Moderator: At this point we’re going to switch over to juvenile hallux abducto valgus and I'm going to bring Brian Fitzgerald up, who is bright, articulate, has a tremendous command of the English language, understands mechanics. And I would like you to welcome Ryan Fitzgerald.

Ryan Fitzgerald: Okay. So with that with my command of English language we should definitely be able to encourage the vendors at stake as a lot of products are going to get used in my talk. I'm going to be talking about juvenile hallux valgus deformities, it’s really important, first of all I guess to say, number one, I'm really tempting anybody, so you can talk to anybody out there, it’s okay.

The hallux valgus deformity as everybody has said thus far today, it’s important to think of it as not just one plane. And when you are considering the different types of corrections that you are going to perform as a consequence of this, you have to keep that in mind always in the back of your head that you’re moving things in three dimensions, and that's really important.

For hallux valgus deformity the pathophysiology is fairly common and well understood at this point. There are two essential types; those bunions that get worse and those that don’t. And most of the patients as we’ve seen do get worse, that’s the most common progressive. There are genetic factors and biomechanical instability, systemic arthropathies, these are all fairly common generally speaking with regards to hallux valgus although less so in the juvenile patient.

Juvenile hallux valgus is classified patients that are generally less than 20 years old, or patients in my practice patients that have them as a child but may be slightly older still. You need to think in terms of juvenile patients with a different mindset than you do with your older patients as a function of the osteology and we’ll talk about that to a degree.

When you read the literature, there is a variety of incidents reported from a series of different studies somewhere between 23% to 36% predominately women, and mostly bilateral as well greater than 75%. There is often a family history. So you're talking to your patients about their bunions I ask about their families, ask about their spouses, and their kids if you’re talking adults or certainly the parents if you’re talking about the child, because there is a family history anywhere between 58% to 80% of the cases depending on the literature that you read.

With hallux valgus deformity, particular juvenile hallux valgus deformity, the osteology is going to be very different than the progressive sort of wear and tear arthropathy that we see in a much older patient. My next talk is actually geriatric bunions and we’ll talk about that to a degree. But you can see even on the x-ray here, just the shape of the head is different, and the way the bunion is forming is going to be slightly different in juvenile bunion which changes how you want to go about fixing it.

Obviously you want to assess the PASA and the distal metatarsal articular angle, things like that and joint congruency is going to play a major role in the reconstructive efforts that you perform. So generally speaking, and this is a fairly classic across the board, a general classification of bunions – mild, moderate, severe. And obviously this is going to be a function of how large the intermetatarsal angle is and the other appropriate radiographic angle is throughout the evaluation.

As it progresses we start to see more lateral deviation of the toe, we get that overlapping with the second or underlapping with the second depending on how it goes, as well as increasing the arthritic changes. With the juvenile bunion particularly, you may see it quite large intermetatarsal angle, but relatively little arthritic changes even as they progress into adulthood, and that’s more a function of that genetic component that osteology that we spoke about a minute ago.

In terms of pediatric patients, and this is true across the board no matter what you’re treating, you really have to think of pediatric patients as their own monster. It’s not like treating a small adult, they have very different expectations. very different fear, and it’s really important that if you’re going to be treating these patients to really delve into that with them.

I had a patient whose biggest fear was not the surgery but the cast afterwards that she was going to have. That was what was really worrying her the most, and so I was trying to talk about the surgery, and she didn’t want to talk about that, she wanted to hear about the cast, that was what she was really worried about, cutting the cast off specifically.

So you have to change your thinking process, and as you’re working with these patients, really manage their expectations, but not just the patient but also the patient's families; that’s the other bid. When you dealing with an adult you have to deal with that person as a patient, but when you're dealing with the kids, you got the kids and then their adults which is equally challenging. And you want to establish clear expectations from the get-go; what you expect to happen, exactly how it’s going to progress, and what to do if there are any complications.

So in terms of the workout, this was taped up in the OR at my hospital, I thought it was funny, but you want a tint of your history, and my patients are amusing to me. This is a sheet that we had established for them to fill out. This particular patient found that wrap music made his condition worse, so I encouraged him to lay off the wrap music for just two to three weeks and he would feel much much better.

So with regard to the bunions, a good clinical exam is going to be key. You want to assess the first metatarsal phalangeal joint both for range of motion but also just how it feels structurally; the presence or absence of the medial eminence and where patient’s pain is, whether they have pain dorsally, phalangeally, along the medial side; and then whether or not there is appreciable hypermobility along the medial column.

