Bunion Surgery c.pdf

ANATOMY OF THE MEDIAL COLUMN Talus Navicular Medial cuneiform First metatarsal First proximal phalanx First distal phalanx Tibial & fibular sesamoids FIRST MTPJ - DORSAL Neurovascular bundles reside at the “4 corners” of the first ray FIRST MTPJ - PLANTAR FRONTAL PLANE A - Subcutaneous tissue plane...

ANATOMY OF THE MEDIAL COLUMN Talus Navicular Medial cuneiform First metatarsal First proximal phalanx First distal phalanx Tibial & fibular sesamoids FIRST MTPJ - DORSAL Neurovascular bundles reside at the “4 corners” of the first ray FIRST MTPJ - PLANTAR FRONTAL PLANE A - Subcutaneous tissue plane B - Joint capsule C - Medial collateral ligament D - Tibial suspensory ligament I - Adductor hallucis insertion J - Extensor tendons H - Deep intermetatarsal ligament SAGITTAL PLANE Adductor hallucis tendon (cut) Inserts along fibular sesamoid as well as the proximal phalanx Lateral collateral ligament Fibular suspensory ligament OSTEOTOMY SAFE ZONES HISTORY OF BUNION SURGERY Over 100 surgical bunion procedures have been described. Bunion correction has been evolving for decades Originally, bunion surgery only addressed transverse plane deformities Understanding the anatomy is the key to understanding bunion surgery Anatomy provides the foundation to all techniques and approaches The knowledge of the triplane deformity has led to more contemporary techniques and fixation constructs SURGICAL INDICATIONS FOR BUNION CORRECTION Pain Inability to fit into appropriate shoe-gear Ulceration GOALS OF SURGICAL INTERVENTION Pain relief Reduce shoe gear irritation Improved foot function Aligned 1st MTPJ that bears weight Cosmetic postoperative outcome GOALS OF SURGICAL INTERVENTION We need to figure out where the first metatarsal is sitting Radiographs Physical examination And We need to figure out where we want to put the first metatarsal head so it will: Correct the position of the hallux Have functional ROM (including the sesamoids) Bear weight PERIOPERATIVE CONSIDERATIONS Medical history Fixation options DVT prophylaxis Anesthesia Hemostasis Closure Postoperative course Exposure/incisional approach Procedure selection PATIENT EDUCATION Time to heal What does this mean to you? What does it mean to your patient? Potential risks and complications Return to exercise or sports Maximum medical benefit What else should be done? Shoe gear changes Orthotics SURGICAL APPROACH Incision medial to the EHL Straight medial SURGICAL APPROACH Traditional dorsomedial approach The incision is made medial to the EHL tendon Allows access to the MTPJ from medial to lateral Allows access to the 1st intermetatarsal space Incision can be elongated distally to expose more of the proximal phalanx Incision can be elongated proximally for procedures of the metatarsal shaft or tarsometatarsal joint SURGICAL APPROACH Medial approach The incision is made directly medial between the dorsal and plantar neurovascular bundles Allows access to the MTPJ from medial and dorsal Does not allow access to the 1st intermetatarsal space Incision can be elongated distally to expose more of the proximal phalanx Incision can be elongated proximally for procedures of the metatarsal shaft or tarsometatarsal joint CAPSULOTOMY Capsulotomy in line with the skin incision is the most common Numerous other options Linear T-shaped Inverted L-shaped Oblique Vertical U-shaped H-shaped T-shaped L-shaped ANESTHESIA Will depend on what you are doing Distal first ray work only Typically, amenable to a Mayo block and IV sedation (MAC with local) More proximal usually requires a general anesthetic HEMOSTASIS Epinephrine Ankle tourniquet for distal procedures Thigh tourniquet for proximal procedures Get the ankle tourniquet out of your way for proximal procedures!!! PROCEDURE CATEGORY OUTLINE (PROXIMAL TO DISTAL) Soft tissue (with or without medial eminence resection) Proximal phalangeal osteotomy Distal metatarsal osteotomy (DMO) Shaft/diaphyseal osteotomies First metatarsal-cuneiform joint arthrodesis (Lapidus) First metatarsal-phalangeal joint arthrodesis Juvenile bunionectomy SOFT TISSUE PROCEDURES Silver bunionectomy McBride bunionectomy Modified McBride bunionectomy Medial capsulorrhaphy SILVER BUNIONECTOMY Resection of