AUGUST 2014 | Volume 37 • Number 8 531

n tips & techniques

Adolescent hallux valgus (AHV) is a relatively

common problem with an es-timated incidence of 15% to 46%.1-4 Many patients pres-ent reporting pain, difficulty with shoe wear, and cosmetic concerns. The pathogenesis behind development of the deformity is multifactorial. Family history, pes planus, and metatarsus primus varus all contribute to the devel-opment and progression of AHV.2,3 In contrast to adult hallux valgus, adolescents typically exhibit an increased

distal metatarsal articular angle (DMAA) with a con-gruent first metatarsal pha-langeal (MTP) joint.2,3 This difference in biomechanics portends the need for different surgical correction strategies. Appropriate clinical evalua-tion and treatment planning are critical for good outcomes in this unique population.

Several surgical proce-dures have been described in the treatment of AHV.4-10 Distal osteotomies such as the Chevron or Mitchell have been popularized and are ef-

fective in treating mild to moderate deformities.7-9 In the adolescent population with severe deformities second-ary to high intermetatarsal and distal metatarsal articular angles, a more powerful cor-rection is necessary. Double metatarsal osteotomy (DMO) has been described as a suc-cessful method of surgically correcting severe AHV.4-6 Tra-ditionally, the DMO was held in place by longitudinal pin fixation of the first ray. This method of fixation allowed for superior angular correc-tion, but left many patients with a stiff first MTP joint.

In 2001, Aronson et al6 reported their results using a modified Peterson technique in an effort to minimize first MTP joint stiffness. This pro-cedure used the same DMO but opted instead for a medial plate fixation technique to avoid injury to the MTP joint articular surface.6 The results were promising with no re-ported cases of postoperative first MTP joint stiffness at fi-nal follow-up. Unfortunately this series reported a 16.7% recurrence rate of the valgus

deformity as compared with no recurrences using the tradi-tional Peterson approach with longitudinal pin fixation.4-6

The purpose of this study was to provide an update on the modified Peterson tech-nique for DMO as well as share some slight differences in operative approach that aid in maintaining the cor-rection achieved intraopera-tively. To the authors’ knowl-edge, this study is the largest reported case series using the modified Peterson tech-nique for treatment of AHV.

Operative techniqueA longitudinal incision was

made over the medial aspect of the first metatarsal, extending from the metatarsal base to the midpoint of the proximal pha-lanx. The dissection was per-formed preserving the nervous and vascular structures. The periosteum was incised longi-tudinally down to the level of the joint capsule, where the capsule was incised in a dis-tally based v-shaped pattern. Flaps were raised subperioste-ally, exposing the length of the first metatarsal and MTP joint.

Abstract: Treatment of adolescent hallux valgus with first metatarsal double osteotomy is well described in the literature. Unfortunately, first metatarsal phalangeal joint stiffness and de-formity recurrence have been reported at relatively high rates. The authors revisit a technique aimed at preventing these com-plications. [Orthopedics. 2014; 37(8):531-535.]

The authors are from the Division of Orthopaedic Surgery (TJM, JRS, JGK), University of Alabama, Birmingham; and The Children’s Hospital of Alabama (JGK), Birmingham, Alabama.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Joseph G. Khoury, MD, Divi-

sion of Orthopaedic Surgery, University of Alabama, 316 A.C.C., 1600 7th Ave S, Birmingham, AL 35233-1711 (jkhoury@uabmc.edu).

Received: July 12, 2013; Accepted: September 26, 2013; Posted: August 11, 2014.

doi: 10.3928/01477447-20140728-05

Adolescent Hallux Valgus RevisitedTyler J. Marshall, MD; Joseph R. Shung, BS; Joseph G. Khoury, MD

532 ORTHOPEDICS | Healio.com/Orthopedics

n tips & techniques

The medial eminence of the head of the first metatarsal was excised parallel with the me-dial surface of the foot at the groove of Clark (Figure 1).

The sharp end of a freer elevator was passed through the MTP joint to “pie crust” the lateral capsule. Under fluoroscopic control, 0.045-inch Kirschner wires were inserted to subtend a distal closing wedge osteotomy de-fined by the distal limb par-allel to the DMAA and the proximal limb perpendicular to the long axis of the meta-tarsal. Enough room was left distally to accommodate 1 screw in the plate (Figure 2).

