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					Juvenile Hallux Abducto Valgus

Juvenile HAV
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Definition: an HAV deformity that occurs in an immature or developing foot. Deformity begins in teen or pre-teen years Incidence of juvenile HAV has been researched in several studies

Incidence
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Coughlin 10% of all people with HAV are children average age of onset for juvenile bunions is 11.8 years (age range of 2-18) 40% developed before age 10 84% female
Coughlin M. Juvenile Hallux Valgus: etiology and treatment. Foot and Ankle International 16: 682-697, 1995.

Incidence
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Study by Helat found 92% female Piggot: interviewed large series of adult patients with HAV and found 57% recalled onset during adolescent years Hardy: 40% of all bunions occur before the age of 20

Helal B. Clin Ortho, 1981. Piggott H. Journal of Bone and Joint Surgery, 1960. Hardy R, Clapham J. Journal of Bone and Joint Surgery., 1951.
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Symptoms
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Pain is often not a symptom difficulty wearing shoes and cosmetic appearance are most common desire of young females to wear stylish shoes may initiate symptoms in the previously asymptomatic pt prolonged activity exacerbates symptoms

Symptoms
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Children < 10 seldom have symptoms evaluation often initiated by parents cosmesis often primary concern to parents and pt should never treat on cosmetic basis alone attention should be directed toward overall function of foot and entire LE

Adult vs Juvenile
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Adult: increased incidence of osteoarthritis bursa over medial eminence larger medial eminence increased HA angle
Lynch FR edited by McGlammary. Comprehensive Textbook of Foot Surgery; 1992.

Adult vs Juvenile
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Juvenile: no osteoarthritis or bursa less valgus rotation of the hallux increased IM angle more often associated with hypermobility increased chance of recurrence vs adults remember this is a progressive deformity

Associated Deformities
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predisposing conditions include: flexible flatfoot, met-adductus, and ankle equinus must correct these conditions with HAV juvenile HAV may lead to secondary deformities: hammertoes, 2nd MPJ capsulitis, and transfer lesions
Lynch FR edited by McGlammary. Comprehensive Textbook of Foot Surgery; 1992.
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Associated Deformities

Etiology/Pathogenesis
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Heredity Pes planus ligamentous laxity hypermobile 1st ray tight gastroc-soleus shoewear

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Met adductus/met primus varus short/long 1st met shape of 1st met trauma congenital deformity

Heredity
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Hardy: 77% of pts reported mother having a bunion, 16% said father did Coughlin: 72% had family history, 94% of these showed a maternal pattern of transmission
Coughlin MJ. Surgery of the Foot and Ankle, Couhlin and Mann editors; 1999. Hardy R, Clapham J. Journal of Bone and Joint Surgery, 1951.

Heredity

Pes Planus
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Scranton and Zuckerman: 51% of flatfeet predispose pt to HAV Kalen: found much higher incidence of pes planus due to CP pts in study much more common in HAV pts with neuromuscular disorders Coughlin/Canale: found no correlation between pes planus and HAV

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Scranton P, Zuckerman J. Journal of Pediatric Orthopedics, 1984. Kalen V. Foot and Ankle. 1988. Coughlin. Foot and Ankle International, 1995.

Shoegear
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High heels and constricting toe-boxes increased progression of deformity increased symptoms due to irritation overall shoes play only minor role these pts would get HAV later on anyway

Metatarsal Length
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Long 1st metatarsal leads to increased PASA therefore affecting surgical procedure

Metatarsus Adductus

Anatomy
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Often different than adults M-C and M-P joint shapes and orientation of 1st met medial orientation of M-C joint leads to Met primus varus as a cause for HAV increased incidence of M-C instability and 1st ray hypermobility

Anatomy
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Rounded met head = increased liklihood of HAV due to less resistance to lateral deviation of the hallux abnormal 1st MPJ orientation/shape must be taken into consideration associated with increase in PASA

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Kilmartin TE, Wallace WA. Journal of Foot Surgery. Sep/oct ,1991.