the medial eminence of the metatarsal head Still considered a soft tissue procedure only NO deformity correction NO reduction of the IMA Minimal utility as an isolated procedure SILVER BUNIONECTOMY Indications Medial bump pain Neuritic pain Mild HAV Low functioning geriatric population Appropriate if the goal is to remove the medial prominence only Can accelerate reoccurrence by weakening medial structures SILVER BUNIONECTOMY PEARLS Proper orientation of your saw while resecting the medial eminence is critical SILVER BUNIONECTOMY PEARLS Proper orientation of your saw while resecting the medial eminence is critical You must preserve the tibial sesamoid articulation SILVER BUNIONECTOMY PEARLS Do not “stake” the head Violates the tibial sesamoid articulation “Staking” increases the risk of a hallux varus Stability of the 1st MTPJ is compromised, and the hallux falls off medially MCBRIDE BUNIONECTOMY Performed to rebalance the soft tissue structures of the first MTPJ. Derotates the toe by releasing contracture of plantomedial structures (will not correct frontal plane deformity of the metatarsal) Aligns the sesamoid apparatus Removes/reduces tracking Rarely an isolated procedure Also referred to as a “lateral release” A Modified McBride bunionectomy is usually performed as an adjunct procedure with other techniques MCBRIDE BUNIONECTOMY Steps of a true McBride bunionectomy Resection of the medial eminence if needed (Silver) Medial capsulorrhaphy (tightening of the medial capsule) Excision of the fibular sesamoid Transfer of the adductor hallucis tendon to the first metatarsal MCBRIDE BUNIONECTOMY Steps of a true McBride bunionectomy Resection of the medial eminence if needed (Silver) Medial capsulorrhaphy (tightening of the medial capsule) Excision of the fibular sesamoid Transfer of the adductor hallucis tendon to the first metatarsal Fibular sesamoidectomy has fallen out of favor due to increased risk of hallux varus MCBRIDE BUNIONECTOMY Steps of a Modified McBride bunionectomy Removal of medial eminence if needed (Silver) Release or transfer of adductor hallucis tendon Division of the fibular sesamoid suspensory ligament (fibular sesamoid is kept) Division of the transverse intermetatarsal ligament MEDIAL FIRST MTPJ CAPSULORRHAPHY Reefing/plication of the medial joint capsule during closure Reefing is a nautical term à folding a sail to reduce surface area (safety precaution in strong winds) Plication – The tightening of stretched or weakened tissues by folding the excess in tucks. Excision of redundant capsule Not an isolated procedure MEDIAL FIRST MTPJ CAPSULORRHAPHY Reefing/plication of the medial joint capsule during closure Reefing is a nautical term à folding a sail to reduce surface area (safety precaution in strong winds) Plication – The tightening of stretched or weakened tissues by folding the excess in tucks. Excision of redundant capsule Not an isolated procedure POSTOPERATIVE COURSE FOR SOFT TISSUE PROCEDURES Will vary depending on exact procedures performed Weightbearing as tolerated in a post operative shoe until incision is healed (2-3 weeks) Post-op course based on protection of incision as there is no osteotomy to protect from displacement (soft-tissue procedure only) More WB protection may be warranted for an adductor tendon transfer. PROXIMAL PHALANGEAL OSTEOTOMY PROCEDURES Distal Akin Oblique Akin (diaphyseal) Proximal Akin Cylindrical Akin Sagittal Z osteotomy PROXIMAL PHALANGEAL OSTEOTOMIES Originally described by Akin in 1925 Original procedure included: Resection of medial eminence of 1st metatarsal head Resection of medial base of proximal phalanx Medial closing base wedge phalangeal osteotomy AKIN OSTEOTOMY Described by region the osteotomy is performed Distal Akin Oblique Akin (diaphyseal) Proximal Akin 1st MTPJ should be congruous Properly aligned Region depends on deformity Abnormal DASA = Proximal Akin Abnormal HAIA= Distal Akin “Cheater” Akin – Further correction needed following initial procedure DISTAL AKIN OSTEOTOMY Medial closing wedge of the head of the proximal phalanx Indications Increased hallux abductus interphalangeus angle (HAIA) Distal Akin corrects interphalngeus as the deformity is at the IPJ OBLIQUE AKIN OSTEOTOMY Popular due