A
CONTROLLED
ORTHOSIS
TIMOTHY
From
PROSPECTIVE
FOR
JUVENILE
E. KILMARTIN,
RICHARD
the Northampton
School
TRIAL
HALLUX
L. BARRINGTON,
ofPodiatry,
W.
angle
had
increased
FOOT
WALLACE
England
In a survey of 6000 children
between
9 and 10 years of
age, 122 were found
to have unilateral
or bilateral
hallux valgus. These children
were randomly
assigned
to no treatment
or to the use of a foot orthosis.
About
three
years
later 93 again
had radiography.
The
metatarsophalangealjoint
A
VALGUS
ANGUS
Northampton,
OF
in both
groups
but more so in the treated
group.
During
the
study, hallux
valgus developed
in the unaffected
feet
of children
with unilateral
deformity,
despite
the use
of the orthosis.
aged
between
technique,
8 and
reported
18 years.
Trott
success
(1972),
in 91%
using
of cases.
a similar
Goldner
and
Gaines
(1976)
fused
the metatarsocuneiform
joint
and
performed
distal
soft-tissue
realignment;
they achieved
success
in 88%
of 25 juvenile
cases.
Scranton
and
Zuckerman
(1984)
also reported
initial
success;
in their
series
of 50 operations
the average
intermetatarsal
(IM)
angle
was
reduced
angeal
joint
deformities,
from
12#{176}
to 4#{176}
and the metatarsophal-
angle from 28#{176}
to 1 1#{176}.
Late recurrence
however,
led them
to suggest
that
of the
surgery
should
be avoided
in adolescence,
because
‘the presence
of an open epiphysis
led to an unpredictable
outcome”.
There
is, therefore,
no agreement
about
the ideal
procedure
or the optimum
age for surgery
for hallux
valgus,
nor are the indications
for operation
clear. Pain is
not a common
problem
(Helal
et al 1974)
and cosmetic
‘
J BoneJoint
Received
Surg
5 July
Juvenile
only
[Br]
1994;
Accepted
1993;
and
76-B:2l0-4.
18 August
adolescent
the first
1993
hallux
valgus
metatarsophalangeal
initially
affects
(MTP)joint,
but
as the
condition
progresses
it involves
the whole
forefoot
and
may
be associated
with
deformity
of the lesser
toes,
plantar
callosities,
deformity
ofthe
great toe nail, splaying
of the forefoot
The value
and problems
oftreatment
Helal,
and
Gupta
with shoe fitting.
in the early stages is uncertain.
Gojaseni
(1974)
and
Helal
(1981)
reviewed
eight different
operations
performed
on adolescents
aged between
9 and 19 years
and reported
a poor
result
in 47% of 280 feet. Bonney
advised
against
surgery
for hallux
maturity;
63%
of their
series
of
underwent
in
the
metatarsal
osteotomy
metatarsus
Menelaus
primus
(1960)
repair
with
80%
subjective
used
proximal
showed
varus
objective
(1952)
bone
who
no improvement
angle.
a combination
metatarsal
and
and Macnab
valgus
before
54 adolescents
Simmonds
of distal
osteotomy
success
in 33 feet
Stanton
(1990)
shoe orthoses
growing
foot,
have strongly
recommended
to maintain
postoperative
but the usefulness
of this
the use of incorrection
in the
treatment
awaits
confirmation.
Of potentially
greater
value would
treatment
that could
correct
the hallux
prevent
its progression.
Orthoses
have
reduce
excessive
pronation
of the foot
Rodgers
and Leveau
1982)
which
has
be a conservative
valgus,
or at least
been
shown
to
(Bates
et a! 1979;
long been consi-
dered
and
soft-tissue
and
appearance
may not be a good justification
for surgery.
It
is possible
that surgery
alone will not cure juvenile
hallux
valgus.
Scranton
and Zuckerman
(1984)
and Giessele
and
reported
of girls
1947;
1979;
Holstein
performed
measure
hallux
T. E. Kilmartin,
MChS,
FPodA,
Specialist
in Podiatric
Surgery
Northampton
School
of Podiatry,
Northampton
General
Hospital,
ville, Northampton
NN1 SBD, UK.
