Bunion Surgery

[cool_vkb]

Just wondering what are the common procedures you guys use for IM angle greater than 20 degrees along with some kind of SAGITAL deformity?

I have yet to enter the real world of surgery but from books and notes i can say HOHMANN Procedure will be best for anything related to SAGITAL + Greater IM angles + Greater PASA.

but i wanted to know what is the common procedure in everyday practice?

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[PMSIII]

Just wondering what are the common procedures you guys use for IM angle greater than 20 degrees along with some kind of SAGITAL deformity?

I have yet to enter the real world of surgery but from books and notes i can say HOHMANN Procedure will be best for anything related to SAGITAL + Greater IM angles + Greater PASA.

but i wanted to know what is the common procedure in everyday practice?

At our program we use a fair amount of First met-cuneiform fusions but I've also seen some attendings use Closing base wedge osteotomies. Personally I am a big fan of the fusions but there's also literature out there supporting the use of crescentic osteotomies for High IM angles and first ray hypermobility (JBJS).

 

[PADPM]

It's up to the comfort level of the surgeon. I'm not a huge fan of closing base wedge osteotomies, and prefer Lapidus procedures in those instances.

Cresentic osteotomies have always been more popular in the orthopedic community than the podiatric community due to the instability of the actually cut. It's not the easiest osteotomy to fixate because it doesn't "lock in" and rolls all over the place. Many years ago, a crescentic osteotomy was described that only went partially through the bone dorsal to plantar, and then there was a plantar ledge. So the cut started dorsally and only went 2/3 of the way toward the plantar surface. Then an "exiting" cut was made to create a plantar shelf. The made the osteotomy more stable and allowed the surgeon to "swivel" the osteotomy and also allowed for easier screw fixation. I believe there was an article published many years ago in Journal of Foot & Ankle Surgery by Ira Fox, DPM if my memory is correct.

 

[cool_vkb]

Cresentic osteotomies have always been more popular in the orthopedic community than the podiatric community due to the instability of the actually cut. It's not the easiest osteotomy to fixate because it doesn't "lock in" and rolls all over the place. .

Sir i have heard this other places also that Crescent Osteotomies are more popular with orthos. there are other procedures also which are more fav with orthos than pods.

i was wondering why does this happen? i mean even though we go to two different schools but i believe the philosophy (allopathy) is same and logic of choosing a procedure shud also be same. yet i hve heard how some procedures, tools, even implants/materials being common with Pods while others are common with Orthos. how does this differentiation happen? well i mean we definetly read CHANGS (who is a DPM) and my MD friends read something else. do you think thats how it begins and then goes on developing in surgery residencies etc?

 

[NatCh]

As long as the metatarsal protrusion distance allows it (i.e., 1st met is not too short), and the 1st MTPJ architecture permits it, I prefer the Lapidus with an ex-fix. It allows early weightbearing without a cast. Dr. Wang, who authored a popular paper on this technique, told me he allows immediate weightbearing. I'm still having my patients NWB until 2 weeks p/o though. BK casts are difficult for the patient and can come with complications such as DVT, muscle atrophy, skin breakdown, skin abrasions, and they can occlude cellulitis. I prefer not using a cast if possible. The biggest issue with the Lapidus is that it's very easy to over-shorten the first met. Overzealous denuding of the cartilage can make the bone too short, then the patient will have sub-2nd metatarsal pain later.

I have pretty much abandoned closing base wedge osteotomies (CBWO's). At least when I have done them, the correction looks good on the table, the immediate post-op films look good, then six weeks later they've elevated. The usual one or two screw internal fixation is not sturdy enough IMO. I think that even in a BK cast the pressure against the 1st metatarsal from muscle contraction is enough to fracture the cortical hinge or displace the osteotomy. I have seen p/o films from a surgeon who used a large intramedullary Steinmann pin down the 1st met-shaft into the medial cuneiform and navicular that had good correction even at 8 weeks.

If the 1st met is short pre-op then you may want to do an opening wedge. Arthrex makes a nice opening wedge plate and they have allograft if you want to use it to fill the deficit.

