The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252

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The Journal of Foot & Ankle Surgery

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Longitudinal Epiphyseal Bracket of the First Metatarsal Bone: Three

Case Reports and a Review of the Literature
Josip Vlaić, MD 1, Davor Bojić, MD, PhD 1,2, Erich Rutz, MD 3, Darko Antičević, MD, PhD 4
1Orthopedic Surgeon, Division of Pediatric Orthopedic Surgery, Children’s Hospital Zagreb, Zagreb, Croatia
2
Assistant, Josip Juraj Strossmayer University of Osijek Faculty of Medicine, Osijek, Croatia
3
Orthopedic Surgeon, Pediatric Orthopedic Department, University Children’s Hospital Basel, Basel, Switzerland
4Orthopedic Surgeon, Senior Consultant and Professor of Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Children’s Hospital Zagreb, Zagreb, Croatia

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 4 Longitudinal epiphyseal bracket (LEB) is a rare bone dysplasia of the tubular bones. Owing to an abnor-
mal secondary ossification center, the affected bones can develop progressive shortening and angular
Keywords:
deformity. The aim of our study was to provide an overview of the reported data regarding epidemiol-
congenital hallux varus
first metatarsal ogy and surgical procedures available for LEB of the first metatarsal bone in a pediatric population combined
longitudinal epiphyseal bracket with a small case series. We report a retrospective case series of 3 nonsyndromic pediatric patients with
pediatric patient different ages and with confirmed dysplasia of the first metatarsal bone. All patients presented with uni-
surgery lateral congenital hallux varus deformity and underwent surgical treatment. The radiographs and medical
records were reviewed to evaluate the deformity characteristics, treatment, and clinical results. The mean
patient age at initial surgery was 34 (range 12 to 63) months, and the median follow-up period was 46
(range 31 to 75) months. Almost all specific radiographic measurements showed correction of the de-
formity, and each foot demonstrated functional and cosmetic improvement. A standardized literature
search was performed to obtain studies of LEB of the first metatarsal bone in the pediatric population.
From on our results and the current data available, surgical treatment should be tailored to the pa-
tient’s age and radiographic stage of LEB. However, monitoring until skeletal maturity of the feet is necessary
to assess the final results.
© 2018 by the American College of Foot and Ankle Surgeons. All rights reserved.

Longitudinal epiphyseal bracket (LEB) or bracket epiphysis is a dis-
turbance of bone growth. Tubular bones of the hand or foot with
proximal epiphysis are the most commonly involved. The affected bones
will present with a growth disorder due to an arcuate secondary os-
sification center that extends longitudinally along the diaphysis (1).
LEB of the first metatarsal bone leads to an irregularly short and broad,
trapezoid-shaped bone. The initially observed deformity is usually con-
genital hallux varus with deviation of the metatarsophalangeal joint
and, finally, impairment of function (2). The natural history of LEB has
been described and divided into 4 radiographic stages, depending on
the progressive osseous shortening and angular deformity (3). In stage
I, the epiphyseal bracket is cartilaginous and invisible. In a second stage,
secondary ossification centers appear at the epiphysis and along the
diaphysis. Stage III is characterized by a continuously ossified bracket
epiphyses on diaphyseal part of bone. In the last stage, stage IV, the
bracket and growth plate are ossified and united with the metatar-
sal diaphysis.
To the best of our knowledge, studies of LEB of the first metatar-
sal bone have all been case series or case reports with limited and
low evidence strength. Furthermore, of 13 studies reported, 8 were
only single patient reports (Table 1) (2–14). Owing to the rarity of
LEB of the first metatarsal bone and inconsistency in the reported
data, various surgical procedures have been suggested for treatment
(1,3–6,8,13,14).
The aim of the present study was to report retrospectively ana-
lyzed data obtained after surgical treatment of 3 nonsyndromic
pediatric patients with LEB of the first metatarsal bone. To the best
of our knowledge, we have presented, for the first time, an overview
of the reported data, including the epidemiology and surgical proce-
dures available to treat LEB of the first metatarsal bone in a pediatric
population.