to ability to place a screw across the osteotomy Indications Abnormal DASA and/or interphalangeus Common “cheater” Akin PROXIMAL AKIN OSTEOTOMY Medial closing wedge of the base of the proximal phalanx Corrects abnormal DASA Common “cheater” Akin If you try to correct an abnormal HAIA proximally, you will have to take more bone and risk a short hallux CYLINDRICAL AKIN OSTEOTOMY Indication Shortening of a congenitally long proximal phalanx SAGITTAL Z OSTEOTOMY Indications Shorten a long proximal phalanx Lengthen a short proximal phalanx AKIN FIXATION OPTIONS Kirchner wires (K-wires) Small plate Cerclage wire Staples Screw POSTOPERATIVE COURSE FOR PROXIMAL PHALANGEAL OSTEOTOMIES Will vary depending on exact procedures performed Weightbearing as tolerated in a post operative shoe until bone is healed(4-6 weeks) More WB protection may be warranted if bone quality is poor BUNION SURGERY II PART 1 JARROD SMITH, DPM. FACFAS ASSISTANT PROFESSOR LEARNING OBJECTIVES Demonstrate knowledge of the anatomy of the medial column. Demonstrate knowledge of soft tissue surgical procedures performed at the first MTPJ. Demonstrate knowledge of osteotomies performed in the proximal phalanx of the hallux for bunion correction. Demonstrate knowledge of osteotomies performed in the distal first metatarsal for bunion correction. Demonstrate knowledge of metatarsal shaft osteotomies, proximal first metatarsal procedures and first metatarsal cuneiform joint arthrodesis for bunion correction. Recognize surgical procedures specific to bunion correction in juvenile patients. DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS You must understand the basic concepts of distal metatarsal osteotomies and understand the radiographic corrections (angles & dangles) we are trying to achieve The procedures won’t make sense until you have a firm grasp of the concepts DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Majority of DMO cuts are made at an angle Increases stability More metaphyseal bone contact Faster healing than cortical bone Spares the articulation of the sesamoidal apparatus DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Majority of DMO cuts are made at an angle Increases stability More metaphyseal bone contact Faster healing than cortical bone Spares the articulation of the sesamoidal apparatus This does prevent correction of frontal plane deformities A transverse cut would be required to allow the metatarsal head to rotate DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS The amount of obtainable correction is dependent on metatarsal width You can only slide the metatarsal head so far before you lose stability, and it begins to tip or fall off DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Versatile procedure – multiple corrections can be made depending on procedure selection and angle of cut Unicorrectional – one correction in the transverse plane Axial lengthening Bicorrectional – two corrections in the transverse plane Uniplanar – correction in one plane (transverse plane) Biplanar – corrections in two planes (transverse & sagittal) Axial shortening DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Kirshner wires are often used as guide wires for making osteotomies The direction of your cut will determine what the metatarsal head does when it is shifted laterally Enables you to plan your cut and get visual confirmation before the cut is made DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Unicorrectional DMO One transverse plane correction IMA reduction A – Medial eminence resection D – Capital fragment is compressed to the shaft with fixation E – Proximal osseous shelf is resected B – “V shaped” osteotomy performed C – Capital fragment is distracted and translated laterally F – Final correction (IMA reduced) DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Bicorrectional DMO Two transverse plane corrections IMA reduction PASA correction A – Medial eminence resection B – DMO is performed with a medial wedge C – lateral cortex is severed D- Capital fragment is distracted and translated laterally F – Capital fragment is compressed with fixation which closes the medial wedge G – Proximal osseous shelf is resected H – Final correction (IMA & PASA