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Symptomatic hallux valgus (HV) and hallux flexus (HF) affect 2% of adolescents with cerebral palsy.1 Management of bunions is largely divided into arthrodesis and non-fusion surgery, with the latter including soft tissue balancing and corrective osteotomies.2,3 However, due to the high recurrence rate and lower patient satisfaction it is generally accepted that fusion of the first metatarsophalangeal joint (1st MTPJ fusion) is the primary treatment of choice in symptomatic bunions.3 This aligns with our experience where the long-term outcome of non-fusion operations have been unpredictable. Approximately 50% of patients in our center have required a revision fusion for salvage with an additional 25% experiencing ongoing symptoms but declining further surgery. In our center, only 25% of patients had a successful outcome with non-fusion surgery (unpublished data).
Although the literature supports the role of arthrodesis, there is less agreement about the method of achieving fusion. 7 Fixation with Kirschner wires, screws, and dorsal plates have has been reported with variable success rates. 2,4,5,6 Historically, at our institution, we performed 1st MTPJ arthrodesis by inserting K-wires in a longitudinal fashion, sometimes combined with an oblique screw, followed by 6 weeks when we recommended non-weight-bearing. We frequently noted wear and tear of the casts, loosening of the K-wires and a high prevalence of pin site infections because of inability to comply with long periods of restricted weight-bearing and activities.
In this paper, we describe our surgical technique which we adapted from the technique described by Coughlin and colleagues—preparation of the joint surfaces using cup and cone reamers and fixation with a dorsal plate. Initially, we used a 4-hole Vitallium plate, but our current preference is to use a more robust locking plate.8 The use of these plates has allowed accurate alignment of the fusion and early mobilisation after surgery.8 We have adopted plate fixation as our primary means of fixation for symptomatic bunions in adolescents and young adults with cerebral palsy.