Painful juvenile halluxabducto valgus (HAV) is initially treated conservatively. Whether it bealtering shoe gear, using orthotics or incorporating other modifications, conservativetreatment options are usually exhausted before the consideration of moreinvasive procedures. If symptoms persist, surgical intervention options can beexplored. A major concern for operating on young patients is the possibility ofrecurrence of the HAV deformity due to the progressive nature of thiscondition.
Though there are common surgeries performed currently, exploringother techniques may prove to be beneficial, especially when preoperativelytaking care to plan for adequate correction of the deformity and preventrecurrence, while aiming to completely relieve the pain. Introduction Hallux valgus was firstintroduced by Carl Heuter in 1871, who described lateral angulation of thefirst metatarsophalangeal joint, associated with lateral deviation of thesesamoids.22 Juvenile HAV deformity has several interchangeablenames commonly used, such as, juvenile or adolescent bunion, hallux valgus andmetatarsus primus adductus.6 Juvenile HAV is often bilateral and ismore prevalent in females affecting 22-26% of adolescents.
8, 15However, it is seldom the cause of pain, when compared to adult HAV.19Compared to adults,juvenile HAV commonly has a larger intermetatarsal angle (IMA) with a smaller,less prominent medial eminence. Often, juvenile patients with an HAV deformitycan also present with other conditions such as metatarsus adductus, pes planusand equinus. If present, these deformities must also be addressed.21Banks et al found that 66.7% of cases reviewed, demonstrated that patients withjuvenile HAV had a metatarsus adductus angle of greater than 15 degrees.
Manystudies have shown a high incidence of recurrence after surgical intervention,which is believed to be due to inadequate correction of the IMA.21Generally, conservativetherapy is the initial treatment option for juvenile HAV. These includemodified shoe gear with a wider toe box, splinting, and toe wedges.17, 20Occasionally, orthotics may be helpful in certain situations if the deformityis biomechanical in etiology, and if the deformity is not severe norsignificantly painful.14, 20 However, these treatment options onlyserve to treat the symptoms, while further progression of the deformity isinevitable.23 If conservative treatment options fail, surgicalintervention should be considered as the next line of treatment, especially ifthe deformity is severe and painful.Surgical options need tobe thoroughly explored in order to prevent recurrence and avoid the need for additionalsurgery.
10 Popular procedures include the chevron or double firstmetatarsal osteotomy for HAV in children, however, other techniques should beconsidered based on the deformity and pathogenesis to prevent recurrence.4,13 Though there is no optimal age or accepted criteria for surgicaltreatment in juvenile HAV deformity as each case differs, the following modifiedprocedures may bring light to different techniques that could possibly achievebetter results.18Surgical intervention ofjuvenile HAV is not commonly favorable due to the high recurrence rate of30-40%.1 When considering surgical correction of juvenile HAV, caremust be taken to consider the etiology of the deformity, the timing of thesurgery in regard to bone growth, and the severity of the deformity.1, 6Generally, mild or moderate deformities can be corrected with a distalosteotomy of the first metatarsal, while more severe deformities may require abase osteotomy for greater correction. Surgical technique generally depends onthe severity of the deformity, and thus surgical planning of procedures mustcarefully be considered.
Radiographic findingsThe IMA can be measuredby the intersection of the longitudinal axis of the first metatarsal with the longitudinalaxis of the adjacent metatarsal. An angle of 10 degrees or greater is oftenindicative of pathology.19 A hallux valgus angle of greater than 16degrees is also indicative of pathology. This angle can be measured by theintersection of the long axis of the proximal phalanx with the long axis of thefirst metatarsal. Lateral displacement of the sesamoids is often correlatedwith the severity of a hallux valgus deformity. Any degree of hallux valgusdeformity will rotate the sesamoids along the long axis of the metatarsal,altering their position.19 The proximal articular set angle (PASA) canalso be measured to assess the relationship between the long axis of the firstmetatarsal with the articular surface of the hallux.
5 Together,these angles are useful in determining the severity of a hallux valgusdeformity.Scarf-Akin osteotomy Agrawal et. al describesa procedure in which a Scarf osteotomy is combined with an Akin osteotomy inthe treatment of juvenile HAV. The Scarf procedure is a tricut osteotomy thatis used to correct moderate to severe deformities, correcting an abnormal IMA, anabnormal PASA, and an abnormal hallux interphalangeus angle, especially whencombined with an Akin osteotomy. A Scarf osteotomy allows for considerabletranslation of the metatarsal without any shortening of the first ray, and inturn, allows for significant correction. Adding an Akin osteotomy, a closingwedge osteotomy of the proximal phalanx, further corrects any additionalabnormalities. An Akin osteotomy is generally performed to correct an abnormalarticular set angle.
25 When paired with a Scarf osteotomy, these twoprocedures prove to be powerful in providing the greatest correction.1Of the 47 feet reportedby Agrawal et al who underwent Scarf-Akin osteotomies for moderate to severe HAV,only 14 feet reported a recurrence of hallux valgus. Agrawal et al observed a recurrencerate of 29.
8%, with 21.3% of patients symptomatic enough to require surgicalrevision. The reasons for recurrence were unclear, and may be due to thepatient’s young age or to a more marked deformity.
