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Hallux valgus correction

57 citationsUpdated Sep 2026

Overview

Hallux valgus correction encompasses a spectrum of surgical techniques, ranging from percutaneous and minimally invasive approaches to conventional open osteotomies and soft-tissue procedures. Percutaneous forefoot surgery produces results similar to conventional surgery [1], while minimally invasive distal linear osteotomy achieves good clinical and radiographic outcomes comparable to open techniques, with decreased recovery and rehabilitation times [18]. Arthroscopic correction can also achieve good clinical and radiologic results, provided that careful preoperative clinico–radiologic assessment is made to exclude patients contraindicated for the procedure [19]. For mild and moderate deformities, the Austin osteotomy is a safe and effective treatment [2], and the chevron osteotomy is a reliable procedure with outcomes that do not differ on the basis of age [7]. The syndesmosis procedure yields satisfactory short-term clinical and radiological results two years post-operatively [3].

Indications vary by deformity severity and specific anatomical features. Distal linear metatarsal osteotomy is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity [26]. For moderate to severe symptomatic deformity with metatarsus primus varus, proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective [10]. The combined proximal opening wedge and distal chevron osteotomy is a reliable technique for moderate to severe hallux valgus, providing strong angular correction with satisfactory clinical outcomes [21]. Proximal osteotomy is a good method for treating severe hallux valgus deformity, with 86% of patients stating the operation was worthwhile after 8 years of follow-up [14]. The Hohmann and Lapidus operations are good options for correction, with similar reliable long-term results [15].

Postoperative management must be meticulously carried out to ensure optimal alignment of the hallux [4]. Avoiding the dorsomedial cutaneous nerve zone is recommended during minimally invasive surgery [8]. Obesity was not associated with unsatisfactory outcomes after reversed L-shaped osteotomy [16]. Minimally invasive surgery for juvenile hallux valgus allows another surgery to be done on minimally or undamaged tissues if needed later on [17]. Successful treatment of recurrent hallux valgus requires understanding the underlying reason for initial failure, correcting bony alignment, restoring joint congruity, and balancing soft tissues [9]. Third- and fourth-generation minimally invasive surgical techniques are effective in correcting radiographic parameters and improving pain and functional scores in patients undergoing revision for recurrent hallux valgus, with a low rate of complications [11]. Fourth-generation percutaneous transverse osteotomies demonstrate significant improvement in clinical and radiographic outcomes with a low rate of recurrence [12]. Both modified minimally invasive chevron osteotomy and traditional incision chevron osteotomy effectively treat mild and moderate hallux valgus deformity with significantly improved clinical efficacy and imaging results [13]. Chevron-Akin double osteotomy is a safe and practicable procedure for the treatment of mild-to-moderate hallux valgus [49]. Minimally invasive distal transverse metatarsal osteotomy–Akin osteotomy provides effective correction with excellent radiographic alignment and favorable clinical outcomes [6]. Modified endoscopic distal soft tissue procedure with medial metatarsosesamoid ligament and intermetatarsal ligament augmentation is indicated for symptomatic hallux valgus recalcitrant to conservative treatment but is contraindicated in cases with bony deformity or where the intermetatarsal space cannot be closed manually [24]. Treatment of iatrogenic hallux varus requires careful clinical and radiological work-up to identify causes, with each cause corrected to achieve stable results over time [5].

Anatomy & Pathophysiology

Definition and Etiology

Hallux valgus is defined as lateral deviation of the great toe with medial deviation of the first metatarsal [31], or specifically as lateral deviation of the proximal phalanx on the first metatarsal head [42]. The etiology is multifactorial, involving intrinsic factors such as genetic predisposition, ligamentous laxity, and predisposing anatomy [31], as well as extrinsic factors including narrow toe boxes and high heels [31]. The condition is influenced by both constricting footwear and intrinsic elements like heredity and foot mechanics [48]. Incidence is 10 times greater in women than in men [56] and significantly higher in shod populations than unshod ones [56]. Approximately 70% of patients have a family history, suggesting a hereditary component [42]. The deformity is most common in female patients in their fourth or fifth decades of life [45]. It is usually progressive, though the rate and degree of progression are often nonlinear [45]. Hallux valgus is not associated with chronic tightness of the Achilles tendon or gastrocnemius, increased first ray mobility, bilaterality, or pes planus [56]. In patients with cerebral palsy, the deformity develops in response to an equinovalgus deformity of the hindfoot [72]. Spasticity of the peroneus longus leads to progressive eversion and abduction of the foot, resulting in lateralization of the origin of the adductor hallucis muscle and subsequent increasing pull of the proximal phalanx into adduction [72]. Hallux valgus is a dynamic condition where deformity may correlate more with motions during weightbearing than with plain static measurements [28].