reduced) DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Uniplanar corrections Uniplane = transverse plane only (same as unicorrectional) Reduction of intermetatarsal angle = sliding the metatarsal head laterally (transverse) DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Biplanar corrections Biplane = transverse plane & sagittal plane Reduction of intermetatarsal angle = sliding the metatarsal head laterally (transverse) Angling the cut to allow for plantarflexion or dorsiflexion at the same time (sagittal) DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Uni-plane correction & biplane correction ABC = uni-plane (transverse plane only) DEF = biplane IMA reduction & plantarflexion GHI = biplane IMA reduction & dorsiflexion DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Biplane correction Uni-plane correction Biplane correction Lateral Medial Medial Lateral Lateral Medial The correction follows the direction of the wire DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Metatarsal length can also be adjusted 1. 2. 3. Lengthening Neutral (90° to the 2nd metatarsal) Shortening Adjustment occurs along the axis DISTAL METATARSAL OSTEOTOMIES (DMO) BASIC CONCEPTS Metatarsal length can also be adjusted The correction follows the direction of the wire DISTAL METATARSAL OSTEOTOMY (DMO) PROCEDURES Reverdin Reverdin-Todd Reverdin-Green Reverdin-Laird Austin Peabody DRATO Wilson Biplanar Austin Bicorrectional Austin Hohman Mitchell Youngswick-Austin Roux Minimally invasive (MIS) REVERDIN OSTEOTOMY Medial closing wedge Corrects PASA only Lateral cortex kept intact (hinge) Violates the sesamoid articulations Sesamoiditis is the most common complication No IMA correction REVERDIN-GREEN OSTEOTOMY Corrects PASA only Unicorrectional Lateral cortex kept intact (hinge) The Green modification spares the sesamoid articulations No IMA correction REVERDIN-LAIRD OSTEOTOMY Corrects IMA Complete osteotomy Lateral cortex is severed A B Can correct PASA (wedge is optional) Allows for translation of the capital fragments Check correction after the head is translated. Wedge if necessary Spares the sesamoid articulations with Green modification (Reverdin-Green-Laird) C D DISTAL METATARSAL OSTEOTOMIES Austin (Chevron) Osteotomy Corrects IMA with translation of the metatarsal head DISTAL METATARSAL OSTEOTOMIES Biplanar Austin Corrects IMA (transverse) Allows for mild plantarflexion (sagittal) The only difference between uniplane and biplane is the direction of the wire DISTAL METATARSAL OSTEOTOMIES Bicorrectional Austin Corrects PASA The Reverdin-Laird is much easier, adjustable, and forgiving Corrects IMA Technically difficult DISTAL METATARSAL OSTEOTOMIES Youngswick-Austin Corrects IMA Plantarflexes & shortens the first metatarsal Removal of a dorsal rectangle Useful for long & mildly elevated 1st metatarsals DISTAL METATARSAL OSTEOTOMIES Minimally invasive bunionectomy (MIS) A burr is used to make a percutaneous transverse osteotomy The capital fragment is shifted laterally and fixated with percutaneous screws POSTOPERATIVE COURSE FOR DISTAL METATARSAL OSTEOTOMIES Will vary depending on exact procedures performed Weightbearing as tolerated in a post operative shoe until bone is healed(4-6 weeks) More WB protection may be warranted if bone quality is poor BUNION SURGERY III JARROD SMITH, DPM. FACFAS ASSISTANT PROFESSOR METATARSAL SHAFT OSTEOTOMIES Kalish-Austin Scarf procedure Inverted scarf procedure Ludloff Mau KALISH OSTEOTOMY “Long arm” Austin Cannot correct PASA Easier use of 2 screws SCARF OSTEOTOMY Scarf joint is a carpentry term Corrects IMA Can correct PASA if base is rotated laterally SCARF OSTEOTOMY Controversial regarding utility over a DMO Some believe it can correct higher IMAs than a DMO Dependent on metatarsal width, same as a DMO Requires more soft tissue dissection than a DMO The cut is more technical SCARF OSTEOTOMY Troughing One cortical edge falls into the medullary canal of the other segment Specific complication of the scarf osteotomy Causes elevation (dorsiflexion) of the capital fragment in the traditional osteotomy POSTOPERATIVE COURSE FOR METATARSAL SHAFT OSTEOTOMIES Will vary depending on exact procedures performed NWB for 2 weeks??? Weightbearing as