Surgical treatment of hallux valgus: a review

Jason S. Lin and Jorge Bustillo

Purpose of review Introduction

The treatment of hallux valgus is dependent on multiple The treatment of hallux valgus is dependent on numer-
factors from clinical examination, patient considerations, ous factors from clinical examination, patient consider-
radiographic assessment, and surgeon preference. ations, radiographic assessment, and surgeon preference.
Numerous techniques have been described to address this The multitude of established procedures and technique
common disorder. The purpose of this paper is to provide an modifications in the literature underscores the fact that no
updated review of the surgical treatment of hallux valgus. single approach universally addresses this common dis-
Recent findings order. Here we present an updated review of the surgical
Operative management of hallux valgus involves a treatment for hallux valgus.
combination of both soft tissue and bony procedures.
Various osteotomies, each demonstrating potential Etiology and pathogenesis
advantages and complications, may be selected based on Both intrinsic and extrinsic factors have been implicated
the degree of deformity. Arthrodesis may be utilized to in the development of hallux valgus. Intrinsic factors may
address severe deformities and first ray hypermobility. include pes planus, metatarsus primus varus, rheumatoid
Minimally invasive techniques are now being employed with arthritis, collagen and neuromuscular disorders, first
emphasis on cosmesis and reduced surgical exposure. tarsometatarsal (TMT) hypermobility, and hereditary
Salvage techniques have also been recently described with predisposition. Coughlin and Roger [1] reported, in a
improved clinical results. series of 31, that 94% of mothers whose children had
Summary hallux valgus also were affected.
While several well established surgical methods are
available for hallux valgus, consensus regarding the best Constrictive shoes and high-heel wear play an extrinsic
treatment has yet to be established. Ultimately, this role in hallux valgus. Sim-Fook and Hodgson [2] com-
decision-making process is multifactorial, and further pared the incidence of hallux valgus in shoe-wearing
investigation into more novel approaches may be warranted versus nonshoe-wearing populations, 33% and 1.9%
prior to their broad application. Appropriate surgical respectively. A predilection in the female population
selection and proper technique will usually result in good to for hallux valgus has been reported to be anywhere from
excellent outcomes. 3 : 1 by Hewitt et al. [3] to 15 : 1 by Hardy and Clapham
[4].
Keywords
arthrodesis, arthroscopic, hallux valgus, hypermobility, Ultimately, an imbalance develops around the first meta-
osteotomy, percutaneous, salvage tarsophalangeal (MTP) joint leading to a progressive
hallux valgus deformity and often, patient complaints
Curr Opin Orthop 18:112–117. ß 2007 Lippincott Williams & Wilkins. of pain and cosmetic dissatisfaction. Repetitive valgus
stress to the great toe, such as occurs with narrow
MSHMC Orthopaedics, Hershey, Pennsylvania, USA
shoes, may lead to medial sided soft tissue attenuation.
Correspondence to Jorge Bustillo, MD, Assistant Professor, MSHMC Valgus drift of the proximal phalanx and varus drift of the
Orthopaedics, H-089, 500 University Drive, P.O. Box 850, Hershey, PA 17033-
0850 USA metatarsal head can lead to a painful bursitis over the
Tel: +1 717 531 5638; fax: +1 717 531 7583; e-mail: [email protected] medial eminence. Lateral subluxation of the sesamoids
Current Opinion in Orthopaedics 2007, 18:112–117 with metatarsosesamoid (MTS) degenerative changes
Abbreviations
can develop. The deformity progresses as the extensor
and flexor hallucis longus tendons shift to act as adductors
AOFAS American Orthopaedic Foot and Ankle Society
DMAA distal metatarsal articular angle and lateral capsular and soft tissue contractures develop.
DSTR distal soft tissue release Pronation of the great toe can result from the pull of the
HVA hallux valgus angle
IMA intermetatarsal angle abductor hallucis tendon on the proximal phalanx. Insuf-
MTP metatarsophalangeal ficiency of the first ray and resultant metatarsalgia can
TMT tarsometatarsal
develop from this sequence of events.
ß 2007 Lippincott Williams & Wilkins
1041-9918 Clinical evaluation
Clinical evaluation takes into account patient symptoms
and physical exam findings. A family history of bunions
112