Pathoanatomy

The pathoanatomy involves gradual failure of medial supportive structures, specifically the medial collateral ligament and tibial sesamoid, resulting in a varus position of the first metatarsal [45]. Medial capsular attenuation is a key component [31]. The proximal phalanx drifts laterally, leading to plantar-lateral migration of the abductor hallucis [31]. This positional change causes the proximal phalangeal unit to plantar flex and pronate the hallux [31]. Pronation is amplified by the proximal phalangeal attachment of the adductor hallucis [31]. Stretching of the extensor hood of the extensor hallucis longus occurs [31]. Lateral deviation of the extensor hallucis longus and flexor hallucis longus causes a muscular imbalance and deforming force for valgus progression and pronation [31]. The first metatarsal head moves medially off the sesamoids, increasing the intermetatarsal angle [31]. Pronation leads to rounding of the lateral metatarsal head, which should have a flat contour with no rotational deformity [31]. Secondary contracture of the lateral capsule, adductor hallucis, and lateral metatarsal-sesamoid and intermetatarsal ligaments occurs [31]. As the metatarsal head is pushed medially, the sesamoids slowly erode the crista, allowing for lateral subluxation of the sesamoids from directly plantar to the first metatarsal [56]. With severe deformity, both extrinsic and intrinsic muscles lie lateral to the longitudinal axis of the first metatarsophalangeal joint, further enhancing the deformity [56]. Pronation occurs because attenuation of the weakest portion of the capsule, the dorsomedial aspect, allows the abductor hallucis tendon to slide beneath the metatarsal head and rotate the proximal phalanx into pronation [56]. The sesamoid ridge on the plantar surface of the first metatarsal head flattens due to pressure from the tibial sesamoid [63]. With this restraint lost, the fibular sesamoid displaces partially or completely into the first intermetatarsal space [63]. In this situation, the patient bears less weight on the first ray and more on the lesser metatarsal heads, increasing the likelihood of transfer metatarsalgia, calluses, and stress fracture of a lesser metatarsal [63].

The articular surface of the metatarsal head may be offset, resembling a scoop of ice cream sitting at an angle on a cone, described as the distal metatarsal articular angle [63]. The articular angle of the base of the proximal phalanx in relation to its longitudinal axis may be offset, described as the phalangeal articular angle [63]. The normal range for the phalangeal articular angle is generally considered to be 7 to 10 degrees [63]. The normal range for the distal metatarsal articular angle is generally considered to be 10 to 15 degrees [63]. Failure to correct the distal metatarsal articular angle can cause unsatisfactory results after surgery in some patients [63]. The valgus posture of the great toe frequently causes a hammer toe-like deformity of the second toe [63]. Metatarsal pronation is associated with hallux valgus, with the underlying mechanism generally being cuneometatarsal instability [90]. Hallux valgus is frequently associated with medial deviation of the first metatarsal [42]. It is commonly related to wearing shoes with a narrow toe box [42]. Metatarsus primus varus and pes planus have been implicated in the etiology [42]. Other causes include rheumatoid arthritis, connective tissue disorders, and cerebral palsy [42]. The metatarsal articular surface may have a valgus orientation, as measured by the distal metatarsal articular angle [42].

Juvenile hallux valgus presents distinct characteristics. Hallux valgus occurring in the preteen or teenage years is often associated with a smaller medial eminence prominence, increased magnitude of the first-second intermetatarsal angle, increased hypermobility of the first tarsometatarsal joint, less pronation, and a higher recurrence rate with surgical intervention than in the adult cohort [69]. Juveniles are more likely to have bilateral deformities and a family history of hallux valgus [69]. Typically, the angular deformity is less severe in children than in adults [88]. Large medial prominences are rare in juvenile hallux valgus [88]. A congruent joint with an increased distal metatarsal articular angle is more common in juvenile hallux valgus than in the adult condition [88]. Juvenile hallux valgus is sometimes associated with other deformities, such as metatarsus adductus [88]. Generalized ligamentous laxity may be more common in children with hallux valgus than in the general population [88]. Childhood hallux valgus is mainly due to distal M1 joint surface orientation abnormality, unlike in adults where increased M1M2 angle is the main deformity [51].

In patients with cerebral palsy, hallux valgus deformity usually is associated with other deformities, such as equinovalgus foot, heel valgus, and external rotation of the tibia [65]. These conditions cause the foot to pronate, forcing the first metatarsophalangeal joint into abduction and creating a hallux valgus deformity [65]. The extensor hallucis tendon may sublux into the first web space and become an abductor of the hallux, leading to further deformity in patients with cerebral palsy [65].

Radiographic Assessment

The hallux valgus angle is the angle formed by the line along the first metatarsal shaft and the line along the shaft of the proximal phalanx [31]. The normal hallux valgus angle is less than 15 degrees [31]. The first-second intermetatarsal angle is the angle formed by lines along the first and second metatarsal shafts [31]. The normal first-second intermetatarsal angle is less than 9 degrees [31]. The hallux valgus interphalangeus angle is the angle formed by lines along the shafts of the proximal phalanx and distal phalanx [31]. The normal hallux valgus interphalangeus angle is less than 10 degrees [31]. The hallux valgus interphalangeus angle is associated with a congruent deformity [31]. The distal metatarsal articular angle is the angle formed by the line along the articular surface of the first metatarsal and the line perpendicular to the axis of the first metatarsal [31]. The normal distal metatarsal articular angle is less than 10 degrees [31]. An increased distal metatarsal articular angle is associated with a congruent deformity [31].

The hallux valgus angle identifies the degree of deformity at the metatarsophalangeal joint [42]. The intermetatarsal angle is not influenced by overresection of the medial eminence and is not accurate for postoperative evaluation of distal osteotomies [42]. The offset of the distal metatarsal articular angle is a predisposing factor in the development of hallux valgus [42]. The offset of the proximal phalangeal articular angle is a predisposing factor in the development of hallux valgus [42]. The normal proximal phalangeal articular angle is less than or equal to 10 degrees [42]. The normal distal metatarsal articular angle is less than or equal to 15 degrees [42]. A congruent joint has no lateral subluxation of the proximal phalanx in relation to the first metatarsal head [56]. An incongruent joint has lateral subluxation of the proximal phalanx on the metatarsal head [56]. The first metatarsocuneiform joint angle is based on the distal articular surface of the medial cuneiform and the longitudinal axis of the first metatarsal [56]. Excessive medial deviation of the first metatarsocuneiform joint may indicate that hypermobility may be present [56]. Arthrosis of the metatarsophalangeal joint is characterized by joint space narrowing, subchondral sclerosis, and osteophyte formation [56]. Non-weight-bearing radiographs tend to underestimate the deformity of hallux valgus [45]. Methods using the metatarsal shaft as a reference have poor measurement accuracy for the metatarsophalangeal angle, especially postoperatively [111]. Hallux valgus angles based on margo medialis pedis measurements are slightly but statistically significantly smaller than metatarsophalangeal angles and should be considered conservative estimates [46].

