SLR - July 2018 - Kevin Ragothaman
Reference: Bayhan IA, Kadhim M, Sees JP, Nishnianidze T, Rogers KJ, Er MS, Miller F. Hallux Valgus Deformity Correction Without Fusion in Children with Cerebral Palsy. Journal of Pediatric Orthopaedics B 2017; 26:164–171.
Scientific Literature Review
Reviewed By: Kevin Ragothaman, DPM
Residency Program: MedStar Washington Hospital Center, Washington, DC
Podiatric Relevance: Hallux valgus is common in patients with cerebral palsy. Depending on the disease severity of the patient, as measured by the Gross Motor Function Classification System (GMFCS levels I-V), this deformity can cause a variety of complaints, including pain, hygiene problems of the first interdigital space or poor braceability. Presently, the literature supports the efficacy of first metatarsophalangeal joint (MTPJ) fusion in correcting this spastic deformity. This study aims to determine the role of bunion correction without fusion in this patient population.
Methods: This is a level IV retrospective cohort study of 25 patients (39 feet) who underwent surgical correction of bunion deformity as part of single-event multilevel surgery. Proximal deformities were corrected prior to addressing hallux valgus defromity. Preoperative radiographs and those obtained at minimum follow-up of six months postoperatively were reviewed. All patients underwent gait analysis and pedobarography. For outcomes analysis, the cohort was separated into two groups based on functional status, with group 1 including GMFCS I and II and group 2 being GMFCS III.
Results: The mean age at the time of surgery was 15 years old with average postoperative follow-up of 14.6 months. Surgeries were performed irrespective of GMFCS level. Metatarsal osteotomy was performed for nine feet, of which seven had bunionectomy (resection and medial capsule plication) and five had Akin osteotomy concomitantly. The remaining feet underwent bunionectomy in 18 feet and Akin osteotomy in 27 feet. Eighty-two percent of cohort underwent correction of hindfoot and midfoot deformity in addition to HV correction. Two patients required revision surgery, including one proximal metatarsal osteotomy and one MTPJ fusion. Seventeen patients were in group 1, while eight patients were in group 2.
Clinical hallux deformity, as measured by the angle between the medial border of the foot and longitudinal axis of the great toe, decreased significantly for both groups. Radiographic measurements showed significant improvement postoperatively with measurement of IMA, HVA, HIPA, calcaneal pitch angle and Meary’s angle. Medial forefoot pressures significantly reduced postoperatively in both groups. Analysis of gait parameter relationships showed that HV correction positively correlated with increased step length, stride length and dorsiflexion at heel contact, while correction of arch index correlated with better forefoot alignment and hallux motion.
Conclusion: Although first MTPJ arthrodesis has been supported as a primary treatment for hallux valgus deformity in cerebral palsy, the authors suggest that adequate correction as measured by gait parameters and radiographic findings can be attained without fusion. This patient cohort showed improvement in forefoot and hindfoot alignment clinically and radiographically irrespective of GMFCS level, while also showing relief of medial forefoot pressure following hallux valgus correction. Interpretation of these results are limited by the multilevel procedures performed concomitantly and lack of multivariate analysis. Despite these shortcomings, this article provides objective data pertaining to an underreported treatment approach for hallux valgus deformity in pediatric cerebral palsy.