Orthopedics

Tips & Techniques 

Adolescent Hallux Valgus Revisited

Tyler J. Marshall, MD; Joseph R. Shung, BS; Joseph G. Khoury, MD

Abstract

Treatment of adolescent hallux valgus with first metatarsal double osteotomy is well described in the literature. Unfortunately, first metatarsal phalangeal joint stiffness and deformity recurrence have been reported at relatively high rates. The authors revisit a technique aimed at preventing these complications. [Orthopedics. 2014; 37(8):531–535.]

The authors are from the Division of Orthopaedic Surgery (TJM, JRS, JGK), University of Alabama, Birmingham; and The Children’s Hospital of Alabama (JGK), Birmingham, Alabama.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Joseph G. Khoury, MD, Division of Orthopaedic Surgery, University of Alabama, 316 A.C.C., 1600 7th Ave S, Birmingham, AL 35233-1711 ( jkhoury@uabmc.edu).

Received: July 12, 2013
Accepted: September 26, 2013

Abstract

Treatment of adolescent hallux valgus with first metatarsal double osteotomy is well described in the literature. Unfortunately, first metatarsal phalangeal joint stiffness and deformity recurrence have been reported at relatively high rates. The authors revisit a technique aimed at preventing these complications. [Orthopedics. 2014; 37(8):531–535.]

The authors are from the Division of Orthopaedic Surgery (TJM, JRS, JGK), University of Alabama, Birmingham; and The Children’s Hospital of Alabama (JGK), Birmingham, Alabama.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Joseph G. Khoury, MD, Division of Orthopaedic Surgery, University of Alabama, 316 A.C.C., 1600 7th Ave S, Birmingham, AL 35233-1711 ( jkhoury@uabmc.edu).

Received: July 12, 2013
Accepted: September 26, 2013

Adolescent hallux valgus (AHV) is a relatively common problem with an estimated incidence of 15% to 46%.1–4 Many patients present reporting pain, difficulty with shoe wear, and cosmetic concerns. The pathogenesis behind development of the deformity is multifactorial. Family history, pes planus, and metatarsus primus varus all contribute to the development and progression of AHV.2,3 In contrast to adult hallux valgus, adolescents typically exhibit an increased distal metatarsal articular angle (DMAA) with a congruent first metatarsal phalangeal (MTP) joint.2,3 This difference in biomechanics portends the need for different surgical correction strategies. Appropriate clinical evaluation and treatment planning are critical for good outcomes in this unique population.

Several surgical procedures have been described in the treatment of AHV.4–10 Distal osteotomies such as the Chevron or Mitchell have been popularized and are effective in treating mild to moderate deformities.7–9 In the adolescent population with severe deformities secondary to high intermetatarsal and distal metatarsal articular angles, a more powerful correction is necessary. Double metatarsal osteotomy (DMO) has been described as a successful method of surgically correcting severe AHV.4–6 Traditionally, the DMO was held in place by longitudinal pin fixation of the first ray. This method of fixation allowed for superior angular correction, but left many patients with a stiff first MTP joint.

In 2001, Aronson et al6 reported their results using a modified Peterson technique in an effort to minimize first MTP joint stiffness. This procedure used the same DMO but opted instead for a medial plate fixation technique to avoid injury to the MTP joint articular surface.6 The results were promising with no reported cases of postoperative first MTP joint stiffness at final follow-up. Unfortunately this series reported a 16.7% recurrence rate of the valgus deformity as compared with no recurrences using the traditional Peterson approach with longitudinal pin fixation.4–6

The purpose of this study was to provide an update on the modified Peterson technique for DMO as well as share some slight differences in operative approach that aid in maintaining the correction achieved intraoperatively. To the authors’ knowledge, this study is the largest reported case series using the modified Peterson technique for treatment of AHV.

Operative Technique

A longitudinal incision was made over the medial aspect of the first metatarsal, extending from the metatarsal base to the midpoint of the proximal phalanx. The dissection was performed preserving the nervous and vascular structures. The periosteum was incised longitudinally down to the level of the joint capsule, where the capsule was incised in a distally based v-shaped pattern. Flaps were raised subperiosteally, exposing the length of the first metatarsal and MTP joint. The medial eminence of the head of the first metatarsal was excised parallel with the medial surface of the foot at the groove of Clark (Figure 1).

Intraoperative photographs depicting the groove of Clark (A) and showing the technique for bunion resection (B).