Classification

Hallux Valgus Angle: Preoperative hallux valgus angle defines the severity of the deformity. A preoperative hallux valgus angle of less than 20 degrees is classified as a mild deformity [47]. A preoperative hallux valgus angle of 21 to 40 degrees is classified as a moderate deformity [47]. A preoperative hallux valgus angle of more than 40 degrees is classified as a severe deformity [47].

Other Considerations: Surgical method selection correlates with deformity severity and joint congruency. The chevron osteotomy is a reliable procedure for the correction of mild and moderate hallux valgus deformity [7]. Percutaneous distal metatarsal osteotomy is an effective and reliable method for correction of a mild-to-moderate hallux valgus deformity [23]. The percutaneous technique is reliable for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of a painful mild-to-moderate hallux valgus deformity [40]. Minimally invasive distal linear osteotomy allows to achieve good clinical and radiographic outcomes comparable to those obtained with open surgical techniques in the management of mild to severe hallux valgus deformity [18]. DLMO is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity [26].

For moderate to severe deformities, combined or proximal techniques are indicated. The combined proximal opening wedge and distal chevron osteotomy is a reliable technique for the correction of moderate to severe hallux valgus [21]. Better clinical and radiological outcomes can be achieved in patients with moderate to severe hallux valgus deformity operated by Lindgren–Turan distal metatarsal osteotomy when it combines with transosseous capsuloplasty [29]. Proximal osteotomy is a good method for treating a severe hallux valgus deformity [14]. The modified Kramer osteotomy can achieve normal angular configuration, even with severe deformities, without significant long-term loss of correction [76]. Clinically, congruency of the MTP joint should be considered when choosing surgical methods for different degrees of hallux valgus [55].

Clinical Presentation

Definition and Etiology

Hallux valgus is a progressive deformity, though the rate and degree of progression are often nonlinear [45]. The condition is more common in women than in men [42]. Etiology involves both intrinsic and extrinsic factors. Intrinsic contributors include genetic predisposition, ligamentous laxity, and predisposing anatomy such as a convex metatarsal head or pes planus [31]. Extrinsic factors primarily involve specific types of shoewear, including narrow toe boxes and high heels [31].

Pathoanatomy

The deformity begins with first metatarsal varus, which creates a prominent medial eminence at the first metatarsal head, commonly referred to as a "bunion" [45]. This prominence is a frequent source of pain related to shoe wear [45]. As the deformity progresses, valgus deviation develops at the metatarsophalangeal (MTP) joint of the proximal phalanx [45]. Concurrently, the alignment of the flexor and extensor hallucis longus tendons shifts laterally relative to the MTP joint, further exacerbating the deformity [45]. Chronic deformity leads to attenuation of the medial joint capsule and contraction of the lateral joint capsule [56]. The sesamoids slowly erode the crista as the metatarsal head is pushed medially, allowing lateral subluxation of the sesamoids from directly plantar to the first metatarsal [56]. Stretching of the extensor hood of the extensor hallucis longus also occurs [31]. Secondary pathology may develop in the lesser toes, such as symptomatic hammertoes and claw toes [45]. In a small percentage of patients, rapid progression occurs if the first metatarsocuneiform joint demonstrates significant instability [56].

Symptoms and Signs

The most common symptom is pain over the medial eminence [56]. Patients also report joint pain and pain under the second metatarsal head, known as a transfer lesion or metatarsalgia [56]. The deformity may prevent shoewear, leading to activity limitation [56]. Numbness can occur in the dorsal medial cutaneous nerve distribution due to external pressure from a shoe [45]. The most common constellation of presenting signs and symptoms relates to mechanical pressure on the toes, the first metatarsal, and under the second metatarsal [43]. Common presenting signs include underlapping and overlapping first and second toes, which cause subluxation or dislocation of the second MTP joint [43]. Pain or callus formation under the second metatarsal head is a frequent sign [43]. Symptoms often include metatarsalgia and a sensation of pressure under the second and sometimes third metatarsal head [43]. A significant discrepancy exists between radiographically-assessed and self-recognized hallux valgus, which narrows as severity progresses [36].

Physical Examination

A complete evaluation is performed on both lower extremities with the patient undressed from the knees to the toes [56]. The patient is instructed to stand and walk, noting foot posture and the position of the hallux and lesser toes [56]. The severity of the hallux valgus deformity and any associated pes planus is best assessed while standing [45]. While seated, the first MTP joint area is evaluated for signs of local irritation and bursal hypertrophy secondary to shoe wear [45]. The skin is evaluated for erythema, swelling, ulceration, or callosities [56]. Tenderness over the medial eminence is a clinical sign of hallux valgus [45]. Pain with motion of the first MTP joint may suggest arthritis within the joint [45].

Range of motion is checked for the ankle, subtalar, transverse tarsal, and MTP joints [56]. It is important to note the range of motion of the first MTP joint in both the deformed and corrected position [56]. The amount of motion limitation provides insight into the degree of surgical correction obtainable without impairing joint motion [56]. The first tarsometatarsal joint is evaluated for hypermobility, which remains a diagnostic challenge with poor reproducibility [45]. Specifically, the first metatarsocuneiform joint is examined for hypermobility by stabilizing the medial cuneiform and ranging the first metatarsal dorsomedially and plantolaterally [56]. Pronation of the great toe is easily noted by comparing the angulation of the nail of the great toe in relation to the floor [31].

