Back to the zero-degree angle

Hallux valgus is the most common forefoot deformity, affecting up to 23 percent of 18-to-65-year-olds and over 35 percent of the over-65s.¹ Prof. Dr. med. Kiriakos Daniilidis of OTC Orthopädie Traumatologie Centrum Regensburg explains why starts treatment with conservative methods and how he uses medical products after surgery, if required, for follow-up care.

“When their favorite shoes no longer fit, they develop pressure points and pain exceeds their personal threshold, that is when a lot of patients decide to see a physician. The problems will then determine the next steps. If we have to exclude further options of conservative treatment after making the diagnosis, we will perform hallux valgus surgery,” explains Prof. Kiriakos Daniilidis. The main objectives include correcting the misalignment, eliminating pain and restoring foot function. Obviously, the more advanced the condition, the more complex and difficult the procedure.

Prof. Dr. med. Kiriakos Daniilidis is a Specialist in Orthopedics and Trauma Surgery at OTC Regensburg with the additional designation of Special Orthopedic Surgery and the Certificate for Foot Surgery awarded by the D.A.F.
(German Association for the Foot and Ankle).

In cases of hallux valgus, the patient has a deformity of the metatarsophalangeal joint of the big toe, with the big toe increasingly shifting outward. The toe’s valgus angle causes a characteristic bunion to develop on the metatarsophalangeal joint, which rubs inside footwear. In addition to cosmetic problems, this can lead to painful pressure points, skin irritation, swelling and inflammation. As a concomitant problem, the second and third toe may also shift across each other, or the little toes may develop into claws, accompanied by typical pain in the forefoot referred to as transfer metatarsalgia. The pinpointed inappropriate mechanical stress on the joints poses an additional risk of cartilage damage and therefore osteoarthritis. “When presenting as a secondary condition, hallux valgus is often caused by foot misalignments, such as planovalgus splay foot or flat foot. When the foot arches decrease, this has an inevitable impact on the rest of the complex foot structures,” says Prof. Daniilidis. Among his patients, he can also see the influence of tight and high-heeled footwear on increasing hallux valgus problems, which is frequently discussed. “That could be one of the reasons why, at OTC, our patients with this diagnosis are around 70 percent women and 30 percent men.”

“Whether tried-and-tested or state-of-the-art – our philosophy is to make full use of the conservative options first. Surgery is the last resort at the
end of the treatment journey.”

Prof. Dr. med. Kiriakos Daniilidis

Beneficial: short distances, rapid care

The OTC Orthopädie Traumatologie Centrum Regensburg describes itself as one of Bavaria’s most cutting-edge medical centers for sports medicine, orthopedics and trauma surgery. It has been located in the newly developed Dörnbergforum south west of Regensburg city center since 2018. Again, the feel-good factor plays a significant role. Shades of brown and beige, combined with materials like glass and timber, create a pleasant ambience. Even the reception area is more reminiscent of a hotel lobby than a medical practice. In an area of 1,800 square meters, around 12 physicians and their 60 staff provide diagnosis and treatment for sports injuries and conditions related to the entire locomotor system. The basic idea is that everything is located under one roof. In this way, specialists for every area of the body can leverage joint capabilities – from X-rays to gait analysis. A separate MRI machine on the same level complements the diagnostic imaging technology. The benefits for patients: short distances and rapid care. Prof. Daniilidis comments on the treatment methods used: “Whether tried-and-tested or state-of-the-art – our philosophy is to make full use of the conservative options first. Surgery is the last resort at the end of the treatment journey. And if surgery is ultimately needed, we will take care of it personally.” For this, the OTC is equipped with two operating theaters and six beds in the recovery room for same-day surgery. Beds are also available at the center for hospitalized surgical patients. Prof. Daniilidis is an expert in the field. Following his clinical rotation at Münster and Marburg University Hospitals, he was Head of the Foot and Ankle Department at Hannover Medical School, where he received his qualification as a university lecturer and still enjoys a faculty appointment. His specialist field at OTC in Regensburg includes the foot and ankle, with a focus on the surgical and non-surgical treatment of hallux valgus. Every year, he performs around 350 surgeries, 70 percent of these are corrections of the metatarsophalangeal joint.

“These medical products allow us to protect the outcome of the surgery more effectively.”

Prof. Dr. med. Kiriakos Daniilidis

Non-surgical options come first

At the beginning of a hallux valgus examination, in addition to performing a comprehensive medical history, X-rays are taken – “while the patient is standing to ensure full visibility of the foot deformity under load,” explains Prof. Daniilidis. “Depending on the case, we will look at the foot from different views. Oftentimes, there are concomitant misalignments, such as claw or hammer toes. The axial alignment can only be properly assessed in connection with the ankle or even the knee.” If circumstances permit, Prof. Daniilidis will start with conservative treatment: foot orthoses, braces and physiotherapy make up his three-pronged approach. “If the hallux valgus is still flexible, we can use a night-time postural splint to try and return the toe to a zero-degree angle, which relieves the ligaments and muscles and corrects the misalignment.” He uses the ValguLoc II brace, where the extension angle can be individually adjusted. Attached around the instep and toe, it stretches shortened ligaments and allows loose ligaments to be tightened slightly. Whether conservative treatment is successful, always partly depends, in the physician’s opinion, on patient compliance as well as on the severity of the misalignment. He recommends using the product for three to six months. This period can also be regarded as preparation time for potential surgery: “We primarily try to fix the misalignment and eliminate pain. If this doesn’t work, patients have enough time to think about surgery. They can then be sure that they tried everything to avoid surgery,” Prof. Daniilidis elaborates.

