- Email: [email protected]
Hallux valgus its cause and simplified treatment
HALLUX VALGUS * ITS CAUSE
AND SIMPLIFIED
JOHN MARTIN
TREATMENT
HISS, M.D.
COLUMBUS, OHIO
T
is the spring arch. In waIking, the streams of weight-bearing (or moving Ioad) trave1 through the foot in an orderly manner,
purpose of this articIe is to show: I. That halIux valgus is not an enIarged joint;
HE
0.
$J
APE
MAN FIG.
2. That broken are the resuIt of on the foot; 3. That there for haIIux vaIgus; 4. That haIIux tendon imbaIance joint; 5. That haIIux without removing tarsa bone.
I.
A,
ape;
B,
man; c, haIIux vaIgus.
arches and haIIux vaIgus the same forces working is a phyIogenetic
HALLUX VALGUS
from the hee1 to the outer side of the foot, across the baI1 and through the toes (see Fig. I, B).
set-up
HALLUX VALGUS AND BROKEN ARCHES
vaIgus is the resuIt of across the great toe
ImproperIy proportioned shoes produce a disorderIy irreguIarity of the distribution of the moving Ioad. Figure 2 shows a foot vaIgus can be corrected imprint in reIation to the insoIe pattern the head of great metaof an ordinary shoe. Point A is a fixed point ahead of the great toe joint caused by the cap or boxing; point B is a fixed ANATOMY point produced by the counter; and point For brevity’s sake, onIy the anatomy of c is a pressure point because shoes do not the IongitudinaI arches wiI1 be mentioned. have enough room in them at this point, The outer one, composed of cuboid due to the faiIure of Iast makers to put bone, and fourth and fifth metatarsals, enough wood in the Iast. Point c, working is the main weight-bearing arch. The inner against points A and B, insidiously moIds one, composed of scaphoid, cuneiforms, the foot out of line or in a position of and first, second and third metatarsals, eversion. I beIieve it is commonIy accepted * Submitted for publication September 2, 1930. 5’
42
American Journal of Surgery
Hiss-HaIIux
that eversion is an earIy step that produces unbaIanced foot action and broken arches. This wiI1 disturb the distribution of the
VaIgus great toe joint. Note that all of the muscles are attached to the phalanges, distal to the metatarsal bead. Figure 3 shows the
the
abductor haIIucis and adductor haIIucis in the monkey (macaque) A, chimpanzee B, ape c and man D. The macaque’s foot has a strong adductor with which to firmIy grasp a Iimb, the onIy function of the abductor being to puI1 the great toe outward for the next strong grasp. The chimpanzee spends most of the time in the trees and part of the time on the ground, the ape spends most of the time on the ground, and man a11 of the time on the ground. Note the gradua1 change of structure of the skeIeton, with the retention of the same adductors and abductors.
But remember the adductor is by far the stronger muscle. The bIack dots on these
FIG. 2. Foot imprint ordinary shoe.