The neurovascular status of the foot is carefully assessed, noting absent pulses and venous stasis changes [56]. If there is compromise of vascularity, vascular studies may be obtained [56]. Doppler studies are obtained if there is any question regarding the circulatory status of the foot [56].

Radiographic Evaluation

Diagnostic confirmation is made using standard AP and lateral weight-bearing radiographs, as non-weight-bearing radiographs tend to underestimate the deformity [45]. Radiographs are assessed for the presence of arthritis at the first MTP joint [45]. Severity is determined by measuring the intermetatarsal angle between the first and second metatarsals [45]. Other assessments include sesamoid subluxation, the hallux valgus angle, first tarsometatarsal hypermobility, and congruency of the MTP joint [45]. Congruency is assessed by measuring the distal metatarsal articular angle of the first metatarsal head [45].

Key angular measurements include: * Hallux valgus angle: The angle formed by a line along the first metatarsal shaft and a line along the shaft of the proximal phalanx [31]. * First-second intermetatarsal angle: The angle formed by lines along the first and second metatarsal shafts [31]. * Hallux valgus interphalangeus angle: The angle formed by lines along the shafts of the proximal phalanx and distal phalanx [31]. * Distal metatarsal articular angle: The angle formed by a line along the articular surface of the first metatarsal and a line perpendicular to the axis of the first metatarsal [31]. * Proximal phalangeal articular angle: The articular angle of the base of the proximal phalanx in relation to its longitudinal axis [42].

The offset of the distal metatarsal articular angle and the offset of the proximal phalangeal articular angle are both predisposing factors in the development of hallux valgus [42]. The intermetatarsal angle is not influenced by overresection of the medial eminence and is not accurate for postoperative evaluation of distal osteotomies [42]. Clinically, congruency of the MTP joint should be considered when choosing surgical methods for different degrees of hallux valgus [55]. The MTP joint angle and congruency index can be used as quantitative evaluation indicators for congruency [55]. Hallux valgus angles based on margo medialis pedis measurements are slightly but statistically significantly smaller; therefore, these measurements should be considered conservative estimates of the MTP angle [46].

Juvenile and Adolescent Presentation

Hallux valgus is rare in children but often requires treatment [39]. Adolescent hallux valgus is frequently hereditary and usually seen in early adolescence [39]. Family history is frequently positive in these patients [52]. The condition is almost always found in conjunction with a wide forefoot caused by varus (medial deviation) of the first metatarsal shaft (metatarsus primus varus) [39]. This wide forefoot allows severe lateral deviation of the great toe, causing the prominent base to rub against the inside of the shoe and create a painful bunion [39]. Although conservative measures may relieve discomfort, many adolescent bunions are progressive and require surgical management [39].

Recurrence of the deformity after surgical correction is a critical factor separating juvenile and adolescent patients from adults [52]. Varus of the first metatarsal with a large intermetatarsal angle is commonly present in juvenile and adolescent hallux valgus [52]. The distal metatarsal articular angle is typically increased, and hallux valgus interphalangeus may be present [52]. Ligamentous laxity may be present, and a history of Ehlers-Danlos or Marfan syndrome should be elicited [52]. Examination for generalized hyperlaxity should be performed to determine whether a first tarsometatarsal arthrodesis is required [52]. Unlike in adults, where an increased first-second metatarsal angle is the main deformity, childhood hallux valgus is mainly due to distal first metatarsal joint surface orientation abnormality [51]. When combined with external tibial torsion, the toe is pushed laterally as weight is borne by the everted forefoot [72].

In patients with cerebral palsy, the first toe comes to lie beneath the second toe in hallux valgus [72]. The head of the first metatarsal becomes uncovered as the toe deviates laterally, and a painful bunion develops [72]. These patients complain of discomfort and swelling over the prominent head of the first metatarsal and difficulty wearing shoes [72].

Hallux Varus Presentation

Hallux varus is described as a medial deviation of the great toe at the MTP joint [27]. In children, it can be congenital or acquired, though acquired cases are rare [27]. In adults, it is usually acquired as a complication of hallux valgus surgery [27]. The deformity is believed to worsen with age [27]. Symptoms are both cosmetic and related to the ability to wear shoes, with shoe wear becoming nearly impossible due to the deviation [27].

Hallux varus was not widely recognized until McBride reported its occurrence in 5% of patients treated with his procedure in 1935 [54]. Incidences after operations for hallux valgus range from 2% to 17% [54]. Few patients complain about appearance unless the varus is greater than 10 to 15 degrees [54]. Discomfort is rare and usually associated with degenerative changes of the first MTP joint [54].

Main causes for hallux varus after hallux valgus surgery include: * Complete release of the lateral structures of the MTP joint combined with excessive plication of the medial capsule [54]. * Excessive resection of the medial eminence, leading to loss of medial bony buttress for the proximal phalanx [54]. * Excision of the fibular sesamoid [54]. * Release of the lateral head of the flexor hallucis brevis at its insertion into the fibular sesamoid [54]. * Closure of the intermetatarsal angle to neutral or a negative value [54].

Hallux varus is classified into two types: static (supple) and dynamic (fixed) [54]. Static hallux varus is asymptomatic and mainly a cosmetic complication [54]. In static hallux varus, the hallux rests in varus in a weight-bearing position, the MTP joint rests in a normal position in the sagittal plane, and the interphalangeal joint is in a normal position [54]. Most often, the hallux is not rotated abnormally in an axial plane and does not assume a "snake-in-the-grass" appearance in the frontal plane [54].

