Bibliographic Source(s)

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

Guideline Status

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).

Guideline Category

Diagnosis
Treatment

Intended Users

Podiatrists

Guideline Objective(s)

To provide recommendations for the diagnosis and treatment of hallux abductovalgus

Target Population

Patients with hallux abductovalgus

Interventions and Practices Considered

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

Major Outcomes Considered

Not stated

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

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.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Not stated

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not applicable

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

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

Major Recommendations

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.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

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

Potential Benefits

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

Potential Harms

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

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

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

Adaptation

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

Source(s) of Funding

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Guideline Committee

Preferred Practice Guidelines Committee

Composition of Group that Authored the Guideline

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.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

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).

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available from the Academy of Ambulatory Foot and Ankle Surgery (AAFAS) (formerly the Academy of Ambulatory Foot Surgery) 1601 Walnut Street Suite 1005 Philadelphia PA 19102; Web site www.academy-afs.org.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

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.

COPYRIGHT STATEMENT

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

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