View
114
Download
2
Category
Preview:
Citation preview
Copyright 1992 by The Journal of Bone and Joint Surgery, Incorporated
VOL. 74.A, NO. 9. OCTOBER 1992 1367
Juvenile Hallux ValgusA CONSERVATIVE APPROACH TO TREATMENT*
BY JORGE A. GROISO, M.D.t. BUENOS AIRES, ARGENTINA
Investigation performed at the National Pediatric Hospital, Buenos Aires
ABSTRACT: A conservative method consisting of use
of a thermoplastic splint at night as well as passive and
active exercises was used for the treatment of hallux
valgus in fifty-six children and teen-agers who were
between one month and sixteen years old. The splint
was remodeled periodically. At the time of follow-up,
which ranged from two to six years, the metatarso-
phalangeal joint angle or the intermetatarsal angle, or
both, had improved in approximately half of the feet.
No recurrences were detected among the patients who
improved.
Deviations of the toe are frequent among children
and teen-agers. Many patients are asymptomatic, and
the deviations are often incidental findings. When symp-
toms are present, they are mild, but the deformity is
sometimes unsightly, progressive, or worrisome for the
parents.
There is a strong hereditary trait for juvenile hal-
lux valgus’5. The deformity can be found at all ages, in-
cluding the first months of life. The findings include
occasional pain over the medial eminence and a mild
deformity. The metatansophalangealjoint is usually con-
gruous, the more pronounced deformities involve pro-
nation of the toe, and malalignment of the sesamoids
is rare’9.
There are conflicting opinions about the usefulness
of conservative therapy27. However, it is advisable to
postpone operative treatment until the completion of
bone maturation, as earlier operative intervention has
been associated with a high rate of necurrence2”�#{176}22�’.
The purpose of this study was to evaluate the non-
operative treatment of juvenile hallux valgus with the
use of a thermoplastic splint at night.
Materials and Methods
This seven-year study included fifty-six patients in
whom a deviation of the great toe had been treated with
night splints and exercises. The patients were between
one month and sixteen years old. The management of
each patient was carried out over a period of two years
*At the time of publication. no benefits in any form have been
received from a commercial party related directly or indirectly to the
subject of this article. No funds were received in support of this study.
tArenales 2245-El, Buenos Aires 1124, Argentina.
or more. The maximum age at the time of the follow-up
evaluation was twenty-one years. The minimum dura-
tion of follow-up was two years from the onset of treat-
ment, and the maximum duration was six years.
The criterion for the selection of patients for treat-
ment was an obvious deviation of the toe with a radio-
graphic metatansophalangeal angle of 15 degrees or
more, or the appearance of a prominent metatarsal
head that concerned the patient or the family. The pa-
tient had to be no older than sixteen years and without
any associated congenital anomalies (neurological or
connective-tissue disease) to be included in the study.
Classification of the Patients
The patients were divided into three groups, de-
pending on the findings and on the records available.
Group A included twenty-five patients (twenty girls and
five boys) who were chosen for the study because din-
ical photographs and radiographs made before and two
years on more after treatment were available. These
patients had true hallux valgus with an initial metatar-
sophalangeal angle of at least 15 degrees’7 or an in-
terphalangeal angle of 9 degrees or more4 (Figs. 1-A
through 2-D).Group B included five patients who did not have
true hallux valgus because the metatarsophalangeal an-
gle was less than 15 degrees. The patient or family ne-
quested the treatment for correction of a prominence
on the medial side of the foot. These patients were eval-
uated in the same manner as the patients in Group A
(Figs. 3-A and 3-B).
Group C included thirty-one patients who had ap-
parent hallux valgus but for whom radiographic studies
were not available. These patients had been followed
clinically and with photographs for two years or more.
Orthotics
The use of an office-made low-temperature thermo-
plastic splint at night was the mainstay of treatment. The
splint is cut according to a pattern drawn on paper (a
paper towel or typing paper). A pre-cut splint (Alimed,
Dedham, Massachusetts) can also be used (Fig. 4-A). A
pattern is prepared over a tracing of the patient’s foot,
and the flanges that will be needed are drawn. A flange,
half of the width of the foot, is needed on both sides to
hold the splint in place, and a transverse distal flange is
�j1�
FIt;. I-A
1368 J. A. GROISO
THE JOURNAL OF BONE AND JOINT SURGERY
Figs. i-A through I-D: Case 5. a seven-year-old boy in Group A.