From what I've seen, Orthopods prefer the Lapidus/gastroc recession. I think it has a lot to do with what one's Attendings did. I have never seen an Austin from an Orthopod. They also tend to favor a medial incisional approach to the bunion plus a dorsal first interspace incision for the lateral release, whereas I've mostly seen single dorsomedial approaches from DPMs. I've done both. Each method has benefits and drawbacks.

 

[krabmas]

At my program we do lots of ausitns for small IMs, mostly long arms but some traditional. The ped ortho guy does a traditional austin w/ one k-wire and a medial incision (I just mentioned this to prove that ortho does do an austin).

We do the crescentic shelf that PADPM mentioned. It is OK but I'm not a huge fan. I think if you are that far back you might as well fuse the met cun joint and prevent the recurrence. If the met is short put a graft in it or do weils (or whatever shortening osteotomy you like) to the lesser mets as needed.

The other benefit to the lapidus is that the whole midfoot also narrows where as with the crescentic or other base procedures only the IM decreases but not the width of the foot.

There was an article that came out a while ago in FAI I think that talked about most common bunionectomies by ortho. It was a mail survey to ortho residency attendings that did primarly foot surgery. The #1 osteotomy was a crescentic followed by a ludloff or mau. The crescentic was not w/ a shelf though.

The reason for doing it this way was that it was how they were taught or they got consistent results.

If I had my bunions fixed I'd want a lapidus and my IM is not even that high, maybe 12.

About the homann (sp?) ostoetomy that was mentioned in a previous post it is very difficult to fixate w/ screws, it would need a plate that was not linear due to the shift which would only buttress the osteotomy or circlage wire or maybe ex-fix.

 

[NatCh]

Part of the art of picking a procedure is tailoring it to the patient. You have to be able to size up the patient (rather quickly too) and anticipate his or her post-op behavior. Although a certain procedure might look best on radiograph, will the patient be able to handle the post-op course? Will being in a cast for two months mean losing a job or going bankrupt? Will the fixation be stable enough that the patient doesn't mess it up in the first week because he is big and clumsy without any help at home to get up and down stairs? If the surgery is on the right foot, will your patient be able to find someone to drive her around for eight weeks since she won't be able to operate the accelerator pedal? Is the patient an aggro triathlete who is likely to push the limits of your intructions?

Bunionectomies seem to go bad during the post-op period rather than on the table. Six weeks NWB in a cast sounds fine on paper but patients have a hard time with it. Crutches start hurting armpits, backs start aching, weightbearing leg starts hurting, transportation is difficult, basic hygiene is difficult. I like anything that eases recovery for the patient, if for no other reason to make them less likely to bugger up their surgery. In your pre-op discussion it would be wise to explain very clearly the upcoming post-op course, so the patient can prepare for it. It's not good to have the patient suddenly realize on post-op day #2 that she can't drive to get to work, or to be told, "Oh yeah, you're going to need crutches for the next couple of months. I hope that's okay." It's better to prepare them for the worst rather than have them expecting the best case scenario.

As the old adage goes, "underpromise/overdeliver."

If the met is short put a graft in it

If the first met is short before you start surgery then you can plan for it.

However, if the 1st met is normal pre-op and then you suddenly realize intraoperatively that it looks too short after you've denuded the cartilage (for a Lapidus), then you could either harvest an autograft or use allograft. Either way will prolong the case unexpectedly and add potential graft-related morbidity so it's not an ideal situation. If you are trying to throw screws across graft, doing so can compromise the graft integrity. A mini-rail or locking plate would be nice in this case, and hopefully the O.R. has the hardware ready and sterile. If the hardware is not available and ready, then best of luck to you.

or do weils (or whatever shortening osteotomy you like) to the lesser mets as needed

If I understand krabmas' statement correctly, she suggested that to account for a short first met one could shorten the lesser mets to accomodate. If you just shortened one lesser met, you'd likely get transfer lesions. If you shortened all of the lesser mets then you'd do five metatarsal osteotomies when the patient only needed one to begin with. The patient would also end up with one foot that is much smaller and fatter looking than the other, and would have a lifetime of miserable shoe-buying experiences ahead. If the first met is short then I wouldn't choose to shorten the lesser mets to accomodate. I'd instead try to lengthen the first met to form the appropriate parabola. Krabmas, did I misunderstand your suggestion?

