In adolescence, and particularly in girls, where there is competition between the rapidly growing foot, tight stockings and often small, high-heeled, unsuitable shoes, valgus deformity of the great toe first appears. In some cases a hereditary short and varus first metatarsal may contribute to the problem. As the deformity progresses, the drifting proximal phalanx of the great toe uncovers the metatarsal head, which presses against the shoe and leads to the formation of a protective bursa (bunion), often associated with recurrent episodes of inflammation (bursitis). The great toe may pronate, and further lateral drift results in crowding of the other toes; the great toe may pass over the second toe or, more commonly, the second toe may ride over it. The second toe may press against the toe cap of the shoe, where there is little room for it, and develop painful calluses. Later it may dislocate at the metatarsophalangeal joint. The sesamoid bones under the first metatarsal head may sublux laterally, leading to sharply localized pain under the first metatarsophalangeal joint. In the late stages of the condition, arthritic-changes may develop in the metatarsophalangeal joint. More commonly, there is associated disturbance of the mechanics of the forefoot, leading to anterior metatarsalgia.
A number of surgical procedures are available to correct hallux valgus deformity. The most popular are (a) fusion of the metatarsophalangeal joint in a corrected position; (b) Keller's arthroplasty (excision of the prominent part of the metatarsal head and removal of the basal portion of the proximal phalanx); (c) osteotomy of the first metatarsal neck (Mitchell operation); and (d) in early cases, simple excision of the prominent part of the metatarsal head may give relief. Silicone replacement of the metatarsophalangeal joint is no longer advocated, as it has been found that a troublesome silicone granuloma almost invariably develops in the region within 4 years of surgery.
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