Fig. 1-A: Before treatment.
Fig. I-B: After two years and nine months of treatment and six years of follow-up.
Fig. 1-C: The initial radiograph of the right foot. showing a metatarsophalangeal angle of 24 degrees and an intermetatarsal angle of 11
degrees.
Fig. I -D: Radiograph of the right foot made sixteen months later. showing a metatarsophalangeal angle of I 6 degrees and an intermetatarsal
angle of 10 degrees.
necessary to push the toe in the proper direction. The
drawing is cut out of the paper and checked on the foot.
Modifications are made if needed so that the paper
template conforms to the foot as noted.
The completed template is placed on a sheet of per-
forated low-temperature thermoplastic (Alimed). andthe outline is drawn on the thermoplastic with a ball-
point pen. The thermoplastic is softened in warm water
and cut with regular scissors. It is then heated to 70
degrees Celsius in a skillet or in a special-purpose plas-
tic bag (Alimed). Once the splint is pliable, it is removed
from the hot water with plastic forceps and placed on a
cloth towel, where it is allowed to cool first on one side
and then on the other for a few minutes. When the
doctor feels that the splint is no longer too hot to be
held, it is applied on the contralateral foot. on which no
FIG. 2-A FI�. 2-B FI;. 2-C Flu. 2-D
Figs. 2-A through 2-D: Case 17. a twelve-year-old girl in Group A.
Fig. 2-A: Before treatment.
Fig. 2-B: After two years of treatment.
Fig. 2-C: The initial radiograph of the right foot. showing a metatarsophalangeal angle of 30 degrees and an intermetatarsal angle of 8
degrees.
Fig. 2-D: Radiograph of the right foot. two years and four months postoperatively. showing a metatarsophalangeal angle of I I degrees and
an intermetatarsal angle of 8 degrees.
JUVENILE HALLUX VALGUS 1369
FIG. 4-A
lit� �
- �
‘fl
FIG. 3-AFIG. 4-B
Fig. 4-A: A pre-cut splint for the treatment of hallux valgus.
Fig. 4-B: A molded splint.j[( . .
FIG. 3-B
Figs. 3-A and 3-B: An eleven-year-old girl (Group B) who had a
prominent metatarsal head.
Fig. 3-A: Initial photograph.
Fig. 3-B: Cosmetic improvement was seen two years later.
VOL. 74-A, NO. 9. OCTOBER 1992
weight is borne because the patient is lying on an exam-
ination table. It is then molded on the metatarsal area,
with mild pressure exerted on the medial and lateralsides of the foot in the region of the first and fifth
metatarsal shafts and with enough room left to prevent
pressure on the metatarsal heads.
The transverse distal flange is folded to double its
thickness and is placed on the lateral side of the toe to
produce a varus deviation at the metatarsophalangeal
joint. The ankle joint must be in mild plantar flexion to
relax the plantar fascia and the flexor tendons to in-
crease the lateral mobility of the great toe. The borders
of the flange should be rounded to prevent pressure on
the nail-bed or at the edges (Fig. 4-B).
Sometimes, when the final position is not satisfac-
tory, it may be necessary to reheat the transverse distal
flange of the splint and, while holding the metatarsals
firmly, to redirect the great toe, molding the distal part
of the splint into the corrected position. The corrective
pressure must be exerted in a medial direction proxi-
mally, avoiding the nail-bed.
The splint is held in place with a Velcro strap that
mildly compresses the forefoot. The splint is worn only
at night. A sock can be worn over the splint to help hold
it in place.
The fit of the splint is checked every three months,
and the toe section is altered if the medial mobility of
the phalanx allows for increased medial placement ofthe flange. The metatarsophalangeal joint must be in
neutral position as regards flexion and extension in or-
den to obtain the maximum stretch of the lateral struc-
tunes (the capsule, ligament, and adductor tendon).
Exercises
There are two types of passive exercises. For the
first, the metatarsals are held together and a varus lat-
eral movement of the phalanges of the great toe is per-
FIG. 5-A FIG. 5-B
Figs. 5-A and 5-B: Case 16, a twelve-year-old girl (Group A) demonstrating the program of active exercise.