Financial Disclosure: None reported. Patients and Methods

Conflict of Interest: None reported.
Address correspondence to: Darko Antičević, MD, PhD, Division of Pediatric
Orthopedic Surgery, Children’s Hospital Zagreb, Klaićeva 16, Zagreb 10000, Croatia. All subjects were treated and followed up at our institution from
E-mail address: darko.anticevic@gmail.com (D. Antičević). March 2010 to February 2018, with a mean follow-up time of 46

1067-2516/$ - see front matter © 2018 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2018.03.049
Table 1
Reported studies presenting patients with longitudinal epiphyseal bracket of the first metatarsal bone

Investigator Year Patients (n) Feet (n) Mean Surgical Surgery Follow-Up Outcomes/Complications
Age (mo) Treatment (mo)

Light et al (4) 1981 1 1 120 Yes Resection of duplicated first metatarsal ray NA Unremarkable postoperative course
Bright (5) 1990 1 1 NR Yes Excision of LEB before ossification NR NR
Mubarak et al (6) 1993 4 5 35 Yes Central physiolysis (central resection of chondro- 72 In all patients, the metatarsal resumed longitudinal growth
osseous bar with obstruction interposition) and correction of hallux varus was maintained; a superficial
wound infection developed in 1 patient; excision of a bony
bar was required in 1 patient and first metatarsophalangeal
arthrodesis in 1 patient
Sobel et al (7) 1996 1 1 132 No NA NA Surgical correction was not indicated
Shea et al (3) 2001 3 5 16 Yes Excision of the LEB. The defect was irrigated and filled 55 No cases of LEB recurrence; none of the patients underwent
with a local fat graft or PMMA graft subsequent surgery for angular deformities
Kucukkaya et al (8) 2002 1 2 102 Yes Circular fixator for distraction osteotomy 18 Excellent clinical result obtained
Schreck (9) 2006 1 2 36 Yes Resection of central portion of the bracket; lateral- 4 Radiographs showed some improvement in the first
based wedge osteotomy at first metatarsal metatarsal but patient was subsequently lost to follow-up
Marcdargent et al (10) 2007 3 5 23 Yes Cartilage bracket removal; metatarsophalangeal 59 Correction of angle deformities was observed in all feet; the
centromedullary pinning degree of correction depended on patient age at surgery
Lampropulos et al (11) 2007 1 1 72 Yes Bracket excision before physeal closure 72 Successful treatment of a stage III medial metatarsal LEB
Nguyen et al (12) 2007 1 2 11 Yes Bracket removal and metatarsophalangeal joint Not available Excellent clinical results
transfixed with Kirschner wire
Scott et al (13) 2011 1 1 108 Yes Excision of cartilaginous bracket; mini-rail external 72 The patient was able to resume all activities, without any
fixator for callus distraction before physeal closure; significant complaints
lateral capsulorrhaphy
Shim et al (14) 2013 2 3 80 Yes Medial open wedge osteotomy of first metatarsal; 80 One patient with bilateral LEB had a good outcome; the other
Farmer procedure patient, a poor outcome
Bor et al (2) 2015 2 3 20 Yes Insertion of PMMA after excision of aberrant 133 An excellent clinical result was observed in 2 feet, and a good
epiphyseal bracket result was documented in 1 foot
J. Vlaić et al. / The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252

Present study 2018 3 3 34 Yes For stage I resection of LEB with no interpositional 46 Satisfactory outcomes, with a second procedure required for 1
material; for stage III resection of LEB with PMMA for patient with stage III LEB (medial open wedge osteotomy of
interpositional material the first metatarsal bone)

Total number of cases involving LEB of the first metatarsal bone was 35.
Abbreviations: LEB, longitudinal epiphyseal bracket; NA, not applicable; NR, not reported; PMMA, polymethylmethacrylate.
1247
1248 J. Vlaić et al. / The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252

months. The analyzed data were collected from the medical records

Abbreviations: IOA, intraosseous angulation; LEB, longitudinal epiphyseal bracket; MPA, metatarsophalangeal angle; MDLI, metadiaphyseal length index; NA, not applicable; PMMA, polymethylmethacrylate; Preop, pre-
Last follow-up
Metatarsophalangeal
and other diagnostic tools used and the medical history taken from
the patients and their parents (Table 2). The effect of LEB excision on
bone growth was evaluated by measuring the intraosseous angula-

Angle (MPA)

20

2
tion (IOA) and metadiaphyseal length index (MDLI) (3). Correction of
the hallux varus deformity was evaluated by measuring the metatar-

Preop.
sophalangeal angle (MPA). The clinical outcomes were evaluated at

36

22

22
the most recent examination. The parents of all 3 patients provided

Last follow-up
informed consent for publication. A standardized search of the re-

length index (MDLI)

ported data on search engines was performed to identify studies of

Meta-diaphyseal
LEB of the first metatarsal bone in a pediatric population. A total of

0,71

0,84

0,95
13 studies were obtained and reviewed.