in reIation
to insole pattern
of
moving Ioad, resuIting in foot strain because the weight-bearing wiI1 move mesiaIIy on to the spring arch (see Fig. I, c.) This vicious action of shoes not onIy throws too much weight on the great toe joint, but produces a mesiaIIy directed force, shown by the long arrow in Figure 2, which pushes the head of great metatarsa bone inward and off the foundation which is made up of sesamoid bones, muscIe and fascia. In the writer’s series of 18 12 cases comprising 3092 bunions, 60.3 per cent had everted feet, 32.4 per cent had drop of spring arch, and 82.1 per cent had maIposition of arch bones. CAUSE
OF
HALLUX
VALGUS
The phyIogenetic development and the human anatomy of the great toe joint rev& the fact that there is nothing to resist this mesia1 thrust caused by shoes. Figure 4, A shows the structures beIow
skeIetons show the weight-bearing focus which is at the interna cuneiform bone in our progenitors (see side view of ape Fig. 3, E) as they do not have an arch. In this evoIutionary deveIopment, suddenIy an arch deveIops in man and the weight-bearing is focused at cuboid bone (see Fig. I, B, and Fig. 3, D and F.) Shoes evert the foot and throw the weight-bearing mesiaIIy, which is a retrogression to primitive type walking, aIthough most cases maintain the arch thereby throwing the extra Ioad on the great toe joint (see Fig. I, c and compare it with Fig. I, A). Shoes aIso destroy the function of great toe abduction; that is: no one who wears shoes can separate the great toe from the second toe as we puI1 the thumb away from the index finger. Newborn babes can do it and so can barefoot natives of South Africa. It is a we11 known fact in treatment of deformities that when one muscIe Ioses its function through paraIysis, the antagonistic muscIe wiI1 puI1 the joint into a deformed position. PuIIing across the great toe joint we have a strong adductor, and a weak abductor that has Iost its function through the disturbing action of shoes. On top of this we have a mesial thrust from shoes which pushes the great toe joint inward. Figure 4, B
Hiss-HalIux
NEW SERIES VOL. XI, No. I
shows the resuIt. The adductor puIIs the great toe outward through its attachment to the proxima1 phalanx; the useIess
VaIgus
American
FIG. 3. Abductor
With
these
43
APE
CHIMPANZEE
haIIucis and adductor
hallucis, A, monkey (macaque); view of ape; F, arch in man.
abductor tendon slides under the joint; and the great toe joint buckIes over the top and mesiaIIy. The flexor brevis haIIucis, whose doubIe tendons contain the sesamoids, pIays a secondary &Ye, but puIIs the outer sesamoid between the first and second toes. Therefore hallux valgus is primarily a buckle joint and not an enlarged joint, the osteophytic outgrowth on the great metatarsal head and the inflamed bursa or bunion being secondary to ir&tationfromshoe pressure, as the joint buckles with every step. To sum up, halIux valgus is the resuIt of: I. PhyIogeneticaIIy deveIoped stronger adduction than abduction; 2. Tendon imbaIance from Iost abduction; 3. Joint buckIing from mesia1 thrust of shoes; and 4. Excess weight-bearing from eversion of whoIe foot. VARIOUS
of Surgery
it is easy to judge the efficacy of the various bunion operations. The Heuter-Mayo method of amputa-
V
AE
Journal
BUNION
OPERATIONS
causative
factors
in mind,
B, chimpanzee;
c, ape; D, man; E, side
tion of the head of the great metatarsal and interposition of a ffap, needs onIy be mentioned to be condemned. It not onIy faiIs to correct the tendon imbaIance, but destroys the most important weightbearing point in the front of the foot. The procedure is so radica1 that the foot may never readjust to the abnorma1 change. FueI is often added to the flame by thus removing a weight-bearing point that is aIready carrying too much Ioad, thereby causing increased foot strain. The KeIIer method of removing the mesia1 haIf of the head of the great metatarsa is not quite so radica1, but it does not correct the tendon imbalance and thereby does not reIieve the buckIing. However, those cases of patients unsuccessfuIIy operated by this method can stir1 be corrected by the overcoming of tendon imbaIance. The remova of a wedge of bone (cuneiform osteotomy) from inner side of meta-
54
American
Journal
of Surgery
Hiss-HalIux
tarsa head as we11 as cutting the outer Iigaments of the joint capsuIe and overIapping the inner Iigaments (Silver’s method)
FIG. 4. A, Structures
VaIgus attention to tendon imbaIance, I cannot accept his theory. The remova of both sesamoids to cure haIIux vaIgus does not
beIow great toe joint. B, mesial thrust from shoes which pushes great toe joint inward.
