Does Patient Age Influence First Ray Procedure Selection?

These authors offer a closer look at hallux abducto valgus and the impact of age on treatment decisions in adolescents and elderly patients.

Hallux abducto valgus (HAV) is the most common pathology involving the first ray that we see as podiatric surgeons. In regard to the prevalence of this deformity in the general population, one study reported a 38 percent prevalence while another study cited a 58 percent prevalence.1,2 While epidemiologic studies of HAV tend to focus on adults over the age of 30, researchers have documented that this ubiquitous deformity occurs in both pediatric and geriatric populations with an increased incidence in older patients and females.3

   The medical literature is replete with articles detailing the effectiveness or ineffectiveness of conservative and surgical interventions for the treatment of HAV. However, there is a lack of literature in regard to the treatment of hallux abducto valgus based on patient age despite patient age playing a pivotal role in the determination of appropriate treatment. Instead, the treatment of HAV appears to be reported independently for adolescent deformities due to its unique characteristics.

   An adolescent HAV is often defined by the presence of an open growth plate located at the base of the first metatarsal. Other unique characteristics associated with adolescent hallux abducto valgus include: metatarsus primus varus; a long first metatarsal; an oblique first metatarsal medial cuneiform articulation; hypermobility; and generalized ligamentous laxity with over 50 percent of patients exhibiting flexible flat feet.4

   The most glaring obstacle for the correction of HAV in the adolescent population is the need to avoid any disruption to the open growth plate of the first metatarsal. As a result, most of the medical literature on surgical intervention describes performing first metatarsal head osteotomies in this patient population. The Mitchell osteotomy for adolescent HAV is probably the most described technique with researchers reporting average to good results.5 However, significant complications of this procedure include: further shortening of the first metatarsal; stiffness of the metatarsophalangeal joint; and transfer lesions of the second metatarsal secondary to dorsal tilt of the osteotomy.

   In addition to the significant complications following distal metatarsal procedures, the recurrence rates following HAV surgery in the adolescent population are reportedly as high as 60 percent.6 Surgeons have attributed this high recurrence rate to a variety of factors including: the presence of a long first metatarsal; incomplete correction of the intermetatarsal angle; or incomplete correction of the hallux valgus angle.

Why The Lapidus Bunionectomy Is The Best Choice For Adolescent HAV

As a result of the high rate of complications and recurrence following distal first metatarsal HAV procedures, the literature has described more proximal procedures in the adolescent such as a crescentic base osteotomy, a closing base wedge osteotomy and a Lapidus bunionectomy.7-8 More proximal procedures possess the advantage of providing greater intermetatarsal angle correction in addition to potentially shortening the first metatarsal, an inherent finding with adolescent HAV.

   The Lapidus bunionectomy further addresses the obliquity of the first metatarsal cuneiform articulation and hypermobility common to the adolescent HAV. Furthermore, authors have demonstrated that there is a reduced loss of intermetatarsal angle correction following the Lapidus bunionectomy in comparison to closing base wedge osteotomies.9

   For those aforementioned reasons, it is our opinion that the Lapidus bunionectomy is the procedure of choice for adolescent HAV in the presence of characteristics such as a higher intermetatarsal angle (greater than 14 degrees), hypermobility and an elongated first metatarsal. Given the presence of the open growth plate in the surgical site, we recommend allowing closure of the growth plate prior to surgical intervention. Proceeding in this manner ensures that one will perform the appropriate procedure for a durable correction with minimal complications.

Choosing A Procedure For Hallux Abducto Valgus In The Elderly

While surgical design for adolescent patients is influenced by hallmarks of development as well as cosmetic concern, surgical planning of hallux abducto valgus in adult or elderly populations differs depending on factors including recovery, home support and the goals of the procedure.

   As a person ages and matures, drifting and contraction of soft tissues lead to an increased deformity. One can appreciate this in cases with overlapping second digits as well as intermetatarsal angles that have continually worsened over time with conservative care. Time not only influences the severity of the defect but bone density and other age-related arthritic conditions alter surgical options. With diminished bone quality, surgery utilizing plates, implants or grafts can cause an increased risk of negative outcomes such as nonunion, delayed union or failure of implants.

   Finally, it is well documented that increasing age is an independent risk factor for postoperative complications such as pulmonary edema, heart attack, abnormal heart rhythms, bacterial pneumonia, respiratory failure and in-hospital mortality.10 As a result, it may be tempting to discourage surgical intervention in the elderly patient with HAV deformity.