Preop.
Patient 1

0,61

0,68

0,65
A 19-month-old male was referred to our outpatient clinic with

Last follow-up
a 1-year history of physical therapy for a left foot metatarsus varus
deformity. The patient history revealed no other orthopedic condi-

Angulation (IOA)
tions. He had begun to walk at the age of 13 months and was in

Intraosseous

63

30

6
excellent health. The physical examination showed a rigid left foot varus
deformity of the great toe, and parents complained of the child’s poor

Preop.
shoe fitting. Congenital hallux varus was diagnosed after the initial

60

38

55
assessment. Anteroposterior (AP) radiographs confirmed marked de-

Follow-up
formity of the left foot and pointed to LEB of the first metatarsal bone.
Radiographic classification of LEB was stage I with no ossification (3).
(mo.)
Surgery was performed at the age of 26 months. Longitudinal skin in-

75

32

31
cision was made on the medial side of the left first metatarsal bone

fibular autologous
Medial open wedge
osteotomy of first
from the cuneiform-metatarsal joint to the metatarsophalangeal joint

metatarsal with
distally. The abductor hallucis muscle was then released. The first meta-

bone graft.
tarsal diaphysis was exposed and the periosteum incised to observe
Secondary

procedure

the medial and plantar side. The bracket was visualized under an image
surgical

intensifier, and the margins were marked with Kirschner wires. The

NA

NA
bracket epiphysis was removed between the Kirschner wires with a
blade scalpel, and no interpositional graft was used. The corrected po-
through metatarsophalangeal

through metatarsophalangeal
Longitudinally placed K-wire

Removal of an accessory great

removed. No interpositional

No interpositional graft was

toe. Capsulotomy of medial

Longitudinally placed K-wire

metatarsophalangeal joint.
sition of the first metatarsal bone was held by 1 longitudinally placed

joint. Resection of bracket.

first metatarsophalangeal
cuneiformmetatarsal and
material. Longitudinally
PMMA for interposition
Resection of bracket with
Initial surgical procedure

Kirschner wire, and a plaster splint was applied for 6 weeks. The initial placed K-wire through
The bracket physis was

follow-up examination after 6 weeks showed clinical and radio-

graphic improvement of the condition. The Kirschner wire was
graft was used.

removed, and the patient was recommended to use specially adapted

shoes for hallux varus correction.
At 4.5 years after the index surgery, it was evident that the hallux

used.
joint.

joint.
varus deformity had partially recurred. An AP radiograph of the left
foot indicated LEB of the first metatarsal in stage III with part of the
aberrant epiphysis still open laterally (3). A second surgery was per-
preaxial polydactyly
LEB of first metatarsal

LEB of first metatarsal

LEB of first metatarsal

Congenital hallux

Congenital hallux

Congenital hallux

formed, using a medial open wedge osteotomy of the first metatarsal

varus Complex

bone with an autologous bone graft from the ipsilateral fibula. A soft
tissue release on the medial side of metatarsophalangeal joint was also
Diagnosis

performed. A corrected first metatarsophalangeal joint line was

varus

varus

achieved, and a Kirschner wire was placed to stabilize the oste-

otomy. Finally, a plaster splint was applied. The first follow-up visit
after 6 weeks showed clinical and radiographic improvement. The
Side

Kirschner wire was removed, but the splint was continued for pro-
R
L

tection. The child was instructed to gradually bear weight as tolerable.

Radiographic

At last follow-up visit, 24 months after the second surgery, satisfac-

operative; Pt. No., patient number.

tory treatment results were observed. Although the AP radiograph of

stage

the left foot did not show the desired correction of the deformity, the
III
I

child was able to wear regular shoes and participate in sports activi-
surgery (mo.)/

ties (Fig. 1).