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 Surgical treatment of hallux valgus Lin and Bustillo 113

and the specific location of pain should be noted. A ‘deep’ were once widely used but are now seldom seen. Other
ache or plantar pain is associated with sesamoid involve- procedures, such as the Mitchell and Wilson osteotomies,
ment whereas medial pain can be from bursal inflam- are performed more regularly in Europe [8]. Here we
mation. Pain that occurs while being barefoot can also discuss well established techniques that are frequently
indicate more joint (MTP or MTS joint) involvement used in addition to more recent surgical approaches.
than pressure over the medial eminence. Problems with
shoewear, painful bunion, cosmetic dissatisfaction, and Distal soft tissue procedure
metatarsalgia of the lesser toes are common presenting In 1923, Silver discussed the correction of hallux valgus
complaints. by performing a medial exostectomy and release of con-
tracted lateral structures (adductor hallucis, lateral joint
Physical exam should be conducted with the patient capsule, transverse metatarsal ligament) along the first
seated and standing. Exam findings may reveal associated MTP joint. Further modifications were made by McBride
planovalgus deformity, tight heel cord, rigid or correct- and DuVries. Today, this technique is almost always
able hallux valgus, great toe pronation, corns or calluses of combined with a bony procedure. In addition, a medial
the lesser toes, second MTP joint synovitis, interdigital eminence resection and capsular plication are often per-
neuromas, or first TMT joint hypermobility. formed. This procedure is contraindicated if there is a
congruent joint present with a large DMAA.
Radiographic evaluation
Standard preoperative radiographic assessment of hallux At a recent meeting, Conti et al. [9] reported on the
valgus includes anterior–posterior, oblique, and lateral degree of sesamoid correction and the extent of meta-
weightbearing views of the foot. In addition, a sesamoid tarsosesamoid arthritis affecting surgical outcomes. This
view can be obtained to assess subluxation of the was a retrospective study looking at 96 patients: group 1
sesamoids as well as degenerative changes. Specific (41 patients) underwent distal chevron osteotomy
measurements include the hallux valgus angle (HVA), alone and group 2 (55 patients) underwent distal chev-
intermetatarsal angle (IMA), and distal metatarsal articu- ron osteotomy with a modified distal soft tissue release
lar angle (DMAA). In addition, first MTP joint con- (DSTR) through a medial incision to incise the lateral
gruency should be noted as well as the position of the metatarsosesamoid ligament. There were no significant
sesamoids [5]. Severity of the deformity may be classified differences between the groups in regards to demo-
according to these measurements [6] (Table 1). graphics or preoperative radiographic measurements.
They reported a significantly greater preoperative to
Nonoperative management postoperative change in sesamoid position when the
Footwear modification is the mainstay of nonoperative modified DSTR was combined with the chevron osteot-
treatment for hallux valgus. Orthotics have not been omy versus osteotomy alone. In group 1, 81% of the
shown to prevent progression of the deformity. Torkki patients had sesamoid subluxation of grade 2 or higher
et al. [7] performed a randomized controlled trial of 209 preoperatively, while 51% had persistent subluxation of
patients comparing immediate operation versus 1 year of grade 2 or higher postoperatively. In group 2, 76% of the
waiting with or without orthoses. The authors concluded patients had sesamoid subluxation of grade 2 or higher
that the surgical group had better outcomes with regards preoperatively, while only 9% had persistent subluxation
to foot pain, cosmetic disturbance, functional status, of grade 2 or higher postoperatively. Significant differ-
treatment satisfaction, footwear problems, and patient- ences were seen in patients under and over the age of
derived global assessments. The orthosis group showed 50 years. In patients under age 50 years, the degree of
only short-term, symptomatic relief, with pain returning observed intraoperative eburnated bone was 5% at the
to previous levels after 12 months. MTP joint and 32% at the metatarsosesamoid joint. In
patients over the age of 50 years, these numbers were
Operative management 15.5% at the MTP joint and 74% at the metatarsosesa-
Surgery for hallux valgus is indicated for pain not moid joint. Mean postoperative American Orthopaedic
adequately controlled by nonoperative measures. Histori- Foot and Ankle Society (AOFAS) scores were also higher
cally, some techniques, such as the Keller procedure, for the modified DSTR group (91 versus 85). The authors
concluded that early surgical intervention emphasizing
Table 1 classification of hallux valgus according to HVA and proper sesamoid alignment and before significant arthro-
IMA
sis becomes present, may improve outcomes following
HVA IMA bunion surgery.
Mild 198 138
Moderate 20–408 14–208 Osteotomies
Severe >408 >208 The choice and level of osteotomy (proximal, diaphyseal,
HVA, hallux valgus angle; IMA, intermetatarsal angle. or distal) depends largely on the degree of deformity and

