Current And Emerging Concepts In Treating Juvenile Hallux Valgus

I just returned from lecturing at the American College of Foot and Ankle Pediatrics (ACFAP) Annual Meeting in Bay Harbor, Maine. If you have an interest in pediatric foot and ankle care, it really is a must attend meeting. This year, one of the topics I spoke on was juvenile hallux valgus (HAV). What I learned reading through the 50-plus articles to put my lecture together was fascinating so I thought I would share this information with you.

Coughlin’s 1995 article is clearly the hallmark article on this topic.¹ While the article examines procedural outcomes for juvenile HAV, the goldmine is the epidemiological findings. The study examined 719 HAV patients having surgery over an 11-year period. Sixty-five patients of the 719 had juvenile HAV (9 percent) with 60 feet in 45 patients meeting study inclusion criteria with an average follow-up of 60 months. The female to male ratio was consistent with other studies on adults with HAV (88 percent women to 12 percent men). The average age of onset was 11.8 years with 40 percent having an onset prior to 10 years of age. The average age at surgery was 15.9 years with 12 percent receiving surgery with an open growth plate. Ninety-six percent of the patients related deformity progression, 82 percent related pain and only 24 percent related constrictive shoe wear.

In the adult patient with HAV, it is commonly accepted that shoe wear is not causative but is related to deformity progression. However, in the juvenile HAV patient, shoe wear is of little consequence. A family history of HAV was present in 72 percent of the patients with most of them having maternal transmission.¹

Coughlin did not find the presence of metatarsus adductus, despite prior speculation by other authors, to correlate to the degree of deformity or post-operative correction.¹ A first metatarsal greater than 1 mm longer than the second metatarsal had a significantly larger distal metatarsal articular angle, a non-significantly increased hallux valgus (HV) angle and no difference in intermetatarsal angle. Despite the documented relationship between pes planus and juvenile HAV, the study showed no significant association with preoperative deformity or postoperative recurrence.

The average closure of the epiphysis at the base of the first metatarsal, according to Sarrafian and Kelikian, is 13.7 years for females and 15.6 years for males.² In Coughlin’s study, the seven patients having surgery with an open epiphysis had significantly worse deformities, requiring greater correction and higher complication rates.¹ The distal metatarsal articular angle in the open epiphysis group was twice that of the closed epiphysis group, possibly relating to the increased complication rates for the open group. Similarly, those with juvenile HAV onset prior to age 10 demonstrated significantly worse deformities, requiring significantly more deformity correction.

Before discussing surgical treatment outcomes, physicians should attempt non-surgical treatment. Kilmartin and colleagues showed in a study of 6,000 children ages 9 and 10 that 122 had a radiographic diagnosis of juvenile HAV (2 percent).³ A randomized study for 93 children who were not lost to follow-up compared the use of a custom-molded orthotic for the treatment group with juvenile HAV and no treatment for the control group with juvenile HAV. The study found that custom orthotics did not change the rate of juvenile HAV progression and for those with unilateral deformity, custom orthotics increased the development of juvenile HAV on the unaffected limb. Although clinicians utilize custom orthoses for pediatric flatfoot deformity, this treatment modality is questionable for juvenile HAV.

In Coughlin’s study, there were four different surgical treatments (McBride bunionectomy, Chevron bunionectomy, distal soft tissue procedure with proximal osteotomy and double osteotomy).¹ The McBride and Chevron procedures failed to provide the same correction as the distal soft tissue procedure with the proximal osteotomy and double osteotomy by a statistically significant amount. Excellent or good outcomes occurred in 92 percent of the cases for all types of procedures.

The concept of HAV being a triplanar deformity, put forth by Dayton and colleagues, plays an important role in juvenile HAV.^4-6 Those arguing this concept seem to be saying the same thing as Dayton but they are just using different reference points (midline of the body rather than the second metatarsal). The argument against in fact becomes supportive of Dayton when one takes it into context. The recent literature, such as studies by Perera, Kim and their respective colleagues, clearly supports Dayton’s concepts.^7,8

The literature authors use to argue/confirm (especially comparing apples to apples) is dated at best. Those applying the concept surgically see confirmation of Dayton’s findings both intra-operatively and postoperatively. Any procedure that does not allow for triplanar correction is doomed to recurrence because the proximal phalanx will ultimately follow the sesamoids due to their attachment to the proximal phalanx via the plantar plate. Translational osteotomies fail to correct the valgus position of the sesamoids. This would explain the poor outcomes of the chevron procedure in Coughlin’s study and the 73 percent recurrence rate cited by Pentikainen and coworkers in the longest follow-up study on the chevron osteotomy.^1,9

