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^T^^B^D: Foot condition where the first metatarsal bone deviates medially (metatarsus primus varus) with lateral deviation of the big toe.

Unknown but likely joint hypermobility in combination with biomechanical ^^ forces result in progressive deformity.

Q/Q Associated family history of the condition in 50-60%. Anatomically associated

Hwith other toe deformities, e.g. hammer toe (flexion of proximal interphalan-geal joint), depression of the metatarsal bones, and with a 'bunion' an adventitious bursa that forms over the prominent metatarsal head.

Common, often affecting adolescents and the elderly. Female > male.

Often asymptomatic.

Discomfort or pain dueto ill-fitting shoes, an inflamed bunion, metatarsalgia or secondary osteoarthritis of the first MTP joint.

The patient may have a wide forefoot, with lateral deviation of the big toe. A medial swelling or bunion is present that may be swollen and inflamed. Skin keratoses are under the metatarsal heads.

If osteoarthritis has developed, there is # range of movement in the 1st MTP joint.

The first metatarsal bone deviates medially (>40° in severe cases) and also becomes dorsally angulated, with lateral displacement of the toe. Pressure of the prominent metatarsal head on overlying tissue results in synovial hypertrophy and an overlying bursa secondary to friction. Secondary osteoarthritis of the joint is common in older individuals.

Radiographs (AP and lateral): Of the weightbearing foot; the characteristic deformity is seen with medial and dorsal deviation of the metatarsal head.

Conservative: Advice to wear wider shoes. Metatarsal support cushions can help with metatarsalgia.

Mitchell's operation: An osteostomy is made through the neck of the metatarsal and the head displaced medially; performed for adolescents and young adults.

Keller's operation: In older, less active patients, the proximal third of the proximal phalanx, the medial and dorsal exostoses of the metatarsal are excised, resulting in formation of a fibrous ankylosis. Arthrodesis of the first MTP joint: Gives good long-term function.

From disease: Pain, deformity, bursitis and synovial thickening over the MTP joint, osteoarthritis, plantar keratosis and hyperostosis.

From surgery: Recurrence of the deformity, metatarsalgia and excessive shortening of the hallux can occur with Keller's operation, stiffness of the MTP joint. Arthrodesis can be complicated by malposition, intertarsophalangeal osteoarthritis and failure of fusion.

Symptoms often mild, but progressive, often responding to conservative measures. Those with severe symptoms benefit from surgery; in young adults, there is a 90% success rate from reconstructive operations.

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