Anatomy
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Location of epiphysis is paramount when planning an osteotomy met primus varus causes increase in compression on medial aspect of proximal epiphysis corresponding tensile force to lateral aspect this creates an epiphyseal abnormality

Anatomy
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Growth stimulated laterally and inhibited medially at growth plate correction should be proximal to epiphysis if this abnormality exists opening wedge of medial cuneiform bypasses any possible injury to epiphysis

Anatomy
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Juvenile HAV almost always pain free with MPJ motion no DJD and medial eminence usually not prominent may not have to resect any redundant eminence after osteotomy/lapidus

Evaluation
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Pay attention to prescence of hypermobility, lig. laxity, and a tight gastroc-soleus. Surgery reserved for symptomatic children that fail conservative treatment never do surgery for cosmetic purposes alone often pain free except for shoe irritation

Evaluation
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Evaluate length of first metatarsal Mitchell osteotomy is common in children, but must consider shortening opening wedge of med. cuneiform contraindicated if met is already long lapidus for hypermobile first ray/lig laxity

Evaluation and Surgical Selection
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Age of child evaluate met adductus and IM angle look at 1st met length and articular surface open epiphysis not an absolute contraindication to surgery complete lateral soft tissue release usually not necessary

Evaluation and Surgical Selection
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Mild to moderate HAV = distal met osteotomy usually performed look at PASA if HA angle >30 this is usually associated with increased IM necessitating a more proximal osteotomy
Jay RM. Pediatric Foot and Ankle Surgery, 1999.

Stages
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Stage 1: juvenile HAV with slight abduction of hallux, full ROM, irritation is present Stage 2: greater deviation of hallux in transverse plane, passively reduced, full ROM, pain free

Stages
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Stage 3: more severe deformity, trackbound 1st MPJ, lateral displacement of sesamoids Stage 4: rare in juvenile HAV, (+) crepitus and pain, (-) ROM

Conservative Treatment
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often adequate splints, bunion shields, and wider shoes modification of footwear may provide reief of symptoms compliance is issue in this age group with regard to corrective footwear low heel, soft upper, and wide toe-box may diminish symptoms
Coughlin MJ. Surgery of the Foot and Ankle, Coughlin and Mann editors; 1999.

Conservative Treatment
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use of orthotics to prevent progression of juvenile HAV is controversial at best patients with flexible flatfoot and ligamentous laxity may benefit from custom orthotics postoperatively when conservative care fails to halt symptoms or progression of the deformity, surgery is considered

Surgical Intervention
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Surgical results not as satisfactory as adult HAV Scranton and Zuckerman: 36% failure rate, 56% recurrence rate if child had hypermobile flatfoot, 50% recurrence rate for those with a long first ray
Scranton P, Zuckerman J. Bunion Surgery in Adolescents: results of surgical treatment. Journal of Pediatric Orthopedics. 4:39-43, 1984.

Surgical Intervention
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Myerson: non-operative treatment usually adequate must address PASA, oblique MC joint, hypermobile first ray surgery may not result in normal appearance of foot, but should restore alignment thereby relieving pain from shoe irritation

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Myerson MS. Foot and Ankle Disorders 2000. Hallux Valgus. 273-288; 2000.

Requirements for Surgical Success
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relief of pain improvement in appearance prevention of recurrence restoration of joint alignment and reduction of IM angle helps to prevent recurrence

Surgery and Juvenile HAV
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Perform sx at or near skeletal maturity, usually done at 11-15 years joint should be preserved, never replaced avoid sesamoid removal

Surgical Procedures
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soft tissue phalangeal osteotomy distal 1st met osteotomy proximal 1st met osteotomy 1st MPJ arthrodesis

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Lapidus medial cuneiform osteotomy multiple osteotomies epiphysoidesis

Distal Soft Tissue Realignment
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Silver: popularized procedure of medial capsulorrhaphy, medial exostectomy, and a lateral capsular/adductor release McBride: modified Silver technique with removal of lateral sesamoid and a transfer of adductor tendon Mann and Coughlin: removal of lateral sesamoid increases rate of hallux varus
Silver D. Journal of Bone and Joint Surgery. 5: 225-232; 1923. McBride E. J of Bone and Joint Surgery. 1967. Mann R, Coughlin M. Clin Orthopedics;1981.
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Indications
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mild-moderate deformity with noncongruent MPJ HA >30, IM<15 1st met-cun joint must allow correction of IM angle often used as adjunct procedure with osteotomies or lapidus

Soft Tissue Procedures
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Isolated McBride for Juvenile HAV= high failure rate (anywhere from 43-75% in the literature). Bonney and McNabb: noted that with the McBride, IM angle returned to preop value or even increased in nearly 2/3‟s of pts.
Bonney G, McNabb I. Hallux Valgus and Rigidus a critical survey of operative results. J of Bone and Joint Surgery. 34B: 366-385; 1952.