are theoreticaIIy unsound, as tendon imbaIante and buckhng stiII persist. In 1911 Dr. Curtis Brigham removed sesamoids for haIIux vaIgus, but later dropped the procedure. Since 1915 Dr. H. W. Robinson has been removing sesamoids aIso, and cIaims that a11bunions are hereditary and that shoes never caused a bunion. The fact that haIIux vaIgus is comparativeIy rare in men who wear sensibIe shoes, not onIy refutes the hereditary idea, but augments the argument that shoes are the immediate cause. His theory aIso cIaims that sesamoids push the head of great metatarsa1 mesiaIIy. In view of the facts brought out that sesamoids are onIy a secondary factor and that he pays no
correct tendon imbaIance, but is IikeIy to produce an upward buckIing of the great toe, because compIete severing of both flexor brevis haIIucis tendons is unavoidabIe (as sesamoids are imbedded therein), Ieaving the extensor brevis free to puI1 the proxima1 phaIanx upward. In other words a dorsopIantar tendon imbaIance may be produced, which is as painfuI as haIIux vaIgus. RemovaI of both sesamoids Ieaves the flexor Iongus haIIucis tendon unprotected, so this tendon flattens out and becomes adherent in the connective tissue mass in the deep fascia resuIting from surgica1 trauma. Even though this procedure is unphysioIogica1, it does not
NEW SERIES VOL. XI, No.
Hiss-HaIIux
I
destroy a weight-bearing point, and may reduce the severity of the buckhng, ahhough tendon imbalance stiI1 exists.
Valgus
METHOD
The method devised by the writer, which he terms the Base Correction Method, has for its purpose: I. To correct tendon imbaIance; 2. To overcome joint buckIing; 3. To strengthen phyIogenetic weakness; 4. To place the metatarsa1 head on its base; and 5. To relieve excess Ioad on the great toe joint. In the first pIace there is no set orthodox technique that wiII meet the various complex situations met in the many varieties of bunions. Arch treatment wiII aid in the proper distribution of the moving Ioad and the writer prefers to do this by manipuIation. This relieves the excess weight on the great toe joint. To correct tendon imbaIance adductor
Journal
of Surgery
$3
tenotomy is aIways done. TranspIanting of the abductor tendon is done, without tenotomy, puIIing it up to the norma
FIG. 5. Before and after operation by base correction AUTHOR’S
American
method.
mesia1 position and suturing it to the periosteum of the great metatarsa1 bone. The mesia1 side of metatarsa1 head is denuded, thereby removing the osteophytic bone, and furnishing a bed for the re-Iocation of the abductor tendon. Here we take advantage of the postoperative joint inhItration, which firmIy anchors abductor to joint capsuIe and bone by a firm fibrous mass. This aIso overcomes the phyIogenetic and shoe-acquired abductor weakness, and restores joint action without buckhng. In order to produce this restoration of tendon balance, other secondary procedures wiII have to be restored to according to the conditions presented by the type of case at hand. IntermetatarsaI resistance, produced by tissue changes from the chronic nature of the deformity, must be overcome. So IateraI capsuIotomy may be necessary. Often interphaIangea1
56
American Journal of Surgery
Hiss-HaIIux
fasciotomy and skin Iengthening are done. The maIposition of the outer portion of the ffexor brevis haIIucis may require
FIG. 6. Before
and after operation
VaIgus
JANUARY. ,931
function; and (2) a deep appreciation of pressure points in shoes. The writer constantIy checks joint function in making a
by base correction method. This patient walked four miles, three weeks after her operation.