Together, the Scarf and Akinosteotomies are strong surgical procedures when considered for the managementof HAV. However, the high recurrence rate of 29.6% should be considered andsurgical intervention utilizing this method should be reserved for adolescentpatients with a significantly painful and severe HAV deformity.1 Percutaneous Osteotomy Gicquel et alretrospectively reviewed 33 percutaneous hallux valgus procedures in femalepatients at an average age of 12.5 years.
The IM and distal metatarsalarticular (DMAA) angles were measured on weight-bearing radiographs todetermine the hallux valgus angle (HVA). Abnormal values were as follows: IMAgreater than 10 degrees, DMAA greater than 8 degrees and HVA greater than 15. AReverdin-Isham distal metatarsal osteotomy was used in combination with abunionectomy (only if the first metatarsal head was prominent), release of thefirst metatarsophalangeal joint and a wedge osteotomy of the proximal firstphalanx. In patients with an IMA greater than 18 degrees, they performed alateral wedge osteotomy at the base of the first metatarsal.12 Inplace of internal fixation, a bandage was used to hold the first ray in an overcorrectedposition for six weeks postoperatively, followed by a toe spacer for sixmonths.
Averages for the preoperative IMA, DMAA and HVA were 13.61, 15.97 and28.6 degrees, respectively. Postoperative averages of IMA, DMAA and HVA were12.
74, 8.97 and 19.45 degrees, respectively. Of the 33 cases, 20 had a postoperativeHVA greater than 16 degrees and after 31.5 months, all 20 cases demonstrated undercorrection. Having a high preoperative IMA and insufficient DMAA correctionwere risk factors correlated with under correction. The results from thepercutaneous osteotomy showed under correction which was inversely related to ahigh-rated patient satisfaction. Since this study had a relatively small samplesize, and a short-term follow-up, there is not sufficient data to determinewhether the procedure could be effective amongst a larger population.
12 CrespoRomero and colleagues performed a percutaneous forefoot surgery (PFS) on 108patients having a recurrence of medial first metatarsal head pain in 22 cases.Though their patients had a low postoperative pain level, their results showedinsufficient HVA correction, as well.9 Proximal Abduction-Supination Osteotomy In 2013, Okuda et alpublished a preliminary report on a technique combining a proximalabduction-supination osteotomy of the first metatarsal with a distalsoft-tissue procedure for the surgical treatment of adolescent hallux valgus. Atotal of 11 symptomatic female patients (12 feet) underwent the procedure. Theaverage age at the time of surgery was 17 years old. The surgical techniqueconsisted of a few steps after initially releasing the distal soft tissues.
Themedial eminence was minimally excised to preserve the distal articular surfaceof the first metatarsal head. The adductor hallucis tendon was then dissected fromits insertion site, while also releasing the transverse metatarsal ligament. At1.5 cm distal to the metatarsocuneiform joint, a proximal crescentic osteotomywas performed on the first metatarsal.22 Once the proximalfragment was moved medially, the distal fragment of the first metatarsal wasabducted, and then manually supinated. Once the desired correction was achieved,1.
5 mm Kirschner wires were used to stabilize and secure the osteotomy site.This technique reduced the hallux valgus angle to less than or equal to 17degrees, and the IMA to less than 10 degrees. The preoperative hallux valgusand IMA averaged 32.3 and 14 degrees, respectively.22 In this study, Okuda etal used the Japanese Society for Surgery of the Foot (JSSF) standard ratingsystem which incorporates pain, function and alignment to a numerical value of100 points maximum. Preoperatively the JSSF score was 62.
0 points andpostoperatively the score increased to 99.2 points. All patients were pleasedwith their results postoperatively and there were no recurrences of halluxvalgus.22 Surgical techniques for HAVin juveniles tends to steer clear of the proximal aspect of the firstmetatarsal in order to avoid the growth plate, which may be why there have beenmore literature on the distal metatarsal osteotomies.24, 26 Thoughthis study advocates for more proximal osteotomies in adolescents, one caveatis all the patients had closed first metatarsal epiphyses and were thereforeskeletally mature for this type of procedure. Depending on the age of thepatient, this procedure may not be an option for the adolescent with painful halluxvalgus.22Conclusion Treatinga juvenile hallux abducto valgus deformity is challenging. Considerations suchas the growth plate at the first metatarsal base and allowing the young andactive adolescent to weight bear needs to be taken into account when choosingan appropriate procedure.
11, 16Though there is no criteria when deciding a particular procedure andno single technique to address all HAV deformities, modifications of previouslydocumented osteotomies can benefit the growing patient.27 Thepurpose of analyzing the Scarf and Akin osteotomies, percutaneous osteotomy,and proximal abduction-supination osteotomy are in hopes of further advancementof modified osteotomies in juvenile bunions.Surgical treatment forhallux abducto valgus deformity in juveniles are typically avoided whenpossible due to the limited number of studies. In skeletally immature patients,the risk of recurrence after surgery appears to be higher.2 Manystudies recommend waiting until the patient has reached skeletal maturitybefore proceeding with surgical intervention due to the high recurrence rate,related to the presence of an open metaphysis.7, 11Acknowledgements Wegratefully acknowledge the support of Dr.
Thomas Merrill at Barry UniversitySchool of Podiatric Medicine for mentoring and inspiring this literaturereview.