Figure 1:

Intraoperative photographs depicting the groove of Clark (A) and showing the technique for bunion resection (B).

The sharp end of a freer elevator was passed through the MTP joint to “pie crust” the lateral capsule. Under fluoroscopic control, 0.045-inch Kirschner wires were inserted to subtend a distal closing wedge osteotomy defined by the distal limb parallel to the DMAA and the proximal limb perpendicular to the long axis of the metatarsal. Enough room was left distally to accommodate 1 screw in the plate (Figure 2).

Dorsoplantar views by intraoperative fluoroscopy showing the technique for lateral capsular release (A) and Kirschner wire placement as guides for osteotomies (B).

Figure 2:

Dorsoplantar views by intraoperative fluoroscopy showing the technique for lateral capsular release (A) and Kirschner wire placement as guides for osteotomies (B).

The proximal osteotomy was also crafted to leave enough room for 1 screw. The lateral cortex of both osteotomies was left intact to act as a hinge. The proximal osteotomy site was booked open with a straight osteotome hinging the lateral cortex. Lamina spreaders were inserted and the degree of correction was measured by intraoperative fluoroscopy. A piece of tri-cortical bone allograft was measured to fit the desired wedge defect and inserted to create an opening wedge.

The closing wedge osteotomy was reduced and both osteotomies were fixed with a 2.5-mm titanium plate and screws. The periosteum was repaired over the plate and the distal capsule was repaired with 1 nonresorbable suture tied through 1 hole in the plate while the toe was held in a slightly overcorrected position (Figure 3). Two additional capsular sutures were placed for re-enforcement. The subcutaneous tissues were repaired with a running 3-0 Vicryl (Ethicon Inc, Blue Ash, Ohio) suture. The skin was closed with running 4-0 Monocryl (Ethicon Inc) and Dermabond (Ethicon Inc).

Intraoperative photograph demonstrating capsular repair and anchoring to the plate.

Figure 3:

Intraoperative photograph demonstrating capsular repair and anchoring to the plate.

The patient was made non-weight bearing in a short leg cast for 4 weeks. Subsequently, the patient was placed in a boot and weight bearing was progressed as tolerated (Figure 4).

Preoperative dorsoplantar radiograph of the hallux valgus deformity (A). Postoperative fluoroscopy demonstrating correction of deformity (B). Pre-operative photograph of bunion deformity (C). Postoperative photograph of bunion deformity (D).

Figure 4:

Preoperative dorsoplantar radiograph of the hallux valgus deformity (A). Postoperative fluoroscopy demonstrating correction of deformity (B). Pre-operative photograph of bunion deformity (C). Postoperative photograph of bunion deformity (D).

Materials and Methods

From 2007 to 2012, the senior author (J.G.K.) performed first metatarsal double osteotomy with medial plate fixation on 22 feet in 18 adolescent patients. There were 16 female and 2 male patients included in the study. The average patient age was 15 years (range, 12–18 years). The average follow-up was 25 months (range, 5–60 months). All patients were followed clinically and radiographically until evidence of bony union at the osteotomy site had occurred. The authors included patients who had pain, deformity, and difficulties with shoe wear despite appropriate shoe modification as a consequence of moderate to severe hallux valgus. The authors excluded patients who had prior surgical intervention to address the hallux valgus deformity or who had mild hallux valgus radiographically. The design of this study was approved by the university’s institutional review board and consent was obtained from all participating patients.

Adolescent hallux valgus was classified as mild, moderate, or severe based on values previously accepted in the literature.4 Patients with hallux valgus angles greater than 16° but less than 25° and intermetatarsal angles greater than 9° but less than 11° were classified as mild; those with hallux valgus angles greater than 25° but less than 40° and intermetatarsal angles greater than 11° but less than 16° were classified as moderate; and those with hallux valgus angles greater than 40° and inter-metatarsal angles less than 16° were classified as severe.

Patient charts and pre- and postoperative radiographs were reviewed and the hallux valgus angle, intermetatarsal angle, and DMAA were recorded (Figure 5). Patients were surveyed via telephone and scored on satisfaction levels and radiographically via the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale (Table 1).11 The results were tabulated and patients were scored 0 to 100 according to patient-specific outcomes. On the basis of the AOFAS score, patients were classified as having excellent, good, fair, or poor final outcomes. Patients were also asked whether they would choose to have the procedure again (definitely yes, probably yes, probably not, definitely not).