Fig. 5-A: Photograph made while the patient was standing with the muscles relaxed.
Fig. 5-B: Photograph showing active contraction of the abductor hallucis muscles bilaterally.
FIG. 6-A FIG. 6-B FIG. 6-C FIG. 6-D
Figs. 6-A through 6-D: Case 1. a thirty-day-old boy in Group A.
Fig. 6-A: Before treatment.
Fig. 6-B: After application of the plantar plastic splint.
Fig. 6-C: The initial radiograph of the left foot, showing a metatarsophalangeal angle of 26 degrees and an intermetatarsal angle of 14
degrees.
Fig. 6-D: Correction after four months of treatment and five years of follow-up.
1370 J. A. GROISO
THE JOURNAL OF BONE AND JOINT SURGERY
formed several times to relax the capsule. For the other
passive exercise, the plantar aspect of the first metatar-
sal head is pushed upward with the ankle dorsiflexed,
while the great toe is dorsiflexed and deviated in a varus
direction to elongate the adductor and the flexor hallu-
cis brevis.
For the active exercises, the patient stands with the
feet slightly apart and attempts to touch one great toe
with the other great toe without moving the feet (Figs.
5-A and 5-B). After several trials, most children learn
how to contract the abductor muscles, but some, mostly
in the younger age-group, cannot learn to perform this
movement, perhaps because they do not have a good
understanding of the instructions on because the abduc-
ton muscles do not have an independent voluntary con-
traction. The active and the passive exercises are done
once a day with twenty repetitions of each. It is con-
venient to start the physical routine with the help of a
physiotherapist.
If there is a contracture of the Achilles tendon, it
should be treated with stretching exercises done with
the patient standing and the knees extended to neutral.
It is advisable to continue the treatment until bone
maturation, as is recommended for the treatment of
other angular deviations in children.
When a patient has excessive pronation of the fore-
foot, he or she can be fitted with an arch support to
prevent exaggerated pressure on the medial side of the
great toe (Figs. 7-A and 7-B). Twelve patients in this
series wore arch supports.
FIG. 7-A FIG. 7-B
JUVENILE HALLUX VALGUS 1371
VOL. 74-A, NO. 9. OCTOBER 1992
Figs. 7-A and 7-B: Case 9, a ten-year-old girl (Group A) who had pronation of the forefoot.
Fig. 7-A: Photograph made before treatment while the patient was standing.
Fig. 7-B: After treatment. there was improvement in the alignment of the toes and the pronation of the great toes.
Evaluation ofthe Patient
Initial photographs and radiographs were made
with the patient bearing weight. The follow-up was per-
formed with paper-copy photographs, made every four
to eight months. The follow-up radiographs, made at
least two years after treatment, were made with the
patient standing and at least six hours after the splint
had been removed. The feet were not evaluated for
metatarsus pnimus varus because it has been reported
that the alignment of the first ray is normal in patients
who have hallux valgus’5.
Group A
Results
Group A included twenty-five patients (twenty girls
and five boys) whose average age was ten years (range,
one month to sixteen years) (Table I). They were eval-
uated at a mean of three years and four months (range,
two to six years) after the start of treatment.
For the purpose of the study, the feet were consid-
ered independently of one another”. A total of forty-
eight feet (twenty-five left and twenty-three right) with
an abnormal metatarsophalangeal angle were analyzed.
A change in the angle of 2 degrees or more was
considered valid; this took into account the error of themethod according to Piggott.
The initial metatarsophalangeal angles of the forty-eight feet averaged 22 degrees (range, 15 to 35 degrees).The angle in twenty-eight feet improved (decreased) an
average of 6 degrees (range, 2 to 19 degrees). The angle
did not change in thirteen feet, and it increased an aver-
age of 5 degrees (range, 2 to 9 degrees) in seven feet.
