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Valgus deformity

Valgus deformity is an angular distortion of a bone or joint in which the distal segment deviates laterally away from the body's midline relative to the proximal segment, often resulting in misalignment and potential functional impairment.^[1] This condition can affect various parts of the body, most commonly the knee (genu valgum, or knock-knees), the foot (hallux valgus, or bunions), the ankle, and the elbow (cubitus valgus).^[2]^[3] It arises from a combination of genetic predisposition, biomechanical factors, trauma, or underlying diseases, leading to altered joint mechanics and progressive symptoms if untreated.^[1] Common types include genu valgum, characterized by valgus angulation of the distal femur or tibia, causing the knees to approximate while the ankles remain apart, which is often physiologic in young children but pathological in adults or severe cases.^[2] In the foot, hallux valgus involves lateral deviation of the great toe at the first metatarsophalangeal joint with medial prominence of the metatarsal head, frequently exacerbated by ill-fitting footwear.^[3] Other variants, such as ankle valgus or hindfoot valgus, may stem from tendon dysfunction or post-traumatic changes, contributing to instability and altered gait.^[1] Causes of valgus deformity are multifactorial, including congenital anomalies, developmental variations, inflammatory conditions like rheumatoid arthritis, neuromuscular disorders, or iatrogenic factors such as prior surgeries or fractures.^[2]^[3] Symptoms typically involve pain at the affected joint, swelling, reduced mobility, and compensatory gait abnormalities, with severity depending on the degree of angulation and associated soft tissue changes.^[1] Treatment ranges from conservative measures like orthotics, physical therapy, and observation in mild or physiologic cases to surgical interventions such as osteotomies, tendon transfers, or joint realignments for symptomatic or progressive deformities.^[2]^[3] Early intervention is crucial to prevent complications like osteoarthritis or chronic instability.^[1]

Definition and Terminology

Definition

Valgus deformity refers to the outward angulation of the distal segment of a bone relative to a joint, positioning it away from the body's midline in the coronal plane.^[4] This structural deviation results in the mechanical axis of the limb forming a lateral angle at the affected joint.^[2] In contrast, varus deformity involves the inward, or medial, angulation of the distal bone segment toward the midline.^[4] Both conditions represent angular misalignments that can alter load distribution across the joint, though valgus specifically directs the distal portion laterally.^[1] The severity of valgus deformity is typically quantified by measuring the deviation in the joint angle, such as the hip-knee-ankle angle or tibiofemoral angle, with values exceeding 5-10 degrees often regarded as pathologic in adults, depending on the specific joint involved.^[5] For instance, a valgus angle of 10 degrees or greater at the knee is commonly classified as a significant deformity requiring evaluation.^[5] The term "valgus" originates from Latin, denoting "bent outward" or "knock-kneed," and entered orthopedic literature in the 19th century to describe such angular distortions.^[6] This etymology reflects its application to various sites, such as the knee (genu valgum) or foot (hallux valgus), as illustrative examples of the general pattern.^[7]

Terminology

The term "valgus" originates from Latin, where it denotes a knock-kneeed or bowed outward condition, reflecting an angulation away from the body's midline.^[6] This etymology underscores its use in describing deformities where the distal segment of a bone or joint deviates laterally relative to the proximal segment. A common mnemonic in orthopedic education associates the "L" in valgus with "lateral" deviation to distinguish it from opposing alignments.^[7] In contrast, the related term "varus" derives from Latin "vārus," meaning bent inward or bow-legged, indicating medial angulation toward the body's midline.^[8] Neutral alignment, referred to simply as "neutral" in orthopedic terminology, describes the straight, non-deviated positioning of bones and joints in the coronal plane, serving as the reference for assessing valgus or varus deformities.^[4] Joint-specific nomenclature combines "valgus" with anatomical prefixes to denote location: "genu valgum" for knee involvement, "hallux valgus" for the big toe, "cubitus valgus" for the elbow, and "coxa valga" for the hip, allowing precise description of the affected structure.^[9] In orthopedic classification, valgus represents a subtype of angular deformities occurring in the coronal (frontal) plane, differentiated from rotational deformities (in the transverse plane) or translational shifts (displacements without angulation).^[4] This categorization facilitates targeted diagnosis and treatment by focusing on the plane and nature of the deviation.

