Natural progression of radiographic indices in juvenile hallux valgus deformity

doi:10.1016/j.fas.2018.02.001

Foot and Ankle Surgery

Volume 25, Issue 3, June 2019, Pages 378-382

https://doi.org/10.1016/j.fas.2018.02.001 Get rights and content

Highlights

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HVA was correlated with HIA, IMA, MAA, DMAA, and AP talo-first metatarsal angle.
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JHV deformity could progress with aging.
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Most of the deformity progression could occur before the age of 10 years.

Abstract

Background

This study aimed to estimate the annual change in radiographic indices for juvenile hallux valgus (JHV) and to analyze the factors that influence deformity progression.

Methods

Patients aged <15 years who had JHV and were followed up for at least 1 year were included. Hallux valgus angle (HVA), hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-first metatarsal angle, and lateral talo-first metatarsal angle were evaluated. The progression rate of HVA was adjusted by multiple factors by using a linear mixed model.

Results

A total of 133 feet were included. The HVA and distal metatarsal articular angle both increased by 0.8° per year (p < 0.001 and p = 0.003, respectively). HVA increased by 1.5° per year (p < 0.001) at under the age of 10, and the HVA progression in the older patients was not statistically significant.

Conclusions

JHV deformity could progress with aging. Most deformity progression could occur before the age of 10 years.

Introduction

Juvenile hallux valgus (JHV) deformity is described as varus deviation of the first metatarsal and valgus deviation of the first proximal phalanx in a child who is skeletally immature [1]. Compared with the adult deformity, JHV deformity shows less valgus deformity at the first metatarsophalangeal (MTP) joint, a smaller medial eminence, less bursal thickening, and typically no joint degeneration at the first MTP joint [1].

Although a strong hereditary trait for JHV exist [2], the incidence, etiology, risk factors, and natural history of JHV have not been completely defined [3]. A research on first ray axis pathology is also still required [4]. Although controversies regarding JHV treatment were reported, operation is recommended to be performed after the completion of bone maturation because of high recurrence rate with early surgical treatment [2]. The probability of progression of deformity is assumed on the basis of the remaining skeletal growth, and currently, no study has documented the progression of JHV without treatment [3].

Patients with hallux valgus (HV) can be assessed with weightbearing foot radiographs, which have been widely used for preoperative assessment and postoperative follow-up [5], [6], [7], [8]. Radiographic indices on weightbearing foot radiographs showed good to excellent reliability [7]. In addition, radiographic findings showed a good correlation with the clinical appearance of HV [9].

Therefore, this study aimed to estimate the annual change of radiographic indices for JHV and to analyze the factors that influence deformity progression.

Section snippets

Patients selection

This retrospective study was approved by the institutional review board at our hospital. Informed consent was waived because of the retrospective nature of the study.

We reviewed the medical records of consecutive patients with JHV (age <15 years) who were followed up for at least 1 year and who underwent weightbearing foot radiographs (anteroposterior [AP] and lateral view) more than twice between May 2003 and December 2016. JHV was deemed to be present if the hallux valgus angle (HVA) was ≥15°

Results

A total of 133 feet from 69 patients were included in this study. The mean age during the initial examination was 10.2 ± 4.0 years. Five patients showed unilateral involvement, while 64 patients showed bilateral involvement. The mean follow-up duration was 2.8 ± 2.4 years (range, 1.0–9.6 years). The mean HVA and IMA were 18.4 ± 8.0° and 14.9 ± 6.7°, respectively, at the initial examination (Table 1). Radiographic measurements for JHV showed good to excellent reliability. Intraobserver reliability was

Discussion

Information on the natural progression of JHV is lacking. Hence, we conducted this study to estimate the annual change of radiographic indices for JHV and to analyze the factors that influence the deformity progression. Our results showed that the HVA increased by 1.5° per year in patients age <10 years, whereas no significant change in the HVA was noted in patients age ≥10 years.

This study has some limitations. First, this was a retrospective study. As the natural progression of the deformity

Conclusions

In conclusion, JHV deformity could progress with aging. Our study indicated that increased HVA with aging primarily causes the progression of JHV deformity, most deformity progression could occur before the age of 10 years, and physicians can predict the degree of progression of each radiographic measurement in patients with JHV as the patients grow older. Moreover, our results could also help physicians choose the optimal surgical treatment strategy for JHV before skeletal maturation. Further

Funding sources

This work was supported by the new faculty research fund of Ajou University (S-2015-G0001-00092).

