Coughlin, J Bone Joint Surg Am 1996 - Hallux Valgus

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Hallux Valgus

Coughlin·J Bone Joint Surg Am·1996·361 citations·Review article

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Coughlin's 1996 AAOS instructional course lecture systematically reviews hallux valgus pathoanatomy, radiographic grading, and operative decision-making. The central question: how do you match the right procedure to the right deformity based on severity and joint congruency? All three radiographic parameters — HVA, IMA, and sesamoid subluxation — are needed to classify deformity and guide surgical selection.

Key Findings

Deformity severity is classified across three radiographic parameters — all three thresholds must be confirmed before selecting a procedure:
- Mild: HVA <20°, IMA ≤11°, sesamoid subluxation <50%
- Moderate: HVA 20–40°, IMA <16°, subluxation 50–75%
- Severe: HVA >40°, IMA ≥16°, subluxation >75%
Joint congruency is the single most important determinant of procedure selection — a congruous MTP joint requires extra-articular correction (chevron, Mitchell, Akin, or proximal osteotomy); performing an intra-articular realignment on a congruous joint risks recurrence or arthrosis.
Chevron osteotomy corrects HVA an average of 12–13° and IMA 4–5°, but satisfaction drops from 94% to 74% when preoperative IMA exceeds 12°, which is why chevron is reserved for mild and select moderate deformities with IMA <13°.
AVN of the first metatarsal head occurs in 20% of feet after chevron osteotomy alone and rises to 4 of 10 feet when combined with lateral adductor tenotomy — lateral release must never be added to a chevron.
Distal soft-tissue reconstruction combined with proximal crescentic osteotomy achieves 92% satisfaction with HVA correction of 23–24° and IMA correction of 8–11°, making it the workhorse for moderate-to-severe subluxated deformity.
Preserving the fibular sesamoid reduces hallux varus risk nearly in half — lateral sesamoidectomy is the primary driver of overcorrection and should be avoided.

Board PearlCongruous MTP joint requires extra-articular correction regardless of severity — intra-articular realignment on a congruous joint causes recurrence or arthrosis.

Hallux Valgus.

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Hallux Valgus

Coughlin·J Bone Joint Surg Am·1996·361 citations·Review article

|

Coughlin's 1996 AAOS instructional course lecture systematically reviews hallux valgus pathoanatomy, radiographic grading, and operative decision-making. The central question: how do you match the right procedure to the right deformity based on severity and joint congruency? All three radiographic parameters — HVA, IMA, and sesamoid subluxation — are needed to classify deformity and guide surgical selection.

Key Findings

Deformity severity is classified across three radiographic parameters — all three thresholds must be confirmed before selecting a procedure:
- Mild: HVA <20°, IMA ≤11°, sesamoid subluxation <50%
- Moderate: HVA 20–40°, IMA <16°, subluxation 50–75%
- Severe: HVA >40°, IMA ≥16°, subluxation >75%
Joint congruency is the single most important determinant of procedure selection — a congruous MTP joint requires extra-articular correction (chevron, Mitchell, Akin, or proximal osteotomy); performing an intra-articular realignment on a congruous joint risks recurrence or arthrosis.
Chevron osteotomy corrects HVA an average of 12–13° and IMA 4–5°, but satisfaction drops from 94% to 74% when preoperative IMA exceeds 12°, which is why chevron is reserved for mild and select moderate deformities with IMA <13°.
AVN of the first metatarsal head occurs in 20% of feet after chevron osteotomy alone and rises to 4 of 10 feet when combined with lateral adductor tenotomy — lateral release must never be added to a chevron.
Distal soft-tissue reconstruction combined with proximal crescentic osteotomy achieves 92% satisfaction with HVA correction of 23–24° and IMA correction of 8–11°, making it the workhorse for moderate-to-severe subluxated deformity.
Preserving the fibular sesamoid reduces hallux varus risk nearly in half — lateral sesamoidectomy is the primary driver of overcorrection and should be avoided.

Board PearlCongruous MTP joint requires extra-articular correction regardless of severity — intra-articular realignment on a congruous joint causes recurrence or arthrosis.

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