Anatomy and Pathophysiology

Relevant Anatomy

Valgus deformity primarily affects the lower limbs, particularly at the knee, hip, and foot, as well as the elbow in the upper limb. In the knee, the relevant structures include the distal femur, proximal tibia, and fibula, where the tibiofemoral joint facilitates weight transmission from the femur to the tibia.^[10] The hip involves the femoral neck articulating with the acetabulum, while the foot encompasses the metatarsals, especially the first metatarsal and proximal phalanx at the metatarsophalangeal (MTP) joint. In the upper limb, the elbow joint features the distal humerus and proximal ulna.^[11]^[9]^[12] Normal alignment in the lower limb is characterized by the mechanical axis, which extends from the center of the femoral head through the knee's intercondylar notch to the center of the ankle's tibiotalar joint, ensuring balanced load distribution. At the knee, the tibiofemoral angle measures approximately 5-7 degrees of valgus in adults, promoting even contact between the medial and lateral compartments. In the hip, the femoral neck-shaft angle is typically 125-135 degrees, supporting neutral positioning of the lower limb. For the foot, normal alignment includes a hallux valgus angle of less than 15 degrees at the first MTP joint, with the metatarsals aligned parallel to the long axis of the foot. At the elbow, the carrying angle averages 11 degrees in males and 14 degrees in females, allowing the forearm to clear the body during arm swing.^[10]^[13]^[14]^[9]^[15] Ligamentous supports are crucial for maintaining alignment across these sites. The medial collateral ligament (MCL) of the knee, with superficial and deep components attaching from the medial epicondyle of the femur to the proximal tibia, resists valgus forces and ensures medial stability. Similarly, the elbow's MCL provides primary resistance to valgus stress at the medial aspect. In the foot, ligaments around the first MTP joint, including the medial collateral ligament, preserve joint congruence, while the peroneal tendons (longus and brevis) act as dynamic evertors to counter inversion and support hindfoot alignment during weight-bearing.^[16]^[12]^[9]^[17] Muscular contributions include the quadriceps group at the knee, which via the patellar tendon influences patellofemoral tracking and overall limb alignment. At the foot, the peroneal muscles evert the hindfoot, aiding in maintaining a neutral arch and preventing excessive pronation. Biomechanically, these structures ensure congruent joint surfaces in the neutral position, distributing compressive forces evenly—typically 50-60% medially and 40-50% laterally at the knee during stance—while the mechanical axis optimizes weight-bearing from the hip through the ankle to minimize shear stresses.^[10]^[17]^[10]

Pathophysiological Mechanisms

Valgus deformity arises primarily through biomechanical imbalances that alter joint alignment, leading to uneven distribution of mechanical loads across the joint surfaces. In affected joints, such as the knee, excessive valgus angulation shifts weight-bearing forces laterally, resulting in accelerated wear of the lateral compartment cartilage while relatively sparing the medial side. This uneven loading promotes progressive joint space narrowing and osteoarthritis-like changes in the lateral region, as the increased compressive stresses exceed the cartilage's adaptive capacity.^[18] Concomitant ligamentous changes exacerbate this misalignment, with weakening or elongation of medial stabilizing structures, such as the medial collateral ligament, allowing further lateral deviation under load. This laxity disrupts the normal tension balance, permitting abnormal joint subluxation and perpetuating the cycle of malalignment. In parallel, bone remodeling occurs in response to these altered stress patterns, governed by Wolff's law, whereby bone adapts its architecture to prevailing mechanical demands; in valgus deformity, this manifests as increased density and hypertrophy in the lateral tibial subchondral bone, coupled with potential medial resorption, thereby reinforcing the angular deviation over time.^[5]^[19] Inflammatory processes contribute by inducing synovitis and erosive changes that distort joint geometry. Synovial inflammation leads to effusion and capsular distension, which weaken supporting ligaments and promote valgus tilting, while erosions at the joint margins further compromise structural integrity, particularly in conditions like inflammatory arthropathies affecting the hindfoot or knee.^[20]^[2] In pediatric cases, valgus deformity often stems from disruptions in the growth plate (physis), where asymmetric closure or injury results in differential longitudinal growth between medial and lateral aspects. For instance, premature physeal arrest on the lateral side relative to the medial allows unchecked medial overgrowth, culminating in angular deformity; this is commonly observed following trauma or infection, with radiographic evidence of physeal narrowing confirming the mechanism.^[16]^[2]