Soft Tissue Procedures
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Coughlin: noted that 1/2 of his patients had recurrence after an isolated McBride for juvenile HAV for mild to moderate deformities in the juvenile, an associated Austin osteotomy is usually necessary always be aware of hallux varus
Coughlin MJ. Surgery of the Foot and Ankle, Coughlin and Mann editors; 1999.

Phalangeal Osteotomy
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Akin procedure: attains correction via medial capsulorrhaphy, medial eminence resection, and medial closing wedge osteotomy of proximal phalanx distal Akin indicated for juvenile with hallux valgus interphalangeous proximal Akin for increased DASA
Akin O. Med Sentinnel. 1925.

Akin Procedure
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More common in adults since proximal phalanx rarely deformed in juvenile combined with 1st metatarsal or medial cuneiform osteotomy often insufficient if used alone does not correct 1-2 IM angle must use caution to avoid growth plate

Technique
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Medially based wedge resected with lateral cortex of phalanx left intact approximately 2-3 mm wedge usually fixated with k-wires, place obliquely from a distal medial direction avoiding growth plate and joint space

Akin Procedure for Juvenile HAV
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Studies by both Goldberg and Freid reported high recurrence rates and concluded that isolated phalangeal osteotomy is a contraindication mainly indicated as an adjunct to other bunion procedures
Goldberg and Freid. Orthopaedics, 1985.

Distal First Metatarsal Osteotomies
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Austin Kalish Reverdin Mitchell Wilson Hohman

Distal First Metatarsal Osteotomies
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Mostly same procedures used for adult bunions mild-moderate deformities HA <30, IM 1-2 <15 can correct PASA and reposition head over sesamoids contraindications are severe deformities and an open epiphysis

Complications
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Generally have good results shortening elevatus transfer lesions and lesser metatarsalgia Mitchell and Wilson notorious for shortening

Austin Osteotomy
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IM <15, corrects mild PASA elevation chevron „V‟ cut 60 degrees , distal apex capital fragment shifted laterally to correct IM angle adductor release

Austin Osteotomy
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Displacement of capital fragment at osteotomy site creates prominent medial eminence that must be resected stable internal fixation usually with k-wires immediate WB in post-op shoe aggressive early ROM excercises decrease incidence of limitus triplanar correction with K-wire axis guide

Austin Osteotomy

Complications
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Fx of metatarsal head hallux limitus shortening delayed or nonunion, not common due to large area of cancellous bone contact

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AVN elevation of capital fragment transfer metatarsalgia

Kalish
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Long armed Austin with cut performed at 55 degrees longer dorsal arm allows for fixation with 2.7 cortical screws no PASA correction

Reverdin
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indicated to reduce PASA usually combined with modified McBride complications are uncommon but include: possible sesamoid damage, AVN, elevatus, over/under correction Green modification protects sesamoids

Reverdin
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First cut proximal and parallel to articular cartilage second cut proximal to 1st cut and perpendicular to shaft wedge of bone removed, medial base to correct PASA cuts are distal to sesamoids, therefore WB unaffected and metatarsalgia uncommon

Mitchell Osteotomy
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historically popular for juvenile HAV should only be used with long first met distal cut leaves lateral cortex proximal cut through and through head shifted laterally notorious for shortening

Complications
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Shortening (up to 5mm) leads to transfer lesions AVN joint stiffness malunion may occur if loop fixation used

Mitchell Osteotomy for Juvenile HAV
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Ball and Sullivan: 11 out of 18 patients had recurrences Karbowski: appropriate in adolescents with long first met and met primus varus, but short 1st met is absolute contraindication
Ball J, Sullivan J. Osteotomy. Orthopaedics, 1985. Karbowski A, Schwitalle M, Eckardt A. Acta Orthop Belgium. Sep; 1998.
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Mitchell Osteotomy for Juvenile HAV
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Weiner et al: used modification of procedure with trapezoidal wedge to maintain ray length fixated with smooth k-wire 6 year follow up of 46 adolescents had a 96% success rate
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Weiner et al. J of Pediatric Orthopedics; 1997.