This is going to be tremendously important as you’re going about your reconstructive efforts. If there's hypermobility that you do not address, you’re going to come back. Somebody somewhere along the line is going to have to go back in. So you really want to assess that on the front end and be ready to manage those competitions if they occur.

Also pain, a lot of juvenile patients with large bunions don't have the same amount of pain that you would expect in an adult patient with that degree of deformity. So you really want to determine whether it's worth trying to fix and then what you’re going to do if needs be. Obviously the radiographic examination is key and it’s something that we’ve talked about thus far this morning.

We’ve had tremendous lecture on it, all of them far better than mine, so I would submit to their discussions of it, but you want to assess joint congruency obviously, the intermetatarsal angle, you want to determine the proximal articular set angle as well as the distal articular set angle, and then also establish that tibial sesamoid position. Now I absolutely agree with Dr. Laporta [phonetic] that that is a function of where the foot is when the x-ray is taken, and you can make it seem worse you can make it seem better, but to get a sense generally speaking, because you definitely want to try to establish relining the assessment apparatus underneath the metatarsal head as part of your correction.

Also I assess the base of the first metatarsal, the torso-metatarsal joint both medially and then also laterally. If there is a large lateral flare on the base of the first metatarsal, that can be something that can keep you from being able to correct the deformity particularly as you start talk about more proximal procedures, and that’s something that we’ll talk about.

So metatarsus adductus, you could have an entire conference on metatarsus adductus frankly. It's something that is significantly found in patients with juvenile hallux valgus deformities, and you really want to notice it if it's there. In [Indecipherable] [0:07:01] it was determined that about 75% of patients had a metadductus in those patients with juvenile hallux valgus deformities. And this can give you a falsely low intermetatarsal angle.

Again, if you make a bad choice on procedure based on a low intermetatarsal angle – presumptively low intermetatarsal angle in a patient with a metatarsus adductus you’re going to be unhappy with the outcome. So you have to really consider the true IM versus the relative IM, and this is you know, we all remember back from our podiatry school days that how do you figure that out, but you really want to consider these patients. And there are variety of different ways to measure depending on which literature we read, there's different degree values.

But I would encourage you to use some of the software that is now available to make those measurements. I usually do like what’s described here, I measure that off the second metatarsal with the bisection from the tarsal joints. But you definitely want to assess the presence or absence of metadductus before getting into a surgical encounter.

So in terms of treatment options, you have to consider the skeletal age of the patient. What you're going to do is going to matter based on how open or close the growth plates may be. You may wish to delay surgery if you need a more aggressive correction until the growth plates close. You may use the facts if the growth plates are open as part of your correction.

You want to determine if there's other coexisting comorbidities, any others things that might need to be addressed. If they have a malice or a significant hallux deformity in conjunction with the increased metatarsal angle. The age and onset of the bunion is important as well as the rapidness of progression. That’s something that you can get a sense of how quickly the disease process is progressing, and that can also establish how quickly you want to try to address the correction.

Family history obviously there is a significant component, genetic associate with that, and then the degree of symptoms. If it doesn't hurt a lot of times I'm just leaving it alone until it does or until the patient’s skeletal mature and really want to have something done. And again, you have to consider what the expectations are. If the patient or a parent has an unrealistic expectation, there should be a tremendous red flag, you can't negotiate it down and educate them as to what really they should be expecting, that's not somebody you want operating because they're going to be unhappy.

In terms of nonsurgical treatment, these are largely the same for anything frankly. The gold conservative care is to relieve symptoms and to establish biomechanical control, particularly in those patients with hypermobility, and to delay surgery theoretically. Now there are some arguments for earlier intervention to change what you might do, but you can make the contra argument as well depending on what type of procedure is required we can discuss that further.

Activity modification is going to be key for these patients. We want to make sure that you can manage their symptoms appropriately, and sometimes that means changing what they're doing, or the shoes they're wearing, things like that, and obviously medications can be can be utilized in a limited fashion. You really don't want to have these kids on too much medicine to address, and if it’s that uncomfortable you want to go ahead and fix it.

I use a lot of orthotics in my practice to address these kinds of things. I use the metaphor that orthotics are like eyeglasses. In the same way that eyeglasses improve your vision without changing your eyes, orthotics improve the way you function without changing your feet themselves. My patients have a tremendous misconception that if they wear orthotics that their feet will somehow weaken or get worse, something like that.