The intermetatarsal angle was 9 degrees or more
(average, 1 1 degrees; maximum, 16 degrees) in thirty-
seven feet. The angle improved an average of 3 degrees(range, 2 to 7 degrees) in twelve feet. The angle did
not change in seventeen feet, and it increased an aver-
age of 3 degrees (range, 2 to 4 degrees) in eight feet.No conclusion can be made with regard to the influ-
ence of the rate of exact compliance with the regimen
of treatment. It was presumed that the compliance oc-
casionally was not as good as was reported because the
information provided by the parents, mostly with regard
to the prescribed exercises, varied markedly from the
information provided by the patients. It was very useful
to show the patients the photograph that had been made
at the beginning of the treatment so that they would see
the improvement. For some patients, interruption of the
use of the splint was deleterious, but for others, the
improvement that had been obtained was not affected.One interesting result was in a six-year-old girl
(Case 4) who had complied very well with the regimenof treatment. The mother had requested treatment forher daughter because the mother had severe hallux val-gus. The girl had initial improvement over a four-month
period, followed by regression of the correction as seen
nadiographically. At the most recent follow-up examina-tion, the metatarsophalangeal angle on the left was 3
degrees larger than before treatment. The metatarso-phalangeal angle on the right remained the same. Thecosmetic appearance was improved and the family waspleased with the result of the treatment.
For one patient (Case 1), use of the splint was
stopped when he was seven months old. after four
months of wear. There was no recurrence five yearsafter the cessation of treatment (Figs. 6-A through 6-D).
Two children (Cases 3 and 5) stopped wearing the splint,for psychological reasons, after at least two years of use
with six months of weaning. The radiographic angles
were less than 15 degrees at the time of follow-up. The
routine for weaning was to remove the splint one day aweek over a period of two months, then to remove it
two days a week for two months and then three days aweek for the last two months. One patient (Case 3) who
1372 J. A. GROISO
TABLE I
GROUP A
Change in
Affected
Metatarso-
phalangeal Angle*
(Degrees)
Intermetatarsal
Angle*
(Degrees)
Duration
of
Follow-
Metatarsophalangeal
Angle
(Degrees)
Change in Inter-
metarsal Angle
(Degrees)
Metatarso-
phalangeal
Congruence*
Case Age Sex Relative Left Right Left Right up Left Right Left Right Left Right
(Yrs�) (Yrs.)
1 1 mo. M 26/15 7/13 14/7 13/10 6 +11 -6 +7 +3 Dev./ Congr./
congr. congr.
2 3 F Grand- 24/22 23/22 11/10 10/7 4 +2 +1 +1 +3 Dev./ Dev./
mother dev. dev.
3 5 F Grand-mother
15/11 16115 10/10 10/12 6 +4 +6 0 -2 Dev./
congr.Dev./
congr.
4 6 F Mother 15/18 16/17 8/10 9/11 4 -3 -1 -2 -2 Congr./
congr.
CongrJ
congr.
5 7 M Grand-
mother
24/14 25/12 11/10 11/9 6 +10 +15 +1 +2 Dev./
congr.
Dev./
congr.
6 9 F Mother 19/27 29/37 10/12 10/11 2 -8 -8 -2 -1 Sublux./
sublux.
Congri
sublux.
7 9 F 35/32 20/19 10/12 9/9 3 +3 +1 -2 0 Sublux./
sublux.
Congr./
congr.
8 10 M 15/16 13/13 9/13 10/9 4 -1 0 -4 +1 Congr./
congr.
Congr./
congr.
9 10 F 24/28 28/29 13/8 14/12 4 -4 -1 +5 +2 CongrJ
congr.
Congr./
congr.
10
11
10
10
F
F
Mother
Father
23/18
16/13
23/16
16/17
8/8
8/11
7/7
7/7
2
2
+5
+3
+7
-1
0
-3
0
0
Congr./
congr.
Congr./
congr.
Dev./
congr.
Congr./
congr.
12 10 F 30/21 30/20 6/11 14/12 3 +9 +10 -5 +2 Sublux./
dev.
Sublux./
dev.
13
14
10
11
M
F
19/15
21/24
25/16
16/9
9/9
11/10
11/12
6/10
2
3
#{247}4
-3
+9
+7
0
+1
-1
-4
Dev./
congr.
Sublux./
sublux.
Congr./
congr.
Sublux./
congr.
15 11 F 20/10 17/5 10/12 9/10 2 +10 +12 -2 -1 Congr./
congr.
Congr./
congr.
16 11 F 18/19 21/23 8/6 9/7 3 -1 -2 +2 +2 Dev./
dev.
Dev./
dev.
