoid arthritis or degenerative diseases of nerve tissue. External causes include mainly unsuitable footwear and increased body weight.

What kind of footwear should we use then?

You should avoid shoes with a narrow toe box, or the tip placed in the center of the front edge of the shoe, as well as high heels. Narrow shoes with an inappropriately placed tip are not just a thing of women’s fashion anymore, we can see men wearing them too. Appropriate footwear is wide in the front, with a round toe box, and of course without a high heel. I should mention that if our feet are predisposed to the emergence of this deformity, even slight pressure on the big toe can lead to it manifesting.

How many people struggle with bunions?

This deformity occurs very often due to its definition. Worldwide incidence is reported at roughly 23% and it increases with age. It is reported to be around 36% in people above the age of 65.

You were involved in research focusing on bunion treatment. What are the conclusions?

The last 15 years have seen great development in surgical methods used to treat this problem. We systematically evaluate the results of our surgeries in order to use correct procedures for specific cases in the future. We have seen significant progress in the materials (screws and splints) used during the surgery. In the past four years, I have started practising minimally invasive forefoot surgery, allowing for new treatment options. It enables you to focus more precisely on the area in the foot that needs fixing and avoid tissue that often gets damaged during open surgery. Bone cutting is not done with an oscillating saw, but instead with specialized cutters, inserted into the body under x-ray supervision via minute ingresses in the skin. These surgeries are not only about reducing the size of the scar, but they also allow us to perform a complex treatment of the deformity of the big toe as well as all the other toes at the same time.

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