Analysis of Serial Radiographs of the Foot to Determine Normative Values for the Growth of the First Metatarsal to Guide Hemiepiphysiodesis for Immature Hallux Valgus

First Metatarsal Hemiepiphysiodesis for the Treatment of Juvenile Hallux Valgus: A Systematic Review

INTRODUCTION

Juvenile hallux valgus (JHV) is a pediatric deformity characterized by the varus deviation of the first metatarsal and valgus deviation of the proximal phalanx. Among the several surgical techniques available, hemiepiphysiodesis consists of the unilateral growth arrest of the first metatarsal physis. Despite this technique has been proposed over 70 years ago, only a few studies including clinical and radiological outcomes have been published, making the procedure unclear in terms of results. This systematic review aimed to evaluate the outcomes of hemiepiphysiodesis of the first metatarsal in the treatment of JHV.

METHODS

Google Scholar, Embase, PubMed, and Cochrane databases were searched for all the articles reporting on clinical and radiological results of hemiepiphysiodesis of the first metatarsal in the treatment of JHV. The selected articles were reviewed to extract demographic data, surgical techniques, complications, clinical outcomes, and radiological parameters.

RESULTS

Six articles were included in the qualitative analysis. A total of 85 patients with 144 halluces valgus were treated through hemiepiphysiodesis of the first metatarsal. The mean age at surgery was 10.7 years (range 5 to 15). The mean follow-up was 2.7 years (range 1 to 7.5). Hemiepiphysiodesis was performed through 2 different techniques. Eighteen (12.5%) complications occurred. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score increased from 70.6 (range 49 to 93) preoperatively to 89.4 (range 72 to 100) postoperatively. The mean HVA improved from 28.3 (range 14 to 46) to 24.03 degrees (range 0 to 54), and the mean IMA improved from 13 (range 8 to 33) to 10.9 degrees (range 8 to 33).

CONCLUSIONS

This review showed that hemiepiphysiodesis of the first metatarsal is a safe treatment for JHV. Improvement in both clinical and radiological results has been observed in all the studies, sometimes being statistically significant. Despite the improvement, mean postoperative radiological angles remained altered and consistent with mild-moderate hallux valgus. This suggests that hemiepiphysiodesis plays a bigger role in preventing the worsening of the deformity rather than correcting it. Randomized controlled trials with longer follow-up and a larger number of patients are needed to further investigate the efficacy and safety of this treatment.

Growth Modulation for the Treatment of Juvenile Hallux Valgus: A Systematic Review of Literature

Background

Juvenile hallux valgus (JHV) is a forefoot deformity that causes pain and functional limitation. Treatment poses a challenge in terms of the optimal technique and timing of intervention. A systematic review of the literature on the use of growth modulation in treating JHV was conducted.

Materials and methods

The literature review was performed using PubMed and EMBASE searches for articles investigating growth modulation in the treatment of JHV published before December 1st, 2021. Seven articles were included in the final review that matched the inclusion and exclusion criteria. The primary outcomes included the degree of correction of hallux valgus angle and intermetatarsal angle. A qualitative assessment of the articles was done due to the heterogeneity of the growth modulation methods used in these articles.

Results

A total of 135 feet from 78 patients were included from the reviewed articles. Growth modulation methods included temporary screw lateral hemiepiphysiodesis of the first metatarsal, lateral drilling hemiepiphysiodesis of the first metatarsal, and a trephine plug removal of the lateral epiphysis followed by cancellous bone graft insertion. The degree of correction of the hallux valgus and intermetatarsal angles were found to be statistically significant in all studies, regardless of the technique.

Conclusion

Growth modulation for JHV by lateral hemiepiphysiodesis using minimally invasive techniques produced favourable radiologic outcomes with some evidence of clinical improvement. Larger, prospective and comparative studies with objective clinical outcome measures may further consolidate this surgical approach as a mean to treating this deformity.

How to cite this article

AlZeedi M, Park JP, Marwan Y, et al. Growth Modulation for the Treatment of Juvenile Hallux Valgus: A Systematic Review of Literature. Strategies Trauma Limb Reconstr 2023;18(1):51-55.