The opening wedge osteotomy is a commonly deployed procedure in juvenile HAV. The results of the procedure are mixed. The most recent study by Iyer and coworkers in 2015 occurred on adults, not children, but demonstrated significant early recurrences, leading the authors to abandon the procedure in favor of the Lapidus procedure.¹⁰

Another procedure described in the literature for juvenile HAV is lateral hemiepiphysiodesis of the first metatarsal. Davids and coworkers examined this procedure and recommended it for children with two or more years of growth remaining (prior to 10 years of age in girls and 12 years of age in boys).¹¹ Although the correction of HAV and intermetatarsal angles showed statistical significant improvement, the postoperative averages were still abnormal (31.18 degrees and 13.13 degrees respectively).¹¹ These abnormal radiographic values bode poorly as the adolescent transitions to adulthood.

A study performed by Grace and colleagues examined the role of the Lapidus procedure for juvenile HAV.¹² The study occurred well before the concept of triplanar correction arose but the authors cited 28 excellent or good results in 30 feet. The authors stated, “The modified Lapidus arthrodesis accomplishes two major goals not attainable with metatarsal osteotomies. This procedure will restore stability to the first ray and eliminate disturbances in weightbearing patterns of the forefoot.” The recurrence rate in the study was only 6 percent.

Most authors recommend waiting until the epiphysis is closed before operating on juvenile HAV. I would agree with this recommendation, especially because I recommend a Lapidus procedure for juvenile HAV. The Lapidus procedure provides triplanar correction closest to the center of rotation of angulation (according to LaPorta and colleagues, the CORA is located at the proximal lateral first cuneiform).¹³ I also recommend correcting any concurrent deformities such as equinus or pes planus at the same time. While Coughlin’s study consisted of a significant 60-month follow-up, it does not cover the next 50 to 60 years of life for these adolescents.¹

Juvenile HAV provides unique challenges and considerations. Hopefully, this blog will provide some evidence-based support for your decision-making process regarding this deformity.

References

1. Coughlin MJ. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995; 16(11):682-697.
2. Kelikian AS, Sarrafian SK. Sarrafian's Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, Third Edition. Lippincott Williams & Wilkins, Philadelphia, 2011.
3. Kilmartin TE, Barrington RL, Wallace WA. A controlled prospective trial of a foot orthosis for juvenile hallux valgus. Bone Joint J. 1994; 76(2):210-214.
4. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013; 52(3):348-354.
5. Dayton P, Feilmeier M, Kauwe M, et al. Observed changes in radiographic measurements of the first ray after frontal and transverse plane rotation of the hallux: does the hallux drive the metatarsal in a bunion deformity? J Foot Ankle Surg. 2014; 53(5):584-587.
6. Dayton P, Kauwe M, Feilmeier M. Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy. J Foot Ankle Surg. 2015; 54(1):102-111.
7. Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg Am. 2011; 93(17):1650-1661.
8. Kim Y, Kim JS, Young KW, et al. A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. Foot Ankle Int. 2015; 36(8):944-952.
9. Pentikainen I, Ojala R, Ohtonen P, et al. Preoperative radiological factors correlated to long-term recurrence of hallux valgus following distal chevron osteotomy. Foot Ankle Int. 2014; 35(12):1262-1267.
10. Iyer S, Demetracoupoulos CA, Sofka CM, Ellis SJ. High rate of recurrence following proximal medial opening wedge osteotomy for correction of moderate hallux valgus. Foot Ankle Int. 2015; 36(7):756-763.
11. Davids JR, McBrayer D, Blackhurst DW. Juvenile hallux valgus deformity: surgical management by lateral hemiepiphyseodesis of the great toe metatarsal. J Pediatr Orthopaed. 2007; 27(7):826-830.
12. Grace D, Delmonte R, Catanzariti AR, Hofbauer M. Modified Lapidus arthrodesis for adolescent hallux abducto valgus. J Foot Ankle Surg. 1999; 38(1):8-13.
13. LaPorta GA, Nasser EM, Mulhern JL, Malay DS. The mechanical axis of the first ray: a radiographic assessment in hallux abducto valgus evaluation. J Foot Ankle Surg. 2016; 55(1):28-34.