The sooner, the better

“Many people wait too long before seeking medical advice. This not only decreases the chances of conservative treatment methods being successful, but it also increases the extent of the then required surgery. We must then also ask ourselves whether surgery will fix the problem of the hallux valgus overall, or whether the midfoot or hindfoot, for example, are still pathological, which will increase the risk of recurrence, of course,” explains the experienced foot surgeon. The objective of any surgery is to straighten the joint axes and to stop pain. Referring to the guidelines provided by the German Society for Orthopedics and Orthopedic Surgery, he will choose an appropriate method depending on the type and severity of the misalignment – always based on HV and IM angles (see box on page 31). In each case, he tries to preserve as much of the joint as possible and performs supporting corrective osteotomies on the instep or hindfoot, while using the whole range of options – if necessary, even stiffening the toe.

Prior to the surgery, OTC patients receive a folder with all the appointments for the procedure and follow-up care. This also includes prescriptions for the relevant products and physiotherapy. Prof. Daniilidis: “We will carry out follow-up examinations with X-rays after two, four and six weeks and a final examination after three or six months, depending on the situation.” During follow-up care, the physician also relies on medical products from Bauerfeind. In addition to the ValguLoc II brace, which protects the corrected position of the big toe, he prescribes a two-part compression product one week after surgery. It consists of a VenoTrain curaflow toe cap that surrounds the toes like a glove and a VenoTrain curaflow compression stocking with an open toe. The idea behind it: “These medical products allow us to protect the outcome of the surgery more effectively.” On the one hand, swelling is restricted, thus positively influencing wound healing, and on the other hand, patients fresh out of surgery are provided with a certain stabilization. For reducing swelling in particular, Prof. Daniilidis finds flat-knit products very suitable: “Especially in the area of the foot, there’s a risk of stasis and therefore swelling after surgery, and swelling impedes wound healing. In contrast to bandages, compression products don’t slip during the patient’s everyday activities. And patient compliance for wearing the product is better. That’s crucial.” He considers compression products necessary until the swelling has subsided and recommends wearing a night-time postural splint for three to six months.

Leveraging treatment potential

Patient feedback relating to the use of medical products is mixed: “Whether during conservative hallux valgus treatment or post-operative follow-up care – only patients who use their products consistently will see progress,” Prof. Daniilidis points out. He can see that conservative treatment is increasing in general. The times when surgery was performed straight away are over. Outpatient treatment promoted by politics contributes to this as well as people’s social desire to remain active for longer. They therefore try to delay joint replacement for as long as possible. “With this in mind, we also observe an increasing expansion of conservative treatment options. While even five years ago, surgery was required for a ruptured Achilles tendon, for example, conservative treatment will now be an option offering similar results. The same applies to typical sprains,” Prof. Daniilidis summarizes.

Hallux valgus

“Hallux valgus is a misalignment of the big toe with an axis deviation in a fibular direction (valgus) with simultaneous axis deviation of metatarsal I in a tibial direction (varus),” as defined by the DGOOC (German Association of Orthopedics and Orthopedic Surgery) in its S2e Guidelines1. The severity of the deformity is classified based on the deviation of the hallux valgus angle (HV) or of the intermetatarsal I/II
angle (IM) in “mild” (IM: 11–15°, HV: 21–30°), “moderate” (IM: 16–20°, HV: 31–40°) and “severe” (IM: >20°, HV: >40°). As a result, the head of the first metatarsal bone protrudes and forms the characteristic bunion, which is often red and hurts during walking. 

1  Nix S, Smith M, Vicenzino B: Prevalence of hallux valgus in the general population: a systematic review and metaanalysis. J Foot Ankle Res, 2010; 3: 21.
2 https://register.awmf.org/de/leitlinien/detail/187-051

Flat-knit made-to-measure products

VenoTrain curaflow flat-knit compression products help restrict swelling after surgery and optimize wound healing. With their high level of stiffness and sufficient working pressure, flat-knit products offer maximized resistance in cases of edema. Consistent, external compression promotes drainage of the lymphatic fluid from the tissue and counteracts further accumulations. With the product’s toe cap – also available as a seamless option – compression protects the surgical outcome as well.

An exact correction angle

The ValguLoc II is a toe splint with a hinge that can be adjusted in three dimensions. This means the correction angle can be individually adapted to the shape of the foot in accordance with the treatment goal. The angle setting also remains intact during the rolling movement of the big toe. Additionally, the brace can be locked in 15 degree increments, for flexion as well as extension. This allows the ValguLoc II to immobilize the metatarsophalangeal joint after surgery. The brace hinge can be released again for mobilization. It provides support during non-surgical functional treatment of the misalignment. The inside of the anatomically contoured half-cup offers pleasant padding, ensuring excellent wearing comfort. 

Bilder: Bauerfeind, Conny Kurz