 

[Feli]

It's up to the comfort level of the surgeon....

Yep^

We have dozens of attending surgeons at my program. For big bunions, some do lapidus, some proximal osteotomies (base wedge, shaft, etc), and some Austins pushed to the max since the pt won't/can't be NWB for 6+ wks or has significant bone healing risks. I've never seen Hohmann boarded anywhere I've rotated... I think that's mostly just a Chicago thing.

With saggital plane instability +/- large IM, the most common choice would usually be a Lapidus (and that's the answer you'd wanna pick on a test). If the first met/ray is short, you can adjust for that by adding graft, translate further plantarly, or do distraction scarf along with lapidus (Rodgers, JFAS 2008). In the end, each pt is different and surgeons will make different choices based on training and personal pref... and you'd always rather have under/partial correction than a nonunion.

 

[krabmas]

Part of the art of picking a procedure is tailoring it to the patient. You have to be able to size up the patient (rather quickly too) and anticipate his or her post-op behavior. Although a certain procedure might look best on radiograph, will the patient be able to handle the post-op course? Will being in a cast for two months mean losing a job or going bankrupt? Will the fixation be stable enough that the patient doesn't mess it up in the first week because he is big and clumsy without any help at home to get up and down stairs? If the surgery is on the right foot, will your patient be able to find someone to drive her around for eight weeks since she won't be able to operate the accelerator pedal? Is the patient an aggro triathlete who is likely to push the limits of your intructions?

Bunionectomies seem to go bad during the post-op period rather than on the table. Six weeks NWB in a cast sounds fine on paper but patients have a hard time with it. Crutches start hurting armpits, backs start aching, weightbearing leg starts hurting, transportation is difficult, basic hygiene is difficult. I like anything that eases recovery for the patient, if for no other reason to make them less likely to bugger up their surgery. In your pre-op discussion it would be wise to explain very clearly the upcoming post-op course, so the patient can prepare for it. It's not good to have the patient suddenly realize on post-op day #2 that she can't drive to get to work, or to be told, "Oh yeah, you're going to need crutches for the next couple of months. I hope that's okay." It's better to prepare them for the worst rather than have them expecting the best case scenario.

As the old adage goes, "underpromise/overdeliver."




If the first met is short before you start surgery then you can plan for it.

However, if the 1st met is normal pre-op and then you suddenly realize intraoperatively that it looks too short after you've denuded the cartilage (for a Lapidus), then you could either harvest an autograft or use allograft. Either way will prolong the case unexpectedly and add potential graft-related morbidity so it's not an ideal situation. If you are trying to throw screws across graft, doing so can compromise the graft integrity. A mini-rail or locking plate would be nice in this case, and hopefully the O.R. has the hardware ready and sterile. If the hardware is not available and ready, then best of luck to you.

If I understand krabmas' statement correctly, she suggested that to account for a short first met one could shorten the lesser mets to accomodate. If you just shortened one lesser met, you'd likely get transfer lesions. If you shortened all of the lesser mets then you'd do five metatarsal osteotomies when the patient only needed one to begin with. The patient would also end up with one foot that is much smaller and fatter looking than the other, and would have a lifetime of miserable shoe-buying experiences ahead. If the first met is short then I wouldn't choose to shorten the lesser mets to accomodate. I'd instead try to lengthen the first met to form the appropriate parabola. Krabmas, did I misunderstand your suggestion?

Of course it depends on the patient for what surgery to choose. All I'm saying is present the best option to the patient as the best option w/ post-op care and then let them know the other options and the likely rate of recurrence for the shorter post op care.