Dorsoplantar radiographs showing preoperative measurement of hallux valgus angle (A) and intermetatarsal angle (B) (A) and distal metatarsal articular angle (B).

Figure 5:

Dorsoplantar radiographs showing preoperative measurement of hallux valgus angle (A) and intermetatarsal angle (B) (A) and distal metatarsal articular angle (B).

Hallux Metatarsophalangeal-Interphalangeal Scale

Table 1:

Hallux Metatarsophalangeal-Interphalangeal Scale

Results

The average preoperative hallux valgus angle was 33° (range, 18.3°–46°) and was reduced to 15.5° (range, 7.5°–30°) at final follow-up for a correction of 17.5°. The average preoperative intermetatarsal angle was 17.0° (range, 11°–26°) and was reduced to 6.5° (range, 1.5°–11°) at final follow-up for a correction of 10.5°. The average pre-operative DMAA was 28.9° (range, 16.5°–45°) and was reduced to 6.3° (range, 0.4°–22°) at final follow-up for a correction of 22.6° (Figure 6). The difference between pre- and postoperative values was found to be significant using a 2-tailed paired t test (P<.001). There were no intraoperative complications. The average time to osteotomy union was 6 weeks.

Bar graph depicting average pre- and postoperative angular deformity. Abbreviations: DMAA, distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle; Postop, postoperative; Preop, pre-operative.

Figure 6:

Bar graph depicting average pre- and postoperative angular deformity. Abbreviations: DMAA, distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle; Postop, postoperative; Preop, pre-operative.

A 2-tailed group t test was used to compare AO-FAS scores in individuals with preoperative AHV scores of moderate and severe. The moderate group had an average AOFAS score of 93.3±8.2. The severe group had an average AOFAS score of 77.4±12.8. These values were found to be significant with a P value of .024.

At final follow-up, all but 1 patient reported normal motion or mild restriction of motion involving the first MTP joint, defined as more than 74° of dorsiflexion and plantarflexion on examination. One patient reported moderate restriction of MTP motion, defined as 30° to 74° of dorsiflexion and plantarflexion on examination, which developed postoperatively. Two of the patients (9%) complained of prominent hardware and subsequently had the hardware removed. One patient developed a neuroma and had the neuroma resected. There was 1 delayed union treated with a bone stimulator. There was 1 asymptomatic nonunion that was revised with repeat open reduction and internal fixation and bone grafting. There was no evidence of hardware loosening or failure and no recurrences of the deformity. No infections occurred.

Of the 18 patients included in the study, 12 responded via telephone survey including 17 of 22 operative feet. The average postoperative AOFAS score was 88 of 100 (good). Eleven of 17 feet (65%) had excellent outcomes according to the AOFAS score. One of the 17 feet (6%) was rated as good, 2 of 17 (12%) were rated as fair, and 3 of 17 (18%) were rated as poor. When asked if they would have the procedure again, 9 of 12 patients (75%) responded “definitely yes” with an average AOFAS score of 95. Two of the 12 (17%) responded “probably yes” with an average AOFAS score of 89. One of the 12 (8%) responded “probably no” with an AOFAS score of 75. The AOFAS score as it correlates with mean pre- and postoperative deformity is depicted in Table 2. Although not statistically significant, these results demonstrate a clear trend between severe preoperative deformities and poor performance on the AOFAS scoring scale.

AOFAS Scores as They Relate to Preoperative and Postoperative Deformity

Table 2:

AOFAS Scores as They Relate to Preoperative and Postoperative Deformity

Discussion

Adolescent hallux valgus remains a difficult clinical condition to treat while maintaining a high level of patient satisfaction. In the current series using the modified Peterson technique with capsular advancement, the authors managed to provide angular correction comparable to that reported in the literature with no recurrence of deformity or first MTP joint stiffness.4–6 The complication rate in the current series is comparable to those reported for similar procedures.4–6,10 The average follow-up time of 25 months strengthens the evidence that the procedure provides adequate correction and patient satisfaction at mid-term follow-up.

The modified DMO with capsular advancement offers solutions to pitfalls experienced with prior surgical techniques. It avoids first MTP joint stiffness and chondral damage by remaining extra-articular. It also allows for reinforcement of the correction achieved by the initial osteotomy by advancing the capsule with nonabsorbable suture through the medial plate. This slight modification in technique has significantly decreased deformity recurrence in the current patients’ feet.

