Hallux valgus, popularly known as bunions, consists of medial deviation or valgus (towards the center of the body axis) of the head of the first metatarsal and the approach of the big toe of the foot towards the rest of the fingers, which may cause even the superimposition of the two first fingers.
It is the most frequent pathology in the forefoot, and is particularly more common in women between 40 and 60 years of age. Classically it has related to them is female footwear, in particular with the distribution of the pressure that causes a pointy shoe and heel.
From a strictly medical point of view, is defined as the deviation of 15 degrees of the first finger and the formation of one intermetatarsal angle greater than 9 °. From these figures, you can define a hallux valgus, mild, moderate and severe.
This condition occurs in the first metatarsal-phalangeal or medial, joint which corresponds to the union of the first metatarsal bone which is part of the instep, with the first bone of the toe of the foot. This articulation differs from the others in that is equipped with two small bones smaller, pea-shaped, called sesamoid.
The forefoot is the part of the body which supports a higher mechanical strength. Not only supports the mechanical strength of the weight, but also the dynamics of the movement when it encourages the person forward and receive the impact of each support. Both the forces of friction and compression are absorbed into the sole of the foot and transmitted to the skeleton. Therefore, there are fatty bodies who order to disperse pressures and to protect vessels and nerves in the area in the forefoot.
Bunions are most common among women, and in some cases are hereditary. There are three different types of hallux valgus: congenital, acquired and pathologically, understanding the latter as the metatarsal-phalangeal deformity associated with diseases such as rheumatoid arthritis or gout. The acquiree is the most common.
- Congenital valgus hallux: very rare cases of this disease are really congenital anomalies of the interphalangeal joint of the first finger.
- Hallux valgus acquired: General, intrinsic and extrinsic factors involved in its appearance.
- Inheritance: the anomaly appears to be transmitted from one generation to another; in fact, there is an entity called hallus valgus familial congenital. More than 90% of cases have a relative of first grade with this involvement.
- Age: Bunions may arise in early ages without causing discomfort, young people aged 14 to 16 (hallux valgus youth). In the case of adults, bunions are symptomatic from the 40 years (hallux valgus of the adult).
- Sex: Hallux valgus is a disease of the forefoot eminently feminine. This female predominance is related to the use of sharp, tight shoes and high heels. With respect to the male, where also exists, there is an overwhelming ratio of 15 to 1.
Many specialists believe the poor fit of shoes as the main cause of bunions, but the reality is that people who have never used shoes have this deformity, and people who do use them have not developed hallux valgus. Therefore, it is accepted that there is a basic structural defect of the foot that predisposes to the development of the disease, and that inappropriate shoes accentuate the situation and accelerate the development of bunions.
For the disease to develop there must be a basic structural disorder.
- Flat feet: advanced position of the first finger and his metatarsal. A big toe too long is the most frequent cause of bunions. Most of bunions are related to Egyptian type feet, and are very rare in foot of Greek type. The first long finger inside a shoe is compressed, deviating, which creates a vicious circle that leads to the initiation and subsequent development of hallux valgus.
- Metatarsus primus varus: this term refers to separation and internal rotation of the metatarsal, considering it as the fundamental cause of the hallux valgus.
- Muscle imbalance: is an origin clear in cases of hallux valgus in paralyzed but in hallux valgus common muscle imbalance is considered more a consequence that the cause of the disease. Once established, the contracted muscles and displaced tendons may aggravate the bad position of the first finger.
The patient presenting a Bunion usually ask for pain, difficulties to fit, or aesthetic problems. Hallux valgus youth is not usually painful, but if offers disadvantages for the adaptation of the footwear, while the hallux valgus of the adult has three problems.
Pain and inflammation, which get worse with movement, are two symptoms of bunions that are well located in the area where the finger joins with the rest of the foot, or directly over the Bunion. Sometimes arises in the face plant (below) joint, face planting forefoot, or whole foot. Pain on the inside is usually due to painful calluses on the Bunion and, above all, to the inflammation of the serous bag. Pain plantar is related problems often joint, such as osteoarthritis.
When using high heel shoes that force the finger in a chronically extended position, or when a hallux valgus pushed a second finger or diverts him hammer, Extender forces maintained for a long time just stretching and slimming capsule from the articulation of the second toe, which also ends being affected.