About the weils, yes there are some feet that would require 4 weils (I don't think I would do that) but if 2 and 3 needed a weil or even 2-4 to make up for the short 1st met I'd do it, if I thought that a lapidus was the right procedure for the patient.

I understand the difficulties of hardware and grafts. And yes if it is decided intra-op that a graft is needed that would not be ideal, but do-able and if it is what the patient needs then it is better to take the time necessary to do what is right than wish after the fact that you had.

About driving, I tell patient that I don't care if they can press on the accelarator any person sober or partially maimed or under the influence could do that, but can they slam on the break to stop the car and save theirs or someone elses life? Because legally they should not be driving unless they can slam on the break. They cannot drive while taking narcotics for pain in the post-op course and even after an austin (distal met osteotomy) according to some fairly recent paper it was about 6 weeks (I may be off a bit) before the patient could slam on the break pain free. Then there was another study again fairly recently that tested the reflex to slam on the break after ankle fractures I think and it was not until 6 weeks after WB that the breaking reflex was not hindered.

There was another paper that was less of research but talked about the liability of the physician if the patient drives early and crashes if the physician gave the patient permission to drive.

So do you that are in practice routinely document when you give the patient permission to drive or that you have not yet given permission? Do you put this in the packet that you give to the patient pre-op about their post-op course?

 

[krabmas]

Yep^

We have dozens of attending surgeons at my program. For big bunions, some do lapidus, some proximal osteotomies (base wedge, shaft, etc), and some Austins pushed to the max since the pt won't/can't be NWB for 6+ wks or has significant bone healing risks. I've never seen Hohmann boarded anywhere I've rotated... I think that's mostly just a Chicago thing.

With saggital plane instability +/- large IM, the most common choice would usually be a Lapidus (and that's the answer you'd wanna pick on a test). If the first met/ray is short, you can adjust for that by adding graft, translate further plantarly, or do distraction scarf along with lapidus (Rodgers, JFAS 2008). In the end, each pt is different and surgeons will make different choices based on training and personal pref... and you'd always rather have under/partial correction than a nonunion.

the scarf is a good lengthening choice. Just to add another option you could also add a lengthing ludloff or mau instead of the scarf or corticotomy w/ callus distraction. And these procedures could also be staged if necessary and presented to the patient that multiple procedures may be necessary.

 

[PADPM]

I think that NatCH nailed several excellent points. First of all, although Krabmas was academically correct, in all practicality it is not likely that you will realistically perform several lesser metatarsal osteotomies on a patient that only has a pathology of the first metatarsal, just to maintain the length of that first metatarsal.

In private practice, if something went wrong post operatively, it would be very difficult to rationalize your surgical decision in court. It's difficult to justify performing an osteotomy on four asymptomatic metatarsals, just to maintain the length of one metatarsal, when there are other possible choices.

Another point that NatCH made was although a particular procedure may be the best for a patient, it isn't always practical. I've had patients that simply could not afford to take off significant time from work, or could not ambulate with crutches, remain non weight bearing, etc.

Some patients may have carpal tunnel syndrome, arthritis in the hands, etc., limiting their ability to use assistive ambulatory devices. I have a lengthy pre op discussion with these patients explaining that I will be able to decrease his/her pain, but will not be able to reduce the deformity as well as I would like to due to the restrictions. On these cases, I get a "little" more aggressive with my "bump" removal and more aggressive with my distal osteotomy. I use a longer arm on my Austin to get the greatest correction that I can, and I use screw fixation and let the patient ambulate with a removable walking cast. That way they do not need hand held assistive devices.

This almost always allows for decreased pain and an excellent cosmetic result, although "academically" some of these patients should have had a proximal procedure.

Naturally and thankfully, these types of patients are rare, but these issues must be addressed and the needs of these types of patients can not be forgotten. The feet we operate on ARE connected to a real person!!!

I also agree with NatCH that no matter how you angle your cuts, (parallel to the weightbearing surface, etc.) and no matter how careful you are or how pretty it looks in the O.R., the closing base wedge osteotomies seem to inevitably elevate magically sometime in the post operative period.