tenotomy or Iateral sesamoidectomy. Extensor brevis haIIucis tenotomy may heIp, due to the anguIar puI1 of this muscIe. Restoration of joint aIignment may be prohibited by an obstructing joint Iipping on the mesial side of dista1 end of great metatarsal, which must be removed with the other osteophytic bone. The cIosure invoIves mesia1 eIIiptica1 capsuIectomy which not onIy removes the proIiferating cartiIage, but takes up capsuIar sIack and strengthens the position of the imbedded abductor haIIucis tendon. Skin cIosure invoIves eIIiptica1 remova of excess skin which not onIy removes the subcutaneous bursa (the bunion), but the painfu1 caIIus also. The writer has often said that foot surgery involves two main thoughts: (I) A thorough understanding of complex foot
choice of the combination of procedures to be used in an operation, and is aIways Iooking for bony prominences that may Iater cause shoe pressure. In cIosing this operation, he always looks for exostoses on the me&a1 wing of the base of proximal phaIanx, on the superomesial aspect of the head of great metatarsal, and on the base of the sesamoid bones. If present they must be removed. The work is a11 done under IocaI conduction anesthesia, using a I per cent procaine soIution. When tendon baIance is properIy restored the great toe wiI1 stand up in perfect ahgnment, without support, and the patient can fIex and extend the toe before Ieaving operation room. Therefore no splints or casts are used. A soft surgical dressing is IooseIy appIied, and a Ioose,
N
I:W~
SERIES
VOL.
Xl,
No.
I
Hiss-HaIIux
gauze-covered cotton pad is placed between first and second toes. Stitches are removed in ten days and the patient is ahowed to walk on the tweIfth day. The feet are pIaced in shoes as narrow as we can get them into. The convaIescent period is very short because normaI function has been restored and no weightbearing points removed. Figure 3 shows a case before and after operation by the Base Correction method. Dotted lines show the restored baIance in tendons. The head of the metatarsal has not been removed. CONCLUSIONS I.
HaIIux valgus is not an enlarged
joint;
Valgus
American Journal of Surgery
47
2. HaIIux vaIgus is primarily tendon imbalance and joint buckhng; 3. Phylogenesis pIays an important predisposing rBIe; 4. Shoes are the immediate cause of haIIux valgus; 3. Broken arches and haIIux valgus are the result of the same vicious forces; 6. Excess weight-bearing on the great toe joint can be reIieved by treatment to the arches; 7. Surgery involves restoration of tendon balances, rather than destruction of weight-bearing points; 8. No set orthodox technique wiII cope with all varieties of haIIux vaIgus.
AND SIMPLIFIED
JOHN MARTIN
TREATMENT
HISS, M.D.
COLUMBUS, OHIO
T
is the spring arch. In waIking, the streams of weight-bearing (or moving Ioad) trave1 through the foot in an orderly manner,
purpose of this articIe is to show: I. That halIux valgus is not an enIarged joint;
HE
0.
$J
APE
MAN FIG.
2. That broken are the resuIt of on the foot; 3. That there for haIIux vaIgus; 4. That haIIux tendon imbaIance joint; 5. That haIIux without removing tarsa bone.
I.
A,
ape;
B,
man; c, haIIux vaIgus.
arches and haIIux vaIgus the same forces working is a phyIogenetic
HALLUX VALGUS
from the hee1 to the outer side of the foot, across the baI1 and through the toes (see Fig. I, B).
set-up
HALLUX VALGUS AND BROKEN ARCHES
vaIgus is the resuIt of across the great toe
ImproperIy proportioned shoes produce a disorderIy irreguIarity of the distribution of the moving Ioad. Figure 2 shows a foot vaIgus can be corrected imprint in reIation to the insoIe pattern the head of great metaof an ordinary shoe. Point A is a fixed point ahead of the great toe joint caused by the cap or boxing; point B is a fixed ANATOMY point produced by the counter; and point For brevity’s sake, onIy the anatomy of c is a pressure point because shoes do not the IongitudinaI arches wiI1 be mentioned. have enough room in them at this point, The outer one, composed of cuboid due to the faiIure of Iast makers to put bone, and fourth and fifth metatarsals, enough wood in the Iast. Point c, working is the main weight-bearing arch. The inner against points A and B, insidiously moIds one, composed of scaphoid, cuneiforms, the foot out of line or in a position of and first, second and third metatarsals, eversion. I beIieve it is commonIy accepted * Submitted for publication September 2, 1930. 5’
42
American Journal of Surgery
Hiss-HaIIux
that eversion is an earIy step that produces unbaIanced foot action and broken arches. This wiI1 disturb the distribution of the
VaIgus great toe joint. Note that all of the muscles are attached to the phalanges, distal to the metatarsal bead. Figure 3 shows the
the
abductor haIIucis and adductor haIIucis in the monkey (macaque) A, chimpanzee B, ape c and man D. The macaque’s foot has a strong adductor with which to firmIy grasp a Iimb, the onIy function of the abductor being to puI1 the great toe outward for the next strong grasp. The chimpanzee spends most of the time in the trees and part of the time on the ground, the ape spends most of the time on the ground, and man a11 of the time on the ground. Note the gradua1 change of structure of the skeIeton, with the retention of the same adductors and abductors.