Temporary Screw Lateral Hemiepiphysiodesis of the First Metatarsal for Juvenile Hallux Valgus Deformity: A Case Series of 23 Feet

Juvenile hallux valgus (JHV) can limit the quality of life of the affected children. This study aims to evaluate the outcomes of temporary screw lateral hemiepiphysiodesis of the base of the first metatarsal. A chart review of patients who underwent temporary screw lateral hemiepiphysiodesis of the first metatarsal at a tertiary care pediatric orthopedic center was done. A total of 23 feet of 14 patients were included. The mean age of the patients was 10.6 ± 1.8 years, while the bone age was 11.1 ± 1.8 years. The mean follow-up duration was 24.7 ± 13.4 months (range: 12-60 months). The hallux valgus angle (HVA) improved from a mean of 30.9° ± 6.7° to a mean of 27.6° ± 8.2° (p = .001), while the intermetatarsal angle (IMA) improved from a mean of 14.6° ± 2.3° to a mean of 12.5° ± 3.0° (p < .001). Revision surgery was done for 5 (21.7%) feet of 3 patients for symptomatic uncorrected deformity (4 feet) or screw migration due to bone growth (1 foot). The mean HVA correction was 5.00° ± 3.7° in patients with bone age of 12 years or less compared to 1.50° ± 4.6° in patients with bone age of more than 12 years (p = .060). The radiological outcomes of temporary screw lateral hemiepiphysiodesis of the first metatarsal for JHV deformity correction are promising, especially in children with lesser bone age. The procedure was technically simple to perform and had minor complications.

Forefoot malformations, deformities and other congenital defects in children

Congenital pathologies of the forefoot encompass two broad entities with vastly different treatments and prognosis: malformations, which occur during the embryonic period and cause anatomical defects, and deformations, which occur during the fetal period on a foot that is configured normally. These deformities are more easily cured when they occur later during the fetal period. When the anomaly is bilateral, a genetic origin must be considered. There are two main entities under the term "deformity": metatarsus adductus and skewfoot (aka "Z"-foot or serpentine foot). Within malformations are brachydactyly (transverse defects), longitudinal defects, syndactyly, polydactyly, clinodactyly and macrodactyly. Among other forefoot abnormalities are hallux valgus, which rarely presents in congenital form, and for which conservative treatment is sometimes sufficient. Also in this group are sequelae of amniotic band constriction, forefoot anomalies secondary to the treatment of congenital pathologies (talipes equinovarus and congenital vertical talus) and nail-related pathologies (ingrown toe nail and incorrect nail position).

Effectiveness of subtalar arthroereisis with endorthesis for pediatric flexible flat foot: a retrospective cross-sectional study with final follow up at skeletal maturity

BACKGROUND

Pediatric flexible flatfoot is sometimes asymptomatic but it can rarely cause physical impairment, pain, and difficulty walking. We evaluated the radiographic effectiveness of intervention of subtalar arthroereisis with endorthesis for pediatric flexible flatfoot with final follow-up at skeletal maturity.

METHODS

This is a retrospective cross-sectional study. 56 consecutive patients (112 feet) who underwent surgical treatment with subtalar arthroereisis for pediatric flexible flatfoot (mean age at final follow-up 15.5±1.2 years, 39.3% female) were enrolled. All the radiographic studies were performed in the hospital. Radiographs (standard weight-bearing radiographs of the foot with anteroposterior and lateral view) were used to measure lateral talocalcaneal angle (LTC), calcaneal pitch angle (CP), Meary's angle (MA), anteroposterior talonavicular angle (APTN), talonavicular uncoverage percent (TNU). Minimum follow-up was 18 months. Measures were assessed pre-operatively and at the final follow-up. Clinical and functional parameters were assessed at the final follow-up.

RESULTS

Children who underwent surgical treatment with subtalar arthroereisis for pediatric flexible flatfoot exhibited a statistically significant improvement in all radiographic measurement parameters at the last follow-up at skeletal maturity (all, p<0.004). Mean follow-up was 40.1±23.6months. Clinical parameters were not correlated with the foot radiographic parameters at follow up period.

CONCLUSIONS

Our results suggest that endorthesis in pediatric flexible flatfoot was effective for improving radiographic parameters at skeletal maturity. The amount of the morphologic correction at the end of the skeletal growth should be expected mainly for lateral tarso-metatarsal alignment and talo-navicular congruency (MA, APTN, TNU).

LEVEL OF EVIDENCE

Level III, retrospective study.