Investigations

Plain radiography: Diagnostic confirmation of hallux valgus requires standard AP and lateral weight-bearing radiographs [45]. These images are essential for evaluating the type and severity of the deformity [56]. Assessment must include the presence of arthritis at the first metatarsophalangeal joint, the severity of deformity determined by the intermetatarsal angle and hallux valgus angle, and sesamoid subluxation [45]. Weight-bearing views also allow evaluation of excessive medial deviation of the first metatarsocuneiform joint, which may indicate hypermobility [56]. The characteristics of the medial eminence, particularly its size measured from the sagittal groove, are evaluated on these films [56].

Radiographic Angles and Measurements: The hallux valgus angle (HVA) is defined as the angle formed by the intersection of lines along the shaft of the first metatarsal and the shaft of the proximal phalanx [31]. The first–second intermetatarsal angle (IMA) is defined as the angle formed by lines along the shafts of the first and second metatarsals [31]. The hallux valgus interphalangeus (HVI) angle is defined as the angle formed by lines along the shafts of the proximal phalanx and the distal phalanx [31]. The distal metatarsal articular angle (DMAA) is defined as the angle formed by a line along the articular surface of the first metatarsal and a line perpendicular to the axis of the first metatarsal [31]. Alternatively, the DMAA is defined as the angle of the line bisecting the metatarsal shaft with a line through the base of the distal articular cartilage cap [42]. The proximal phalangeal articular angle (PPAA) is defined as the articular angle of the base of the proximal phalanx in relation to its longitudinal axis [42].

Joint Congruency and Measurement Limitations: Congruency of the metatarsophalangeal joint is assessed by measuring the distal metatarsal articular angle of the first metatarsal head [45]. The metatarsophalangeal joint angle and congruency index can be used as quantitative evaluation indicators for joint congruency [55]. Hallux valgus angles based on margo medialis pedis measurements are slightly but statistically significantly smaller than metatarsophalangeal angle measurements [46]. Consequently, margo medialis pedis measurements should be considered conservative estimates of the metatarsophalangeal angle [46]. The first–second intermetatarsal angle is not influenced by overresection of the medial eminence [42]. However, the first–second intermetatarsal angle is not accurate for postoperative evaluation of distal osteotomies [42].

Other Considerations: Augmented reality guided osteotomies can potentially improve accuracy during hallux valgus correction, particularly for less experienced surgeons [66].

Treatment

Non-Operative

Non-operative treatment cannot correct the hallux valgus deformity but can help control symptoms [83]. For juvenile hallux valgus, nonsurgical management should be considered first in all patients, especially those with ligamentous laxity or neuromuscular disorders, because of the higher recurrence rate with surgical intervention [69]. Shoes with a wide toe box, toe spacers, and night splints may be used for symptomatic management of juvenile hallux valgus until physeal closure but are unlikely to correct the deformity [69]. For iatrogenic hallux varus, nonoperative treatment is limited to accommodation of the deformity with shoe modifications and shoe stretching [52].

Operative

Indications: Surgical intervention is indicated when non-operative measures fail to control symptoms or when deformity correction is required. In juvenile and adolescent hallux valgus, if arthrodesis of the first tarsometatarsal joint is required for ligamentous laxity, surgical intervention is delayed until physeal closure [52]. In patients with cerebral palsy, any other underlying deformities, such as heel valgus or external rotation of the tibia, should be corrected before surgical correction of the hallux valgus [65].

Surgical Approach / Technique: The chevron osteotomy is a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age [7]. The minimally invasive distal linear osteotomy allows to achieve good clinical and radiographic outcomes comparable to those obtained with open surgical techniques in the management of mild to severe hallux valgus deformity, with decreased recovery and rehabilitation times [18]. Proximal osteotomy is a good method for treating a severe hallux valgus deformity, with 86% of patients stating the operation was worthwhile after 8 years of follow-up [14]. The Hohmann and Lapidus operations are good options for correction of a hallux valgus deformity, with similar reliable long-term results [15]. For adolescent bunions, surgery must address each aspect of the deformity by trimming the bunion, correcting the varus angulation of the first metatarsal by osteotomy, and centralizing and balancing the hallux valgus by lengthening the adductor hallucis muscle [39]. In juvenile and adolescent hallux valgus, a first tarsometatarsal arthrodesis substitutes for a proximal osteotomy to correct the intermetatarsal angle in cases of ligamentous laxity [52].

Minimally Invasive and Percutaneous Techniques: Percutaneous forefoot surgery produces results similar to conventional surgery for hallux valgus and hallux rigidus [1]. MITA (Minimally Invasive Distal Transverse Metatarsal Osteotomy–Akin Osteotomy) provides effective correction of hallux valgus, achieving excellent radiographic alignment and favorable clinical outcomes [6]. Fourth-generation percutaneous transverse osteotomies for hallux valgus demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence [12]. Third-generation minimally invasive chevron and Akin osteotomies (MICA) provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence [25]. Third- and fourth-generation minimally invasive surgical techniques have proven effective in correcting radiographic parameters and improving pain and functional scores in patients undergoing revision for recurrent hallux valgus, with a low rate of complications [11].

Arthroscopic and Soft Tissue Procedures: Arthroscopic correction of the hallux valgus deformity can achieve good clinical and radiologic results, provided that careful preoperative clinico–radiologic assessment is made to exclude patients contraindicated for the procedure [19]. The use of a syndesmosis procedure for the treatment of hallux valgus yields satisfactory short-term results, with good clinical and radiological results two years post-operatively [3]. Modified endoscopic distal soft tissue procedure (mEDSTP) and arthroscopic Lapidus arthrodesis for correction of severe hallux valgus is technically demanding and reserved to experienced foot and ankle arthroscopists [74].

