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An Avant-Garde, minimally traumatic surgical technique for hallux varus with lesser digit deviation; a comprehensive review
∗Corresponding author: Alan T. Shih
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Non-iatrogenic hallux varus, a rare deformity without prior surgical history, presents unique challenges when compounded by medial deviation of lesser digits. This case report details a 57-year-old female with non-iatrogenic hallux varus managed via a novel hybrid technique combining lateral collateral ligament (LCL) stabilization with suture anchors, and medial capsule release. Concurrent second metatarsophalangeal joint (MPJ) stabilization using the "keystone concept" indirectly realigned lesser digits without direct osteotomies. Postoperative hallux valgus angle improved, with restored lesser digit alignment and preserved hallux dorsiflexion. Functional, Rapid recovery underscores this approach as a less invasive alternative to traditional arthrodesis or multi-metatarsal osteotomies.
1 Introduction
Hallux varus, traditionally linked to iatrogenic overcorrection of hallux valgus, is well documented in the surgical literature. However, idiopathic cases are rare and lack consensus on etiology or management. Non-iatrogenic hallux varus often coexists with medial deviation of lesser digits, exacerbating forefoot instability and complicating surgical planning. Traditional approaches of first MPJ arthrodesis or Weil osteotomies sacrifice motion or require extensive soft tissue work, increasing morbidity. This report introduces a motion preserving technique inspired by thumb UCL repairs and the keystone principle, addressing both hallux varus and transverse plane instability of lesser rays through minimally traumatic means. This case is unusual as it involves a non-iatrogenic hallux varus with lesser digit deviation (see Figs. 1 and 2) (Figs. 3 and 4).
2 Literature review
Hallux varus, characterized by medial deviation of the great toe, remains a complex surgical challenge, particularly when iatrogenic. Traditional and emerging techniques aim to restore anatomical alignment while balancing joint stability and mobility. This review synthesizes existing approaches, their limitations, and the rationale for the novel technique proposed in this study, incorporating recent evidence on soft-tissue sustainability and innovative devices.
3 Traditional surgical techniques
3.1 First metatarsophalangeal joint (MTPJ) fusion
Arthrodesis remains a gold standard for severe or arthritic hallux varus, providing reliable pain relief and stability by eliminating joint motion. However, it sacrifices dorsiflexion and plantarflexion, altering gait mechanics and limiting footwear options.1 While effective in elderly patients, fusion is less ideal for younger, active individuals due to functional trade-offs.
3.2 Tendon transfers
Dynamic tendon transfers harness native muscle forces to rebalance the hallux without sacrificing joint motion. In the most common variant, the extensor hallucis longus is rerouted laterally and secured to the dorsal capsule carefully tensioned to oppose medial drift while preserving interphalangeal mobility. Split-tendon modifications further refine force distribution by dividing the EHL slip, allowing one limb to maintain extension and the other to counteract varus deviation, though meticulous handling is vital to avoid tendon weakening. In a pooled series of over 60 feet treated with these techniques, recurrence hovered around 4 % with complication rates under 20 %, underscoring tendon transfer as a durable, motion-preserving option for flexible hallux varus2
3.3 Reverse osteotomies
Osseous corrections, such as reverse scarf or chevron osteotomies, address bony malalignment and overcorrection of the intermetatarsal angle (IMA). Akhtar et al.3 reported improved IMA and hallux valgus angles post-reverse scarf osteotomy, but complications like metatarsal shortening, nonunion, and transfer metatarsalgia persist. Similarly, medial opening-wedge osteotomies with bone grafting restore medial buttress integrity but carry risks of graft resorption and prolonged healing.4
3.4 Lateral collateral ligament (LCL) reconstruction and medial release
Effective correction of hallux varus hinges on rebalancing both sides of the joint: simply loosening the medial capsule risks instability and persistent lateral laxity, while isolated lateral reconstructions without relieving medial contracture leave the deformity unaddressed. A combined approach loosening contracted medial structures and reinforcing the lateral collateral ligament (for example, with suture anchors or synthetic tape) restores joint equilibrium, preserves motion, and markedly reduces recurrence, albeit at the expense of increased soft-tissue dissection which can lead to postoperative stiffness, wound complications, and delayed rehabilitation.
