Does Patient Age Influence First Ray Procedure Selection?

Thanh Dinh, DPM, and Patricia Kim, DPM

These authors offer a closer look at hallux abducto valgus and the impact of age on treatment decisions in adolescents and elderly patients.

Hallux abducto valgus (HAV) is the most common pathology involving the first ray that we see as podiatric surgeons. In regard to the prevalence of this deformity in the general population, one study reported a 38 percent prevalence while another study cited a 58 percent prevalence.1,2 While epidemiologic studies of HAV tend to focus on adults over the age of 30, researchers have documented that this ubiquitous deformity occurs in both pediatric and geriatric populations with an increased incidence in older patients and females.3

   The medical literature is replete with articles detailing the effectiveness or ineffectiveness of conservative and surgical interventions for the treatment of HAV. However, there is a lack of literature in regard to the treatment of hallux abducto valgus based on patient age despite patient age playing a pivotal role in the determination of appropriate treatment. Instead, the treatment of HAV appears to be reported independently for adolescent deformities due to its unique characteristics.

   An adolescent HAV is often defined by the presence of an open growth plate located at the base of the first metatarsal. Other unique characteristics associated with adolescent hallux abducto valgus include: metatarsus primus varus; a long first metatarsal; an oblique first metatarsal medial cuneiform articulation; hypermobility; and generalized ligamentous laxity with over 50 percent of patients exhibiting flexible flat feet.4

   The most glaring obstacle for the correction of HAV in the adolescent population is the need to avoid any disruption to the open growth plate of the first metatarsal. As a result, most of the medical literature on surgical intervention describes performing first metatarsal head osteotomies in this patient population. The Mitchell osteotomy for adolescent HAV is probably the most described technique with researchers reporting average to good results.5 However, significant complications of this procedure include: further shortening of the first metatarsal; stiffness of the metatarsophalangeal joint; and transfer lesions of the second metatarsal secondary to dorsal tilt of the osteotomy.

   In addition to the significant complications following distal metatarsal procedures, the recurrence rates following HAV surgery in the adolescent population are reportedly as high as 60 percent.6 Surgeons have attributed this high recurrence rate to a variety of factors including: the presence of a long first metatarsal; incomplete correction of the intermetatarsal angle; or incomplete correction of the hallux valgus angle.

Why The Lapidus Bunionectomy Is The Best Choice For Adolescent HAV

As a result of the high rate of complications and recurrence following distal first metatarsal HAV procedures, the literature has described more proximal procedures in the adolescent such as a crescentic base osteotomy, a closing base wedge osteotomy and a Lapidus bunionectomy.7-8 More proximal procedures possess the advantage of providing greater intermetatarsal angle correction in addition to potentially shortening the first metatarsal, an inherent finding with adolescent HAV.

   The Lapidus bunionectomy further addresses the obliquity of the first metatarsal cuneiform articulation and hypermobility common to the adolescent HAV. Furthermore, authors have demonstrated that there is a reduced loss of intermetatarsal angle correction following the Lapidus bunionectomy in comparison to closing base wedge osteotomies.9

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