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05/17/2013 Keith L. Gurnick, DPM
Painful Bunion in a 12 Year Old
Additional non-surgical treatment should be attempted first due to her youth. Make her new properly-designed custom orthotics to stabilize her foot and suggest proper shoes and see if you can improve her symptoms, and allow more growth and maturity for at least 4 years.
She is still a bit young for bunion surgery unless good conservative care is tried and failed. An "aching" joint on an initial presenting visit and a diagnosis of bunion should not automatically mean it is time for surgery. Did you tape her, prescribe PT, try NSAIDs, shoe modifications, and orthotics? Did she sustain an acute injury to cause the "ache"?
The relevant x-ray findings includes the high metatarsus adductus angle and the rounded shape of the 1st metatarsal head which is causing lateral overload (imbalance) of the adductor hallucis oblique and transverse muscles and the extensor hallucis brevis.
You did not comment about her biomechanics findings above the foot. Did you check for internal torsional abnormalities or overly tight hamstrings and Achilles structures? If surgery were done at this time, I would suggest removing as little bunion bone as possible, lowering the IM angle to 4-5 degrees via a distal osteotomy that transfers the head laterally, releasing the adductor hallucis and also the extensor hallucis brevis attachment and possibly even remove a small wedge from the proximal phalanx via an Aiken procedure to straighten the Hallux inter- phalangeal abductus.
Also, if and when you consent this patient for surgery make it clear to the family members and the child that the likelihood of a recurrence of the condition over time even with the best judgment and technical skills when bunion surgery is done at this age group is extremely high.
Keith L. Gurnick, DPM, Los Angeles, CA, keithgrnk@aol.com
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05/21/2013 S. Jeffrey Siegel, DPM
Painful Bunion in a 12 Year Old
This represents an excellent case from both a clinical and a didactic standpoint. I am just going to discuss the surgical aspects.
Metatarsus adductus creates a significant issue because the parents are bringing their child to you for bunion surgery and you need to tell the them that in order to have a successful outcome, you have to essentially break all the bones their daughters forefoot in order to correct her bunion. Sounds insane; yet if you ignore the MTA, when they present for the first dressing change, she will still have a bunion. Or worse yet, 6 months later, they return because "the bunion came back."
So, you just did surgery on a 12 y/o kid for a bunion that you under-corrected - or in their eyes, was never corrected "All the pain and suffering, and my daughter still has a bunion". So..be careful.....if you are not experienced in treating MTA...refer to a friend who is and scrub the case together so you can get the experience.
The challenge here is being able to communicate effectively with the parents and grandparents as to why you need to treat the MTA at the same time as the HAV. I suggest multiple office visits to accomplish this. In doing so, this will allow the parents time to: 1. research on the Internet (they are going to anyway); so you instruct them what to look up; 2. time to gain confidence in you; 3. plenty of time for you to get your point across why treating both deformities is necessary; 4. time for them to sleep on it and bring back questions and 5.an opportunity to seek a 2nd opinion. Always offer this and if you have earned their trust..they will feel its unnecessary and will proceed with you. As far a procedure choices....lets assume no hindfoot compensation. The C.O.R.A. is at the Liz Franc's joint; not the midtarsal joint 1. Gastroc. Recession. 99% will have an equinus.
2. If PASA is high and it usuallly is..I combine a Reverdin..and opening medial cuneiform osteotomy. I have found that the wedge removed from the Reverdin is not wide enough to reduce the 1st ray deformity. I love using pre-op paper templates. They are an excellent tool not only to help me choose the proper wedge size, but also identify any risk for excessive shortening of the 1st ray. Also, they represent another opportunity for you to educate the parents during one of your pre-op visits - the before and after effects will solidify their relationship and trust in you.
3. Metatarsal osteotomies 2-5. Pay attention to the 5th ray - in some cases w/splay foot and MTA/HAV - osteotomy 1-4 is all that's needed as the 5th ray is already in the corrected position.
4. If PASA is normal, met. osteotomies 1-5. I will use a modified Lepird procedure. Dorsal- distal to proximal-plantar osteotomies on all 5 mets. The whole forefoot is derotated as a unit and with fluoroscopy, I can dial in exactly the correct amount of abduction. I currently have 25 cases pending publication.