tolerated in a post operative shoe until bone is healed(6-8 weeks) Cortical bone takes longer to heal the metaphyseal bone The first ray lever arm puts more force across the shaft than the head More WB protection may be warranted if bone quality is poor METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS You must understand the basic concepts of proximal metatarsal osteotomies and understand the radiographic corrections (angles & dangles) we are trying to achieve The procedures won’t make sense until you have a firm grasp of the concepts METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Most common metatarsal base osteotomy is a closing base wedge osteotomy (CBWO) Correction of a bunion deformity from a more proximal location increases the “swing” of the metatarsal thus allowing you to correct larger deformities We are taking metatarsal width out of the equation More anatomic than distal head procedures METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Shortening will always occur if you are removing a wedge of bone You can’t remove bone without making the bone shorter The ideal patient to get a CBWO has a long first metatarsal to begin with This is very rare METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS More technically difficult osteotomy to perform Difficult to get cut within the metaphyseal bone Harder to fixate due to proximity to the TMTJ Safe zones??? Guides wires are used here as well Dorsiflexion and plantarflexion can be done Guide wires create a hinge axis METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Axis guides are very helpful If you know how to use them The axis guide will be inserted from dorsal to plantar A medial hinge (axis) is created and left intact as an additional point of fixation for closing base wedge osteotomies Medial Lateral METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Axis guides are very helpful If you know how to use them The axis guide will be inserted from dorsal to plantar (parallel to the cut) A medial hinge is created and left intact as an additional point of fixation for closing base wedge osteotomies METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Axis guides are very helpful If you know how to use them The axis guide will be inserted from dorsal to plantar (parallel to the cut) A medial hinge is created and left intact as an additional point of fixation for closing base wedge osteotomies METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS If you place your axis guide wire perpendicular to the long axis of the metatarsal you will cause elevation of the metatarsal head upon correction This axis causes movement in both the transverse and sagittal planes METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS If you place your axis guide wire perpendicular to the weightbearing surface, the metatarsal head will remain neutral This axis causes movement in only the transverse plane METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Hinge axis guide concept for closing base wedge osteotomies The axis of the medial hinge can be altered to cause desired neutral movement, dorsiflexion, or plantarflexion of the metatarsal head A vertical axis creates a medial hinge A medial hinge allows for neutral movement of the metatarsal head METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Hinge axis guide concept for closing base wedge osteotomies The axis of the medial hinge can be altered to cause desired neutral movement, dorsiflexion, or plantarflexion of the metatarsal head A laterally angled superior pole creates a dorsomedial hinge A dorsomedial hinge allows for plantarflexion of the metatarsal head METATARSAL BASE OSTEOTOMIES BASIC CONCEPTS Hinge axis guide concept for closing base wedge osteotomies The axis of the medial hinge can be altered to cause desired neutral movement, dorsiflexion, or plantarflexion of the metatarsal head A medially angled superior pole creates a plantomedial hinge A plantomedial hinge allows for dorsiflexion of the metatarsal head THE HINGE AXIS CONCEPT Plantarflexion Neutral Dorsiflexion METATARSAL BASE PROCEDURES Closing base wedge osteotomy (CBWO) Transverse – Loison & Balacescu Oblique – Juvara Juvara modifications Opening base wedge