Age at initial

gender

Patient 2
26/M

63/M

12/F
Patient data

A 4-year-old male was referred to our outpatient clinic after pre-

Table 2

Patient

vious treatment with insoles for 1 year for an extreme bilateral flatfoot
No.

deformity and slight varus position of the right great toe. His parents
1

3
 J. Vlaić et al. / The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252 1249

Fig. 1. (A) Anteroposterior radiograph of the left foot at the first visit showing longitudinal epiphyseal bracket of the first metatarsal in stage I with no ossification of the bracket.
(B) Anteroposterior radiograph of the left foot 4 years after the initial surgery showing stage III longitudinal epiphyseal bracket of the first metatarsal, with an aberrant epiphysis
still present at the distal and lateral side. (C) Anteroposterior radiograph of the right foot at the final follow-up visit 24 months after the second surgery showing a wider and
shorter first metatarsal. Also, a defect on the medial side of distal part of the first metatarsal can be noted. The regular epiphysis is open.

complained of the progressive nature of the deformity despite the con-
servative treatment measures. The child also experienced difficulties
with shoe fitting. The patient history revealed surgery had been per-
formed to treat hypospadias at 1.5 years of age, with no other
orthopedic conditions. On physical examination, the right great toe
was in varus position and shorter. AP radiographs of the feet showed
a wider and shorter first metatarsal on the right, which pointed to a
LEB deformity. The LEB was classified as stage III with unification of
the ossification centers (3). Magnetic resonance imaging (MRI) con-
firmed the diagnosis and showed the morphology and extent of bone
growth disturbance. Surgery was performed when the child was 5.5
years old. Excision of the LEB of the right first metatarsal bone
was performed with polymethylmethacrylate (PMMA) used as
interpositional material. A short Kirschner wire was placed perpen-
dicular to the diaphysis to retain the PMMA properly. The corrected
position of the first metatarsal bone was maintained with 1 longitu-
dinally placed Kirschner wire and a plaster splint. At the 6-week follow-
up visit, clinical and radiographic improvement of the condition was
noted, and the longitudinally placed Kirschner wire was removed. The
child gradually started to bear weight as tolerable. At his last follow-
up visit, 32 months after surgery, an excellent functional and cosmetic
result of right foot was observed (Fig. 2). The child was able to wear
readymade shoes and to participate in sports with no complaints.
Patient 3
A newborn female was referred to our outpatient clinic for a second
opinion regarding the suggested surgical removal of an accessory great
toe on her left foot. Her parents complained of a curved great toe with
a wider space between the first and second digit. The patient history

Fig. 2. (A) Intraoperative oblique radiograph of the right foot showing stage III longitudinal epiphyseal bracket of the first metatarsal with unification of the ossification centers.
The bracket margins are marked with Kirschner wires. (B) Lateral radiograph of the right foot at the final follow-up visit 32 months after surgery. No bracket can be observed.
The Kirschner wire is perpendicular to the diaphysis and retains the polymethylmethacrylate properly. (C) Anteroposterior radiograph of the right foot at the final follow-up visit
showing a wider and shorter first metatarsal. The open epiphysis is on the regular proximal and typical distal side of the first metatarsal, ensuring future growth in length.
1250 J. Vlaić et al. / The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252

Fig. 3. (A) Preoperative photograph of the left foot with congenital hallux varus deformity accompanied by an accessory great toe. (B) Preoperative magnetic resonance imaging
of the left foot showing a medial cartilaginous bracket of the first metatarsal bone. Complex preaxial polydactyly can also be seen. (C) Photograph of the left foot at the final
follow-up visit 31 months after surgery showing excellent correction of the hallux varus deformity. (D) Anteroposterior radiograph of the left foot at the last visit 31 months
after surgery showing the first metatarsal bone is wider and slightly shorter than usual. No bracket could be noted.