4 Emerging techniques and innovations
4.1 Ligamentoplasties and suture button constructs
Synthetic ligament augmentation most commonly via suture-button constructs like the Mini TightRope® provides immediate, static lateral support by threading braided sutures through divergent bone tunnels to recreate the lateral collateral ligament's restraint, allowing full weight-bearing as early as two weeks postoperatively with preserved joint motion. Biomechanical studies have shown that these devices can achieve tension levels comparable to native ligaments, reducing transverse-plane laxity more predictably than soft-tissue suturing alone. However, the reliance on transosseous fixation concentrates stress at drill holes, raising the risk of metatarsal fracture or tunnel widening over time, and the braided sutures themselves may abrade surrounding soft tissues if not seated properly. Additionally, while a small series report low immediate complication rates, long-term data are limited on suture fatigue or delayed anchor pullout before biologic ingrowth, which could compromise stability in high-demand patients. Finally, the need for precise tunnel placement and hardware removal in the event of irritation adds operative complexity. These considerations underscore the appeal of hybrid techniques that minimize bone drilling yet still harness the principles of anatomic ligament reconstruction.5
4.2 Suture tape anchor reconstruction
Suture-tape anchor reconstruction employs braided, high-strength tape fixed at the lateral collateral ligament footprint via small bone tunnels to recreate native ligament tension, offering immediate transverse-plane stability, preserved dorsiflexion and plantarflexion, and avoidance of donor-site morbidity, with radiographic correction of hallux valgus and intermetatarsal angles comparable to traditional methods; however, concentrating load at tunnel sites can risk drill-hole fractures or tunnel widening, braided tape may abrade surrounding soft tissues or provoke foreign-body reactions, and hardware prominence or anchor pull-out—reported in up to 10–12 % of cases can necessitate secondary procedures, while long-term data on suture-tape fatigue and biologic integration remain limited.6
4.3 Combined osseous-soft tissue reconstruction
Combined osseous–soft tissue reconstruction corrects hallux varus by realigning the first metatarsal (e.g., reverse scarf osteotomy) while simultaneously tightening or reefing the lateral joint capsule, and when needed using a small medial opening-wedge graft to rebuild the medial buttress. This single-stage hybrid restores both bony alignment and ligament balance, achieves average intermetatarsal angle improvements of 5°–8° and hallux valgus corrections of 15°–20°, and preserves joint motion, though it requires careful osteotomy planning and a slightly longer immobilization period to ensure graft incorporation.1
4.4 Rationale for the novel technique
By combining anatomic LCL stabilization via a suture anchor with targeted medial capsule release, this approach restores transverse-plane stability and unloads medial contracture in a single, soft-tissue–preserving procedure. Anchoring the LCL at its native footprint reconstitutes ligament tension and preserves the metatarsal parabola minimizing transfer metatarsalgia while releasing the medial capsule relieves contracture without risking over-tightening. Dynamic lateralization of the extensor tendon further counteracts residual varus forces, providing a self-adjusting check against deformity recurrence. This hybrid leverages principles of ligamentous integrity in joint preservation7 and synthetic augmentation techniques that have demonstrated durable alignment with early mobilization,6 yet avoids the bony disruption and prolonged recovery inherent to osteotomy-based methods. Early clinical experience suggests faster rehabilitation, less periarticular stiffness, and ready options for future revision if needed.
4.5 Conclusion of literature review
While traditional techniques provide foundational strategies, their limitations underscore the need for innovations that harmonize stability, mobility, and technical feasibility. Emerging methods like suture button constructs and suture tape anchors demonstrate efficacy in diverse etiologies, broadening the therapeutic arsenal. The novel technique integrates ligamentous stabilization, dynamic rebalancing, and anatomical precision, offering a promising alternative to osteotomy-dependent or motion-sacrificing procedures. Further clinical studies are essential to validate its efficacy, particularly in addressing multifactorial hallux varus etiologies.