But remember the adductor is by far the stronger muscle. The bIack dots on these
FIG. 2. Foot imprint ordinary shoe.
in reIation
to insole pattern
of
moving Ioad, resuIting in foot strain because the weight-bearing wiI1 move mesiaIIy on to the spring arch (see Fig. I, c.) This vicious action of shoes not onIy throws too much weight on the great toe joint, but produces a mesiaIIy directed force, shown by the long arrow in Figure 2, which pushes the head of great metatarsa bone inward and off the foundation which is made up of sesamoid bones, muscIe and fascia. In the writer’s series of 18 12 cases comprising 3092 bunions, 60.3 per cent had everted feet, 32.4 per cent had drop of spring arch, and 82.1 per cent had maIposition of arch bones. CAUSE
OF
HALLUX
VALGUS
The phyIogenetic development and the human anatomy of the great toe joint rev& the fact that there is nothing to resist this mesia1 thrust caused by shoes. Figure 4, A shows the structures beIow
skeIetons show the weight-bearing focus which is at the interna cuneiform bone in our progenitors (see side view of ape Fig. 3, E) as they do not have an arch. In this evoIutionary deveIopment, suddenIy an arch deveIops in man and the weight-bearing is focused at cuboid bone (see Fig. I, B, and Fig. 3, D and F.) Shoes evert the foot and throw the weight-bearing mesiaIIy, which is a retrogression to primitive type walking, aIthough most cases maintain the arch thereby throwing the extra Ioad on the great toe joint (see Fig. I, c and compare it with Fig. I, A). Shoes aIso destroy the function of great toe abduction; that is: no one who wears shoes can separate the great toe from the second toe as we puI1 the thumb away from the index finger. Newborn babes can do it and so can barefoot natives of South Africa. It is a we11 known fact in treatment of deformities that when one muscIe Ioses its function through paraIysis, the antagonistic muscIe wiI1 puI1 the joint into a deformed position. PuIIing across the great toe joint we have a strong adductor, and a weak abductor that has Iost its function through the disturbing action of shoes. On top of this we have a mesial thrust from shoes which pushes the great toe joint inward. Figure 4, B
Hiss-HalIux
NEW SERIES VOL. XI, No. I
shows the resuIt. The adductor puIIs the great toe outward through its attachment to the proxima1 phalanx; the useIess
VaIgus
American
FIG. 3. Abductor
With
these
43
APE
CHIMPANZEE
haIIucis and adductor
hallucis, A, monkey (macaque); view of ape; F, arch in man.