17
18
12
13
F
F
Mother
Mother
20/15
28/26
30/11
20/11
8/12
12/15
8/8
9/13
3
5
+5
+2
+19
+9
-4
-3
0
-4
Dev./
congr.
Sublux./
sublux.
Sublux./
congr.
Sublux./
dev.
19 13 F Mother 22/23 22/31 9/4 10/10 2 -1 -9 +5 0 Sublux./
sublux.
Sublux./
sublux.
20 13 M 27/25 18/13 10/10 9/8 2 +2 +5 0 +1 Sublux./
sublux.
Dev./
congr.
21 14 F 24/24 31/30 13/9 16/16 3 0 +1 +4 0 Sublux./
sublux.
Sublux./
sublux.
22 14 F 27/27 28/24 11/9 14/12 4 0 +4 +2 +2 Sublux./
sublux.
Sublux./
dev.
23 14 F Grand-mother
18/14 22/17 7/10 10/10 2 +4 +5 -3 0 Dev./
dev.
Dev./
dev.
24 14 F 20/19 30/28 10/10 11/10 2 1 +2 0 +1 Dev./
dev.
Sublux./
sublux.
25 16 F 17/13 15/16 8/8 6/7 3 +4 -1 0 -1 Dev./
congr.
Dcv.!
dcv.
THE JOURNAL OF BONE AND JOINT SURGERY
*Before treatment I at the time of follow-up.
had discontinued use of the brace had no recurrence prominent metatarsal head in both feet. The angles werefour years after treatment was stopped on the right and within the normal range. There was an improvement ineighteen months after treatment was stopped on the the appearance of eight feet. Radiographic measure-left. The other patient (Case 5) had no recurrence more ments did not improve for five of the feet, even thoughthan four years after treatment was stopped. the patients felt that the foot had improved.
Group B Group C
This group included five patients (three girls and two There was no way to measure changes in these feet,boys), between seven and sixteen years old, who had a as radiographs had not been made, but the over-all din-
JUVENILE HALLUX VALGUS 1373
VOL. 74-A, NO. 9. OCTOBER 1992
ical impression, and a comparison of photographs madebefore and after treatment, suggested that there had
been an improvement in more than half of the feet.
Recurrence
The deformity recurred during the course of treat-
ment in three patients (Cases 4, 20, and 25), and it re-
curred during an interruption in treatment in a patient
(Case 6) who did not use the splint for six months at the
age of ten and one-half years. The deformity did not
recur in any patient after the treatment was stopped.
Discussion
Some authors’7 have reported a low frequency ofhallux valgus in children, but others have found a valgus
deformity in 22 per cent’ and 39 per cent” of school-age
girls. In another report, 57 per cent of adults who had
the deviation recalled having had it since adolescence2.
Scranton and Zuckerman stated that bunions are rare
before the age of ten. However, I have seen bunions invery young children, even in the first months of life.
The structural factors in the development of halluxvalgus include metatarsus varus, pes planus, ligamentouslaxity, and a tight heel-cord’7. There is a strong heredi-
tany factor’6, as was confirmed in this series: eleven pa-tients (40 pen cent) had a close relative who had the
deformity. Ill fitting footwear has been cited as a cause
of the deformity7’424, but it was not the cause among our
patients. One patient (Case 1) had always been bare-
foot, and most had worn only sport shoes or sneakers.The natural history of this deviation, according
to Piggott, is that the congruous type of deformity re-mains stable. As deviated and subluxated joints areprone to deteriorate, these patients should be candi-
dates for prophylactic operations. However, I found nomention of spontaneous regression of the angulation in
the literature.
Juvenile hallux valgus is different from the bunionseen in the adult. The deviation of the toe is less pro-
nounced, the medial eminence is smaller with excep-
tional bursal thickening, and a rotation deformity is
present only in patients who have a more pronounced
lesion. There are no degenerative changes at the meta-
tarsophalangeal joint, and the physes are still open7.Treatment of juvenile hallux valgus is controversial.
The patient or the family asks for improvement of an
unsightly deformity, and the prescription, ugly shoes, is
as unpleasant as the deviation. Other patients are told
to watch passively how the deviation worsens while they
wait for the optimum age to have an operation. Nor is
there general consensus as to the final result of either
therapy.
Operative treatment of hallux valgus is not an easy
proposition to a youngster. The indications for opera-
tion are not precise: some authors have included cos-
metic appearance as an indication9”�, while others havenot mentioned it”.