revealed no other medical conditions other than the left foot poly-
dactyly. The physical examination and AP radiographs of the left foot
showed congenital hallux varus, left complex preaxial polydactyly, and
LEB of the first metatarsal bone. Radiographic classification of the LEB
was stage I with no ossification (3). MRI of the left foot confirmed the
diagnosis and better visualized the cartilaginous morphology of the
anomaly. Surgery was performed when the child was 1 year of age.
Using the racket approach, complete removal of the left accessory great
toe was performed, followed by capsulotomy of the medial cuneiform-
metatarsal and first metatarsophalangeal joint. Using an image
intensifier, the central part of the LEB was excised, leaving the prox-
imal and distal part of the epiphysis untouched. The corrected MPA
was held in place using 1 longitudinally placed Kirschner wire. A plaster
splint was applied. At the initial follow-up visit at 5 weeks postop-
eratively, satisfactory improvement was seen, and the Kirschner wire
was removed. At her last follow-up visit, 31 months after surgery, ex-
cellent cosmetic and functional results were noted (Fig. 3). Although
her left foot remained slightly wider, the child was able to wear
readymade shoes without difficulties.
Discussion
The LEB is a rare developmental ossification anomaly of the tubular
bones with an abnormal epiphysis bracket of the diaphysis (11). The
etiology of LEB is not completely understood but is thought to be
due to incomplete development of primary ossification centers during
intrauterine growth (4). Abnormal bone growth occurs in a side to
side direction, instead of lengthwise. The first metatarsals involved
will be triangularly shaped and shorter and wider than normal (7).
Furthermore, the proximal epiphysis of the first metatarsal bone is
L-shaped or C-shaped and situated on the medial aspect (15). The
first description of such an epiphyseal deformity was given by Jones
(16) in 1964. He described a triangular and continuous epiphysis
running from the proximal to distal end along the shortened side of
a finger phalanx and coined the name “delta phalanx.” Jäger and
Refior (17) observed such epiphyseal deformities first in the meta-
tarsals and questioned the use of the term “delta phalanx.” Owing to
the particular abnormality of ossification in all known varieties of
this condition, Theander and Carstam (18) found the expression
 J. Vlaić et al. / The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252
“longitudinally bracketed diaphysis” more applicable. Finally, Light
and Ogden (4) in 1981 suggested the term “longitudinal epiphyseal
bracket” for this condition. They reported that the abnormal epiphy-
seal ossification center brackets the normal primary diaphyseal
ossification center instead of the usual transverse orientation of the
growth plate. LEB can also be present on both sides of a bone, which
is known as a duplicated longitudinal epiphysis or “kissing bracket”
(19). The reported data have associated LEB with numerous syn-
dromes, including Rubinstein-Taybi syndrome (20), Cenani-Lenz
syndactyly, isolated oligosyndactyly (7), and Nievergelt syndrome,
where it was described in the tibia (21).
The usual clinical appearance of LEB in the first metatarsal bone
is congenital hallux varus. Clinically, other than the visible deformi-
ty, the affected first metatarsal will be significantly shorter and
biomechanically insufficient, predisposing the foot to significant dif-
ficulties such as poor shoe fitting and chronic foot pain (2,22). If the
presented foot deformity is marked and rigid on physical examina-
tion, radiographs should be obtained. The radiographic appearance of
LEB of the first metatarsal will show a shortened and rounded di-
aphyseal contour and can be recognized early in its development (2).
However, if one is not fully familiar with the characteristics of LEB of
the first metatarsal, it could be easily overlooked (23).
Our cases of LEB of the first metatarsal were diagnosed when the
3 patients were aged 19 months, 48 months, and 1 month. We believe
that the late referral for the first 2 cases resulted from the clinical sim-
ilarity of the observed condition with much more simple and frequent
foot deformities such as metatarsus varus and pes planus. The radio-
graphic stage of LEB in our patients was classified as I, III, and I in
patients 1, 2, and 3, respectively (3). Nevertheless, when examining
younger patients, in particular, the AP radiographs of LEB in radio-
graphic stage I, the abnormal continuous epiphysis will not be seen
because it will not yet have ossified. In such cases, MRI can be used
to confirm the diagnosis (24).
To correct the marked deformity of the forefoot, all our patients
were treated surgically. The average patient age at surgery was 34
(range 12 to 63) months. The average follow-up period was 46 (range
31 to 75) months. The average MPA preoperatively was 27° and on
the last follow-up was 10°. The average MPA correction of 17° was
clinically visible and led to better patient satisfaction. The average pre-
operative and on the last follow-up MDLI was 0.65 and 0.83,
respectively. The average preoperative and on the last follow-up IOA
was 51° and 36°, respectively. Our first patient showed an increase
of the IOA of a few degrees, showing that poor results could be ex-
pected. The IOA of the second patient decreased but only slightly. Only
the last patient had a marked decrease in IOA. However, all 3 pa-
tients were completely satisfied with their cosmetic and clinical
improvement at their last follow-up visit.
Our literature search yielded only 31 reported cases of the LEB of
the first metatarsal bone that had been surgically treated with mainly