Revision: Successful treatment of recurrent hallux valgus requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring joint congruity, and balancing soft tissues [9]. Soft-tissue repair for recurrent hallux valgus is indicated when the first-second intermetatarsal angle is ≤13 degrees, the hallux valgus angle is ≤30 degrees, the distal metatarsal articular angle is normal (<10-15 degrees), there are minimal degenerative changes at the first metatarsophalangeal joint, and there is 50 to 60 degrees of passive motion of the first metatarsophalangeal joint [33]. Appropriate treatment for iatrogenic hallux varus requires careful clinical and radiological work-up to identify the causes, and each cause must then be corrected to achieve stable results over time [5]. For flexible iatrogenic hallux varus deformity, correction can be achieved with a soft tissue procedure involving release of the abductor hallucis muscle and fascia and transfer of a portion of the extensor hallucis longus or extensor hallucis brevis tendon under the transverse intermetatarsal ligament to the distal metatarsal neck [52]. For fixed iatrogenic hallux varus deformity, or deformity with limited first metatarsophalangeal joint motion, joint pain, or presence of first metatarsophalangeal joint degenerative joint disease, treatment is first metatarsophalangeal joint arthrodesis [52].

Other Considerations: In patients with cerebral palsy, isolated soft-tissue procedures for hallux valgus rarely are successful and have a high recurrence rate, and great toe metatarsophalangeal joint fusion is recommended [65]. Obesity was not associated with unsatisfactory outcomes after reversed L-shaped osteotomy for hallux valgus, challenging previous recommendations for preoperative weight loss [16].

Complications

Iatrogenic Deformity and Recurrence: Iatrogenic hallux varus is usually acquired in adults as a complication of hallux valgus surgery [27]. Causes of acquired hallux varus include overcorrection from bunion surgeries such as the McBride procedure, trauma, and systemic arthritis [27]. Postoperative management must be meticulously carried out to ensure optimal alignment of the hallux [4].

Nerve Injury: A potentially dangerous zone of the dorsomedial cutaneous nerve exists in minimally invasive surgery for hallux valgus [8]. Avoiding this zone is recommended during minimally invasive surgery for hallux valgus [8].

Technical and Anatomical Complications: In patients with large eminences and narrow metatarsals, complications related to insufficient postoperative fragment contact can be expected [64]. Sufficient hallux valgus correction in patients with small eminences and long metatarsals is questionable [64].

Recovery

Other Considerations: The minimally invasive distal linear osteotomy allows for decreased recovery and rehabilitation times compared to open surgical techniques [18]. Male feet undergoing MITA present with worse baseline functional impairment but show greater early functional recovery, with clinical and radiographic outcomes comparable to those of female feet at 1 year [73].

