Surgical treatment for bunions in adolescents

Great Toe Interphalangeal Fusion for Hallux Valgus Interphalangeus Deformity in Young Patients

OBJECTIVES

The purposes of this study were to examine indications, radiographic outcomes, and clinical complications for primary arthrodesis of the great toe interphalangeal (IP) joint in young patients.

BACKGROUND

Hallux valgus interphalangeus deformity of the great toe is uncommon in the pediatric population and often requires fusion of the IP joint.

METHODS

A retrospective review of patients, ages 8 to 19 years, who underwent operative fusion of the great toe IP joint, and had >1 year radiographic follow-up was performed. Medical records and radiographs were reviewed to determine indications for surgery, concomitant procedures, success of fusion, complications, and need for revision procedures or elective hardware removal. Differences between pre and postradiographic outcomes for the hallux valgus angle, IP angle, and intermetatarsal angle were analyzed.

RESULTS

Twenty-seven patients (31 feet) were included in the analyses. The average age at fusion surgery was 14.9 years (SD ± 2.3) with a mean follow-up visit of 35.2 months. The most common indications for fusion of the great toe IP joint were pain and deformity. Kirschner wire fixation was utilized in 7 cases, with the remaining 24 cases fixed with a single retrograde cannulated screw. Fifty-five concomitant toe and foot procedures were performed in 21 feet (68%) to address additional foot and toe deformity. Successful fusion occurred in 30 of 31 toes after the primary fusion. Patient satisfaction with the toe position and diminished pain were high (94.1%). Significant improvement was noted in the measure of the IP angle ( P < 0.001), with minimal clinical change in the hallux valgus angle ( P = 0.24) or the intermetatarsal angle ( P = 0.03).

CONCLUSIONS

Hallux valgus interphalangeus of the great toe was successfully managed with the fusion of the IP joint. Single screw fixation or the use of Kirschner wires led to similar outcomes. Hardware-related issues with the use of screws were the most common adverse outcome. Patients should be made aware of the possible need for hardware removal after fusion utilizing screw fixation.

LEVEL OF EVIDENCE

Level IV-a retrospective case series.

Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

PURPOSE

Proximal first metatarsal osteotomies are recommended for the surgical treatment of moderate to severe hallux valgus deformity. This study aimed to compare correction of intermetatarsal and hallux valgus angles and complications of proximal crescentic, Ludloff, proximal opening wedge, proximal closing wedge, proximal chevron and other proximal first metatarsal osteotomies.

METHODS

A systematic search for the keywords "(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR Ludloff) AND osteotomy" in the online databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed.

RESULTS

There was a mean correction of hallux valgus angle of 20.1° [confidence interval (CI) 18.7-21.4] and of intermetatarsal angle of 8.1° (CI 7.7-8.9). The overall complication rate reached 18.7 %.

CONCLUSIONS

The results of this study reveal higher corrective power of proximal osteotomies compared to meta-analysis data on diaphyseal osteotomies.

Osteotomy of the hallux proximal phalanx

Osteotomy of the proximal phalanx appears to be used more frequently and with increasing indications. It rarely is indicated as the only surgical procedure and often is combined with a secondary procedure. In hallux valgus surgery, a proximal or distal metatarsal osteotomy often is used, and in hallux rigidus, a cheilectomy usually is added. The advantage of a proximal phalanx osteotomy is that it enables an extra-articular correction, which avoids breaching the metatarsophalangeal joint. This extra-articular correction may prevent joint stiffness and long-term joint changes.