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Hallux Valgus: Wait and See, Orthosis, or Surgery?
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Am Fam Physician. 2002 Jan 1;65(1):126.
Repair of a hallux valgus deformity is one of the most common orthopedic surgeries in industrialized countries. The chevron osteotomy is a commonly used procedure, but recurrence or undercorrection is a problem in up to 14 percent of patients. In a randomized, controlled trial conducted in four community hospitals in Finland, Torkki and associates compared the effectiveness of orthotic treatment and surgical repair of hallux valgus.
Adult patients who were referred to an orthopedist for evaluation of a hallux valgus deformity were included if they had a painful bunion, a hallux valgus angle of no more than 35 degrees and an intermetatarsal angle of no more than 15 degrees. Exclusion criteria included previous bunion surgery, hallux limitus, rheumatoid disease, pregnancy, age older than 60 years, and use of functional orthoses.
Each patient completed a baseline questionnaire that provided information on the foot disorder and its effects (e.g., time lost from work). Weight-bearing radiographs of both feet were obtained. The intermetatarsal angle between the first and second metatarsals and the hallux valgus angle between the first metatarsal and the proximal phalanx were measured. To gather information about pain, function and alignment, the American Orthopaedic Foot and Ankle Society's hallux-metatarsophalangeal clinical rating scale was completed for each foot.
Patients were randomized to receive no treatment (control group), orthotic treatment (a functional foot orthosis), or surgery (chevron procedure). After the surgery, an abduction splint was used for six weeks, and weight bearing was allowed only on the heel and lateral foot. Follow-up questionnaires were requested from all patients at six months and one year. At one year, radiographs of surgically treated feet were obtained.
There were 71 patients in the osteotomy group and 69 patients each in the orthosis and control groups. At the end of the study, 66 of the 71 patients in the surgical group had the chevron procedure; no patients in that group had used orthotics. In the orthosis group, nearly all patients reported using their orthosis for about 5.5 hours each day for six days of the week. Because of severe foot pain, four of the patients in the control group had surgery during the study period.
Patients in the surgical and orthosis groups reported less foot pain than those in the control group. Footwear problems were least common in the surgical group. Not unexpectedly, patient satisfaction was lowest in the control group. Functional status and satisfaction were greatest in the surgical group. Four surgical complications, including one recurrence of hallux valgus, occurred in the 12-month follow-up period.
The authors concluded that conservative treatment with orthoses, which showed effectiveness at the six-month follow-up visit, is reasonable for use in patients with mild to moderate deformity and bunion pain severe enough to warrant referral if patients with such pain had to wait for surgical intervention. Otherwise, the outcomes in the surgical group were superior to the outcomes in those who received orthotic therapy or no treatment.
Torkki M, et al. Surgery vs orthosis vs watchful waiting for hallux valgus. A randomized controlled trial. JAMA. May 16, 2001;285:2474–80.
Copyright © 2002 by the American Academy of Family Physicians.
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