osteotomy (OBWO, Trethowan) Crecentic osteotomy Double first metatarsal osteotomy (Logroscino) TRANSVERSE CLOSING BASE WEDGE OSTEOTOMY Osteotomy placed 1 cm distal to the TMTJ Can be difficult to fixate Crossed K-wires Cerclage wire Locking plates Templating can determine amount of bone to be removed Axis guide placed at the medial cortex, perpendicular to the WB surface Plantarflexion/dorsiflexion then determined by tilting the superior pole OBLIQUE CLOSING BASE WEDGE OSTEOTOMY Hinge placed 1 cm distal to the TMTJ Easier than a transverse osteotomy to fixate due to increased surface area Screws Templating can determine amount of bone to be removed Axis guide placed at the medial cortex, perpendicular to the WB surface Plantarflexion/dorsiflexion then determined by tilting the superior pole OBLIQUE OSTEOTOMY (JUVARA) MODIFICATIONS Juvara A Oblique closing base wedge osteotomy for transverse plane correction Juvara B-1 Complete oblique osteotomy (no hinge) to allow for sagittal plane correction Juvara B-2 Complete oblique osteotomy (no hinge) to allow for metatarsal length adjustment Juvara C-1 One osteotomy is made (no wedge) to allow for sagittal plane correction only Juvara C-2 One osteotomy is made (no wedge) to allow for metatarsal length adjustment JUVARA C-1 CLOSING BASE WEDGE COMPLICATIONS Shortening Elevatus Mal-union Non-union CLOSING BASE WEDGE COMPLICATIONS Shortening Elevatus Mal-union Non-union CLOSING BASE WEDGE COMPLICATIONS Shortening Elevatus Mal-union Non-union OPENING BASE WEDGE OSTEOTOMY Lengthens metatarsal Useful for revision surgery Requires a bone graft Specialized plates with spacer cleats Transverse option OPENING BASE WEDGE OSTEOTOMY Lengthens metatarsal Useful for revision surgery Requires a bone graft Specialized plates with spacer cleats Oblique option CRESCENTIC OSTEOTOMY Requires specialized crescentic blade Can correct a large IMA Difficult to fixate due to instability and proximity to the TMTJ K-wires DOUBLE FIRST METATARSAL OSTEOTOMY Closing base wedge osteotomy + Reverdin Bone removal x 2 = more shortening POSTOPERATIVE COURSE FOR METATARSAL BASE OSTEOTOMIES Will vary depending on exact procedures performed NWB for 6-8 weeks then transition to WB in a post operative shoe for 4 weeks Cortical bone takes longer to heal the metaphyseal bone (bone type depends on procedure) The first ray lever arm puts more force across the base than the shaft and head These procedures are more unstable than more distal procedures More WB protection may be warranted if bone quality is poor ARTHRODESIS PROCEDURES First metatarsal-cuneiform arthrodesis (Lapidus) First metatarsal-phalangeal joint arthrodesis FIRST METATARSAL-CUNEIFORM ARTHRODESIS Most versatile of all bunion procedures Capable of triplanar correction Transverse plane – IMA Sagittal plane – metatarsus primus elevatus Frontal plane – metatarsal rotation Addresses the deformity at its origin Decreases recurrence Definitive – the metatarsal can’t drift without a fulcrum FIRST METATARSAL-CUNEIFORM ARTHRODESIS Triplanar deformity correction LAPIDUS FIXATION OPTIONS Crossed screws Locking plates Compression staples Combinations FIRST METATARSAL-CUNEIFORM ARTHRODESIS COMPLICATIONS Arthrodesis carries higher risk of complications Nerve entrapment Non-union Elevatus Lever arm à dorsiflexory force at the fusion site Traditionally NWB 6-8 weeks Malunion Premature WB (non-compliance) Poor surgical technique Shortening of the first ray FIRST METATARSAL-CUNEIFORM ARTHRODESIS COMPLICATIONS Arthrodesis carries higher risk of complications Nerve entrapment Non-union Elevatus Lever arm à dorsiflexory force at the fusion site Traditionally NWB 6-8 weeks Malunion Premature WB (non-compliance) Poor surgical technique Shortening of the first ray FIRST METATARSAL-CUNEIFORM ARTHRODESIS COMPLICATIONS Arthrodesis carries higher risk of complications Nerve entrapment Non-union Elevatus Lever arm à dorsiflexory force at the fusion site Traditionally NWB 6-8 weeks Malunion Premature WB (non-compliance) Poor surgical technique Shortening of the first ray FIRST METATARSAL-CUNEIFORM ARTHRODESIS COMPLICATIONS Arthrodesis carries higher risk of complications Nerve entrapment Non-union Elevatus Lever arm à dorsiflexory force at