But it's really helpful when they can say, oh well, I wear eyeglasses and I need my glasses to see, they get the sense of that's what the orthotics are doing for them, and so I discuss that with them. And you can see here in the picture, a kid with a pes planus deformity, and we’re getting him realigned with just a pair of over-the-counter orthotics.

I also do a lot of physical therapy, not as important frankly for hallux valgus deformity, but there is a place for it to a degree. Certainly with strengthening of range of motions in these patients that have concomitant deformities like a flatfoot frankly. And then shoe modifications; I have them wear wider shoes, bigger shoes that will allow for just the shape of their foot until they decided they’ll act on it.

In terms of surgical intervention, which is kind of the meat of this talk, there are variety of options, the least aggressive of which are the soft tissue procedures, and I would caution you against doing a simple isolated soft tissue procedure. It’s not going to be enough. There are literature articles that describe it, and they’ve had reasonable outcomes frankly, but it's always something that you're going to have to go back on.

In the picture here, this is a simple tightening up along the VL [Phonetic] [0:11:08] capsule and doing a tendon transfer for the hallux adductus. There is a place for it but frankly I think if you’re going to go to the trouble of operating and you’re going to cut these kids open, you want to give them the best outcome that you possibly can in least likelihood you want to return OR. So I think in those contexts, you are almost always going to have to do something with the bone.

Distal metaphyseal osteotomy is kind of the Austin’s -- the usual bunion corrections that people are used to. And there is a whole variety. I mean, you could even spend days talking about the different types. There are many that are described and it’s indicated for mild to moderate bunions. There are some among us who can use a very aggressive distal osteotomy to correct a fairly large IM and there's certainly a place for that. I'm one of them, that can get – depending on the patient, depending on the intermetatarsal angle, you can do a really aggressive Austin or a Mitchell or something on a 15-degree IM and get it corrected the way you need to.

But you really want to think that through, and I use cutouts, I still make the cutouts on my x-rays and I move them around, then I kind of decide what is going to be the best option. Largely these are transpositional which is to say you're cutting the distal metatarsal and you're sliding it over much like the procedure that Dr. Laporta just described to us.

Austin, Reverdin, Mitchell, Wilson, Peabody, you can look at McGlamary’s [phonetic] and there's, you know, tons that are out there, but whatever you’re trained in, whatever you’re comfortable in, these are the mild to moderate corrections. Also double osteotomies, [Indecipherable] [0:12:30] obviously described this, and I do a lot of Austin Akins for patients that get a little bit of correction with the Austin and then the tarsal has deformity in the hallux and so we can correct that as well.

In terms of increasing levels of metatarsal abnormalities and increasing intermetatarsal angles, we move more proximally to the proximal metatarsal osteotomies, and these are kind of lumped into those base procedures frankly. They are commonly used in patients with IM greater than 15, although I have done it in patients with smaller than 15, and I've done the other where you do distal procedures on more than 15.

These are the closing base wedges, the opening base wedges, crescentics, SCARFs, Ludloff’s. The literature really supports the use of the closing base wedge recently, and the Ludloff is becoming increasingly popular as the fixation techniques progress. This is actually a Ludloff of mine with a plate. The Ludloff itself is technically fairly easy to perform but it’s difficult to fixate. The plate makes it very very easy and it’s a really sleek procedure, really easy to do, and the patient you can see she had an acne as well with the staple.

The risk with an opening base wedge is that when you put the graph down and there are some potential for jamming of the joints distally because you’re changing the long axis of the way the metatarsal is moving, you have to go back to that first statement which is remember these are three-dimensional deformities, so it’s not just lengthening the transverse plane, you’re actually plantarflexing it and you can rotate it as well.

So you really want to think through the shape and size of your graft. Closing base wedges work really well because you're putting the bones back together. Again, consider that the shape and size of the wedge that you’re moving because you’re changing things in three dimensions. And ultimately you can combine any of these with the distal procedure to correct whatever other additional distal deformity that you may have.

Epiphysiodesis is something that I don't think it’s a great deal, there’s a guy down in Virginia Beach who does a bunch of these where I am, so I just send to him if it's going to be somebody who is really skeletally immature patient, but this is essentially the concept of arresting the growth plate on one side laterally to let the bone grow sort of straighten itself out as it grows.

