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 ofthe HAV deformity to reoccur due to the progressive nature of this condition.
Though there are common surgeries performed currently, exploring othertechniques may prove to be beneficial, especially when preoperatively takingcare to plan for adequate correction of the deformity and prevent recurrence,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 juncture of the longitudinal axis of the first metatarsal with the longitudinalaxis of the adjacent metatarsal.
A 10 degrees angle or greater is oftenindicative of pathology.19 A hallux valgus angle more than 16degrees is also indicative of pathology. This angle can be measured by the junctureof the long axis of the proximal phalanx with the long axis of the firstmetatarsal. Lateral displacement of the sesamoids is often correlated with theseverity of a hallux valgus deformity.
Any degree of hallux valgus deformitywill rotate the sesamoids along the long axis of the metatarsal, altering theirposition.19 The proximal articular set angle (PASA) can also bemeasured to assess the relationship of the longitudinal 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 joined with an Akin osteotomy in thetreatment of juvenile HAV. The Scarf procedure is a tricut osteotomy that isused 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 decrease in length of the first ray,and in turn, allows for significant correction. Adding an Akin osteotomy, a proximalphalanx closing wedge osteotomy, further corrects any additional abnormalities.An Akin osteotomy is generally performed to correct an abnormal articular setangle.25 When paired with a Scarf osteotomy, these two proceduresprove to be powerful in providing the greatest correction.1Of the 47 feet reportedby Agrawal et al who had 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 need surgical reintervention.The reasons for recurrence were unclear, and may be due to the patient’s youngage or to a more marked deformity.
Together, the Scarf and Akin osteotomies arestrong surgical procedures when considered for the treatment of HAV. However, theelevated recurrence rate of 29.6% should be considered and surgicalintervention utilizing this method should be reserved for adolescent patientswith a significantly painful and severe HAV deformity.1 Percutaneous Osteotomy Gicquel et alretrospectively reviewed 33 percutaneous hallux valgus procedures in femalepatients with ages averaging of 12.5 years. The IM and distal metatarsalarticular (DMAA) angles were evaluated on weight-bearing x-rays to determinethe hallux valgus angle (HVA). Abnormal values were as follows: IMA greaterthan 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 over18 degrees, they performed a lateral wedgeosteotomy at the base of the first metatarsal.12 Inplace of internal fixation, to hold the first ray in an overcorrected position,they used a bandage for six weeks postoperatively, followed by a toe spacer forsix months. Averages for the preoperative IMA, DMAA and HVA were 13.61, 15.97and 28.6 degrees, respectively.
Postoperative averages of IMA, DMAA and HVAwere 12.74, 8.97 and 19.45 degrees, respectively. Of the 33 cases, 20 had apostoperative HVA greater than 16 degrees and after 31.
5 months, all 20 cases demonstratedunder correction. Having an elevated preoperative IMA and lacking appropriateDMAA correction were risk factors correlated with under correction. The resultsfrom the percutaneous osteotomy showed under correction which was inverselyrelated to a high-rated patient satisfaction. Since this study had a fairly smalltrial population, and a short-term follow-up, there is not sufficient data todetermine whether 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 level of pain postoperatively, their resultsshowed insufficient 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 juvenile hallux valgus. Atotal of 11 symptomatic female patients (12 feet) underwent the procedure. Atthe time of surgery, the average age was 17 years. The surgical technique comprisedof a few steps after initially releasing the distal soft tissues. The medialeminence was partially removed to maintain the distal articular surface of thefirst metatarsal head. They then removed the adductor hallucis tendon from itsinsertion site and released the transverse metatarsal ligament. At one and ahalf cm away from the metatarsocuneiform joint, a proximal crescentic osteotomywas performed on the first metatarsal.
22 The proximal fragmentwas then moved medially, the distal first metatarsal fragment was abducted, andthen supinated. Once the desired correction was achieved, stabilization wasachieved with1.5 mm Kirschner wires.
This technique reduced the hallux valgusangle to less than or equal to 17 degrees, and the IMA to less than 10 degrees.The preoperative hallux valgus and 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 part of the first metatarsal toexclude the growth plate, which may be why there have been more literature onthe distal metatarsal osteotomies.24, 26 Though this studyadvocates for more proximal osteotomies in adolescents, one caveat is all thepatients had closed first metatarsal epiphyses and were therefore skeletallymature for this type of procedure. Depending on the age of the patient, thisprocedure may not be an option for the adolescent with painful hallux valgus.22Conclusion Treatinga juvenile hallux abducto valgus deformity is challenging. Considerations suchas the epiphyseal plate at the first metatarsal base and allowing the young andactive adolescent to weight bear needs to be acknowledged when choosing a suitableprocedure.11, 16 Thoughthere is no criteria when deciding a particular procedure and no singletechnique 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.