the fusion site Traditionally NWB 6-8 weeks Malunion Premature WB (non-compliance) Poor surgical technique Shortening of the first ray FIRST METATARSAL-CUNEIFORM ARTHRODESIS COMPLICATIONS Arthrodesis carries higher risk of complications Nerve entrapment Non-union Elevatus Lever arm à dorsiflexory force at the fusion site Traditionally NWB 6-8 weeks Malunion Premature WB (non-compliance) Poor surgical technique Shortening of the first ray POSTOPERATIVE COURSE FOR FIRST METATARSAL-CUNEIFORM ARTHRODESIS Will vary depending on fixation used NWB for 6-8 weeks then transition to WB in a post operative shoe for 4 weeks has been typical New hardware constructs allow for earlier weightbearing The first ray lever arm puts more force across the fusion site than the base, shaft, and head Fusions typically take longer to heal than osteotomies due to surrounding support structures (joint capsule vs periosteum) More WB protection may be warranted if bone quality is poor FIRST METATARSAL-PHALANGEAL JOINT ARTHRODESIS Positioning is critical Dorsiflexed hallux = hallux malleus Plantarflexed hallux = IPJ arthrosis Newer constructs allow for earlier WB FIRST METATARSAL-PHALANGEAL JOINT ARTHRODESIS Can be used as a primary or revision procedure FIRST METATARSAL-PHALANGEAL JOINT ARTHRODESIS Traditional fixation construct FIRST METATARSAL-PHALANGEAL JOINT ARTHRODESIS Interfragmentary compression screw with neutralization locking plate FIRST METATARSAL-PHALANGEAL JOINT ARTHRODESIS Locking plate with compression staple POSTOPERATIVE COURSE FOR FIRST METATARSAL-PHALANGEAL ARTHRODESIS Will vary depending on fixation used NWB for 6-8 weeks then transition to WB in a post operative shoe for 4 weeks has been typical New hardware constructs allow for earlier weightbearing Fusions typically take longer to heal than osteotomies due to surrounding support structures (joint capsule vs periosteum) More WB protection may be warranted if bone quality is poor FIRST METATARSAL-PHALANGEAL ARTHRODESIS COMPLICATIONS Non-union Malunion Hallux malleus IPJ arthrosis FIRST METATARSAL-PHALANGEAL ARTHRODESIS COMPLICATIONS Non-union Malunion Hallux malleus with proximal phalangeal dorsiflexion IPJ arthrosis with proximal phalangeal plantarflexion (hyperdorsiflexion) JUVENILE HALLUX ABDUCTO VALGUS Lack of definitive guidelines for conservative or surgical care There is controversy regarding surgical timing 60 – 80% of juvenile patients with HAV have a family history of HAV or hypermobility Ideally, growth plates are closed before surgery is performed JUVENILE HALLUX ABDUCTO VALGUS Evaluate for: Metatarsus adductus Equinus Pes planovalgus Hypermobility JUVENILE HALLUX ABDUCTO VALGUS Radiographic evaluation Extent of closure of the growth plate at the base of the first metatarsal Usually open if patient is < 16 years old Check for a secondary growth plate in the metatarsal head JUVENILE HALLUX ABDUCTO VALGUS PROCEDURES Distal metatarsal osteotomy Closing base wedge osteotomy Metatarsal-cuneiform arthrodesis Epiphysiodesis JUVENILE DMO Will work for mild to moderate bunions without metatarsus adductus and hypermobility (unlikely) No secondary growth plate present Recurrence will be high Waiting for osseous maturity is ideal JUVENILE CBWO Can be performed without damage to the growth plate Will not address hypermobility (the probability of which is high) Recurrence will be high Waiting for osseous maturity is ideal JUVENILE LAPIDUS Will work for mild to severe bunions Proximal growth plate must be closed Considered definitive Recurrence will be low EPIPHYSIODESIS Arrest of the lateral portion of the physis Medial portion continues to grow, thus decreasing the IMA Waiting for osseous maturity is still ideal You are trying to hit a moving target JUVENILE HALLUX ABDUCTO VALGUS Timing and type of procedure will be dependent on osseous maturity and concomitant pathology (hypermobility) Parent education is critical You should prepare them for the need for more surgery down the road Wait if you can The variables decrease significantly HAV CORRECTION COMPLICATIONS Post-operative infection Recurrence Joint stiffness Hallux Varus Hallux assumes an adducted position in the transverse plane Medial structures obtain a mechanical advantage