R. L. Barrington,
Kettering
and
Northamptonshire
FRCS,
District
NN16
Consultant
Orthopaedic
Surgeon
General
Hospital,
Rothwell
8UZ, UK.
Road,
Clifton-
Kettering,
should
be sent
©1994
British
Editorial
Society
0301-620X194/273S
$2.00
210
to Mr T. E. Kilmartin.
of Bone
and Joint
Surgery
and
Not-
factor
Root,
to hallux
Orien
1980;
and
Kalen
valgus
Weed
and
(Rogers
1977;
and
Greenberg
Brecher
1988).
We
a prospective,
randomised
controlled
study to
the effect
of the use of an orthosis
on juvenile
valgus.
PATIENTS
A group
w. A. Wallace,
FRCS Ed, FRCS Ed(Orth),
Professor
of Orthopaedic
Accident
Surgery
University
Hospital,
Queen’s
Medical
Centre,
Clifton
Boulevard,
tingham
NG7 2UH, UK.
Correspondence
a predisposing
Joplin
AND
of 6000
METhODS
children
aged
9 to 10 years
state schools
in the Kettering
district
was screened;
150 of these children
of hallux
valgus
and had radiography.
poliomyelitis
cases
of
disorder.
attending
of Northamptonshire
had clinical
evidence
One child with old
was excluded
but there were no other known
systemic,
neurological
or connective-tissue
After
measurement
of the radiographs
122
children
(16 boys, 106 girls) met the criterion
in the study,
namely
a metatarsophalangealjoint
THE JOURNAL
OF BONE
for inclusion
angle,
in
AND JOINT
SURGERY
A CONTROLLED
one or both
dorsoplantar
feet,
of
radiograph
PROSPECTIVE
TRIAL
OF A FOOT
ORTEOSIS
FOR
JUVENILE
HALLUX
VALGUS
211
more
than
14.5#{176}measured
on a
taken with the child standing
on
both
feet.
The
X-ray
beam,
directed
vertical,
was aimed
at the navicular.
at
The
15#{176}
from
the
focus
to film
distance
was 100 cm.
Parental
consent
was given
for randomisation
into a
treated
or untreated
(control)
group.
The treated
children
all had a biomechanical
examination
as described
by
Root,
Orien
of in-shoe
pronation
and Weed
(1971)
and were
orthoses
(Fig. 1), designed
ofthe
subtalarjoint
(Philps
prescribed
a pair
to prevent
excessive
1989; Sanner
1989).
The children
were reviewed
every six months
for the
next three
to four years.
Compliance
with
the orthotic
treatment
was judged
by whether
they attended
follow-up
appointments
showed
orthoses.
wearing
signs
the orthoses
of wear
and
tear
and
from
if the shoe
regular
insoles
use
of the
Fig.
An
early
abandoned
attempt
to lack
due
fashions
during
the
children
wearing
shoes,
or trainers.
Three
years
to
of
period
either
standardise
compliance,
of
the
trial
foot-shaped,
after
their
first
footwear
was
but footwear
were
good,
low-heeled
examination
and
the
proximal
phalanx
The biomechanical
orthosis
we used.
It was
using rigid thermoplastic
materials
and dental
the forefoot
and hindfoot
to prevent
excessive
custom-made
for each child
acrylic.
The orthosis
wedges
pronation
and eversion.
lace-up
the children
in both groups
underwent
a second
radiological
ment.
The MTP joint angle was then measured
lines
longitudinally
bisecting
the
shafts
of
metatarsal
all
1
of the
assess-
between
the
first
hallux.
Cl)
a,
0)
0
The
a,
was measured
between
lines
second
metatarsals.
All
the
by one observer
(RLB)
who
C
0,
intermetatarsal
bisecting
the
measurements
(IM)
first
were
angle
and
made
did not know which
children
had used the orthosis.
The mean
IM and MiT
angles
were calculated
for
the treatment
and control
groups
before
and after the trial
and the statistical
significance
of the difference
was
estimated
using
a paired
t-test.
interval
of the difference
was
In children
with bilateral
The
95%
also determined.
hallux
valgus
right feet were analysed
independently;
the affected
and unaffected
feet were
CD
>-
CD
Cl)
C
C
0
CD
0
a,
a,
0
confidence
C
CD
a,
the
left
and
in unilateral
cases
analysed
separately.
