Hallux valgus or bunions, generally included in what is known as acquired forefoot deformity, represents a spectrum of progressive alterations in the shape and position of the toes. It mainly affects women and its incidence increases with age due to the combination of multiple factors.

The correction of these deformities is prescribed when they cause pain or alter function, making it difficult to use normal footwear. Although these are well-established procedures, among the general public there are certain erroneous beliefs based on bad experiences resulting from non-specialized treatment. The individualized study of each case, detecting the different problems that may occur, combining it with the needs and expectations of our patients, allows us to design an a la carte treatment with which to correct what is appropriate to achieve satisfaction.

To illustrate this mentality, we present a typical case, it is a 74-year-old patient, with no history of interest, who consulted for progressive pain and deformity of her right foot. Specifically, he refers that the Hallux, that is, the largest toe of the foot, has been diverted towards the rest, generating an alteration in the internal profile of the foot, which is known as a bunion, being this painful with the rubbing of the footwear and making it difficult wear closed shoes. In turn, he suffers from pain in the fourth toe, which is clawed, that is, with flexion of the interphalangeal joints but hyperextension of the metatarsophalangeal joint. Finally, he also suffers from a tailor’s bunion or bunionette, which is basically the reverse deformity of Hallux valgus but in the fifth toe, which deviates towards the rest generating a prominence on the outer edge of the foot, in addition the toe is below the fourth , that is, underduct.

To assess this type of problem, it is usually only necessary to obtain the correct radiological projections in addition to an adequate and detailed clinical examination. Surgery in this type of pathology can be performed open, that is, making wounds to directly access the areas to be treated, or percutaneous, incisions that allow the blind introduction of different instruments that are manipulated under control by intraoperative x-rays. Depending on the pathology, both techniques can be perfectly combined to offer a personalized treatment to each patient.

Specifically, in this case, a percutaneous tenotomy was performed with a specific scalpel for percutaneous surgery to completely release the hallux adductor and achieve internal opening of the first metatarsophalangeal joint. Then, in an open manner, a bunionectomy was performed, removing the excess bone in the bunion area and a combined Chevron and Scarf osteotomy of the first metatarsal, fixing it with cannulated screws in the desired position. An osteotomy of the proximal phalanx is added that serves to finish realigning the Hallux including the rotation of the nail, in the same way it is fixed with a cannulated screw to ensure the adequate position. In the soft tissues, the capsule that was opened at the beginning is applied to add a gesture to the correction and the good joint range of movement is checked.

Although the fourth finger is the one with the most claws, the second and third fingers also present deformity, so all three are corrected by performing selective tenotomies and arthroplasties. Specifically in the fourth finger, the internal deviation it presents is also realigned. They are fixed temporarily with Kirschner wires that will later be removed in the office. Finally, osteotomies similar to those of the first finger are performed on the fifth finger, fixing them with Kirschner wires and correcting the claw and the position under the fourth finger. In other words, the five spokes of the foot have been acted upon, making specific surgical gestures for each one of them and in this way being able to achieve the result of aligning the toes with respect to each other without deformities.

During the postoperative period, directed cures are carried out that favor keeping the corrections in their ideal position. Immediate support of the foot is allowed with a post-surgical shoe with a rigid but straight sole, without a raised heel, achieving a more normal gait without hip pain due to the discrepancy of that shoe. The needles are removed in consultation at 4 weeks and the shoe and bandages are discontinued at 5 weeks. Afterwards, he changes to a normal comfortable shoe and the rehabilitation consists of walking. Radiological result at 12 weeks with all osteotomies consolidated and deformities corrected. Note the effect of realignment of the articular facet of the first metatarsal, the arthroplasties in the proximal interphalangeal joints of the second, third and fourth fingers, as well as the elimination of the tailor’s bunion of the fifth finger.