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Guideline Summary
Guideline Title
Hallux abductovalgus.
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). According to the guideline developer, this guideline has been reviewed and is still considered current as of September 2009. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

Scope

Disease/Condition(s)

Hallux abductovalgus (bunion)

Guideline Category
Diagnosis
Treatment
Clinical Specialty
Podiatry
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

Methodology

Methods Used to Collect/Select the 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.

Recommendations

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

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

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

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

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.

Date Released
2000 (revised 2003 Sep; reviewed 2009 Sep)
Guideline Developer(s)
Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society
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). According to the guideline developer, this guideline has been reviewed and is still considered current as of September 2009. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

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 External Web Site Policy.

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.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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