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

Other messages in this thread:

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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

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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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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