5 Case report
A 57-year-old active female presented with hallux varus and overlapping of the second toe, resulting in difficulty wearing closed-toe shoes. She reported no history of prior foot surgery or trauma, supporting a diagnosis of non-iatrogenic hallux varus. Living in Arizona, she had managed symptoms with sandals and accommodative footwear, but was motivated to pursue surgical correction in anticipation of a move to a colder climate. Conservative measures—including padding and shoe modifications—had failed. She expressed a strong preference to avoid aggressive procedures such as first metatarsophalangeal joint (MPJ) fusion or plantar incisions for second toe correction, prioritizing preservation of joint motion and reduced recovery time due to an upcoming trip. After extensive discussion, a minimally invasive, joint-sparing approach was planned.
6 Surgical technique
1.Second MPJ Stabilization (Keystone Correction):
To correct the overlapping second digit and create space for proper hallux alignment, a dorsal approach to the second MPJ was used. A suture anchor was placed at the base of the proximal phalanx to reconstruct the attenuated lateral collateral ligament. This restored central stability to the second digit and indirectly improved alignment of the third and fourth toes, consistent with the "keystone effect" principle.2.Hallux Varus Correction:
A lateral incision approximately 4 cm in length was made just lateral to the extensor hallucis longus (EHL) tendon. An L-shaped capsulotomy was performed to expose the lateral aspect of the first MPJ, including the lateral base of the proximal phalanx and the metatarsal head. Scarring from presumed capsular tearing was identified and addressed. A McGlamery elevator and sharp dissection were used to release plantar adhesions between the sesamoids and first metatarsal head. Medial capsular tension was relieved to reduce varus positioning of the hallux. To correct the deformity, a suture anchor was placed at the lateral metatarsal head, and the lateral collateral ligament was reconstructed and tightened, bringing the hallux into improved alignment. The EHL was not fully lateralized but visualized and preserved without additional rerouting. Capsulorrhaphy of the lateral capsule was completed to maintain correction. Closure of the site was performed using horizontal mattress sutures.3.Additional Procedures:
A suture anchor repair of the second toe's lateral capsule was performed to address crossover deformity initially. A bunionectomy of the fifth metatarsal head (without osteotomy) was also performed to reduce lateral foot prominence and discomfort.4.Postoperative Care:
The patient was allowed immediate partial weight-bearing in a pneumatic walking cast. By week 3, she transitioned to full weight-bearing. She was casted for orthotics 4 weeks post op. No complications were observed at the surgical sites.
7 Results
Postoperative radiographs demonstrated improved alignment of the hallux and lesser digits, without the need for osteotomies or fusion. The hallux was rectus in appearance, and the second digit was well-centered above the metatarsal head. No complications occurred, though mild stiffness was noted in the early postoperative period but resolved within six weeks. The patient tolerated weight-bearing and daily activities without recurrence of deformity.
8 Conclusion
This case highlights a minimally invasive, soft tissue focused approach to non-iatrogenic hallux varus with second digit crossover. By first stabilizing the second MPJ, the keystone effect creates adequate space for restored hallux correction, eliminating the need for bony intervention on the lesser rays. Lateral capsular tightening with suture anchor reconstruction of the LCL, combined with selective medial release, corrected the deformity while preserving motion at the first MPJ. This technique reflects principles of dynamic balance and joint preservation, offering a less aggressive yet effective alternative to fusion or osteotomy-based procedures. Notably, realignment of the third and fourth digits occurred without direct surgical intervention, demonstrating how targeted correction at a central stabilizer can produce broader structural improvement with minimal surgical trauma.
CRediT authorship contribution statement
Zachary A. Shih: Conceptualization, Data curation, Writing – original draft, Visualization, led the project, conducted data collection, and drafted the manuscript. Alan T. Shih: Attending Physician, Investigation, Methodology, Supervision, Writing – review & editing, the attending physician, provided clinical oversight, performed the procedure, and contributed to methodological input and manuscript revisions. David G. Armstrong: Supervision, provided supervisory oversight and support for the research and publication process.
Consent for publish
I consent to the use of my pedal images and radiographs, along with discussion of my case for publication in scientific journals or presentations to help advance the field of foot and ankle surgery.
Ethical statement
There are no ethical dilemmas to discuss.
Funding
This research received no external funding
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