There is disagreement about the ideal procedure
or the optimum age for the operation. Some authors
have advised against an operation before bone matuna-
tion3�, and others have found no difference in the re-
sults of operative treatment of severe bunion deformity
whether or not bone maturation has taken place’5.
The results of operative treatment have not been
uniform, and the rate of recurrence has been high: 61
per cent in the study of Ball and Sullivan and 47 per cent
in that of Geissele and Stanton. Helal reported a 45.7per cent rate of failure in his operatively treated pa-tients. Studies of patients who were operated on before
the age of fifteen years old revealed a 25 per cent�’ anda 12 per cent’ prevalence of unsatisfactory results.
Other complications of operative treatment include
the need for revision procedures, hypentrophic scars,
cramps, narrowing of the metatarsal head”, metatarsal-gia, stiffness of the metatarsophalangeal joint2, overcor-
rection, and shortening of the first metatarsal5’2.
Non-operative therapy for juvenile hallux valgususually includes the prescription of a commercial splint25
and the use of roomy footwear or an arch support7, butit is unlikely that fashion-conscious patients in this age-
group would wear shoes that are markedly different
from those of their peers1’.
There are numerous splints on the market, but these
are poorly tolerated by youngsters. As the orthotics are
mass-manufactured, there is little possibility of adaption
to the different sizes and anatomical variations of the
children.
In the present study, a non-operative approach was
attempted for patients who were too young for an op-
eration or in whom the deviation of the toe was not
severe enough to justify an operation. An office-made
splint modeled directly onto the patient’s foot was cho-
sen for this study because it allows accommodation for
the anatomical and pathological characteristics of the
individual. The splint can also be reset periodically,
which allows intermittent positioning. It exerts an in-
elastic traction on the soft tissues that surround the
joint. The structures are held near the end of their elastic
limit until they relax or grow into this position. Then the
splint is reset and a new elastic limit is reached”.
The program of treatment includes passive and ac-tive medial mobilization of the metatarsophalangeal
joint. Piggott stated that active side-to-side movements
do not normally occur, but when our patients were prop-
erly trained most could perform such movements.
It is also advisable to prescribe onthotics for cx-
tremely pronated feet, with the only aim being reliefof the pressure on the medial side of the toe26. It wasfound that patients who had been managed with an
operation for flexible flat feet, and were not managed
with arch supports postoperatively, had a recurrence of
the deviation”1’.Some authors have dismissed non-operative treat-
ment as futile5, and others have stated that the long-term
I 374 J. A. GROISO
THE JOURNAL OF BONE AND JOINT SURGERY
results are unknown3 or that the effects of such treat-
ment are only symptomatic27. These less satisfactory re-
suits could have been due to the use of improper splints
- that is, those that had been mass-manufactured or
that were elastic or poorly contoured - or perhaps they
were due to a lack of compliance. which is difficult at
this young age.
However. the results in the group of patients in the
present analysis were very satisfactory. Fifty per cent of
the feet in Group A had an improvement of the meta-
tansophalangeal angle. but only 32 per cent had an im-
provement of the intermetatarsal angle. Geissele and
Stanton also found that insufficient diminution of the
width of the forefoot was the most common complaint
among youngsters who had had an operation.
As the response to treatment was not reflected sim-
ilarly by both measurements in the same patient (one
parameter can improve as the other remains stable or
deteriorates), the conclusion was that, of twenty-five
patients in Group A. three (12 per cent) did not have an
improvement in either of the measured angles.I believe that the described approach deserves to be
tried, as many youngsters were helped by a benign treat-
ment that delayed or stopped the progression of the
deviation in some and improved or even totally cor-
rected the deformity in others.
Noii The author thanks Nora (‘ampora. M.D.. for assistance with thc analysis of the
records.
References
I . American Academy of Orthopaedic Surgeons: Orthopaedic Knowledge Update 3. Home Study Syllabus. Park Ridge, Illinois, The
American Academy of Orthopaedic Surgeons. 1990.
2. BaIl, John, and Sullivan, J. A.: Treatment of the juvenile bunion by Mitchell osteotomy. Orthopedics. 8: 1249-1252, 1985.