abductor tendon slides under the joint; and the great toe joint buckIes over the top and mesiaIIy. The flexor brevis haIIucis, whose doubIe tendons contain the sesamoids, pIays a secondary &Ye, but puIIs the outer sesamoid between the first and second toes. Therefore hallux valgus is primarily a buckle joint and not an enlarged joint, the osteophytic outgrowth on the great metatarsal head and the inflamed bursa or bunion being secondary to ir&tationfromshoe pressure, as the joint buckles with every step. To sum up, halIux valgus is the resuIt of: I. PhyIogeneticaIIy deveIoped stronger adduction than abduction; 2. Tendon imbaIance from Iost abduction; 3. Joint buckIing from mesia1 thrust of shoes; and 4. Excess weight-bearing from eversion of whoIe foot. VARIOUS
of Surgery
it is easy to judge the efficacy of the various bunion operations. The Heuter-Mayo method of amputa-
V
AE
Journal
BUNION
OPERATIONS
causative
factors
in mind,
B, chimpanzee;
c, ape; D, man; E, side
tion of the head of the great metatarsal and interposition of a ffap, needs onIy be mentioned to be condemned. It not onIy faiIs to correct the tendon imbaIance, but destroys the most important weightbearing point in the front of the foot. The procedure is so radica1 that the foot may never readjust to the abnorma1 change. FueI is often added to the flame by thus removing a weight-bearing point that is aIready carrying too much Ioad, thereby causing increased foot strain. The KeIIer method of removing the mesia1 haIf of the head of the great metatarsa is not quite so radica1, but it does not correct the tendon imbalance and thereby does not reIieve the buckIing. However, those cases of patients unsuccessfuIIy operated by this method can stir1 be corrected by the overcoming of tendon imbaIance. The remova of a wedge of bone (cuneiform osteotomy) from inner side of meta-
54
American
Journal
of Surgery
Hiss-HalIux
tarsa head as we11 as cutting the outer Iigaments of the joint capsuIe and overIapping the inner Iigaments (Silver’s method)
FIG. 4. A, Structures
VaIgus attention to tendon imbaIance, I cannot accept his theory. The remova of both sesamoids to cure haIIux vaIgus does not
beIow great toe joint. B, mesial thrust from shoes which pushes great toe joint inward.
are theoreticaIIy unsound, as tendon imbaIante and buckhng stiII persist. In 1911 Dr. Curtis Brigham removed sesamoids for haIIux vaIgus, but later dropped the procedure. Since 1915 Dr. H. W. Robinson has been removing sesamoids aIso, and cIaims that a11bunions are hereditary and that shoes never caused a bunion. The fact that haIIux vaIgus is comparativeIy rare in men who wear sensibIe shoes, not onIy refutes the hereditary idea, but augments the argument that shoes are the immediate cause. His theory aIso cIaims that sesamoids push the head of great metatarsa1 mesiaIIy. In view of the facts brought out that sesamoids are onIy a secondary factor and that he pays no
correct tendon imbaIance, but is IikeIy to produce an upward buckIing of the great toe, because compIete severing of both flexor brevis haIIucis tendons is unavoidabIe (as sesamoids are imbedded therein), Ieaving the extensor brevis free to puI1 the proxima1 phaIanx upward. In other words a dorsopIantar tendon imbaIance may be produced, which is as painfuI as haIIux vaIgus. RemovaI of both sesamoids Ieaves the flexor Iongus haIIucis tendon unprotected, so this tendon flattens out and becomes adherent in the connective tissue mass in the deep fascia resuIting from surgica1 trauma. Even though this procedure is unphysioIogica1, it does not
NEW SERIES VOL. XI, No.
Hiss-HaIIux
I
destroy a weight-bearing point, and may reduce the severity of the buckhng, ahhough tendon imbalance stiI1 exists.
Valgus
METHOD
The method devised by the writer, which he terms the Base Correction Method, has for its purpose: I. To correct tendon imbaIance; 2. To overcome joint buckIing; 3. To strengthen phyIogenetic weakness; 4. To place the metatarsa1 head on its base; and 5. To relieve excess Ioad on the great toe joint. In the first pIace there is no set orthodox technique that wiII meet the various complex situations met in the many varieties of bunions. Arch treatment wiII aid in the proper distribution of the moving Ioad and the writer prefers to do this by manipuIation. This relieves the excess weight on the great toe joint. To correct tendon imbaIance adductor
Journal
of Surgery
$3
tenotomy is aIways done. TranspIanting of the abductor tendon is done, without tenotomy, puIIing it up to the norma
FIG. 5. Before and after operation by base correction AUTHOR’S
American
method.