These different varieties of presentation and location of pain require specialist to explore not only the forefoot, but also the foot entirely, instead of focusing exclusively on the first finger deformity.
A proper diagnosis of hallux valgus includes the study of the symptoms of patients with bunions, data obtained by physical examination and complementary explorations.
The aim of the exploration is:
- Relate the symptoms with one or more anatomic locations.
- Identify anomalies mechanical, both static and dynamic.
- Detect disease States underlying, such as ischemia, neurologic diseases, and inflammatory effects as arthritis or gout.
Exploration of hallux valgus
To diagnose bunions or hallux valgus, the physician will measure and score the degree of deflection out of the big toe, and also whether it is above or below the second toe. It is important to know the range of motion of the first metatarsal-phalangeal joint (the big toe has at least 30 degrees of extension). The limited mobility of this articulation and crepitation suggest erosion surfaces of joints. It is necessary to also assess the State of the skin overlying the deformity, and if it has existed or not recently any inflammatory process, since this prevents the surgery for at least three months.
Exploration of the foot
The foot should be explored from the point of view of static, vascular and neurological.
- Static: assess the situation of the forefoot and toe altogether. The valuation of the forefoot includes the State of the next finger. The position of the hammer or claw toes is associated with the appearance of hallux valgus. Callosity plant always points to your finger or fingers with the problem. Also explores the existence of pain intense, planting and the emergence of a painful Exostoses on the fifth metatarsal head (tailor’s Bunion). We must assess the status of full foot, noting if there are static alterations, such as flat feet.
- Vascular: it is aimed to check the circulatory condition of the foot.
- Neurological: it means the study of sensitivity, motility and reflexes of the foot.
Examination of the patient
Age, occupation and general condition of the patient are data of interest when it comes to propose surgery pra treat a Bunion. It is necessary to know if there are diseases General cone arteriosclerosis, gout, diabetes and diseases joints such as arthritis.
Includes the radiological examination of the foot, the podoscopia, the study of fingerprints Plantar and analyses.
- Radiological examination: by means of x-rays Imaging anteroposterior and lateral foot-supported. The lateral x-ray allows to assess the static foot (flat, cavo) alterations, as well as the position of the finger (claw or hammer). In the anteroposterior are appreciated in detail the characteristics of hallux valgus, such as metatarso-phalangeal angulation, or the angle between the first and second metatarsal. Today the radiological study is essential to carry out the measurements that define hallux valgus in its different phases.
- Podoscopia: to assess dynamic alterations of the foot.
- Analytics: it can provide information on cases related to drop by their relationship with hyperuricemia and in cases of rheumatoid arthritis for the determination of their diagnostic antibodies.
The treatment of a Bunion can be of two types: conservative or surgical.
Conservative treatment is the first therapeutic option. They are often given pain relievers and anti-inflammatories to reduce symptoms. Pain and inflammation can be removed avoiding touching the shoe with the own Bunion, modifying or changing the shoes, so it has the front more broadband, adapts to the foot and hold it securely. A patient with associated Flatfoot will deal with a template.
The shortening of the Achilles tendon can be through stretching exercises, and even, with a surgical lengthening of tendon. It is very frequent use of Orthotics (devices that are inserted into the shoes to correct a form of abnormal walking), trying to avoid deformation joint.
In addition to conservative measures, some patients require an operation. Depending on the intensity of the deformity, different pathological elements and anatomical anomalies, there are several surgical techniques. The choice of one or other generally depends on the severity of hallux valgus and intermetatarsal angle. The chosen technique must correct all the factors that cause the problem to make it successful.
Currently two types of techniques to operate on the bunions can be distinguished:
Open surgery, through osteotomies, which consists of modifications surgical parts of bones involved for the correction of the pathological angle. They are surgeries with multiple varieties, which have chosen depending on the experience of the orthopaedic surgeon and the degree of hallux valgus, age and characteristics of patients, and that have been refined over the years.
On the other hand, cases operated by techniques of minimally invasive surgery, through the implementation of correction of the deviation of bone needles, or through the implementation of small titanium plates together by a few stitches of specific material which corrects the deviation and maintain the angle grow the closest thing to the normality.
As it is to be expected, they are less bloody interventions, with faster recovery and less download time, i.e. the foot support is done in less time. Its realization is limited to specific cases in which the orthopaedic surgeon consider indicated