Pain management is going to be tough. I admit for a 23 hr. stay and insert an OnQue pain pump w/lidocaine 2% over the common peroneal nerve. This provides 21/2 days of continuous anesthesia. Interestingly, kids do better than adults in managing pain. S. Jeffrey Siegel, DPM, Bensalem, PA, heeldoc@verizon.net
05/18/2013 Ed Cohen, DPM
Painful Bunion in a 12 Year Old
Most painful bunions are aggravated by shoes. I find that it can be a big problem for young active people 12 years and older. I generally will not do bunion surgery on patients under 12, but I feel that these young patients over 12 do as well or better than the other age groups that have bunion surgery.
These painful bunions that appear on young people will can get dramatically worse with time and can also cause significant hammertoe and metatarsal problems later in life if untreated, with the big toe shifting more laterally. With time, the bunion becomes larger and takes up more room in the shoe and helps to create other deformities. This is especially true with a long big toe because the shoe will accelerate the process of lateral deviation faster than with a bunion and normal big toe.
In the geriatric patient, the surgical treatment can be more conservative because they are generally less active and have less years for the conditions to recur.
This case presented is particularly interesting because there is joint pain. It would be helpful to have a lateral x-ray and a picture of the foot. The length of the big toe relative to the other toes is important as well as seeing the relationship of the dorsal aspect of the hallux and 1st metatarsal head. A picture of the plantar aspect of the foot would show the transverse metatarsal arch which could yield additional information that an axial x-ray doesn't always yield. I would also like to see how the toes are purchasing the ground.
I have had good results using an MIS non-fixated Reverdin-Isham-Akin bunionectomy, especially on young patients. The patients have minimal pain and the recovery is usually very fast. An important point is that there is pain in the 1st MPJ. One of the great advantages of this procedure is that by doing a first metatarsal and a hallux osteotomy you get additional 1st MPJ decompression.
Dr Peacock mentioned the 1st metatarsal osteotomy in one of his posts, however a lot of podiatrists and orthopedists in the AAFAS feel the osteotomy of the hallux gives you additional decompression of the 1st MPJ than just doing the 1st metatarsal osteotomy.
Other possible procedures might be to reduce some of the dorsal head of the 1st metatarsal and possibly an osteotomy of the 2nd metatarsal along with digital osteotomies. 95% of the time the patient does great with just the Reverdin-Isham- Akin bunionectomy and possibly a 2nd and rarely a 3rd MIS digital osteotomy procedure. I find this can be very important in bunion surgery because after the procedure there can be a gap between the first and second toes and if this gap is not corrected the big toe will tend to shift in a lateral direction over time which can undo the surgical correction to some extent and can eventually lead to a recurrence of the bunion.
If the big toe is longer than the other toes you can shorten the big toe by removing a little move bone from the base of the hallux than the traditional MIS Akin procedure.
Ed Cohen, DPM, Gulfport, MS, ECohen1344@aol.com
05/18/2013 Name Withheld
Painful Bunion in a 12 Year Old
Thank you all to those that gave me your input. I did not provide an extensive biomechanical exam with my first presentation. This patient has at least 10 degrees of ankle dorsiflexion with her knee extended or flexed. Her hamstrings are not tight. She has symmetrical hip motion more with no internal position. There is no internal tibial torsion. She does not have ligamentous laxity. Her first ray is stable on exam. She is only moderately pronated in stance and gait. Her lateral x-ray does not have an anterior break in the cyma line. There is no Kirby's sign. There is no elevation of 1st ray (Seeberg's index).
She has noticed the bunions for several years, and has had moderate aching in the joint for the past year. She is a serous athlete. Although she is only 12, she has reached menarche and her appearance is that of several years older. I tell all my patients that these are progressive deformities and that there is a high rate of reoccurrence, especially in a young patient. I always recommend orthotics, both before and after a surgical approach.
On radiographs her growth plates are almost closed. I suspect there is very little additional length of her metatarsals to come. I do not believe that she will "escape" surgery in her life time. Perhaps if not surgery this year than next. She is living at home and has the summer off. She does not have a job and is in a protective environment. Should we wait until she has to make sacrifices both socially and academically to deal with this? Do we wait until she is in college or has a job that put stress on the either living with the deformity or the stress of the surgical recovery?
With a 25 degree met adductus angle and a 15 IM, the true 1st IM is closer to 25. Do I do a head procedure or base or tight rope? again, perhaps not this year, but maybe next.
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