The proximal osteotomy was also crafted to leave enough room for 1 screw. The lateral cortex of both osteotomies was left intact to act as a hinge. The proximal osteoto-my site was booked open with a straight osteotome hinging the lateral cortex. Lamina spreaders were inserted and the degree of correction was measured by intraoperative fluoroscopy. A piece of tri-cortical bone allograft was measured to fit the desired wedge defect and inserted to create an opening wedge.

The closing wedge oste-otomy was reduced and both osteotomies were fixed with a 2.5-mm titanium plate and screws. The periosteum was repaired over the plate and the distal capsule was repaired with 1 nonresorbable suture tied through 1 hole in the plate while the toe was held in a slightly overcorrected position (Figure 3). Two ad-ditional capsular sutures were placed for re-enforcement. The subcutaneous tissues were repaired with a running 3-0 Vicryl (Ethicon Inc, Blue Ash, Ohio) suture. The skin

was closed with running 4-0 Monocryl (Ethicon Inc) and Dermabond (Ethicon Inc).

The patient was made non-weight bearing in a short leg cast for 4 weeks. Subsequently, the patient was placed in a boot and weight bearing was pro-gressed as tolerated (Figure 4).

Materials and MethOdsFrom 2007 to 2012, the se-

nior author (J.G.K.) performed first metatarsal double oste-otomy with medial plate fixa-tion on 22 feet in 18 adolescent patients. There were 16 female and 2 male patients included in the study. The average patient age was 15 years (range, 12-18 years). The average follow-up was 25 months (range, 5-60 months). All patients were followed clinically and radio-graphically until evidence of bony union at the osteotomy site had occurred. The authors included patients who had pain, deformity, and difficulties with shoe wear despite appropriate shoe modification as a conse-quence of moderate to severe hallux valgus. The authors ex-

cluded patients who had prior surgical intervention to address the hallux valgus deformity or who had mild hallux valgus ra-diographically. The design of this study was approved by the university’s institutional review board and consent was obtained from all participating patients.

Adolescent hallux valgus was classified as mild, mod-erate, or severe based on val-ues previously accepted in the literature.4 Patients with hallux valgus angles greater than 16° but less than 25° and intermetatarsal angles greater than 9° but less than 11° were classified as mild; those with hallux valgus angles greater than 25° but less than 40° and intermeta-tarsal angles greater than 11° but less than 16° were clas-sified as moderate; and those with hallux valgus angles greater than 40° and inter-metatarsal angles less than 16° were classified as severe.

Patient charts and pre- and postoperative radiographs were reviewed and the hallux valgus angle, intermetatarsal angle,

Figure 1: Intraoperative photographs depicting the groove of Clark (A) and showing the technique for bunion resection (B).

A B

Figure 2: Dorsoplantar views by intraoperative fluoroscopy showing the tech-nique for lateral capsular release (A) and Kirschner wire placement as guides for osteotomies (B).

A B

Figure 3: Intraoperative photograph demonstrating capsular repair and anchoring to the plate.

AUGUST 2014 | Volume 37 • Number 8 533

n tips & techniques

and DMAA were recorded (Figure 5). Patients were surveyed via telephone and scored on satisfaction levels and radiographically via the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal- Interphalangeal Scale (Ta-ble 1).11 The results were tabulated and patients were scored 0 to 100 according to patient-specific outcomes. On the basis of the AOFAS score, patients were classi-fied as having excellent, good, fair, or poor final outcomes. Patients were also asked whether they would choose to have the procedure again

(definitely yes, probably yes, probably not, definitely not).

resultsThe average preoperative

hallux valgus angle was 33° (range, 18.3°-46°) and was reduced to 15.5° (range, 7.5°-30°) at final follow-up for a correction of 17.5°. The aver-age preoperative intermeta-tarsal angle was 17.0° (range, 11°-26°) and was reduced to 6.5° (range, 1.5°-11°) at final follow-up for a correction of 10.5°. The average pre-operative DMAA was 28.9° (range, 16.5°-45°) and was reduced to 6.3° (range, 0.4°-22°) at final follow-up for a

correction of 22.6° (Figure 6). The difference between pre- and postoperative val-ues was found to be signifi-cant using a 2-tailed paired t test (P<.001). There were no intraoperative complica-tions. The average time to os-teotomy union was 6 weeks.