mesia1 position and suturing it to the periosteum of the great metatarsa1 bone. The mesia1 side of metatarsa1 head is denuded, thereby removing the osteophytic bone, and furnishing a bed for the re-Iocation of the abductor tendon. Here we take advantage of the postoperative joint inhItration, which firmIy anchors abductor to joint capsuIe and bone by a firm fibrous mass. This aIso overcomes the phyIogenetic and shoe-acquired abductor weakness, and restores joint action without buckhng. In order to produce this restoration of tendon balance, other secondary procedures wiII have to be restored to according to the conditions presented by the type of case at hand. IntermetatarsaI resistance, produced by tissue changes from the chronic nature of the deformity, must be overcome. So IateraI capsuIotomy may be necessary. Often interphaIangea1
56
American Journal of Surgery
Hiss-HaIIux
fasciotomy and skin Iengthening are done. The maIposition of the outer portion of the ffexor brevis haIIucis may require
FIG. 6. Before
and after operation
VaIgus
JANUARY. ,931
function; and (2) a deep appreciation of pressure points in shoes. The writer constantIy checks joint function in making a
by base correction method. This patient walked four miles, three weeks after her operation.
tenotomy or Iateral sesamoidectomy. Extensor brevis haIIucis tenotomy may heIp, due to the anguIar puI1 of this muscIe. Restoration of joint aIignment may be prohibited by an obstructing joint Iipping on the mesial side of dista1 end of great metatarsal, which must be removed with the other osteophytic bone. The cIosure invoIves mesia1 eIIiptica1 capsuIectomy which not onIy removes the proIiferating cartiIage, but takes up capsuIar sIack and strengthens the position of the imbedded abductor haIIucis tendon. Skin cIosure invoIves eIIiptica1 remova of excess skin which not onIy removes the subcutaneous bursa (the bunion), but the painfu1 caIIus also. The writer has often said that foot surgery involves two main thoughts: (I) A thorough understanding of complex foot
choice of the combination of procedures to be used in an operation, and is aIways Iooking for bony prominences that may Iater cause shoe pressure. In cIosing this operation, he always looks for exostoses on the me&a1 wing of the base of proximal phaIanx, on the superomesial aspect of the head of great metatarsal, and on the base of the sesamoid bones. If present they must be removed. The work is a11 done under IocaI conduction anesthesia, using a I per cent procaine soIution. When tendon baIance is properIy restored the great toe wiI1 stand up in perfect ahgnment, without support, and the patient can fIex and extend the toe before Ieaving operation room. Therefore no splints or casts are used. A soft surgical dressing is IooseIy appIied, and a Ioose,
N
I:W~
SERIES
VOL.
Xl,
No.
I
Hiss-HaIIux
gauze-covered cotton pad is placed between first and second toes. Stitches are removed in ten days and the patient is ahowed to walk on the tweIfth day. The feet are pIaced in shoes as narrow as we can get them into. The convaIescent period is very short because normaI function has been restored and no weightbearing points removed. Figure 3 shows a case before and after operation by the Base Correction method. Dotted lines show the restored baIance in tendons. The head of the metatarsal has not been removed. CONCLUSIONS I.
HaIIux valgus is not an enlarged
joint;
Valgus
American Journal of Surgery
47
2. HaIIux vaIgus is primarily tendon imbalance and joint buckhng; 3. Phylogenesis pIays an important predisposing rBIe; 4. Shoes are the immediate cause of haIIux valgus; 3. Broken arches and haIIux valgus are the result of the same vicious forces; 6. Excess weight-bearing on the great toe joint can be reIieved by treatment to the arches; 7. Surgery involves restoration of tendon balances, rather than destruction of weight-bearing points; 8. No set orthodox technique wiII cope with all varieties of haIIux vaIgus.