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 114 Ankle and foot

amount of correction needed. Greater correction can be procedures). Follow-up averaged 35.9 months. Magnan
achieved with more proximal-based osteotomies, while reported 91% patient satisfaction with a mean American
distal procedures are usually reserved for smaller deform- Orthopaedic Foot and Ankle Society (AOFAS) score of
ities and require less exposure and shorter recovery times. 88.2  12.9 points. Significant postoperative improve-
ments were seen in mean HVA, IMA, DMAA, and
Distal osteotomies sesamoid position. Complications included three recur-
Distal osteotomies are used for mild/moderate deform- rent valgus deformities (2.5%), eight stiff first meta-
ities and contraindicated in severe deformities. tarsophalangeal joints (6.8%), and one deep infection
that resolved with antibiotic therapy (0.8%). While the
Distal chevron authors concluded the clinical results appear to be com-
The features of the distal chevron osteotomy are parable with those of open techniques, further investi-
as follows: a V-shaped osteotomy through metatarsal gation may be warranted.
head/neck with lateral displacement of head (5–6 mm)
[10]; advantages include minimal shortening and intrinsic Diaphyseal osteotomies
stability; it can be used for mild/moderate deformity of a Diaphyseal osteotomies are recommended for moderate
congruent joint with normal DMAA; if DMAA exceeds hallux valgus and are usually performed with medial
15–208, biplanar osteotomy is indicated [11]; patient capsular plication and lateral soft tissue release.
satisfaction decreases after age 60 years (increased pain
and stiffness around MTP joint) [12]; it is contraindicated Scarf osteotomy
in moderate/severe deformity (HVA >358 and IMA The Scarf osteotomy is a Z-shaped step-cut osteotomy
>158). that allows translation of the head. It is highly stable
biomechanically and indicated for moderate to severe
Hattrup and Johnson [12] reported 1 year follow-up deformities with IMA over 148. It is technically demand-
results on 154 patients who underwent 225 chevron ing with extensive surgical exposure and risks stiffness.
osteotomies for hallux valgus between 1976 and 1982.
Interviewed patients expressed 79.1% complete satisfac- Jones et al. [14] prospectively reviewed 24 patients
tion, 12.9% partial satisfaction, and 8% dissatisfaction. (35 feet) treated by Scarf osteotomy and Akin closing-
Factors producing incomplete satisfaction included fail- wedge osteotomy for hallux valgus. Follow-up averaged
ure to achieve correction and technical errors. No cases of 20 months. Fifty percent of the patients were very
avascular necrosis, osteotomy nonunion, or hallux varus satisfied, 42% were satisfied, and 8% were not satisfied.
were reported. Mean AOFAS score improved significantly from 52 to 89
points. Mean IMA improved from 158 to 98 and mean
Akin HVA improved from 338 to 148. DMAA did not change
The Akin osteotomy can often be used in conjunction significantly. Mean pedobarographic measurements of
with a distal chevron osteotomy to correct residual valgus. the first and second metatarsals also did not change
It can be used with many bunion procedures where significantly and were within normal range at more than
valgus remains. It is most useful for hallux interphalan- one year postoperatively. Complications included two
geus or increased DMAA. The Akin is a closing wedge wound infections, one intraoperative first metatarsal frac-
osteotomy of proximal phalanx. It is contraindicated as a ture, and one symptomatic screw requiring removal.
primary procedure for an incongruent joint
Smith et al. [15] reported six (6%) perioperative compli-
Percutaneous cations for their first 100 Scarf osteotomy procedures.
Percutaneous osteotomy is indicated for mild to moderate Intraoperative complications included three cases of a
hallux valgus with HVA 408 or under and IMA 10–208. It split first metatarsal and one case of K-wire shearing. Two
is indicated for juvenile hallux valgus with increased postoperative stress fractures were reported. These com-
DMAA and contraindicated in severe hallux rigidus or plications should be considered by those beginning to
previous Keller procedure. A Kirschner wire helps guide master the Scarf osteotomy procedure and by surgeons
and stabilize the correction. The osteotomy is performed teaching surgical trainees.
through a 3–5 mm incision using a corticotomy tech-
nique. No associated soft tissue procedure is performed. Proximal osteotomies
Advantages include minimal invasiveness, shorter oper- Proximal osteotomies are used for moderate to severe
ation time, and reduced surgical exposure complications. deformities.