Mitchell

Proximal First Metatarsal Osteotomies
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Indicated for severe bunions IM >14-15 performed with distal soft tissue procedure may require associated repair of metatarsus adductus important for osteotomies to be distal to growth plate to prevent injury

Proximal 1st Met Growth Plate Disruption

Proximal First Metatarsal Osteotomies
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opening wedge osteotomy closing wedge osteotomy crescentic

Opening Wedge Osteotomy
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Historically poor results for juvenile HAV Scranton and Zuckerman high incidence of MPJ stiffening and recurrence of deformity allows for lengthening of first ray as opposed to closing wedge and crescentic that shorten and maintain met. length respectively
Scranton P, Zuckerman J. Bunion Surgery in Adolescents: results of surgical treatment. Journal of Pediatric Orthopedics. 4:39-43, 1984.
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Proximal First Metatarsal Osteotomies

Closing Wedge Osteotomy
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most common proximal osteotomy for juvenile HAV shortens 1st metatarsal transverse or oblique (juvara) osteotomy

Transverse vs Oblique

Closing Wedge Osteotomy
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Transverse more stable more shortening hinge left intact crossed k-wire fixation

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Oblique less stable less shortening +/- hinge +/- wedge removal 2 screw fixation

Crescentic
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Use crescent shaped saw blade to make osteotomy on which metatarsal is swiveled maintains length difficult to fixate without 1st met elevation and growth plate disruption according to Coughlin orienting the cut proximal concave decreases chance of overcorrection and medial prominence
Coughlin MJ. Surgery of the Foot and Ankle, Couhlin and Mann editors; 1999.
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Crescentic

Crescentic
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Ideally cut should be made 1cm distal to MTC in the metaphysis if physis open then cut should be approximately 1cm distal to it Jay: if performed too far distally, there is increased chance of nonunion due to less cancellous bone and tenuous arterial supply of diaphysis
Jay RM. Pediatric Foot and Ankle Surgery, 1999.

Proximal Osteotomy Complications
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shortening (closing) growth plate disturbance difficult to fixate fixation failure elevatus

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Malunion delayed union nonunion undercorrection overcorrection

Coughlin
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“ In the treatment of moderate and severe hallux deformities with subluxation of the MTP joint, a proximal first metatarsal osteotomy combined with a distal soft tissue reconstruction, although technically demanding, can lead to a successful outcome”

First MPJ Arthrodesis
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indicated for severe deformities usually reserved for special circumstances such as: CP, DJD, a subluxed joint, and/or as a salvage procedure after failed realignment attempt. treatment of choice in adolescents with CP who have symptomatic bunions CP pts often need concomitant flatfoot sx

First MPJ Arthrodesis
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According to Renshaw and an updated study by Jenter et al fusion is the primary procedure in CP pts because it eliminates subluxation and instability of the 1st MPJ and allows for increased function at toe-off Jenter stated it outperformed proximal/distal metatarsal and phalangeal ost‟s in CP kids with HAV
Renshaw TS, Sirkin RB, Drennan JC. Dev Med Child Neurology; 1979. Jenter M, Lipton GE, Miller F. Foot and Ankle International. Dec; 1998.
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First MPJ Arthrodesis
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Davids et al: study with CP pts 81-100% improvement in cosmesis, footwear, activity, and pain. unlike fusion, soft tissue procedures and metatarsal osteotomies have not been shown to normalize FF biomechanics
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Davids et al. J of Pediatric Orthopaedics; 2001.

Complications
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nonunion dissipates normal 1st MPJ motion/heel-totoe gait

First MetatarsalCuneiform Fusion
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Lapidus moderate to severe deformities HA > 30 degrees, IM 1-2 >16 degrees indicated if MTC joint hypermobility or generalized ligamentous laxity often associated with neuromuscular/genetic diseases (CP, Down‟s)
Lapidus P. Clin Orthopedics; 1960.