A 2-tailed group t test was used to compare AO-FAS scores in individu-als with preoperative AHV scores of moderate and se-vere. The moderate group had an average AOFAS score of 93.3±8.2. The severe group had an average AOFAS score of 77.4±12.8. These values were found to be signifi-cant with a P value of .024.

At final follow-up, all but 1 patient reported normal mo-tion or mild restriction of mo-tion involving the first MTP joint, defined as more than 74° of dorsiflexion and plan-tarflexion on examination. One patient reported moder-ate restriction of MTP motion, defined as 30° to 74° of dorsi-flexion and plantarflexion on examination, which developed postoperatively. Two of the

patients (9%) complained of prominent hardware and sub-sequently had the hardware removed. One patient devel-oped a neuroma and had the neuroma resected. There was 1 delayed union treated with a bone stimulator. There was 1 asymptomatic nonunion that was revised with repeat open reduction and internal fixa-tion and bone grafting. There was no evidence of hardware loosening or failure and no recurrences of the deformi-ty. No infections occurred.

Of the 18 patients included in the study, 12 responded via telephone survey including 17 of 22 operative feet. The av-erage postoperative AOFAS score was 88 of 100 (good). Eleven of 17 feet (65%) had excellent outcomes accord-ing to the AOFAS score. One of the 17 feet (6%) was rated as good, 2 of 17 (12%) were rated as fair, and 3 of 17 (18%) were rated as poor. When asked if they would have the procedure again, 9 of 12 patients (75%) responded “definitely yes” with an aver-age AOFAS score of 95. Two

Figure 4: Preoperative dorsoplantar radiograph of the hallux valgus deformity (A). Postoperative fluoroscopy demonstrating correction of deformity (B). Pre-operative photograph of bunion deformity (C). Postoperative photograph of bunion deformity (D).

A B

C D

Figure 5: Dorsoplantar radiographs showing preoperative measurement of hallux valgus angle (A) and intermetatarsal angle (B) (A) and distal metatarsal articular angle (B).

A B

534 ORTHOPEDICS | Healio.com/Orthopedics

n tips & techniques

of the 12 (17%) responded “probably yes” with an av-

erage AOFAS score of 89. One of the 12 (8%) respond-

ed “probably no” with an AOFAS score of 75. The AOFAS score as it correlates with mean pre- and post-operative deformity is de-picted in Table 2. Although not statistically significant, these results demonstrate a clear trend between se-

vere preoperative deformi-ties and poor performance on the AOFAS scoring scale.

discussiOnAdolescent hallux valgus

remains a difficult clinical condition to treat while main-taining a high level of patient

Table 1

Hallux Metatarsophalangeal-Interphalangeal Scale

Scale Score

Pain (40 points)

None 40

Mild, occasional 30

Moderate, daily 20

Severe, almost always present 0

Function (45 points)

Activity limitations

No limitations 10

No limitations of daily activities, limitation of recre-ational activities

7

Limited daily and recreational activities 4

Severe limitation of daily and recreational activities 0

Footwear requirements

Fashionable, no inserts 10

Comfort footwear, shoe insert 5

Modified shoes or brace 0

MTPJ range of motion (dorsiflexion plus plantar-flexion)

Normal or mild restriction (75° or more) 10

Moderate restriction (35°-74°) 5

Severe restriction (less than 30°) 0

IPJ range of motion (plantarflexion)

No restriction 5

Severe restriction (less than 10°) 0

MTPJ-IPJ stability (all planes)

Stable 5

Definitely unstable or able to dislocate 0

Callus related to hallux MTPJ-IPJ

No callus or asymptomatic callus 5

Callus, symptomatic 0

Alignment (15 points)

Good, hallux well aligned 15

Fair, hallux malalignment, no symptoms 8

Poor, symptomatic malalignment 0

Abbreviations: IPJ, interphalangeal joint; MTPJ, metatarsal phalangeal joint. Data from Kitaoka et al.11

Table 2

AOFAS Scores as They Relate to Preoperative and Postoperative Deformity

AOFAS Score HVA IMA DMAA

Excellent

Preop 29 16 22

Postop 12 7 2

Good

Preop 35 18 37

Postop 13 8 7

Fair

Preop 39 19 34

Postop 22 7 13

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; DMAA, distal metatarsal articular angle; HV, hallux valgus angle; IMA, intermetatarsal angle; Preop, preoperative; Postop, postoperative.