Magnan et al. [13] described a percutaneous subcapital Crescentic osteotomy

distal osteotomy technique for the treatment of mild to The Crescentic osteotomy is made 1 cm distal to TMT
moderate hallux valgus in 82 patients (118 consecutive joint with concavity facing proximally. It involves

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Surgical treatment of hallux valgus Lin and Bustillo 115

minimal shortening. Risks include dorsal malunion and occurred at an average of 2 months. Average sesamoid
transfer metatarsalgia. subluxation decreased from 80 to 29%. Subjective foot
score profiles improved from 70.1/100 to 94.4/100, and
Veri et al. [16] reviewed short and long-term results of 84% of patients stated they would undergo the procedure
25 patients (37 feet) treated with combined proximal again without reservation. Complications included
crescentic osteotomy and DSTR. One year follow-up three delayed unions, two metatarsal stress fractures,
included 20 of 25 (31/37 feet) and long-term follow-up one hallux varus, two hallux limitus, one progressive
was 84% at an average of 12.2 years. Mean preoperative arthritis, one cellulitis, and one hallux elevatus.
HVA and IMA were 378 and 168, respectively. Mean
long-term HVA correction was 248 and IMA correction Easley et al. [20] compared the crescentic and chevron
was 108 with no tendency toward recurrence. Sesamoid proximal osteotomies for correction of adult hallux valgus
position and first MTP subluxation was markedly (IMA >138) in a prospective, randomized study. Follow-
improved postoperatively and long-term correction was up included 29 patients (41 feet) in the crescentic group
maintained. Patients reported over 90% complete satis- and 37 patients (43 feet) in the chevron group at an
faction with pain and motion and over 80% with appear- average of 24 and 20 months, respectively. They had
ance. AOFAS score improved from 37/100 to 92/100 at good results with both procedures and found no
both follow-up periods, and 94% said they would have the significant difference in IMA correction or functional
operation again. Complications included two varus over- outcome. The chevron group had statistically significant
corrections, four undercorrections with asymptomatic shorter healing time, however. Easley concluded that a
recurrence (>108 increase HVA), two new transfer chevron osteotomy may have additional benefits over
lesions, and one dorsiflexion malunion. a crescentic osteotomy, including less first metatarsal
dorsiflexion and shortening, more medial distribution
Brodsky et al. [17] looked at the effect of proximal of tibial sesamoids, and reduced potential for transfer
crescentic osteotomy with a modified McBride procedure lesions.
on plantar pressures under the first and second metatarsal
heads in 32 patients (43 feet). Mean follow-up was Modified Ludloff
29 months. Average second metatarsal peak pressure The modified Ludloff osteotomy is used for moderate
increased postoperatively. First metatarsal elevation to severe deformities without associated instability and
greater than 2 mm (12) occurred almost equally with involves rotation of the shaft through 308 with an
depression (11) and resulted in five new second meta- oblique cut 2 mm distal to the TMT joint and minimal
tarsal transfer lesions. Postoperatively, nine feet had shortening. It is more stable biomechanically than
symptomatic second metatarsal transfer lesions. These proximal osteotomies with a lower incidence of dorsal
results demonstrate potential difficulties in controlling malunion and transfer metatarsalgia compared with
the first metatarsal in the sagittal plane with this other proximal osteotomies, such as the crescentic or
technique. chevron.