Causes and Risk Factors

Etiological Factors

Valgus deformity can arise from a variety of congenital etiologies that disrupt normal skeletal development. Genetic disorders, particularly skeletal dysplasias such as Morquio syndrome and spondyloepiphyseal dysplasia, are associated with progressive valgus alignment in the lower extremities due to abnormal physeal growth and cartilage formation.^[16] Additionally, intrauterine positioning can lead to positional deformities like calcaneovalgus foot, where restricted fetal movement in the womb causes dorsiflexion and eversion of the hindfoot, resulting in a valgus orientation at birth.^[21] Acquired causes often stem from external insults that alter bone growth or alignment postnatally. Trauma, such as fractures of the proximal tibia or tibial plateau with subsequent malunion, can produce valgus deformity by uneven physeal damage or asymmetric healing, leading to angular deviation.^[22] Infections like septic arthritis in the knee during early childhood may cause growth plate destruction, resulting in valgus angulation as the medial structures overgrow relative to the lateral side.^[23] Metabolic diseases, including rickets due to vitamin D deficiency, impair mineralization of the growth plates, predisposing to genu valgum through softened bone and altered mechanical loading.^[24] Degenerative conditions contribute to valgus deformity through chronic joint destruction and imbalance. Osteoarthritis of the knee can present with valgus alignment, where the deformity increases load on the lateral compartment, leading to wear there and exacerbating the angulation over time.^[25] Similarly, rheumatoid arthritis leads to valgus hindfoot or knee deformities via synovial inflammation, ligamentous laxity, and erosive changes that weaken medial supports and promote lateral deviation.^[26] Iatrogenic factors typically occur as complications of surgical interventions aimed at correcting opposing deformities. For instance, overcorrection during high tibial osteotomy for varus knee can result in excessive valgus alignment if the medial proximal tibial angle is not precisely restored, leading to progressive instability.^[27] These causes initiate bone remodeling processes that perpetuate the valgus posture.^[16]

Risk Factors

Valgus deformity exhibits distinct demographic patterns that influence its prevalence and presentation. Physiologic genu valgum is common in children aged 2 to 5 years, often resolving spontaneously by age 7 without intervention.^[2] In adults, particularly those over 60 years, valgus deformities frequently arise from degenerative processes such as osteoarthritis, increasing susceptibility with advancing age.^[2] Gender plays a notable role, with hallux valgus occurring more frequently in females, largely attributed to prolonged use of constrictive footwear that alters foot mechanics.^[28]^[3] Lifestyle factors significantly contribute to the development of valgus deformity by imposing mechanical stress on joints. Obesity elevates intra-articular loads, particularly in the knees and feet, thereby heightening the risk of genu valgum and hallux valgus progression.^[2] Ill-fitting or high-heeled shoes compress the forefoot, promoting metatarsophalangeal joint deviation in hallux valgus.^[28] Occupational activities involving repetitive knee bending, prolonged standing, or heavy lifting, such as in construction or agriculture, can exacerbate joint misalignment through cumulative microtrauma.^[29] Genetic predispositions underlie familial tendencies toward valgus deformity, with heritable connective tissue disorders like Ehlers-Danlos syndrome increasing joint laxity and deformity risk, including hallux valgus and pes planovalgus.^[30]^[31] Comorbidities further amplify vulnerability; neuromuscular conditions such as cerebral palsy often lead to progressive valgus foot and knee deformities due to muscle imbalance.^[32] Endocrine disorders, including hyperparathyroidism, can induce skeletal changes resulting in genu valgum, especially during growth phases.^[33] Conditions like arthritis may act as amplifying factors in these scenarios.^[2]

Clinical Presentation

Symptoms

Patients with valgus deformity often experience pain in the medial aspect of the affected joint due to increased mechanical overload on that side, which typically worsens during weight-bearing activities such as walking or standing.^[2] This pain can manifest as an aching sensation in early stages but may become sharp or more intense in advanced cases associated with joint degeneration.^[3] Additionally, some individuals report medial knee or foot pain that occurs occasionally and is exacerbated by prolonged activity.^[34] Functional limitations are common, including gait instability, limping, or an altered walking pattern that leads to reduced mobility and increased fatigue in the affected limb.^[35] These issues arise from the misalignment, which can cause a sensation of the joint giving way or twisting during movement, further impairing daily activities.^[36] Associated sensations frequently include swelling around the joint, stiffness that limits flexibility, and crepitus, described as a grinding or cracking feeling during motion.^[34] In many cases, valgus deformity is asymptomatic in its early or physiologic stages, particularly in children, but symptoms emerge and progress with ongoing degeneration or in pathologic forms, leading to greater discomfort over time.^[2]