Fig.
2
The effect oftreatment
with biomechanical
orthoses
(n = 65) for three
years
on the metatarsophalangcal
angles.
(n
=
74) or no treatment
and intermetatarsal
RESULTS
Twenty-nine
from
the
study
children
group
were
and
lost to follow-up,
17 (1 boy)
from
group.
In the remaining
93 children
the mean
angles
deteriorated
in both groups,
the mean
did not alter (Fig. 2; Tables
I and II). The 95%
intervals
suggest
greater
group
that
deterioration
of the
in children
treated
by orthoses
(Tables
I and II) but this trend
MTP
12 (1 boy)
the control
MTP joint
IM angles
confidence
angle
was
than in the control
is not statistically
to give
an impression
to treatment.
When
statistical
analysis,
of the
individual
right and left feet
the control
group
child’s
response
were combined
for
showed
significant
deterioration
the treated
of the MTP joint angle (p < 0.05; Fig.
group the deterioration
in the Ml?
joint
was
significant
highly
(p
<
0.001;
Fig.
2). In
angle
2).
significant.
Statistically
unaffected
(Table
these
than
significant
feet
of children
II). Before
feet
was
less
deterioration
occurred
in the
with
unilateral
hallux
valgus
the trial the mean MTP joint angle in
than 12#{176},
three years later it was greater
15#{176}
both in the control
and in the treated
groups.
Figures
3, 4 and 5 are cumulative
frequency
graphs
VOL. 76-B, No. 2, MARCH
1994
DISCUSSION
Hallux
valgus
of 10 and
14
biomechanical
angle remained
deteriorates
in children
between
the ages
years
regardless
of whether
they
wear
orthoses
or well-fitting
shoes.
The
IM
the same over the three-year
period
of our
T. E. KILMARTIN.
212
R. L. BARRINGTON,
120
This
100
pushing
C)
C
a,
80
P
unaffected
40
20.
Study
1992
50
(degrees)
and
valgus
in control
(n
=
65)
and study
(n
in the
greater
group
average
< 0.05;
(p
100
however,
groups
80
yet the
condition
60
although
the
with the most
>
CD
40
Control
p<0.05{
1988
Control
20
Study
Study
{
1992
-- -- -
1988
1992
#{149} juvenile
-I-
#{149}
MTP angle
.
of
(degrees)
in the
of MTP
(n
=
21)
angles
in the affected
foot
and study (n = 26) groups.
of the unilateral
120
100
error.
9
walking
>.
and
unilateral
hallux
angle was similar
(Figs 4 and 5) and
in the
throughout
A previous
treated
group,
the
trial
was
intraobserver
for
in the
due to
error
study
on standardised
weighta measurement
error of ± 1#{176}
Wallace
1992).
Any change
in excess
of 2#{176}
is therefore
The 95% confidence
interval
change.
for the MTP
joint
change
was commonly
be
the control
reached
the
to deteriorate,
the change
was
small.
This
may
be
angles
to be a true
may
occurred
in children
(Figs 4 and 5).
angle
deterioration
shows
that the
more than 2#{176}
(Tables
I and II).
Several
studies
have suggested
orthoses
restrict
pronation/eversion
C)
running
(Bates
that biomechanical
of the hindfoot
during
et al 1979;
Rodgers
and
Leveau
1982; Smith,
Clarke
and Hamill
1986; Novick
et
al 1992) and the orthoses
used in this trial were prescribed
with this objective.
Our finding
that these orthoses
did not
80
0
60
.
than
did
therefore
more
trend
valgus
angle
group
with
deterioration
hallux
valgus
radiographic
likely
angle
group
deteriorated
the
have
the treated
group
with
the trial with a significantly
In the subjects
greatest
severe
than in
treated
group
untreated
the average
MTPjoint
at the start of the trial
MTP
angle
measurement
bearing
radiographs
showed
(Kilmartin,
Barrington
and
Fig. 4
Cumulative
frequency
hallux valgus
control
average
measurement
sb
20
sooner.
greater
unilateral
control
in the
joint
3). This
Ml?
hallux
MTP
A
unilateral
than
Fig.