And there's certainly a place for that, and you can see both the x-rays, these are his x-rays that he sent me because we’ll do a lot of these, but it's something that one can do. If you haven't done a lot of it I wouldn’t encourage trying it but it’s out there. There is literature supporting, you get maybe anywhere between about 4 to 7 degree of correction depending on how early along in the process you do the procedure.

For me in a patient like this, I’ll be far more likely to let this growth place close and then do a more aggressive procedure later on. First TMT arthrodesis, the Lapidus bunionectomy, I do a lot of these for juvenile patients because in a lot of my patients that seem to present with hallux valgus deformity they also have that hypermobility that we talked about. And in those patients with an elevated IM and hypermobility, fusion of medial column is a tremendous procedure. I do really really well and it's really really good procedure for this kind of thing.

Again, you have to consider the relative IM versus the true IM in those patients. They might have a lower IM with the metadductus in which case you progress to a Lapidus even with hypermobility. You can also use it for a long or short frankly first metatarsal, or if there’s any arthrosis at the first metatarsal phalangeal or at the first tarsometatarsal joint. Not so common in the juvenile patients that they have this arthrosis, but certainly if a patient that had a juvenile bunion has not progressed into their adulthood can ultimately start to have that.

I also use it for revision surgery. If somebody has come to me as juvenile that has had a distal procedure that has started to have recurrence, I'm far less likely to repeat the distal procedure than I have to try to correct it by a more proximal procedure.

There are some relative and absolute contraindications, obviously a short metatarsal that used to be a relative contraindication I would argue that you can do with the short metatarsal and I can show you how. Poor vasculary is obviously going to be a contraindication for any sort of surgery. Infection with the site and the compliance factor. If you don't get the sense that the patients are really going to stay off of it and do what you need them to do, you don't want to try to do a more aggressive procedure that's going to fail because of their compliance point.

In terms of technique planning, again I use the cutouts to get a sense of exactly what I'm looking for, how much correction that I, how we’re going to go about it. There are variety of ways in the literature that talk about how to do this. One or two incisions approach, small incisions, big incisions whether you go dorsal, whether you go medial, and frankly it’s certain preference whatever works for you.

I do traditional just alongside of dorsal medial incision, little more dorsal than medial, but I've done it with too small incisions. Well, usually with kids I’ll do too small incisions, but it heals fine. You want to protect the sagittal groove no matter what of any of these procedures you're doing. And I like this picture because it gives a really good chance you can actually see it, kind of right there.

It’s important for the mechanics of the sesamoid apparatus and so you want to resect the medial limits to a degree but not overresect to the point that you’re going to destabilize that sesamoid apparatus and give yourself a problem there.

For the Lapidus bunionectomy first TMT fusion, I resect a portion of the base but also that lateral flair, that we’re talking about. That's why I look for that initial radiograph. Sometimes you can have that lateral flair on the first metatarsal, and if you don't resect it other way you’re not going to get your correction in reducing the intermetatarsal angle in the transverse plane.

So it's important to kind of get a sense for what that is. You don’t have to take a lot of bone but you take some bone that allow for that both plantar translocation but also lateral translocation of the metatarsal, and then resection. I use a combination of both power and hand instrumentation.

You have to remember how deep that joint is, it is really a long joint. And so when you are getting in there it is 3 centimeters, too easily to get down in there. So I start the cut with a saw and then I got after with an osteotome and then pull those pieces out.

You want to visualize alignment, again remember that this is a three-dimensional structure even when you are looking at the x-rays you are looking at a two dimensional structures if something plantar flexion is going away from these. You have to get a sense of what the orientation of the joint is otherwise you are going to have the mal-position when you fuse it.

You want to measure twice and cut once that was always my, my residence director told me that so I sit there and I visualize exactly how we want the bone to go on and how you want to hold this on the osteotome to make that happen. And then I would argue that you want to translocate and plantar flex the fragment that will address any length issues that you have with the first metatarsal. You can see here on the, the lower picture of both, there is a slight plantar wedging at the cuneiform but then also some translocation.

Fixation, they are ultimately surgeon preference. There's a couple of studies that came out right and several of the guys out in Atlanta described that a plate and screw construct was the strongest followed by the two cross screws, followed by just the plate followed by wires and things like that. So you know a little bit depends on kind of what you are comfortable with what you are used to frankly.