Figure 6: Bar graph depicting average pre- and postoperative angular de-formity. Abbreviations: DMAA, distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle; Postop, postoperative; Preop, pre-operative.

AUGUST 2014 | Volume 37 • Number 8 535

n tips & techniques

satisfaction. In the current series using the modified Pe-terson technique with capsu-lar advancement, the authors managed to provide angular correction comparable to that reported in the literature with no recurrence of deformity or first MTP joint stiffness.4-6 The complication rate in the current series is comparable to those reported for similar proce-dures.4-6,10 The average follow-up time of 25 months strength-ens the evidence that the procedure provides adequate correction and patient satis-faction at mid-term follow-up.

The modified DMO with capsular advancement of-fers solutions to pitfalls ex-perienced with prior surgical techniques. It avoids first MTP joint stiffness and chondral damage by remaining extra-articular. It also allows for re-inforcement of the correction achieved by the initial oste-otomy by advancing the cap-sule with nonabsorbable su-ture through the medial plate. This slight modification in technique has significantly de-

creased deformity recurrence in the current patients’ feet.

The authors’ statistical anal-ysis points out a significant cor-rection in pre- and postoperative deformity. The patients who fell into the moderate AHV catego-ry had significantly better out-comes and AOFAS scores than those who fell into the severe category.12 The authors believe this outcome can be used to guide preoperative expectations.

The limitations of this study are the small sample size and lack of long-term follow-up. Not surprisingly, patient out-comes according to AOFAS score and by satisfaction survey correlated directly with degree of residual deformity. Patients with the worst preoperative deformities also had poorer postoperative outcomes in the current series. Activity level, shoe wear, and postoperative cosmesis may also contribute to perceived surgical outcomes.

cOnclusiOnThe modified Peterson tech-

nique with capsular advance-ment is a safe and effective treat-

ment for moderate and severe AHV. The procedure is relative-ly easy to perform and mitigates concerns regarding first MTP joint stiffness and deformity recurrence. Patients with severe deformities should be counseled preoperatively about expecta-tions for surgical outcomes. The small sample size in this case series warrants further study with larger patient cohorts.

references 1. Owoeye BA, Akinbo SR, Ai-

yeabusi AL, et al. Prevalence of hallux valgus among youth population in Lagos, Nigeria. Niger Postgrad Med J. 2011; 18(1):51-55.

2. Morrisey RT. Juvenile hal-lux valgus. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopae-dics. Philadelphia, PA: Lip-pincott Williams and Wilkins; 2006:1297-1300.

3. Pique-Vidal C, Sole MT, An-tich J. Hallux valgus inheri-tance: pedigree research in 350 patients with bunion defor-mity. J Foot Ankle Surg. 2007; 46(3):149-154.

4. Johnson AE, Georgopoulos G, Erickson MA, et al. Treatment of adolescent hallux valgus with the first metatarsal double osteotomy. J Pediatr Orthop. 2004; 24:358-362.

5. Peterson HA, Newman SR. Adolescent bunion deformity treated with double osteotomy and longitudinal pin fixation of the first ray. J Pediatr Orthop. 1993; 13:80-84

6. Aronson J, Nguyen LL, Ar-onson EA. Early results of the modified Peterson bunion pro-cedure for adolescent hallux valgus. J Pediatr Orthop. 2001; 21:65-69.

7. Coughlin M. Juvenile hallux valgus: etiology and treat-ment. Foot Ankle Int. 1995; 16(11):682-697.

8. Lin JS, Bustillo J. Surgical treatment of hallux valgus: a re-view. Curr Opin Orthop. 2007; 18:112-117.

9. Weiner BK, Weiner DS, Mirkopulos N. Mitchell oste-otomy for adolescent hallux valgus. J Pediatr Orthop. 1997; 17(6):781-784.

10. Andreacchio A, Origo C, Rocca G. Early results of the modi-fied Simmonds-Menelaus pro-cedure for adolescent hallux valgus. J Pediatr Orthop. 2002; 22:375-379.

11. Kitaoka HB, Alexander IJ, Ad-elaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994; 15(7): 349-353.

12. Thordarson D, Ebramzeh E, Moorthy M, et al. Correlation of hallux valgus surgical out-come with AOFAS forefoot score and parameters. Foot Ankle Int. 2005; 26(2):122-127.