SLR - March 2021 - Zane Qureshi

Management of Juvenile Hallux Valgus Deformity: The Role of Combined Hemiepiphysiodesis

Reference: Chiang MH, Wang TM, Kuo KN, Huang SC, Wu KW. Management of Juvenile Hallux Valgus Deformity: The Role of Combined Hemiepiphysiodesis. BMC Musculoskelet Disord. 2019 Oct 25;20(1):472. doi: 10.1186/s12891-019-2867-7. PMID: 31651315; PMCID: PMC6813977.

Level of Evidence: Level IV, retrospective case series.

Scientific Literature Review 

Reviewed By:  Zane Qureshi, DPM
Residency Program: Inspira Health Network – Vineland, NJ

Podiatric Relevance: As podiatric physicians, one of the most surgically addressed issues we see and treat are bunion deformities. Many patients who have significant bunion deformities are in the pediatric age group. Due to the fact that skeletal maturity is often incomplete with these patients, we need to be able to modify the standard approach we use for adult bunions. Hemiepiphysiodesis is a technique used for angular correction in long bones where a portion of the proximal physis is tethered and this in turns helps to create asymmetrical physeal growth, thus correcting the angular deformity. The authors of this article performed a retrospective case series on patients with juvenile HV and hypothesized that combined hemiepiphysiodesis would help to improve patients pain scores as well as radiographically and clinically reduce bunion deformity. 

Methods: Twenty-four patients with symptomatic juvenile HV were surgically treated with a combined percutaneous medial drilling hemiepiphysiodesis of the first proximal phalanx and lateral transphyseal screw hemiepiphysiodesis of the first metatarsal from 2012 to 2014. Patients that were included in the study had juvenile HV, described as a HV angle of more than 16 degrees, with symptoms unresponsive to conservative treatment. These patients were followed for two years after the interventions. Patients with Juvenile rheumatoid arthritis and tissue disorders were not included. X Rays were taken with full weight bearing DP and lateral views preoperatively, and at three to six month periods after surgery, then followed until their growth plates were closed. Hallux valgus angle (HVA), intermetatarsal angle (IMA), proximal metatarsal articular angle (PMAA), proximal phalangeal articular angle (PPAA) , the metatarsal length ratio (MTLR) and the screw position relative to physis were all evaluated. The AOFAS score was also calculated for patients who underwent surgical intervention.

Results: The mean age at surgery was 12.0 years and mean follow-up after surgery was 35.1 months. After intervention the HV deformity had a mean reduction of HVA by 4.7 degrees and average reduction of IMA of 2.2 degrees. The AOFAS score increased on average from 68.7 to 85.2. 

Conclusions: While osteotomies such as chevron and akin osteotomy can create large clinical and radiographic reductions in bunion deformities, combined hemiepiphysiodesis can also improve HV by limiting pain and increasing functional outcomes. This is important to note as these reductions do not require a major osteotomy in a skeletally immature patient and can help add to the toolset of the practicing podiatric physician to serve as a minimally invasive operative technique. In cases where we are worried about reducing the length of the first ray with an osteotomy, the patients in this study had the metatarsal length ratio and the sagittal alignment of the first metatarsal retained. The percutaneous procedures allow for immediate weight-bearing post operatively, and further allows for good functional outcomes for patients. 

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