The authors’ statistical analysis points out a significant correction in pre- and postoperative deformity. The patients who fell into the moderate AHV category had significantly better outcomes and AOFAS scores than those who fell into the severe category.12 The authors believe this outcome can be used to guide preoperative expectations.

The limitations of this study are the small sample size and lack of long-term follow-up. Not surprisingly, patient outcomes according to AOFAS score and by satisfaction survey correlated directly with degree of residual deformity. Patients with the worst preoperative deformities also had poorer postoperative outcomes in the current series. Activity level, shoe wear, and postoperative cosmesis may also contribute to perceived surgical outcomes.

Conclusion

The modified Peterson technique with capsular advancement is a safe and effective treatment for moderate and severe AHV. The procedure is relatively easy to perform and mitigates concerns regarding first MTP joint stiffness and deformity recurrence. Patients with severe deformities should be counseled preoperatively about expectations for surgical outcomes. The small sample size in this case series warrants further study with larger patient cohorts.

References

  1. Owoeye BA, Akinbo SR, Ai-yeabusi AL, et al. Prevalence of hallux valgus among youth population in Lagos, Nigeria. Niger Postgrad Med J. 2011; 18(1):51–55.
  2. Morrisey RT. Juvenile hallux valgus. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:1297–1300.
  3. Pique-Vidal C, Sole MT, Antich J. Hallux valgus inheritance: pedigree research in 350 patients with bunion deformity. J Foot Ankle Surg. 2007; 46(3):149–154.
  4. Johnson AE, Georgopoulos G, Erickson MA, et al. Treatment of adolescent hallux valgus with the first metatarsal double osteotomy. J Pediatr Orthop. 2004; 24:358–362.
  5. Peterson HA, Newman SR. Adolescent bunion deformity treated with double osteotomy and longitudinal pin fixation of the first ray. J Pediatr Orthop. 1993; 13:80–84
  6. Aronson J, Nguyen LL, Aronson EA. Early results of the modified Peterson bunion procedure for adolescent hallux valgus. J Pediatr Orthop. 2001; 21:65–69.
  7. Coughlin M. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995; 16(11):682–697.
  8. Lin JS, Bustillo J. Surgical treatment of hallux valgus: a review. Curr Opin Orthop. 2007; 18:112–117.
  9. Weiner BK, Weiner DS, Mirkopulos N. Mitchell osteotomy for adolescent hallux valgus. J Pediatr Orthop. 1997; 17(6):781–784.
  10. Andreacchio A, Origo C, Rocca G. Early results of the modified Simmonds-Menelaus procedure for adolescent hallux valgus. J Pediatr Orthop. 2002; 22:375–379.
  11. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994; 15(7): 349–353.
  12. Thordarson D, Ebramzeh E, Moorthy M, et al. Correlation of hallux valgus surgical outcome with AOFAS forefoot score and parameters. Foot Ankle Int. 2005; 26(2):122–127.

Hallux Metatarsophalangeal-Interphalangeal Scale

Scale Score
Pain (40 points)
  None 40
  Mild, occasional 30
  Moderate, daily 20
  Severe, almost always present 0
Function (45 points)
  Activity limitations
    No limitations 10
    No limitations of daily activities, limitation of recreational activities 7
    Limited daily and recreational activities 4
    Severe limitation of daily and recreational activities 0
  Footwear requirements
    Fashionable, no inserts 10
    Comfort footwear, shoe insert 5
    Modified shoes or brace 0
  MTPJ range of motion (dorsiflexion plus plantar-flexion)
    Normal or mild restriction (75° or more) 10
    Moderate restriction (35°–74°) 5
    Severe restriction (less than 30°) 0
  IPJ range of motion (plantarflexion)
    No restriction 5
    Severe restriction (less than 10°) 0
  MTPJ-IPJ stability (all planes)
    Stable 5
    Definitely unstable or able to dislocate 0
  Callus related to hallux MTPJ-IPJ
    No callus or asymptomatic callus 5
    Callus, symptomatic 0
Alignment (15 points)
  Good, hallux well aligned 15
  Fair, hallux malalignment, no symptoms 8
  Poor, symptomatic malalignment 0

AOFAS Scores as They Relate to Preoperative and Postoperative Deformity

AOFAS Score HVA IMA DMAA
Excellent
  Preop 29 16 22
  Postop 12 7 2
Good
  Preop 35 18 37
  Postop 13 8 7
Fair
  Preop 39 19 34
  Postop 22 7 13

10.3928/01477447-20140728-05

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