Although
-0--
the
of randomisation,
valgus
entered
angle
>-
of
treated
that, in spite
bilateral
hallux
74)
=
57%
significantly
53% ofthe
with
subsequently
developed
clinical
and radiological
hallux
valgus
of the initially
normal
foot, indicating
that a raised
IM angle predicts
the development
of hallux
valgus.
The reason
for the greater
deterioration
of hallux
critical
10
of children
group
1988
40
NS
feet
______
Study
was
series
in the
----.
valgus,
in both
E
as in the affected
valgus
In this
and
IM angle
---.--.
120
0
Barrington
that the average
1988
Fig. 3
Cumulative
frequency
of MTP angles
groups
before and after the trial.
showed
varus.
Kilmartin,
1992
30
MTP angle
into
study,
corresponds
against
the second
to act like a wedge
Control
1
20
metatarsal
as well
probably
Control
0
10
valgus
the hallux
abuts
phalanx
begins
unilateral
hallux
normal
children.
CD
E
of hallux
previous
(1991)
60
>
0
a
Wallace
a,
a,
angle
at which
proximal
the first
In
0
.;
critical
to the point
toe and the
>.
I.
W. A. WALLACE
a,
>
40
.
NS
{
E
F,.
0
{
p’zO.05
vo
10
Control 1988
Control 1992
Study 1988
Study 1992
-----..--
_____A
deterioration
with
our
common
in normal
(Kilmartin
and
hindfoot
aetiological
MTP angle
(degrees)
frequency
of MTP
angles
study.
angle
valgus
control
(n
=
21)
in the unaffected
and study
(n
foot
as has
taken
that
been
in conjunction
pes
as in those
Wallace
1992)
pronation/eversion
Biomechanical
of the unilateral
=
26)
groups.
Hardy
and Clapham
(1951)
also found
that
remained
stable
until the so-called
“critical
of hallux
valgus’
was reached
when
both the
hallux valgus
angles began to deteriorate
more
‘
children
factor
the treatment
hallux
valgus
observation
planus
with
leads
as
valgus
to
in
question
fact,
an
suggested
in the
us
is,
so often
was
hallux
past (Rogers
and Joplin
1947; Root et a! 1977; Greenberg
1979; Holstein
1980; Kalen
and Brecher
1988).
Fig. S
Cumulative
ofhallux
previous
whether
:o
0
prevent
the IM
angle
IM
and
rapidly.
orthoses
ofjuvenile
have
hallux
gained
valgus
popularity
because
their
effect
when
the foot
is weight-bearing
subject
to the forces
of ground
reaction
which
to influence
the condition
(Stokes
et al 1979;
1981;
results
Hutton
of our
and
study,
Dhanendran
Groiso
1981).
(1992)
THE JOURNAL
they
and are
are thought
Allen
et al
In contrast
found
OF BONE
in
have
that
AND JOINT
to the
custom-
SURGERY
A CONTROLLED
PROSPECFIVE
TRIAL
Table I.
The differences
before
and after
angles
OF A FOOT
ORThO5I5
in the metatarsophalangeal
the trial, in children
with
Study
group
FOR
joint
bilateral
(n=24)
Control
Right
21±4.18
21.07±5.0
18.22±3.6
18±2.3
MTP angle after trial in
degrees (mean±sD)
23.5±6.0
22.8±6.0
19.13±4.3
19.85±4.6
p value
N5
N5
NS
NS
2 to 5.3
0.48
IM angle before trial in
degrees (mean±sD)
10.44±2.2
10.9±1.9
10.27±1.68
10.63±1.98
IM angle after trial in
degrees (mean±sD)
10.73±3.1
10.79±2.2
10.28±2.2
10.44±2.1
p value
NS
NS
NS
NS
-1 to 0.93
-0.73
of difference
confidence
Table
interval
of difference
confidence
95%
interval
to 1.2
-0.56
to 2.9
H. The differences
in metatarsophalangeal
before
and after the trial, in children
with
angles
Study
to 2
to 0.75
joint
unilateral
to 0.4
and intermetatarsal
hallux valgus
Unaffected
Affected
Unaffected
18.96±3.7
10.9±4.9
17.88±2.0
11.85±1.97
MTP angle after trial in
degrees (mean±sD)
21.84±5.64
15.7±6.9
20.35±4.6
15.85±4.7
p value
NS
<0.05
NS
<0.001
2 to 6.6
0.42
ofdifference
confidence
0.66
trial in
9.74±1.87
8.78±1.58
10.25±1.96
9.64±1.89
IM angle after trial in
degrees (mean±sD)
10.8±2.0
9.72±2.2
10.98±2.3
9.89±1.96
p value
NS
NS
NS
NS
95%
before
to 5.0
gro up (n=21)
interval
IM angle
degrees
of difference
confidence
interval
0.46
to 1.66
0.17
to 1.62
0.11
hallux
patients
(Fig.
