SLR - August 2023 - Marian Kavanaugh, DPM
Title: Reconceptualizing the Juvenile BunionReference: Zide JR, Hardin C, Shivers C, Tulchin-Francis K, Jo CH, Riccio AI. Reconceptualizing the Juvenile Bunion. J Pediatr Orthop. 2023 Jan 1;43(1):e43-e47. doi: 10.1097/BPO.0000000000002277. Epub 2022 Oct 13. PMID: 36224093.
Level of Evidence: III
Reviewed By: Marian Kavanaugh, DPM
Residency Program: MedStar Health, Washington, DC
Podiatric Relevance: Hallux abducto-valgus deformity is a common deformity foot and ankle surgeons treat every day with great results in the adult population. However, in the juvenile population, there are frequent reports of deformity recurrence and patient dissatisfaction. What differentiates these two deformities is important to distinguish, and continues to be a topic of discussion in our field. This study aims to characterize the radiographic and pedobarographic features encountered in juvenile bunions, and determine which of these parameters correlate with patient reported outcomes (PRO).
Methods: This study took patients between the age of 10-18 years old with bunion deformity and retrospectively analyzed their radiographs. Foot specific patient reported outcome measures were given at the initial presentation, as well as a pedobarographic plantar pressure evaluation. Radiographic measurements included distal metatarsal articular angle, hallux valgus angle, intermetatarsal angle, cuneiform obliquity, sesamoid position, first metatarsal phalangeal joint congruency, and metatarsal cuneiform angle.
Results: Thirty-two patients (57 feet) met the inclusion criteria of which 56/57 feet (98.2%) had an elevated DMAA (average 21.4degrees ± 8.9 degrees), and 51/57 (89.4%) had a congruent joint. The DMAA correlated positively with the HVA (r = 0.734 P < 0.001), intermetatarsal angle (r = 0.439 P = 0.001), and SP (r = 0.627 P < 0.001). Pedobarographic analysis (available in 15/ 32 patients) demonstrated that the HVA correlated with increased second metatarsal head peak pressure (r = 0.667 P = 0.011) and pressure-time integral (r = 0.604 P = 0.002), which in turn was strongly correlated with worse PRO. Conversely, increased first metatarsal head contact area correlated with improved PRO. Analysis of radiographic measurements demonstrated that HVA and lateralized SP correlated significantly with worse PRO scores.
Conclusions: From this study, the authors concluded that nearly all juvenile bunions have an elevated distal metatarsal articular angle and this is the defining factor that differentiates a juvenile bunion from an adult. There was also a significant correlation between the severity of radiographic and pedobarographic deformity and worse patient reported outcomes. While this study is not the first to discuss the importance of DMAA and its correction, it drives home the importance of how these deformities differ between our pediatric and adult patients. In order to corroborate these results even further, a prospective study utilizing two surgical techniques and follow up with pedobarometers would be very interesting to see. In Applying the results of this study clinical practice, the correction of the valgus-oriented dysplasia of the first metatarsal head utilizing a double or triple metatarsal osteotomy may be the key to successful deformity correction in juvenile bunions .