Conflict of interest

The authors declare that they have no conflict of interest.

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This study aimed to compare radiographic outcomes of open and minimally invasive surgery (MIS) in patients with hallux valgus. We reviewed data of patients with hallux valgus who underwent open or minimally invasive distal chevron osteotomy at our institution. Radiographic assessment was completed preoperatively, immediate postoperatively, and one year postoperatively using eight weight bearing parameters . The classic distal chevron osteotomy method was used for open surgery and a modified method that added percutaneous K-wire fixation to the minimal invasive Chevron-Akin (third-generation MIS) was used for correction of the distal metatarsal articular angle (DMAA). A total of 65 feet (33 open surgeries and 32 MIS) were included. The HVA, IMA, and DMAA improved significantly following surgery regardless of surgical method (p<0.001). Other radiographic indicators showed no statistically significant differences after surgery. DMAA improved by 71.0±14.2% after surgery, and the open surgery group showed less significant reduction in DMAA (49.7±25.7%, p<0.001). Other parameters showed no difference between the two groups regarding relative postoperative changes. The MIS group showed shorter operation time (p<0.001) and hospitalization period (p=0.034) than did the open surgery group. Therefore, the MIS group is expected to be cost-effective. Radiographic measurements revealed comparable outcomes of MIS compared with open surgery. Additionally, adding percutaneous K-wire fixation during MIS had an advantage in correcting DMAA compared with open surgery. Furthermore, the correction of DMAA could reduce recurrence of valgus deformity of the hallux.
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Citation Excerpt :
The panel recognized and agreed that the pediatric or juvenile HV deformity presents a unique set of characteristics and considerations in comparison to the adult deformity. These might include reduced medial soft tissue hypertrophy, limited medial metatarsal head eminence, reduced valgus orientation of the hallux, more frequent presence of hypermobility, relative plasticity of immature bone, the presence of an open physis at the proximal first metatarsal, and an increased association with other medical conditions including, but not limited to, Down syndrome, connective tissue disorders, juvenile rheumatic disease, and neuromuscular disorders such as cerebral palsy (58,87-102). Perhaps interestingly, a reference to this deformity as “hallux valgus” might not be entirely accurate, as there are seldom adaptive changes in the frontal plane with the pediatric presentation.
Temporary Screw Lateral Hemiepiphysiodesis of the First Metatarsal for Juvenile Hallux Valgus Deformity: A Case Series of 23 Feet
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The mean age of our patients was 10.6 years, while the bone age was 11.1 years. It has been estimated that the HVA increased by 1.5° per year in patient under the age of 10 years, and the HVA progression was not statistically significant in older children (29,30). This might have explained the minimal improvement in the HVA in our series of cases.
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.
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In addition, with increasing severity, the sesamoids are less likely to be underneath the MTPJ and instead subluxate laterally, signifying the increased pull of the soft tissues to worsen the deformity (see Figs. 1 and 2). In growing children (younger than 15 years) with radiographic evidence of JHV, the HVA has been shown to increase about 0.8° per year.25 The DMAA increases in children younger than 10 years at 1.5° per year, but does not increase significantly in the older child.
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¹: These authors contributed equally to the writing of this article.

View full text

Natural progression of radiographic indices in juvenile hallux valgus deformity

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients selection

Results

Discussion

Conclusions

Funding sources

Conflict of interest

J Foot Ankle Surg

J Foot Ankle Surg

The pathophysiology of the juvenile bunion

Instr Course Lect

Juvenile hallux valgus. A conservative approach to treatment

J Bone Joint Surg Am

Juvenile hallux valgus deformity: surgical management by lateral hemiepiphyseodesis of the great toe metatarsal

J Pediatr Orthop

Hallux valgus

Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements

Foot Ankle Int

Reliability and relationship of radiographic measurements in hallux valgus

Clin Orthop Relat Res

Clinical and radiological results after modified distal metatarsal osteotomy for hallux valgus

Foot Ankle Int

Radiographic correlates of hallux valgus severity in older people

J Foot Ankle Res