Conclusions.
Left MTP angle
Right MTP angle
Left lM angle
Right lM angle
should
not
appear
to
progresses.
to 1.35
hallux
=
25;
valgus
on
follow-up
the
36
metatarsomonths)
orthoses
the clinically
night
splints
worn
6).
Biomechanical
be used
to treat
orthoses
juvenile
for
two
years
and
improved
juvenile
years
in 50%
of
of the type we used
valgus;
they
hallux
normal
foot.
acknowledge
Dr D. Woods,
FRCR,
and the
General
Hospital
Radiology
Department
and the
of Kettering
Health
Authority
for screening
6000
was supported
by an Oxford
NHS Region Local
Kettering
Health
Authority
and Nene
College,
gratefully
of Kettering
No benefits
commercial
to 1.2
exercise
programme
over
a period
of two
Chiropody
Department
children.
This study
Research
grant and
Northampton.
Fig. 6
-0.66
increase
the rate
at which
the
condition
In children
with unilateral
hallux
valgus
the
do not halt the development
of hallux
valgus
in
The
authors
radiographers
(n
1.82 to 5
valgus
a supplementary
hallux
valgus
of night splints
for juvenile
and intermetatarsal
angles
to Groiso
(1992).
to 4.5
(mean.tsD)
made
1994
-0.8
Affected
95%
No. 2, MARCH
to 4
0.5
Control
trial in
group
-0.31
(n=26)
MTP angle before
degrees (mean±sD)
76-B,
grou p (n=22)
Left
trial in
213
VALGUS
intermetatarsal
valgus
Right
95%
VOL
and
hallux
HALLUX
Left
MTP angle before
degrees (mean±sD)
The effect
phalangeal
according
JUVENILE
in any form have been received
or will be received
directly
or indirectly
to the subject
of this
party related
from
article.
a
214
T. E. KILMARTIN,
R. L. BARRINGTON,
W. A. WALLACE
REFERENCES
Allen
TR, Gross
M, Miller
J, Lowe
adolescent
hallux
valgus
before
IntOrthop
1981; 5:111-5.
LW, Hutton
and
after
WC. The assessment
first
metatarsal
of
osteotomy.
Novick
Bates
BT, Osternig
modify
Med
Mason
LR,
B, James
LS.
of lower
extremity
selected
aspects
1979; 7:338-42.
Bonney
G, Macnab
I. Hallux
valgus
of operative
results.
J BoneJoint
Giessele
AE,
J Pediatr
Stanton
Orthop
Goldner
JL,
treatment.
Gaines
RP. Surgical
treatment
1990; 10:642-8.
RW.
Orthop
Clin
Adult
rigidus:
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of adolescent
Groiso
JA. Juvenile
hallux
valgus:
J BoneJoint Surg [Am] 1992;
Hardy
RH, Clapham
controlled
series.
B. Surgery
hallux
valgus:
adolescent
a conservative
74-A:1367-74.
hallux
and
Rogers
and first metatarsal
1979; 69:29-34.
approach
palsy.
1974;
Root
feet:
a quantitative
V, Brecher
feet. FootAnkle
Kilmartin
TE, Barrington
RL,
statistical
study. J BoneJoint
Cliii
Kilmartin
hallux
2:7-11.
for
based
on
ML,
RL, Wallace
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