Physical Findings

Physical findings in valgus deformity are primarily identified through clinical examination, revealing characteristic angular misalignments and associated abnormalities across affected joints. Visual inspection typically demonstrates lateral deviation of the distal segment relative to the proximal one, creating an outward angulation; for instance, in genu valgum, the knees may touch medially while the ankles remain separated, resulting in an intermalleolar distance exceeding 8 cm.^[16] In hallux valgus, the great toe exhibits lateral deviation at the metatarsophalangeal joint with a prominent medial eminence on the first metatarsal head, often accompanied by pronation of the hallux.^[9] Similarly, cubitus valgus presents as an increased carrying angle at the elbow greater than 15 degrees, giving the forearm a laterally deviated appearance when the arm is extended.^[37] Palpation often elicits tenderness over medial joint structures stressed by the deformity, such as the medial knee in genu valgum or the medial eminence in hallux valgus, where bursitis or soft tissue irritation may be present.^[16] Joint effusion can also be detected as fluctuance or warmth around the affected area, particularly in inflammatory or arthritic presentations. Assessment of range of motion frequently uncovers limitations attributable to misalignment, including reduced extension or flexion at the joint; for example, in valgus knee deformity, flexion contractures or recurvatum may be noted.^[34] Instability tests, such as the valgus stress test for the knee, yield positive results indicating medial collateral ligament laxity, with excessive medial gapping under applied force.^[34] In hip valgus, restricted abduction and internal rotation are common findings.^[38] Gait analysis discloses abnormal patterns stemming from the deformity, such as circumduction in genu valgum to compensate for medial knee contact.^[16] In hallux valgus, patients may exhibit antalgic gait with reduced weight-bearing on the forefoot to avoid pain over the medial prominence.^[39]

Diagnosis

Clinical Evaluation

The clinical evaluation of valgus deformity begins with a detailed history to determine the etiology and progression. Key components include assessing the onset, which may be acute following trauma such as a proximal tibial fracture leading to post-traumatic valgus, or gradual in cases of physiologic development or degenerative conditions like osteoarthritis.^[2] Inquire about any history of injury, as malunions or growth plate disturbances can contribute to unilateral deformity, and explore family patterns suggestive of hereditary skeletal dysplasias. Additionally, screen for associated diseases, including metabolic disorders (e.g., rickets or renal osteodystrophy), inflammatory arthritis, or neuromuscular conditions, which may present bilaterally and influence management.^[16] Physical examination follows a structured protocol to quantify alignment and function. Begin with alignment assessment in both standing (weightbearing) and sitting (non-weightbearing) positions to evaluate the dynamic and static deformity, measuring the intermalleolar distance with knees extended and medial femoral condyles touching; a distance exceeding 8 cm indicates pathologic valgus.^[2] Use goniometry to measure the tibiofemoral or relevant joint angle precisely, noting any asymmetry or compensatory changes. Incorporate functional tests, such as observing gait for circumduction or instability and performing a single-leg stance to assess balance and medial compartment loading, which can reveal subtle neuromuscular contributions.^[34] Differential diagnosis considerations aim to exclude mimicking conditions through targeted history and exam findings. Rule out varus deformities by confirming the direction of angulation, distinguish rotational deformities via assessment of tibial torsion or femoral anteversion, and investigate neurologic issues such as cerebral palsy if gait abnormalities or muscle weakness are evident.^[16] Physiologic variants in children must be differentiated from pathologic causes like skeletal dysplasias or post-traumatic changes, often guided by age of onset and laterality.^[2] Severity grading relies on clinical metrics to guide intervention. Mild valgus is typically defined as less than 10 degrees of angulation, often passively correctable with minimal soft tissue involvement; moderate ranges from 10 to 20 degrees, featuring contracted lateral structures but functional medial stabilizers; and severe exceeds 20 degrees, with non-functional medial supports and significant instability.^[34] These grades incorporate goniometric measurements and functional impact, such as pain during single-leg stance, to establish context for progression.^[16]