There is no one right answer for any patient, despite the IM angle. Each patient's IM angle, met protrusion distance, HA angle and whether there is a residual metatarsus adductus must be addressed. But in addition to those critical factors, the patient's needs and physical abilities must also be taken into consideration or all the other points are simply academic.

 

[krabmas]

I think that NatCH nailed several excellent points. First of all, although Krabmas was academically correct, in all practicality it is not likely that you will realistically perform several lesser metatarsal osteotomies on a patient that only has a pathology of the first metatarsal, just to maintain the length of that first metatarsal.

In private practice, if something went wrong post operatively, it would be very difficult to rationalize your surgical decision in court. It's difficult to justify performing an osteotomy on four asymptomatic metatarsals, just to maintain the length of one metatarsal, when there are other possible choices.

I don't think that it would be likely to need to do 4 lesser met osteotomies. Usually the 2nd thru 4th are long and the 5th has a bunionette or is normal enough. If you know that you will be causing a transfer lesion by not doing the lesser met osteotomies and you still choose in the OR to not do them, then the patient has continued pain I think that would be more likely to lose in court if it went that far. It is pretty well known what causes transfer lesions.

I don't agree that the answer I gave was purely academic. The patients that we operate on at my program are private patients from the attendings' private offices. We have done this several times - shortening osteotomies of 2-4 or 2-3 when needed to balance the foot.

If a patient came into your office with a bunion w/ an IM of 10 and a met adductus angle of 30 and all they complained about was bump pain would you do a silver? The patient is 35, other wise healthy and has used crutches successfully in the past and can't wait to do it again. She has lots of vacation from work and a husband at home willing to wait on her hand and foot. What procedure would you pick? Would you only fix the symptom of would you address the whole deformity?

The patient knows what hurts but they do not know how to fix it, that is why they come to us, for expertese (sp?). I think it is a diservice to the patient to mearly fix the symtpom if it is possible to correct the foot and prevent a recurrence of pain.

 

[NatCh]

I don't think that it would be likely to need to do 4 lesser met osteotomies. Usually the 2nd thru 4th are long and the 5th has a bunionette or is normal enough. If you know that you will be causing a transfer lesion by not doing the lesser met osteotomies and you still choose in the OR to not do them, then the patient has continued pain I think that would be more likely to lose in court if it went that far. It is pretty well known what causes transfer lesions.

I don't agree that the answer I gave was purely academic. The patients that we operate on at my program are private patients from the attendings' private offices. We have done this several times - shortening osteotomies of 2-4 or 2-3 when needed to balance the foot.

If a patient came into your office with a bunion w/ an IM of 10 and a met adductus angle of 30 and all they complained about was bump pain would you do a silver? The patient is 35, other wise healthy and has used crutches successfully in the past and can't wait to do it again. She has lots of vacation from work and a husband at home willing to wait on her hand and foot. What procedure would you pick? Would you only fix the symptom of would you address the whole deformity?

The patient knows what hurts but they do not know how to fix it, that is why they come to us, for expertese (sp?). I think it is a diservice to the patient to mearly fix the symtpom if it is possible to correct the foot and prevent a recurrence of pain.

Lets back it up a bit and recall the original post:

Just wondering what are the common procedures you guys use for IM angle greater than 20 degrees along with some kind of SAGITAL deformity?

There's no mention of met-adductus in the original post. How we got to the discussion of short first mets was when I stated that a Lapidus can shorten the first met too much if you are overzealous when prepping the joint.

So if this hypothetical patient from the original post has a normal metatarsal protrusion distance up until the time you denuded the 1st MCJ, then I think you should address the first met rather than shorten multiple lesser mets.

 

[NatCh]

I also agree with NatCH that no matter how you angle your cuts, (parallel to the weightbearing surface, etc.) and no matter how careful you are or how pretty it looks in the O.R., the closing base wedge osteotomies seem to inevitably elevate magically sometime in the post operative period.

I'm glad I'm not the only one! Actually I knew that I wasn't the only one, as it seems to have happened to most of the docs with whom I've compared notes.