Coughlin et al. [18] performed a cadaveric study evaluat- Chiodo et al. [21] reviewed 70 of 82 consecutive cases of
ing the change in first ray mobility after proximal cres- moderate to severe hallux valgus corrected with the
centic osteotomy and DSTR. Significant reduction in Ludloff osteotomy combined with a distal soft tissue
mean sagittal first ray motion was found after correction. procedure and medial eminence resection. With an aver-
While this finding suggests that the stability of this age follow-up of 30 months, mean HVA improved from
technique may adequately address first ray hypermo- 318 to 118 and IMA improved from 168 to 78. No sympto-
bility, its clinical efficacy remains less defined. matic transfer lesions developed. Mean AOFAS hindfoot
score improved from 54 to 91 points. Complications
Proximal chevron included prominent hardware requiring removal (five),
The proximal chevron is a proximal V-shaped osteotomy hallux varus (four), delayed union (three), superficial
that is intrinsically stable. It leads to fewer transfer lesions infection (three), and neuralgia (three).
and requires bone graft from excised medial eminence
for stability. Proximal wedge osteotomy
The proximal wedge osteotomy involves an opening or
Sammarco and Russo-Alesi [19] reviewed 88 consecutive closing wedge. The opening wedge elongates, stretches
cases of proximal chevron first metatarsal osteotomy soft tissues and requires bone graft. Risks include stiff-
combined with soft tissue procedure with mean follow- ness and nonunion with the opening wedge. The closing
up of 41 months. HVA improved by an average of 158 wedge causes shortening, and is inherently unstable.
(32.08 to 17.08). IMA improved an average of 5.58 (15.38 to Risks include dorsal malunion and transfer lesions with
9.08). First metatarsal length decreased by 2.0 mm. Union the closing wedge.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 116 Ankle and foot

Shurnas and Sanders [22] presented their results on average of 3.7 years. AOFAS scores improved signifi-
21 proximal opening wedge osteotomies using a low cantly from 52 to 87. IMA improved from 188 to 8.28
profile plate and screw system. They reported 20 excel- and increased by only 0.38 between 1-year and 3.7-year
lent or good results and one fair result with a 6-month follow-up. HVA improved from 378 to 168 and increased
minimum follow-up. They concluded that reliable heal- by less than 18 between 1-year and 3.7-year follow-up.
ing and predictable correction can be achieved with this Complications included TMT nonunion requiring revi-
technique but ongoing functional scores and follow up sion (seven), necessary hardware removal (eight), minor
are needed. wound problems (two), superficial neuroma (two), and
transfer metatarsalgia (four).
Arthrodesis
A first MTP joint arthrodesis is used for rheumatoid Endoscopic/arthroscopic techniques
arthritis, severe deformities, degenerative changes of Lui et al. [26] describe their experience with endoscopic
MTP joint, neuromuscular diseases and salvage following distal soft tissue procedures to address hallux valgus with
failed surgery. emphasis on improved cosmesis. They also describe an
arthroscopic approach to the Lapidus arthrodesis, report-
Coughlin et al. [23] evaluated his results of first MTP joint ing several advantages over the open technique. Some of
arthrodesis as treatment for moderate to severe hallux these included more thorough preparation of the fusion
valgus deformities over a 22-year period (1979–2001). site with minimal bone removal, better positioning con-
Successful fusion with the primary procedure occurred trol, reduced malunion risk, improved cosmetic result,
for 18 of 21 (86%) at an average follow-up of 8.2 years. and minimal postoperative wound pain [27]. The pro-
Time to union averaged 10 weeks. Three nonunions cedures described are technically demanding and learn-
occurred and one required revision. Average corrections ing curves for small joint arthroscopy may limit their
in HVA and IMA were 218 and 68, respectively. Sub- application.
jective satisfaction was rated as excellent in 80% and good
in 20%. Postoperative pain improved significantly, and Complications and salvage procedures
AOFAS scores averaged 84 at follow-up. All patients were Lehman [28] reviews some of the more common com-
able to wear conventional or comfort shoes. Interphalan- plications that are seen following hallux valgus surgery.
geal joint arthritis progressed in seven (33%). He discusses both nonsurgical and surgical options for
treatment to assist in the management of these compli-
Lapidus cations. Among those he addresses (and reported inci-
The Lapidus procedure involves fusion of the first TMT dence) are deformity recurrence (16%), avascular necrosis
joint and is indicated for severe deformities, a hypermo- (0–76%), hallux varus (10–12%), metatarsal osteotomy
bile first ray and degenerative first TMT. It is contra- nonunion and malunion. For symptomatic recurrence,
indicated in adolescents with open physes and degen- revision surgery should follow the same principles of
erative changes of first MTP. It is technically demanding primary hallux valgus correction after scrutiny of the
with a prolonged recovery period and leads to shortening. initial failure. Hallux varus may be addressed with soft
tissue releases, tendon transfers, or extensor hallucis
Hypermobility of the first ray continues to be a focus of brevis tendonesis. Nonunions may require debridement
research. Good results have been reported for the Lapidus and bone grafting, with use of tricortical iliac crest graft
procedure as treatment for hallux valgus with associ- for significant born erosion.
ated first TMT hypermobility. Kopp et al. [24] retro-
spectively reviewed 29 patients (35 procedures) with this In addition to those complications mentioned above,
condition using preoperative and postoperative question- Radl et al. [29] showed a 4% rate of venous thrombosis
naires, physical examination, and radiographs. They in 100 patients (mean age 48.9 years) 4 weeks after chev-
reported 90% (26 of 29) satisfaction with foot function ron bunionectomy using phlebography. The mean age of
and 86% (25 of 29) satisfaction with cosmetic appearance. these four patients was 61.7 years, suggesting advanced age
as a risk factor for deep venous thrombosis. They con-
Coetzee and Wickum [25] prospectively looked at the cluded that prophylactic anticoagulation for hallux valgus
functional outcome of patients with moderate and severe surgery may be justified for patients over age 60 years.
hallux valgus deformities (IMA >148 and HVA >308)
after the Lapidus procedure. AOFAS score, Visual Analog Machacek et al. [30] compared first MTP arthrodesis with
Pain Scale, clinical examination, weightbearing radio- repeat Keller or isolated soft tissue release as salvage
graphs, and a patient satisfaction questionnaire were used technique following failed Keller procedure. Arthrodesis
preoperatively, 6 weeks after surgery, 6 months after (group A) was performed in 28 patients (29 feet), and
surgery, and then yearly. One hundred and five feet either a repeat Keller procedure or isolated soft-tissue
(91 patients, mean age 41 years) were followed for an release (group B) was performed in 18 patients (21 feet).