Imaging and Tests

Radiography serves as the primary imaging modality for confirming and quantifying valgus deformity, particularly in the lower extremities such as genu valgum. Weight-bearing anteroposterior (AP) and lateral X-rays of the affected joint, often including full-length lower limb views from hip to ankle, allow for assessment of alignment and measurement of key angles. For instance, the anatomic tibiofemoral angle, formed by the intersection of the femoral and tibial mechanical axes, is typically evaluated on AP views; normal values range from 5° to 7° of valgus, with deviations indicating deformity severity.^[16]^[34] Additional angles, such as the lateral distal femoral angle (LDFA, normally 85°-90°) and medial proximal tibial angle (MPTA, normally 87°), help localize the deformity to the femur, tibia, or both.^[16] Advanced imaging techniques are employed in select cases to evaluate associated soft tissue or bony abnormalities. Magnetic resonance imaging (MRI) is useful for assessing ligamentous integrity, cartilage damage, and intra-articular pathology, such as in valgus knee where medial compartment osteoarthritis or ligament laxity may contribute.^[16] Computed tomography (CT) provides three-dimensional reconstruction for precise bone morphology evaluation, particularly in complex deformities involving multiple joints or planning surgical correction, though it is less commonly used due to radiation exposure.^[16] Laboratory tests are indicated when an inflammatory or systemic etiology is suspected based on clinical findings. For example, in cases potentially linked to rheumatoid arthritis, erythrocyte sedimentation rate (ESR) and rheumatoid factor (RF) are measured to detect inflammation and autoantibodies, respectively; elevated ESR (>20 mm/hr) and positive RF (>1:80 titer) support an autoimmune process.^[40]^[41]^[42] Functional assessments complement structural imaging by evaluating the biomechanical impact of valgus deformity. Gait laboratory analysis quantifies dynamic alignment, such as excessive medial knee loading or circumduction, using motion capture and force plates to identify compensatory patterns.^[34] Electromyography (EMG) measures muscle activation patterns, revealing imbalances like increased activity in hip abductors or reduced medial knee stabilizers during stance phase.^[43]

Treatment

Conservative Management

Conservative management of valgus deformity aims to alleviate symptoms, improve function, and potentially slow progression in mild to moderate cases, particularly when associated with osteoarthritis or soft tissue imbalances.^[44] This approach is indicated for early-stage deformities where surgical intervention is not yet warranted, focusing on non-invasive strategies to reduce joint stress and enhance stability.^[45] Orthotics and bracing play a key role in redistributing loads across affected joints. For lower extremity valgus, such as genu valgum, valgus offloading knee braces apply a three-point bending force to reduce medial compartment loading by up to 7%, thereby decreasing pain and improving function in patients with medial knee osteoarthritis.^[45] These braces have demonstrated superior pain relief compared to neutral supports in multiple studies involving over 600 patients.^[45] In foot-related valgus deformities like hallux valgus, wedged insoles or custom orthotics with toe spacers can correct alignment, reduce pressure on the first metatarsophalangeal joint, and alleviate symptoms, though evidence for long-term deformity correction remains limited.^[46] Physical therapy emphasizes strengthening and flexibility exercises to address muscle imbalances contributing to valgus alignment. Quadriceps and hip abductor strengthening, such as supervised isotonic exercises or resistance band training, can increase knee extensor strength by up to 42.5% and improve overall function in knee osteoarthritis patients with valgus deformity.^[47] Stretching routines targeting tight iliotibial bands or adductors enhance joint mobility and reduce dynamic valgus collapse during activities like squatting.^[48] Aquatic or low-impact exercises are particularly beneficial for overweight individuals, providing pain relief without excessive joint stress.^[49] Pharmacotherapy primarily involves nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation. Oral NSAIDs like ibuprofen or naproxen are strongly recommended for short-term use in knee osteoarthritis with valgus alignment, offering significant pain reduction supported by high-quality randomized trials.^[49] Topical NSAIDs provide similar benefits with fewer systemic side effects, improving quality of life in symptomatic cases.^[49] Intra-articular corticosteroid injections may be considered for acute flares but are not first-line for ongoing management.^[49] Lifestyle modifications are essential for long-term symptom control. Weight management through sustained loss of 5-10% body weight in overweight patients reduces knee joint load, improves pain, and enhances function, as evidenced by multiple controlled studies.^[49] Appropriate footwear with wide toe boxes and low heels minimizes stress on valgus-affected joints, while activity modifications—such as avoiding high-impact exercises and incorporating low-load alternatives—help prevent exacerbation.^[49] Patient education on these strategies promotes adherence and optimizes outcomes.^[44]