3. Bonney, George, and Macnab, Ian: Hallux valgus and hallux rigidus. A critical survey of operative results. J. Bone and Joint Surg..
34-13(3): 366-385. 1952.
4. Carr, C. R., and Boyd, B. M.: Correctional osteotomy for metatarsus primus varus and hallux valgus. J. Bone and Joint Surg., 50-A:
1353-1367, Oct. 1968.
5. Chomeley.J. A.: Hallux valgus in adolescents. President’s address. Proc. Roy. Soc. Med., 51: 903-906, 1958.
6. Cole, A. E.: Foot inspection ofthe school child. J. Am. Podiat. Ass,i.. 49: 446-454. 1959.
7. Coughlin, M. J., and Mann, R. A.: The pathophysiology of the juvenile bunion. In instructional Course Lecture.s� Tue American Academy
of Orthojmedic Surgeons. Vol. 36, pp. 123- 136, Park Ridge. Illinois. The American Academy of Orthopaedic Surgeons, 1987.
8. Craigmile, D. A.: Incidence, origin, and prevention of certain foot defects. British Med. J., 2: 749-752. 1953.
9. Das De, Shamal: Distal metatarsal osteotomy for adolescent hallux valgus.J. Pediat. Orthop., 4: 32-38. 1984.
10. Fess, E. E., and Philips, C. A.: Stand Splititing, Principles and Methods. Ed. 2. St. Louis. C. V. Mosby. 1987.
II. Geissele, A. E., and Stanton, R. P.: Surgical treatment of adolescent hallux valgus.J. Pediat. Orthop., 10: 642-648, 1990.
12. Goldner, i. L., and Gaines, R. W.: Adult and juvenile hallux valgus: analysis and treatment. Orthop. Clii,. North America, 7: 863-
887. 1976.
13. Helal, Basil: Surgery for adolescent hallux valgus. Cli,t. Orthop., 157: 50-63. 1981.
14. Helfet, A. J., and Gruebel-Lee, D. M.: Disorders ofthe Foot, p. 123. Philadelphia, J. B. Lippincott. 1980.
15. Houghton. C. R., and Dickson, R. A.: Hallux valgus in the younger patient. The structural ahnormality.J. Bone andfoint Surg., 61-B(2):
176-177. 1979.
16. Johnston, Ola: Further studies of the inheritance of hand and foot anomalies. Cli,,. Orthop., 8: 146-159, 1959.
17. Kalen, Vicki, and Brecher, Allan: Relationship between adolescent bunions and flat feet. Foot andAnkle, 8: 331-336, 1988.
18. Luba, Robert, and Rosman, Michael: Bunions in children: treatment with a modified Mitchell osteotomy. .1. Pediat. Orthop., 4: 44-
47. 1984.
19. Mann, R. A. leditorl: Dii Vries Surgery oft/ic Foot. Ed. 5. St. Louis. C. V. Moshy. 1986.
20. Meehan, P. L.: Adolescent bunion. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 31. pp.
262-264. St. Louis, C. V. Moshy. 1982.
21. Piggott, Harry: The natural history of hallux valgus in adolescence and early adult life. J. Bone and Joint Surg., 42-B(4): 749-760, 1960.
22. Richardson, E. C.: The foot in adolescents and adults. In Campbell’s Operative Orthopaedics, edited by A. H. Crenshaw. Ed. 7. vol. 2. pp.
879-880. St. Louis. C. V. Moshy, 1987.
23. Scranton, P. E., Jr., and Zuckerman, J. D.: Bunion surgery in adolescents: results of surgical treatment. J. Pediat. Orthop., 4: 39-43, 1984.
24. Sim-Fook, Lam, and Hodgson, A. R.: A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J. Bone
(l1Z(lJOillt Stag.. 40-A: 1058-1062. Oct. 1958.
25. Simmonds, F. A., and Menelaus, M. B.: Hallux valgus in adolescents.J. Bone andJoint Surg., 42-B(4): 761-768. 1960.
26. Stanton, R. P.: Personal communication. 1991.
27. Tachdjian, M. 0.: Pediatric .9rt/zopedic.s� Ed. 2. Philadelphia. W. B. Saunders, 1990.
28. Tax, H. R.: Podopcdiatric.s� p. 191. Baltimore. Williams and Wilkins, 1980.
Recommended