favorable outcomes. In those 31 cases, various surgical protocols, from
bracket resection to corrective osteotomies and the use of an exter-
nal fixator, were used (Table 1). The outcomes for these cases with a
mean 48-month follow-up period were mainly favorable, with few
complications noted (6,14). Initially, Mubarak et al (6) developed a tech-
nique they termed “central physiolysis” for surgical treatment of LEB
of the metatarsals. Five feet in 4 patients were treated at an age range
of 14 months to 6 years. In this procedure, the use of PMMA was rec-
ommended as an interposition material instead of fat to obtain better
results. Two patients at 14 and 18 months of age, respectively, had
marked correction of the deformity. However, owing to erosive changes
and subluxation, the younger patient underwent arthrodesis of the
metatarsophalangeal joint 3 years after the initial surgery. The second
patient from their study who required secondary surgery was a 3-year-
old child who, after central physiolysis, required resection of a bony
1251
bar. Shea et al (3) reported 5 cases of stage I LEB of the first metatar-
sal bone. The patient age range was 6 to 20 months. Excision of the
LEB with PMMA and fat graft as interposition material was per-
formed with no recurrence of the deformity and excellent results at
a mean follow-up period of 55 months. However, the investigators rec-
ommended that the appropriate treatment of the preossified stage of
LEB of the first metatarsal bone is excision of bracket with fat graft
or no use of interposition material (3). In another study, 3 patients
(5 feet) with an average age of 23 months underwent surgery (10).
Clinical improvement with correction of the angle deformities in all
feet was obtained without complications at a follow-up period of
almost 5 years.
For the initial case (patient 1) and last case (patient 3), the mean
patient age was 19 months. In both cases, LEB was classified as the
preossified stage. Nevertheless, central physiolysis was performed in
both patients; however, in our first patient, recurrence of the defor-
mity had developed 4.5 years after the initial surgery. The patient
presented in stage III with remains of the aberrant epiphysis still open,
and on the distal and medial side of the first metatarsal, a defect could
be noted. For such cases, medial open wedge osteotomy of the first
metatarsal has been suggested (3,14). At the last follow-up visit at 24
months after the second surgery, the MDLI and MPA were slightly cor-
rected and the IOA had increased minimally. Our second patient
underwent surgery at 63 months of age for radiographic stage III LEB.
In addition to bracket resection, in accordance with reported recom-
mendations (3), PMMA was used as the interposition material. Although
the IOA had decreased minimally, the MDLI and MPA showed notable
correction. In our second patient, we observed an osteolytic finding
on the contact surface between the PMMA and first metatarsal bone,
which subsequently resolved. The examination at the last follow-up
visit at 32 months after surgery showed excellent functional and cos-
metic results. Our last patient, a 1-year-old female, showed a
remarkable correction of the IOA, MDLI, and MPA 31 months after the
index surgery. No recurrence developed, and a satisfactory cosmetic
result was achieved. It is possible that the excellent clinical outcome
(no pain, no difficulty with shoe wear, no calluses, no significant de-
formity, and satisfactory cosmetic results) in our third patient resulted
from our “learning curve” in the treatment of this deformity (25).
However, early referral and proper surgical treatment, as occurred in
our last case, has been shown to result in greater success in treating
LEB of the first metatarsal (3).
The most important limitation of the present study was the small
number of included cases. Nevertheless, the largest case series re-
porting on surgical treatment of LEB of the first metatarsal included
only 5 feet in 3 (3,10) or 4 subjects (6). Another limitation was the
relatively short follow-up period (mean 46 months) from the initial
surgery. However, the rarity of LEB of the first metatarsal and our pa-
tients’ satisfactory outcomes encouraged us to present our data.
Although our study included only 3 feet, our findings highlight the
specific challenges in the proper treatment of the congenital hallux
varus deformity due to LEB of the first metatarsal bone. The results
obtained from the present study are comparable to the current data
available when >1 case was treated (1,3,6). However, to the best of our
knowledge, we have presented a comprehensive review of the studies
of LEB of the first metatarsal bone for the first time.
In conclusion, we recommend a selective surgical approach tai-
lored to the subject’s requirements for treatment of LEB. We believe
the surgical procedure should be tailored to the 4 radiographic stages.
Appropriately selected treatment will yield good to excellent clini-
cal and functional outcomes, with proper patient satisfaction. However,
owing to the natural history of the disease, recurrence of the hallux
varus deformity can still develop and require a second surgical pro-
cedure. Monitoring of patients until skeletal maturity of the foot is
mandatory to assess the final results of surgery and functional
1252 J. Vlaić et al. / The Journal of Foot & Ankle Surgery 57 (2018) 1246–1252
outcomes. We believe that, remembering the rarity of LEB of the first
metatarsal bone, the presented data could be useful to practicing phy-
sicians involved in treatment of similar pediatric foot deformities in
the future.
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