and overpower the lateral structures Iatrogenic – overcorrection of HAV Traumatic Metabolic – immunologic arthropathies Neuromuscular dysfunction IATROGENIC HALLUX VARUS Excessive medial capsulorrhaphy Soft tissue procedures used to correct a structural deformity will result in undercorrection or over-correction IATROGENIC HALLUX VARUS Staking of the metatarsal head DON’T DO IT!!! Fibular sesamoidectomy DON’T DO IT!!! IATROGENIC HALLUX VARUS Negative IMA Subluxation of capital fragment post operatively Initial over-correction Revision of a hallux varus is difficult if you want to keep the joint Fusion is the gold-standard treatment IATROGENIC HALLUX VARUS Treatment options Reverse DMO Tibial sesamoidectomy 1st MTPJ fusion is the definitive treatment Reverse Akin Adductor hallucis tendon transfer Tight rope SUMMARY There are many ways to surgically correct a HAV deformity Training dependent If one procedure works better in your hands, then do that one, and send other deformities better treated by a different procedure to someone else Angles and dangles play a role, but are a tool to guide you The many variables of the patient matter more!!! CASE # 1 52-year-old female present with left bunion pain She has tried changing shoe-gear and custom orthotics which did not help sufficiently PMH is + for HTN PE reveals a mild HAV deformity without a hypermobile first ray. She is having difficulty finding shoes that fit and is having substantial pain ROM of the hallux is mildly tracking without crepitus CASE # 1 Pathology? CASE # 1 Mild HAV Pes planus foot-type CASE # 1 What do you want to do? CASE # 1 What type of osteotomy was performed? CASE # 1 Will this patient need anything else? CASE # 1 Before & After CASE # 2 46-year-old female present with left bunion pain She has tried changing shoe-gear and custom orthotics which did not help sufficiently PMH is unremarkable PE reveals a severe HAV deformity with a hypermobile first ray. She is having difficulty finding shoes that fit and is having substantial pain ROM of the hallux is track-bound without crepitus CASE # 2 Pathology? CASE # 2 High IMA Joint subluxation Mild elevatus CASE # 2 What do you want to do? CASE # 2 What procedures were performed? CASE # 2 Before & After CASE # 3 68-year-old female presents for evaluation and treatment of a painful bunion deformity. PMH – unremarkable PE reveals a severe HAV deformity with crepitus throughout ROM Palpable pulses with instantaneous CRT CASE # 3 Pathology? CASE # 3 Severe HAV 1st MTPJ arthrosis CASE # 3 What do you want to do? CASE # 3 What procedures were performed? CASE # 3 Before & After CASE # 4 42-year-old female presents with right bunion pain Conservative measures have failed PMH Gastric bypass surgery PE reveals a severe HAV deformity with a hypermobile first ray. ROM of the hallux is tracking without crepitus CASE # 4 Pathology? CASE # 4 Severe HAV Metatarsus adductus Pes planovalgus foot-type CASE # 4 What do you want to do? CASE # 4 42-year-old female presents with right bunion pain Conservative measures have failed PMH Gastric bypass surgery PE reveals a severe HAV deformity with a hypermobile first ray. ROM of the hallux is tracking without crepitus Concerns??? CASE # 4 42-year-old female presents with right bunion pain Conservative measures have failed PMH Gastric bypass surgery PE reveals a severe HAV deformity with a hypermobile first ray. ROM of the hallux is tracking without crepitus Concerns??? What do you want to order??? CASE # 4 Blood work Vitamin D - 12 What do you want to do? CASE # 4 I start her on 50,000 IU of vitamin D q week We discuss her deformity and that she is not a candidate for the ideal surgery We discuss risks of the ideal surgery and risks of the “safer” procedure CASE # 4 What procedure was performed? CASE # 4 Will this patient need anything else? CASE # 4 Metaphyseal bone heals before cortical bone CASE # 4 Before & After REFERENCES Gerbert J. Textbook of Bunion Surgery. 3rd ed. Philadelphia: W.B. Saunders; 2001. https://www.sciencedirect.com/book/9780721677842/te xtbook-of-bunion-surgery Coughlin MJ. Mann RA. Saltzman CL. Surgery of the Foot and Ankle. 8th ed. St. Louis: Mosby; 2007. 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