   However, this line of reasoning may unfairly and unnecessarily discount the benefits of surgical intervention in this group of patients. The Agency for Healthcare Research and Quality (AHRQ) evaluated the benefits of total knee replacement in its Patient Outcomes Research Team Reports.11 The report cited statistics that despite the risk of complications, quality of life improves for the elderly after knee replacement surgery.

   We can extrapolate the findings of this report to HAV surgery and infer that improved function and reduction of pain symptoms following surgery may be worthwhile goals to attain in this specific patient population.

   Another consideration to take into account when evaluating the elderly patient is the concept of chronologic versus physiologic age. Chronological age is simply age based on the year of birth. In contrast, physiologic age acknowledges the overall health of the individual and is based on function.

   Miller and colleagues attempted to stratify HAV procedure recommendations based on age and severity of deformity.12 In elderly patients (defined as being over the age of 55) with minimal deformity, the authors recommended a Silver procedure and a Keller bunionectomy for more severe deformities. In patients under the age of 55, they recommended a Mitchell procedure.

   While the authors’ recommendations are a good starting point, most surgeons would likely agree that hard age end points do not adequately take into account physiologic age or the individual goals of surgery. Not all patients over the age of 55 are likely to accept the apropulsive gait that ensues following a Keller procedure.

   This highlights the need to accurately assess the patient's goals of the procedure when considering surgical options. Metatarsal head procedures have good results in populations that are relatively healthy and active. Joint destructive procedures such as fusions for more severe HAV cases or older patients also tend to have good results with a faster return to functionality and activity.

   We also stress the importance of long-term versus short-term solutions. Temporary procedures such as Silver procedures may provide five to 10 years of relief but inevitably bony overgrowth begins to develop and cause recurrence of the deformity. For older populations, a short-term procedure may translate into a long-term solution as their activity status and age indicate a proclivity to less “wear and tear,” thus preventing acceleration of HAV symptoms. A salvage procedure with a 10-year symptom relief rate may be successful for a longer period of time for an older patient whose activity level continues to decrease.

In Conclusion

Ultimately, surgical selection is an individualized process. There is no exact formula to determine which procedure is best for which age group. A surgeon must take into account multiple factors including physiologic age, activity level and goals of the procedure for the best possible treatment for each patient. The wide arsenal of procedures and options afforded for HAV deformities allows surgeons great diversity for individualized treatment.

   Dr. Dinh is an Assistant Professor of Surgery at Harvard Medical School and is affiliated with the Beth Israel Deaconess Medical Center in Boston. She is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Kim is a surgical podiatric resident at the Beth Israel Deaconess Medical Center in Boston.

References

1. Roddy E, Zhang W, Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum. 2008;59(6):857-862.

2. Nguyen US, Hillstrom HJ, Li W, et al. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study. Osteoarthritis Cartilage. 2010:18(1):41-46.

3. Gould N, Schneider W, Ashikaga T. Epidemiological survey of foot problems in the continental United States: 1978-1979. Foot Ankle. 1980;1(1):8-10.

4. Scranton P, Zuckerman J. Bunion surgery in adolescents: results of surgical treatment. J of Ped Ortho. 1984;4(1):39-43.

5. Canale PB, Aronsson DD, Lamont RL, Manoli AD. The Mitchell procedure for the treatment of adolescent hallux valgus. A long-term study. J Bone Joint Surg. 1993:75(11):1610-8.

6. Coughlin MJ. Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995;16(11):682-97.

7. Ball J, Sullivan JA. Treatment of juvenile bunion by Mitchell osteotomy. Orthopedics. 1985;8(10):1249-1252.

8. Zimmer TJ, Johnson KA, Klassen RA. Treatment of hallux valgus in adolescents by the chevron osteotomy. Foot Ankle. 1989:9(4):190-193.

9. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A lomng-term follow-up. J Bone Joint Surg Am. 1992;74(1):124-9.

10. Seymour DG, Pringle R. Post-operative complications in the elderly surgical patient. Gerontology. 1983;29(4):262-70.

11. Total Knee Replacement. Summary, Evidence Report/Technology Assessment: Number 86. AHRQ Publication Number 04-E006-1, December 2003. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/clinic/epcsums/kneesum.htm

12. Miller JW. Distal first metatarsal displacement osteotomy: its place in the schema of bunion surgery. J Bone Joint Surg Am. 1974;56(5):923-931.