First Met-Cuneiform Fusion
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According to Coughlin, contraindicated in juveniles with open epiphysis or short 1st ray many studies advocate smooth pin fixation if growth plate is open often combined with distal procedures fixated with pins, screws or a combination of the two
Coughlin MJ. Surgery of the Foot and Ankle, Couhlin and Mann editors; 1999.

First Met-Cuneiform Fusion
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Grafting may be incorporated to maintain length very important to assess 1st ray motion

Assessment of First Ray Motion

First Met-Cuneiform Fusion
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Myerson: reports excellent results with modified lapidus in juvenile pts but avoids if epiphysis is open Clark et al: 91% excellent or good results with only one recurrence Grace et al: 90% excellent or good results with minimal complications and recurrence at 5 year follow up
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Myerson MS. Foot and Ankle Disorders; 2000. Clark et al. Bulletin on Joint Disease, 1992. Grace et al, Ankle and Foot Surgery, 1999.

First Met-Cuneiform Fusion

First Met-Cuneiform Fusion
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Complications: shortening, recurrence (under-correction), hallux varus (overcorrection), long-term stiffness and discomfort Post-op: NWB 6-8 weeks with crutches

Medial Cuneiform Osteotomy
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indicated for severely increased IM with an atavistic cuneiform allows for correction of met adductus and 1st ray elevatus according to Jay, incisional approach between anterior tibialis insertion and EHL medial wedge with lateral cortex intact bicortical cancellous bone graft
Jay RM. Pediatric Foot and Ankle Surgery, 1999.

Medial Cuneiform Osteotomy
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bone graft fixated with k-wires or staple lengthening of the first ray may result lengthening leads to jamming of the 1st MPJ/hallux limitus procedure may be combined with shortening osteotomy of the first met head to correct deviated PASA

Combined 1st Met Shortening Procedure

Multiple Osteotomies

Peterson Osteotomy
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double osteotomy of first metatarsal fixated with single pin distally through IP and MPJ joints and across both osteotomy sites into the proximal 1st met base Aronson: modified with use of medial plate and screws and osteoperiosteal flap to correct MPJ subluxation, reported drastic reduction in IM and HA angles in 16 pt‟s
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Aronson J, Nguyen LL, Aronson EA. J of Pediatric Orthopaedics; 2001. Peterson et al. J of Pediatric Orthopedics, 1993.

Modified Peterson Double Osteotomy

Epiphysoidesis
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Goal: limit growth on lateral aspect of first met base while allowing growth medially, thusreducing the IM angle uses pt‟s own growth for correction best accomplished with staples staples removed if overcorrection rarely performed without soft tissue work

Epiphysoidesis
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timing is critical reserved for juvenile HAV with met primus adductus in children going through final growth spurt 10-12 females, 12-14 males performed too early= overcorrection performed too late= undercorrection

Epiphysoidesis
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extremely important that staple crosses both dorsal and plantar cortices failure to cross plantar cortex results in elevatus due to plantar bone growth at the physis 15 degree inclination of staple is helpful to approximate normal declination of the first metatarsal

Epiphysoidesis
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immediate WB post-op staples only removed if irritation study by Seiberg, Green, and Green 9 kids and 15 feet found average decrease in IM angle of 6.6 degrees and HA angle of 19.6 degrees. bone graft instead of staple not recommended due to irreversibility
Seiberg M, Green R, Green D. J of American Podiatric Medical Association. May; 1994.

Epiphysoidesis

References
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Coughlin M. Juvenile Hallux Valgus: etiology and treatment. Foot and Ankle International 16: 682-697, 1995. Coughlin MJ. Surgery of the Foot and Ankle, Couhlin and Mann editors. Juvenile Hallux Abducto Valgus; 270-319; 1999. Helal B. Surgery for Adolescent Hallux Valgus. Clin Ortho, 157:50-63,1981. Piggott H. The Natural History of Hallux Valgus in Adolescence and Early Adult Life. Journal of Bone and Joint Surgery, 42:749-760, 1960. Hardy R, Clapham J: Observations on Hallux Valgus. Journal of Bone and Joint Surgery. 33b:376-391, 1951. Scranton P. Adolescent Bunions. Pediatric Annals. 11: 518-520, 1982. Lynch FR edited by McGlammary. Comprehensive Textbook of Foot Surgery. Juvenile HAV. 566-577; 1992.