Key Evidence

  • [L5] The procedure is particularly reliable for fifth ray abnormalities and produces results similar to conventional surgery for hallux valgus and hallux rigidus. [1] (10.1016/j.otsr.2013.06.017)
  • [L4] The Austin osteotomy is a safe and effective treatment for mild and moderate hallux valgus deformity. [2] (10.1007/bf00434548)
  • [L4] The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory, with good clinical and radiological results two years post-operatively. [3] (10.1302/0301-620x.96b4.32193)
  • [L5] The postoperative management must be meticulously carried out to ensure optimal alignment of the hallux. [4] (10.5435/00124635-199501000-00005)
  • [L5] Appropriate treatment for iatrogenic hallux varus requires careful clinical and radiological work-up to identify the causes, and each cause must then be corrected to achieve stable results over time. [5] (10.1016/j.otsr.2019.05.018)
  • [L4] MITA provides effective correction of hallux valgus, achieving excellent radiographic alignment and favorable clinical outcomes. [6] (10.1186/s13018-025-06361-3)
  • [L3] At these two follow-up periods, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age. [7] (10.2106/00004623-200010000-00002)
  • [L5] Avoiding this zone is recommended during minimally invasive surgery for hallux valgus. [8] (10.1186/s13018-023-04419-8)
  • [L4] Successful treatment of recurrent hallux valgus requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring joint congruity, and balancing soft tissues. [9] (10.1007/s00402-011-1447-6)
  • [L4] Proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus. [10] (10.1007/pl00013769)
  • [L4] Third- and fourth-generation minimally invasive surgical techniques have proven effective in correcting radiographic parameters and improving pain and functional scores in patients undergoing revision for recurrent hallux valgus, with a low rate of complications. [11] (10.1186/s12891-026-09946-z)
  • [L5] This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence. [12] (10.2106/jbjs.24.01326)
  • [L3] Both modified minimally invasive chevron osteotomy and traditional incision chevron osteotomy effectively treat mild and moderate hallux valgus deformity with significantly improved clinical efficacy and imaging results. [13] (10.1186/s12891-025-08355-y)
  • [L3] Proximal osteotomy is a good method for treating a severe hallux valgus deformity, with 86% of patients stating the operation was worthwhile after 8 years of follow-up. [14] (10.1007/bf00433994)
  • [L1] The Hohmann and Lapidus operations are good options for correction of a hallux valgus deformity, with similar reliable long-term results. [15] (10.1302/0301-620x.95b9.31560)
  • [L3] Obesity was not associated with unsatisfactory outcomes after ReveL for hallux valgus, challenging previous recommendations for preoperative weight loss. [16] (10.1186/s12891-019-2823-6)
  • [L5] Minimally invasive surgery for juvenile hallux valgus allows another surgery to be done on minimally or undamaged tissues if needed later on. [17] (10.1016/j.otsr.2021.103168)
  • [L5] The minimally invasive distal linear osteotomy allows to achieve good clinical and radiographic outcomes comparable to those obtained with open surgical techniques in the management of mild to severe hallux valgus deformity, with decreased recovery and rehabilitation times. [18] (10.1007/s00402-013-1778-6)
  • [L4] Arthroscopic correction of the hallux valgus deformity can achieve good clinical and radiologic results, provided that careful preoperative clinico–radiologic assessment is made to exclude patients contraindicated for the procedure. [19] (10.1016/j.arthro.2008.03.001)
  • [L4] The combined proximal opening wedge and distal chevron osteotomy is a reliable technique for the correction of moderate to severe hallux valgus, providing strong angular correction with satisfactory clinical outcomes. [21] (10.1302/0301-620x.98b9.35984)
  • [L2] The study shows that percutaneous distal metatarsal osteotomy is an effective and reliable method for correction of a mild-to-moderate hallux valgus deformity. [23] (10.1007/s00402-012-1585-5)
  • [L5] The procedure is indicated for symptomatic hallux valgus recalcitrant to conservative treatment but is contraindicated in cases with bony deformity or where the intermetatarsal space cannot be closed manually. [24] (10.1016/j.eats.2023.04.009)
  • [L4] The third-generation MICA provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence. [25] (10.2106/jbjs.20.01178)
  • [L4] DLMO is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity. [26] (10.1007/s00402-012-1665-6)
  • [L5] Hallux valgus is a dynamic condition, and the deformity could be more correlated with motions during weightbearing than with plain static measurements. [28] (10.1097/corr.0000000000002265)
  • [L3] Better clinical and radiological outcomes can be achieved in patients with moderate to severe hallux valgus deformity operated by Lindgren–Turan distal metatarsal osteotomy when it combines with transosseous capsuloplasty. [29] (10.1007/s00402-009-0986-6)
  • [L3] There was a significant discrepancy between radiographically-assessed and self-recognized hallux valgus which narrowed with the progressing severity of hallux valgus. [36] (10.1186/s12891-021-04978-z)
  • [L4] The percutaneous technique proved to be reliable for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of a painful mild-to-moderate hallux valgus deformity. [40] (10.2106/jbjs.d.02280)
  • [L3] [43] (10.1097/01.blo.0000191269.50033.ec)
  • [L4] Because the hallux valgus angles based on margo medialis pedis measurements were slightly but statistically significantly smaller, these measurements should be considered conservative estimates of the metatarsophalangeal angle. [46] (10.1186/1471-2474-15-133)
  • [L4] [47] (10.2106/00004623-199274010-00016)
  • [L5] Hallux valgus is a complex deformity influenced by both extrinsic factors, such as constricting footwear, and intrinsic factors, including heredity and foot mechanics. [48] (10.2106/00004623-199606000-00018)
  • [L2] Chevron-Akin double osteotomy is a safe and practicable procedure for the treatment of mild-to-moderate hallux valgus. [49] (10.1007/s00402-011-1385-3)
  • [L3] Childhood hallux valgus is mainly due to distal M1 joint surface orientation abnormality, unlike in adults where increased M1M2 angle is the main deformity. [51] (10.1016/j.otsr.2021.102938)
  • [L3] Clinically, congruency of the MTP joint should be considered when choosing surgical methods for different degrees of hallux valgus, and the MTPJA and CI can be used as quantitative evaluation indicators. [55] (10.1186/s13018-022-03028-1)
  • [L5] In patients with large eminences and narrow metatarsals, complications related to insufficient postoperative fragment contact can be expected, while sufficient hallux valgus correction in patients with small eminences and long metatarsals is questionable. [64] (10.1186/s13018-015-0304-7)
  • [L5] This pilot-study suggests that AR guided osteotomies can potentially improve accuracy during hallux valgus correction, particularly for less experienced surgeons. [66] (10.1186/s12891-020-03373-4)
  • [L3] Male feet undergoing MITA present with worse baseline functional impairment but show greater early functional recovery, with clinical and radiographic outcomes comparable to those of female feet at 1 year. [73] (10.1186/s12891-026-10023-8)
  • [Paper] This is technically demanding and reserved to experienced foot and ankle arthroscopists. [74] (10.1016/j.eats.2023.06.006)
  • [L3] This technique can achieve normal angular configuration, even with severe deformities, without significant long-term loss of correction. [76] (10.1007/s00402-016-2531-8)
  • [L5] Non-operative treatment cannot correct the deformity but can help control symptoms. [83] (10.1302/2058-5241.1.000005)
  • [L4] The study found metatarsal pronation to be associated with hallux valgus, with the underlying mechanism generally being cuneometatarsal instability. [90] (10.1016/j.otsr.2012.05.005)
  • [L4] Methods using the metatarsal shaft as a reference have poor measurement accuracy, especially postoperatively. [111] (10.2106/00004623-200303000-00015)

See Also

References

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[2] Clinical and radiological results after Austin bunionectomy for treatment of hallux valgus. Archives of Orthopaedic and Trauma Surgery. 1996. DOI: 10.1007/bf00434548

[3] The use of a syndesmosis procedure for the treatment of hallux valgus. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b4.32193

[4] Disorders of the First Metatarsophalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons. 1995. DOI: 10.5435/00124635-199501000-00005

[5] Surgical treatment of iatrogenic hallux varus. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2019.05.018

[6] Outcomes and Complications for Minimally Invasive Distal Transverse Metatarsal Osteotomy–Akin Osteotomy (MITA) for Hallux Valgus: 493 Cases. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06361-3