Surgical Interventions

Surgical interventions for valgus deformity are indicated when conservative treatments fail to alleviate symptoms, in cases of significant deformity (typically >10-15 degrees depending on the affected joint and patient factors), or when associated with arthritis leading to joint degeneration.^[50]^[51]^[52] Treatment approaches vary by affected joint; specific interventions for non-knee deformities such as hallux valgus or cubitus valgus are covered in dedicated sections. These procedures aim to restore mechanical alignment, improve joint stability, and prevent further deterioration, particularly in younger or active patients where preserving native joint function is prioritized.^[53] Preoperative imaging, such as full-length standing radiographs, is essential for precise planning to assess deformity magnitude and guide correction strategy.^[50] Osteotomies represent a cornerstone for correcting valgus alignment by realigning the mechanical axis of the limb, commonly applied in the knee through high tibial osteotomy (HTO) or distal femoral osteotomy (DFO). In HTO, a lateral closing wedge technique removes a bone wedge from the proximal tibia to shift weight-bearing medially, typically secured with plate fixation, and is suitable for isolated tibial valgus contributions up to 10 degrees.^[50]^[53] For predominant femoral involvement, DFO employs a medial closing wedge osteotomy, resecting bone medially and stabilizing with a blade plate or locking plate to achieve varus correction while maintaining joint line orientation.^[50] These biplanar corrections are favored in non-arthritic or early degenerative cases to unload the lateral compartment.^[53] In advanced degenerative valgus deformities, total knee arthroplasty (TKA) serves as a definitive solution, involving joint resurfacing with prosthetic components to restore neutral alignment. The procedure often requires constrained implants, such as varus-valgus constrained designs, for deformities greater than 20 degrees where ligamentous support is compromised.^[54] Bone cuts are adjusted to account for valgus anatomy, with a distal femoral valgus angle of 3 degrees and balanced resection to avoid elevating the joint line.^[54] Soft tissue procedures address ligamentous imbalances contributing to valgus instability, involving selective releases or reconstructions to equalize medial and lateral tensions. Lateral releases target contracted structures like the iliotibial band, lateral collateral ligament, and popliteus tendon, often performed sequentially during TKA or as standalone interventions for reducible deformities.^[54]^[5] In cases of medial ligament attenuation, reconstructions such as medial collateral ligament advancement or imbrication may be employed to enhance stability without excessive constraint.^[54] These techniques are integrated with bony corrections to achieve comprehensive realignment.^[5]

Specific Types

Genu Valgum

Genu valgum, commonly known as knock-knees, refers to a valgus alignment of the knee joint where the mechanical axis of the lower limb deviates laterally, resulting in the knees touching while the ankles remain apart. In adults, a tibiofemoral angle exceeding 10 degrees of valgus is considered pathologic, as the normal alignment stabilizes at 5-7 degrees.^[2]^[55] In children, however, genu valgum is often physiologic, peaking at 10-15 degrees around ages 3-4 years before spontaneously correcting to neutral or mild valgus by age 7.^[2]^[16] Unique causes of genu valgum in the knee include adolescent idiopathic forms, often familial and without identifiable etiology; and arthritis, with rheumatoid arthritis more frequently leading to progressive valgus due to ligamentous laxity compared to osteoarthritis.^[24]^[16]^[35] This deformity alters joint loading, concentrating compressive forces on the lateral compartment and potentially accelerating cartilage wear.^[2] Patients with genu valgum typically present with medial knee pain from increased stress on the medial collateral ligament and medial compartment; patellar maltracking, which predisposes to lateral subluxation or dislocation; and an increased Q-angle, exacerbating quadriceps pull and instability during gait.^[24]^[2] Physical findings may include an out-toed gait and visible medial knee contact on standing.^[24] Diagnosis relies on clinical evaluation supplemented by long-leg standing anteroposterior X-rays to measure the tibiofemoral angle, mechanical axis deviation, and joint space narrowing for precise alignment assessment.^[2]^[24] Treatment in children under 10 years with significant deformity (>15-20 degrees) often involves hemiepiphysiodesis, a guided growth procedure using tension plates to gradually correct alignment at a rate of about 10 degrees per year.^[24]^[2] In skeletally mature adults or severe cases, distal femoral osteotomy is indicated to realign the mechanical axis, typically combined with internal fixation for stability.^[24]^[2]