References
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Scranton P, Zuckerman J. Bunion Surgery in Adolescents: results of surgical treatment. Journal of Pediatric Orthopedics. 4:39-43, 1984. Kalen V. Relationship Between Adolescent Bunions and Flatfeet. Foot and Ankle. 8: 331-336; 1988. Kilmartin TE, Wallace WA. First Metatarsal Head Shape in Juvenile HAV. Journal of Foot Surgery. Sep/oct 30: 506-508; 1991. Myerson MS. Foot and Ankle Disorders 2000. Hallux Valgus. 273-288; 2000. Silver D. The Operative Treatment of Hallux Valgus. Journal of Bone and Joint Surgery. 5: 225-232; 1923. McBride E. The McBride Bunion Hallux Valgus Operation. J of Bone and Joint Surgery. 49A: 1675-1683; 1967.

References
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Mann R, Coughlin M. Hallux Valgus: etiology, treatment, and surgical considerations. Clin Orthopedics 157: 31-41;1981. Bonney G, McNabb I. Hallux Valgus and Rigidus a critical survey of operative results. J of Bone and Joint Surgery. 34B: 366-385; 1952. Akin O. Treatment of Hallux Valgus a New Procedure and its Results. Med Sentinnel. 33: 678-679;1925. Ball J, Sullivan J. Treatment of the Juvenile Bunion by Mitchell Osteotomy. Orthopaedics. 8: 1249-1252, 1985. Karbowski A, Schwitalle M, Eckardt A. Long term results after Mitchell osteotomy in children and adolescents with hallux valgus. Acta Orthop Belgium. Sep 64(3): 263-268; 1998. Weiner et al. Mitchell Osteotomy for Adolescent Hallux Valgus. J of Pediatric Orthopedics. 17: 781-784; 1997.

References
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Canale P., Aronsson D, Lamont R, Manoli A. The Mitchell Procedure for the Treatment of Adolescent Hallux Valgus. J of Bone and Joint Surgery. 75 A 1610-1618, 1993. Jay RM. Pediatric Foot and Ankle Surgery. Juvenile HAV. 273-288, 1999. Jay RM, Schuenhaus HD. Donohue CM. Modified Crescentic Osteotomy in Children. J of Foot Surgery 29: 417-420;1990. Renshaw TS, Sirkin RB, Drennan JC. The Management of Hallux Valgus in Cerebral Palsy. Dev Med Child Neurology. 21: 202-208; 1979. Jenter M, Lipton GE, Miller F. Operative Treatment for Halux Valgus in Chidren with Cerebral Palsy. Foot and Ankle International. Dec. 19(12): 830835; 1998. Davids et al. Surgical Management of Hallux Valgus Deformity in Children with Cerebral Palsy. J of Pediatric Orthopaedics. 21: 89-94; 2001.

References
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Lapidus P, The Author‟s Bunion Operation from 1931-1959. Clin Orthopedics. 16:119-135; 1960. Clark H, Veith R, Hansen S. Adolescent Bunions: treatment by the modified Lapidus procedure. Bulletin Hospital Joint Diseases. Grace D, Delmonte R, Catanzariti AR, Hofbauer M, Modified Lapidus Arthrodesis for Adolescent Hallux Abducto Valgus. J of Foot and Ankle Surgery. 38(1): Jan/Feb ; 8-13; 1999. Aronson J, Nguyen LL, Aronson EA. Early Results of the Modified Peterson Bunion Procedure for Adolescent Hallux Valgus. J of Pediatric Orthopaedics. 21;65-69; 2001. Peterson HA, Newman SR. Adolescent Bunion Deformity Treated with Double First Ray Osteotomy and Pin Fixation of the First Ray. J of Pediatric Orthopedics. 13; 80-84; 1993.

References
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

Thordarson DB, Leventen, EO. Hallux Valgus Correction With Proximal Metatarsal Osteotomy: Two year follow-up. Foot and Ankle. 13:321-326; 1992. Seiberg M, Green R, Green D. Epiphysoidesis in Juvenile Hallux Abducto Valgus. A Preliminary Retrospective Study. J of American Podiatric Medical Association. May; 84(5); 225-236; 1994.


				
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