Hetherington

Fig. 6-12. Compressive and tension forces applied to the 

first metatarsal epiphysis as theorized by Luba and Rossman.

 

cally and radiographically. The growing foot, however, 

adds another dimension to this surgical correction. It 

appears that a slightly elevated intermetatarsal angle, 

at the time of examination in the child, may need 

greater reduction because of its tendency to increase 

with age. The timing of surgery should be related to 

the severity of symptoms, the estimation of progres- 

sion of deformity based on radiographic criteria, and 

the skeletal age of the child. Estimation of skeletal age 

is important especially with regards to procedures 

around or involving the epiphyseal plate. 

The goals of surgery in juvenile hallux valgus are 

primarily to correct the deformity, to reduce the inter- 

metatarsal angle, to reduce the hallux abductus angle, 

to obtain and maintain a congruous metatarsophalan- 

geal joint with realignment of the sesamoids, and to 

have a pain-free range of motion. All this is predicated 

on the choice of the correct procedure. 

A number of surgical procedures that may be used 

in the management of juvenile hallux valgus include 

soft tissue tendon-balancing procedures, whose main 

aim is to realign the osseous structures by correcting 

abnormality of soft tissue ligamentous and capsular 

structures. However, these procedures are infre - 

quently done in the patient with juvenile hallux valgus 

as the primary procedure but are often used in con- 

junction with distal or proximal osteotomies that cor- 

rect structural deformities. Distal metatarsal osteoto- 

mies can decrease the intermetatarsal angle and 

realign structural abnormalities in the transverse 

plane such as abnormal proximal articular set angles. 

They can shorten or maintain the length of the meta- 

tarsal. Distal osteotomies of use in juvenile hallux 

valgus include the Mitchell, Wilson, Austin, Reverdin, 

or Hohman types. Reduction of the intermetatarsal an- 

gle is accomplished by lateral displacement of those 

osteotomies. The degree of reduction will be less than 

that obtained with proximal osteotomies, and there- 

fore lateral displacement osteotomy is used with inter- 

metatarsal angles ranging from 12° to 16°. Proximal 

osteotomies inc lude osteotomies of the metatarsal 

base, of the metatarsocuneiform joint in combination 

with a fusion, or cuneiform osteotomies. These osteot- 

omies are used to correct  hallux valgus deformities 

with increased intermetatarsal angles greater than 16°. 

Phalangeal osteotomy is limited to those cases in 

which structural deformity of the phalanx exist such as 

a transverse plane clinodactyly. Epiphysiodesis has 

been reported to be successful in the management of 

juvenile hallux valgus, and is best used in the child that 

is approaching skeletal maturity.

49

 

Complications following surgery for juvenile hallux 

valgus include recurrence of the deformity, Scranton 

and Zuckerman

50

 reported a failure rate of 50 percent 

in patients with long first metatarsals and a 56 percent 

failure rate associated with collapsing pes valgo 

planus. Drennan,

51

 at an American Academy of Ortho- 

pedic Surgeons meeting in 1990, reported 30 to 50 

percent recurrence of deformity after an initial proce- 

dure requiring secondary intervention. Metatarsalgia 

may occur postoperatively with excessive elevation or 

shortening of distal or proximal osteotomies. Exces- 

sive dorsiflexion may also lead to joint stiffness and 

secondary hallux rigidus. Total or partial premature 

 

122    HALLUX VALGUS AND FOREFOOT SURGERY 

epiphyseal plate closure may occur and result in short- 

ening or angular deformity of the metatarsal, under- 

correction, or overcorrection. Epiphyseal plate clo- 

sure may result secondary to osteotomy or arthrodesis 

of the metatarsal cuneiform  articulation. 

Juvenile hallux valgus is a complex deformity that 

needs careful preoperative clinical and radiographic 

evaluation. Consideration should be given to the ap- 

propriate timing of the procedure relative to the skele- 

tal growth of the child. It  is important to remember 

that no one procedure is appropriate for all juvenile 

or adolescent hallux valgus deformities. 

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