[7] The Chevron Osteotomy for Correction of Hallux Valgus. The Journal of Bone and Joint Surgery-American Volume. 2000. DOI: 10.2106/00004623-200010000-00002

[8] The potentially dangerous zone of the dorsomedial cutaneous nerve in minimally invasive surgery for hallux valgus: a cadaveric study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04419-8

[9] Salvage of recurrence after failed surgical treatment of hallux valgus. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1447-6

[10] Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release. Archives of Orthopaedic and Trauma Surgery. 2000. DOI: 10.1007/pl00013769

[11] Minimally invasive surgery in the correction of recurrent hallux valgus: a case series with 2‑year follow‑up. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09946-z

[12] Fourth-Generation Percutaneous Transverse Osteotomies for Hallux Valgus. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.01326

[13] Modified minimally invasive chevron osteotomy versus traditional incision chevron osteotomy. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08355-y

[14] Proximal osteotomy in hallux valgus, long-term results of 167 operated feet. Archives of Orthopaedic and Trauma Surgery. 1997. DOI: 10.1007/bf00433994

[15] Long-term results of the Hohmann and Lapidus procedure for the correction of hallux valgus. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b9.31560

[16] The influence of obesity and gender on outcome after reversed L-shaped osteotomy for hallux valgus. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2823-6

[17] Treatment of hallux valgus in children and adolescents. Orthopaedics & Traumatology: Surgery & Research. 2022. DOI: 10.1016/j.otsr.2021.103168

[18] Role of percutaneous distal metatarsal osteotomy for the management of hallux valgus deformity. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1778-6

[19] Arthroscopy‐Assisted Correction of Hallux Valgus Deformity. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.03.001

[21] Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b9.35984

[23] Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy for correction of mild-to-moderate hallux valgus deformity. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-012-1585-5

[24] Modified Endoscopic Distal Soft Tissue Procedure With Medial Metatarsosesamoid Ligament and Intermetatarsal Ligament Augmentation. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.04.009

[25] Third-Generation Minimally Invasive Chevron and Akin Osteotomies (MICA) in Hallux Valgus Surgery. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01178

[26] Minimally invasive distal linear metatarsal osteotomy for correction of hallux valgus: a preliminary study of clinical outcome and analytical radiographic results via a mapping system. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-012-1665-6

[27] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Plate 15.3 Kramer/Barmada Osteotomy of the Base of the Femoral Neck for Slipped Capital Femoral Epiphysis > Distal Metatarsal Osteotomy > Hallux Varus.

[28] Impact of First Metatarsal Hyperpronation on First Ray Alignment: A Study in Cadavers. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002265

[29] Transosseous capsuloplasty improves the outcomes of Lindgren–Turan distal metatarsal osteotomy in moderate to severe hallux valgus deformity. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0986-6

[31] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > ADULT HALLUX VALGUS.

[33] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > RECURRENT HALLUX VALGUS WITH NORMAL DISTAL METATARSAL ANGLE AFTER BUNIONECTOMY > BOX 82.6.

[36] The discrepancy between radiographically-assessed and self-recognized hallux valgus in a large population-based cohort. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-021-04978-z

[39] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 10Pediatric Orthopedic Surgery > 9. Adolescent Bunions (Hallux Valgus).

[40] Percutaneous Distal Metatarsal Osteotomy for Correction of Hallux Valgus. The Journal of Bone and Joint Surgery (American). 2005. DOI: 10.2106/jbjs.d.02280

[42] Aaos Comprehensive Orthopaedic Review 3. Disorders of the First Ray > I. Hallux Valgus.

[43] Surgery for Hallux Valgus with Proximal Crescentic Osteotomy Causes Variable Postoperative Pressure Patterns. Clinical Orthopaedics & Related Research. 2006. DOI: 10.1097/01.blo.0000191269.50033.ec

[45] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Foot and Ankle Reconstruction > Hallux Valgus.

[46] The hallux valgus angle of the margo medialis pedis as an alternative to the measurement of the metatarsophalangeal hallux valgus angle. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-133

[47] Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274010-00016

[48] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Hallux Valgus†. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199606000-00018

[49] Clinical outcome after Chevron–Akin double osteotomy versus isolated Chevron procedure: a prospective matched group analysis. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1385-3

[51] Abnormalities in distal first metatarsal joint surface orientation: Distal Metatarsal Articular Angle and Distal Metatarsal-2 Articular Angle. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102938

[52] Miller S Review Of Orthopaedics. JUVENILE AND ADOLESCENT HALLUX VALGUS.

[54] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > ACQUIRED HALLUX VARUS AND INTRINSIC MINUS HALLUX.

[55] Radiographic evaluation of congruency of the first metatarsophalangeal joint in hallux valgus. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03028-1

[56] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > 1. Hallux Valgus.

[63] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > HALLUX VALGUS (BUNION).

[64] Geometric analysis of indications for minimally invasive distal metatarsal osteotomy in treatment of hallux valgus. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0304-7

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[72] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Pigmented Villonodular Synovitis and Giant Cell Tumor of the Tendon Sheath > Hallux Valigus.

[73] Gender differences in early functional recovery after minimally invasive distal transverse metatarsal osteotomy - Akin Osteotomy (MITA) for hallux valgus: a propensity-matched study of 300 cases. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10023-8

[74] Modified Endoscopic Distal Soft Tissue Procedure (mEDSTP) and Arthroscopic Lapidus Arthrodesis for Correction of Severe Hallux Valgus. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.06.006

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[83] Treatment of hallux valgus deformity. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000005

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[90] Axial rotation of the first metatarsal head in a normal population and hallux valgus patients. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.05.005

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a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.