Lateral hemiepiphysiodesis of the first metatarsal for juvenile hallux valgus

BACKGROUND

Juvenile hallux valgus (JHV) frequently results in an impaired quality of life because of pain and deformity. We used a validated clinical score to investigate the efficacy of lateral hemiepiphysiodesis of the first metatarsal base as a treatment for JHV.

METHODS

We conducted a prospective, nonrandomized, single center cohort study of children who underwent lateral hemiepiphysiodesis for 31-IV, with a clinical and radiologic follow-up of at least 2 years. The efficiency of the procedure was assessed with the Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), the metatarsophalangeal angle (MPA), and intermetatarsal angle (IMA).

RESULTS

Twelve patients (22 feet) with JHV were treated by lateral hemiepiphysiodesis between 2012 and 2015. Average age at surgery was 10 years, and average follow-up was 3.5 years. The average HMIS score increased from an average of 56 at baseline, to 92 at last follow-up ( p < 0.01). The average IMA decreased by 2°, from 13° preoperatively to 11° postoperatively. Average MPA decreased from 26° at baseline to 22° after surgery. No complications occurred in the immediate postoperative period, and no patient needed an additional procedure.

CONCLUSION

The HMIS score was significantly improved after lateral hemiepiphyslodesis, with a clear improvement in pain and functional impairment at last follow-up. We noted a stabilization of the IMA and MPA, but the radiologic benefit did not reach statistical significance. Our data support the use of lateral hemiepiphysiodesis as an effective and safe treatment of JHV.

Innovative treatment for pes cavovarus: a pilot study of 13 children

Background and purpose - Pes cavovarus (PCV) is a complex deformity, frequently related to neurological conditions and associated with foot pain, callosities, and walking instability. The deformity has the tendency to increase during growth. Orthotic treatment is ineffective and surgery may be troublesome. We present the preliminary results of a new mini-invasive surgical technique for correction of this foot deformity. Patients and methods - We operated on 13 children (24 feet), age 7-13 years. In 7 children the deformity was neurological in origin. The surgical technique included a dorsal hemiepiphysiodesis of the 1st metatarsal, and a plantar fascia release. The clinical deformity, hindfoot flexibility, and foot callosities, together with a radiological assessment (Meary angle, calcaneal pitch, and talo-calcaneal angle), was done pre- and postoperatively. At final check-up, after a median of 28 months (12-40), the Oxford Ankle Foot Questionnaire for children (OXAFQ-C) was used to assess patient satisfaction. The primary outcome was the hindfoot varus correction. Results - All the operated feet improved clinically and radiologically. Heel varus improved from a mean 6° preoperatively to 5° valgus postoperatively. In those children where treatment was initiated at a younger age, full correction was achieved. Footwear always improved. Interpretation - This treatment may offer a less aggressive alternative in the treatment of PCV in young children and may eventually reduce the amount of surgery needed in the future.

Ossification of the phalanges of the foot and its relationship to peak height velocity and the calcaneal system

PURPOSE

There are multiple skeletal maturity grading systems, but none of them utilizes the phalanges of the foot. To minimize radiation, it would be ideal if one could assess the skeletal maturity of a foot based on bones seen on routine foot radiographs, if guided growth is being considered as a treatment option. We developed a system that correlates changes of the appearance of the foot phalanges to peak height velocity (PHV) and the recently described calcaneal apophyseal ossification grading system.

METHODS

We selected 94 children from the Bolton-Brush study, each with consecutive radiographs from age ten to 15 years old. Using the anteroposterior view, we analyzed the ossification patterns of the phalanges and developed a six-stage system. We then determined the PHV for each subject and defined its relationship with our system. Our system was then compared with the previously established calcaneal system.

RESULTS

We calculated an Intraclass correlation coefficient (ICC) range of 0.957 to 0.985 with a mean of 0.975 and interclass reliability coefficient of 0.993 indicating that this method is reliable and consistent. Our system showed no significant difference between gender with respect to PHV, which makes it a reliable surrogate for determining bone age in paediatric and adolescent patients.

CONCLUSIONS

Our system has a strong association with the calcaneal system. It is a simple six-stage system that is reliable and correlated more strongly with PHV than chronological age. The system requires knowledge of the ossification markers used for each stage but is easily used in a clinical setting.