Hallux Valgus

Hallux valgus, commonly known as a bunion, is a progressive deformity of the forefoot characterized by lateral deviation of the great toe's proximal phalanx at the metatarsophalangeal (MTP) joint and medial deviation of the first metatarsal head, resulting in a medial bony prominence or eminence.^[3] This condition is defined radiographically by a hallux valgus angle (HVA) greater than 15 degrees, measured between the longitudinal axis of the first metatarsal and the proximal phalanx on weight-bearing anteroposterior foot radiographs, with severity graded as mild (15-30°), moderate (30-40°), or severe (>40°).^[3] The medial eminence arises from the uncovered head of the first metatarsal as the joint subluxates, often leading to inflammation of the overlying bursa.^[3] The etiology of hallux valgus is multifactorial, with tight, narrow, or high-heeled shoes contributing by compressing the forefoot and exacerbating metatarsal deviation over time.^[28] Genetic predisposition plays a significant role, including inherited structural abnormalities such as ligamentous laxity and joint hypermobility, which weaken the medial capsular structures and allow progressive valgus angulation.^[3] Additional risk factors include a short or dorsiflexed first metatarsal and conditions like rheumatoid arthritis, though footwear and genetic factors are most commonly implicated in idiopathic cases.^[3] Patients typically present with pain over the medial bunion due to pressure from footwear or bursal inflammation, accompanied by swelling, redness, and aching that worsens with weight-bearing activities.^[3] Calluses or corns often develop on the medial eminence or at the second toe's base from friction, while tingling or burning sensations may arise from compression of the medial dorsal cutaneous nerve.^[28] Hallux valgus is frequently associated with secondary hammertoe deformities of the lesser toes, resulting from overload on the lateral metatarsal heads and altered forefoot biomechanics.^[56] Physical examination reveals a prominent medial eminence, increased hallux abduction angle (>15°), and reduced MTP joint dorsiflexion, with pronation of the great toe on weight-bearing.^[3] Diagnosis relies on clinical evaluation combined with weight-bearing foot radiographs to quantify the HVA and intermetatarsal angle (IMA; normal <9°), confirming the deformity and assessing for associated metatarsus primus varus.^[3] Conservative management, such as orthotics or bunion pads to redistribute pressure, may alleviate symptoms in mild cases.^[28] Surgical intervention is indicated for moderate to severe symptomatic deformities, with procedures like the chevron osteotomy—a distal metatarsal V-shaped cut to correct angulation—offering high satisfaction rates (around 80%) for mild-to-moderate cases, while the Lapidus fusion, an arthrodesis of the first tarsometatarsal joint, is preferred for severe hypermobile deformities with up to 81% pain relief but a 20% nonunion risk.^[3]

Cubitus Valgus

Cubitus valgus refers to a deformity of the elbow in which the forearm deviates laterally from the midline of the body when the arm is fully extended and supinated, resulting in an increased carrying angle beyond normal values. The carrying angle is the angle formed between the long axis of the humerus and the ulna, typically measuring 5° to 10° in males and 10° to 15° in females; cubitus valgus is generally diagnosed when this angle exceeds 15° in either sex, though it can range from 3° to 29° depending on severity and individual variation.^[57]^[58] This condition primarily affects the upper limb and can be unilateral or bilateral, often presenting as a cosmetic issue but potentially leading to functional complications. Unique causes of cubitus valgus include malunion following supracondylar humerus fractures in children, where improper healing results in lateral angulation of the distal humerus. Congenital etiologies are also significant, such as in Turner's syndrome, a chromosomal disorder (45,XO) affecting females, where cubitus valgus occurs in 85% to 94% of cases due to skeletal dysplasias involving the elbow.^[59]^[60] Other less common causes may involve nonunion of lateral condyle fractures, but trauma-related malunion remains the most frequent acquired factor. Symptoms of cubitus valgus are often primarily cosmetic, with the elbow appearing "knocked-out" and the forearm angled outward, which may cause self-consciousness but minimal functional impairment in mild cases. However, progressive deformity can lead to ulnar nerve irritation, manifesting as tardy ulnar neuropathy, characterized by numbness, tingling, and weakness in the ring and little fingers due to nerve stretching across the cubital tunnel.^[61] Physical findings include an exaggerated carrying angle on clinical examination and possible positive Tinel's sign over the ulnar nerve at the elbow. Diagnosis involves clinical measurement of the carrying angle using a goniometer with the elbow extended and forearm supinated, compared to the contralateral side. Radiographic evaluation, typically with anteroposterior (AP) elbow X-rays, assesses the Baumann's angle (normal 64° to 81°), where a decreased angle indicates valgus deformity; lateral views may supplement to evaluate overall alignment and rule out associated fractures. Electromyography or nerve conduction studies are indicated if tardy ulnar neuropathy is suspected to confirm nerve involvement.^[62]^[63] Treatment for cubitus valgus is conservative in asymptomatic cases, focusing on observation and physical therapy to maintain range of motion. Surgical intervention is recommended for significant deformity (>15° to 20° difference from normal) or symptomatic neuropathy, typically involving corrective osteotomy such as supracondylar dome or lateral closing-wedge osteotomy to restore the carrying angle, often combined with anterior transposition of the ulnar nerve to prevent further irritation. Postoperative outcomes show good correction of alignment and relief of neuropathic symptoms in most patients, with low complication rates when performed by experienced orthopedic surgeons.^[64]^[65]