I usually do two cross screws for screws and plates and you’ll see in my case is that there is going to some combination of both, more so you’ll see in the geriatric lecture that we’ll do later but this is kind of constructs that I do two cross screws. I have an opposing outcome from both of the distal here.

And then this is just one of the plates options that are available, the industry is increasingly creating Lapidus specific plates and so there are a lot of, lot of options out there, again I am not really pimping any of them per se.

You can also have some modifications that external fixation is an option for this when used it as an initial procedure for juvenile patients, you don't want to get -- they don’t like ex-fix all that well, but it is an option and you can use it to maintain the length if you had a break in that or other some sort of traumatic bone loss as a consequence of that.

And this is one of my case you can see us doing that with a small incision. Complications, there are sort of two groups of complication, intraoperative complications - things you could have corrected at the time but did not and then the postoperative complications, these are going to happen after the fact. Malposition is a frank I would argue it’s intraoperative complication if it’s not right when you are on the table it’s not going to get right later so you really want to make sure it’s exactly where you want it to be before you throw the screws.

You can also fracture the metatarsal, it doesn’t happen often but occasionally it does. Postoperative things, edema, malposition, again I would argue that’s interoperative complication but non-unary for this kind of procedures really, really low if you are doing it correctly, it’s about 10% depending on who you read the literature. You can have fixation failure but it’s very uncommon particularly if you are using the kind of screws that Dr. Kalish was talking about earlier today, you know headless screws that are solid, very, very likely not to fail.

And then you have to maintain regardless of these procedures you have to maintain appropriate postoperative course so it’s procedure specific. If you do any soft tissue procedure these patients can walk right away, if you are doing Lapidus I keep my patients normally burned for minimum for six weeks until I see radiographic signs of consolidation of the fusion site. So it’s kind of depending on what you’ve done that's what you want to progress to do. You want to maintain edema control that’s largely a pain issue frankly, does slow wound healing down but they are going to more comfortable during pain and that’s more of an issue as well.

And I initiate first metatarsal phalangeal range of motion fairly early on because if they are not moving they’ll stiffen up and kids particularly have a tendency to be somewhat tentative in the motion after their surgical so you really want to make it a game about how many times an hour they can move that joint to start getting moving because you want it to be functional.

So in terms of a few cases we’ve got, I’ve got a few here just to kind of tie things up before we go. This is an eighteen year old female she had a moderate bunion with some Hallux deformity as well, and she got just the standard sort of Austin Aikin construct and she did fine with that. You can see we use compression staple at the phalanx and then just two screw fixation for the long arm Chevron osteotomy.

This is a 19-year-old female, again predominantly female, patients that are having this done, you could see she has a fairly moderate, fairly moderate IM angle, sesamoid position was pretty laterally translocated as well. She progressed onto a Lapidus bunion I think with the Aikin fusion, you can see that we’ve got much better correction, sesamoids are in appropriate position as compared to the original. And she was not, not such a huge IM to start with but she had hyper mobility so this was one of those cases that I would argue that you can get really good correction with the Lapidus in those cases where the IM is low but there are hypermobile, don’t be afraid to make that step and do the fusion.

This is that [phonetic] [0:22:40] that I was talking. She had an IM angle of 17 degree so I'm thinking more of a proximal procedure but she was an hyper mobile so there was no need for us to compromise that first TMJ joint by fusing it so I did level off instead particularly in the context of the plate that’s out there. She also got the Aikin as well.

So in terms of complications for these patients, you know the wrong procedures was always going to be an issue, it's not one-size-fits-all. You can’t do the same procedure for every patient that walks in the door even if it’s the same patient, different feet left and right but I’ve had patients that I did an Austin in one, I did Lapidus on the other based on the pathology it was specific to that foot. So you really have to look at each foot, each patient individually and what's going to be required.

Overcorrection and undercorrection is always a source of complication so you again, what you’ve got on the table is what you’ve got when you are closing so you want to make sure you like where it is because it’s never going to get better than that. Earlier in aggressive management of any competitions frankly it’s going to be important and that's the truth and regardless of bunion surgery, flat foot anything you are going to do, doing a nail lotion, if there's a problem you want to manage it quickly and seem to be doing so. And you want communicate with the patients and the parents to really know what's going on with the process is.

Remember that this seems reasonable to you, you do this every day but these kids are terrified. So you really want to make sure that you're expressing every step of the way what's going to happen, so they know what's what going to happen, they have very, very clear expectations and goals. Do you have any questions? Anybody. Okay.