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Surgical treatment of hallux valgus Lin and Bustillo 117

10 Badwey TM, Dutkowsky JP, Graves SC, Richardson EG. An

In group A, average follow-up was 36 months and fusion anatomical basis for the degree of displacement of the distal chevron
was achieved in 26 of 29 (90%). Satisfaction was excellent osteotomy in the treatment of hallux valgus. Foot Ankle Int 1997; 18:
213 –215.
or good in 23, and postoperative score averaged 76 of 90
11 Nery C, Barroco R, Ressio C. Biplanar chevron osteotomy. Foot Ankle Int
points. Repeat arthrodesis was necessary in five feet due 2002; 23:792–798.
to malposition or pseudarthrosis. In group B, average 12 Hattrup SJ, Johnson KA. Chevron osteotomy: Analysis of factors in patients’
follow-up was 74 months. Satisfaction was excellent or dissatisfaction. Foot Ankle 1985; 5:327–332.
good in six. Postoperative score averaged 48 of 90 points, 13 Magnan B, Bortolazzi R, Samaila E, et al. Percutaneous distal metatarsal
osteotomy for correction of hallux valgus. Surgical technique. J Bone Joint
with valgus deviation and cock-up deformity recurring in Surg Am 2005; 87A:1191–1199.
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arthrodesis resulted in higher patient satisfaction and
15 Smith AM, Alwan T, Davies MS. Perioperative complications of the Scarf
better clinical results. osteotomy. Foot Ankle Int 2003; 24:222–227.
16 Veri JP, Pirani SP, Claridge R. Crescentic proximal metatarsal osteotomy for
Conclusion moderate to severe hallux valgus: a mean 12.2 year follow-up study. Foot
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Hallux valgus is the most common pathologic condition
17 Brodsky JW, Beischer AD, Robinson AH, et al. Surgery for hallux valgus with
affecting the great toe. There are several surgical tech-  proximal crescentic osteotomy causes variable postoperative pressure pat-
niques available but no consensus as to the best treatment terns. Clin Orthop Relat Res 2006; 443:280–286.
This prospective study looked at 43 proximal crescentic osteotomies for hallux
method. Patient expectations, clinical findings, radio- valgus. Radiographic and pedographic measures were performed preoperatively
graphs, and surgeon preference are important factors in and postoperatively. Reliable correction in the transverse plane was obtained. The
osteotomy was highly variable in sagittal plane correction and resulted in a
deciding what type of procedure to perform. Selecting an 20% rate of continued or new areas of increased pressure under the second
appropriate procedure, using good technique, and patient metatarsal.

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a cadaveric study. Foot Ankle Int 2004; 25:537–544.
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