Other Types

Coxa valga is characterized by an increased femoral neck-shaft angle, typically exceeding 135 degrees, which alters hip biomechanics and can predispose to subluxation or dislocation.^[66] This deformity is commonly associated with conditions like cerebral palsy, particularly in nonambulatory children, where it contributes to progressive hip displacement due to muscle imbalances and abnormal growth patterns.^[67] Talipes valgus refers to excessive eversion of the hindfoot and midfoot, often manifesting as a component of flatfoot deformity with collapse of the medial longitudinal arch.^[68] It is frequently linked to posterior tibial tendon dysfunction, which fails to support the arch, leading to valgus alignment of the heel and subtalar joint instability, especially in adult-acquired cases.^[69] Madelung's deformity involves ulnar deviation of the hand/wrist due to genetic dysplasia affecting the distal radial physis, resulting in progressive growth arrest at the ulnar-volar aspect and relative overgrowth of the ulna.^[70] This leads to volar tilting of the distal radius, dorsal subluxation of the ulna, and cosmetic as well as functional wrist impairment, often linked to Leri-Weill dyschondrosteosis.^[71] Valgus deformities are rarer in sites such as the spine, where they may contribute to atypical scoliosis patterns with coronal imbalance, or the temporomandibular joint, potentially altering jaw alignment in select dysplasias. Surgical options like osteotomy can address structural correction in these less common presentations where applicable.

References

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Valgus Deformity - an overview | ScienceDirect Topics
Valgus deformity is defined as a condition characterized by the lateral deviation of a body part, commonly seen in the forefoot at the first ...Missing: reliable medical
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Genu Valgum - StatPearls - NCBI Bookshelf
May 29, 2023 · [8] In cases of post-traumatic valgus deformity of the tibia, the maximum deformity is often seen at 1 year following injury. Observation ...
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Hallux Valgus - StatPearls - NCBI Bookshelf
A hallux valgus is a complex deformity of the first ray of the forefoot. This deformity is, at times, red and painful and can disrupt daily activities.
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Valgus vs varus | Radiology Reference Article - Radiopaedia.org
Sep 18, 2014 · The terms valgus and varus refer to angulation (or bowing) within the shaft of a bone or at a joint in the coronal plane.
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Total knee arthroplasty in the valgus knee - PMC - NIH
The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation.
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Etymology. borrowed from Latin, "knock-kneed," of uncertain origin ; First Known Use. 1884, in the meaning defined at sense 1 ; Time Traveler. The first known use ...
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In normal knee alignment, there is an approximately 5°–7° valgus femorotibial angle [8]. The decrease in this angle increases the load on the medial compartment ...
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The most common cause of valgus deformity is osteoarthritis (OA), a prevalent progressive joint disease that causes chronic pain and functional limitations.
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Valgus deformity of the hindfoot in rheumatoid patients results from exaggerated pronation forces on the weakened and inflamed subtalar joint.Missing: osteoarthritis | Show results with:osteoarthritis
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Severe valgus deformity may rarely occur following high tibial osteotomy and can be treated with joint-sparing surgery.
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A carrying angle is described as either cubitus valgus if the angle is greater than 10°-15° or cubitus varus if less than 5°-10°.
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Antivalgus osteotomy of the knee is the treatment of choice to correct the valgus, to eliminate pain in the young or middle age patient, and to avoid or delay ...
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If conservative therapy fails, surgery should be considered. Surgical ... treatment of unicompartmental OA with associated varus or valgus deformity.
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Physical examination revealed a left cubitus valgus with an ulna claw hand, with weakness and wasting of the intrinsic muscles of the hand (Fig. 1). The ...
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Milch osteotomy is an effective procedure for cubitus valgus deformity correction and its associated tardy ulnar nerve palsy without a decrease in elbow ROM.
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With dysfunction of the posterior tibial tendon, the medial longitudinal arch collapses, the subtalar joint everts, the heel assumes a valgus position, and the ...
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Currently, we know that the deformity is caused by an abnormal growth arrest of the distal radial epiphysis leading to volar and ulnar tilting of the radial ...