sinustarsi

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Do you guys believe in hypermobile 1st ray or are we been fooled by ligamentous laxity? Its more of east vs west coast training. West leans towards lapidus fusion. I know what to look for on xray and clinically when to fuse mtpc joint. Just measuring the hypermobile 1st ray seems bit tricky for me in the clinical setting. If you have a young distance runner pt(age18-45) with a painful bunion and "hypermobile 1st ray" would you do lapidus or austin/proximal osteotomy sparing the joint? Book answer would be lapidus but I believe that should not be the case all the time. Which procedure would be beneficial to the athlete? You might want to do a procedure based on IM, HA etc where it would reduce the pain and reduce the likely hood of having the bunion return. What procedure would you do on your foot or family if you/they love running and want to get back after surgery? Pain should be #1 factor but dont we also want them to get back to running? Decision, Decision!
 
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Feli

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Lapidus has better long term results, less recurrence, etc than Austin. The downside is that it's a technically more complicated procedure which some surgeons were not or are not trained for, it necessitates longer nonweightbearing recovery time than Austin, and MC nonunion or elevatus is more problematic than usual Austin complications (delay union, recurrence, etc). You have to analyze the deformity, so common sense says Lapidus is for large and/or hypermobile bunions while the Austin is sufficient for mild to moderate ones with little or no hypermobility. The problem is that if you do an Austin for a big IM and/or hypermobile bunion in 18-45yo and the HAV painfully recurs at age 60+yo, then they're pretty high risk for a Lapidus nonunion at that age... and they probably would've healed the Lapidus if you'd done what was indicated initially.

Mau and Scarf are the middle ground IMO. They are the most stable diaphyseal osteotomies and (in skilled hands) they have potential for faster time to weightbearing than the Lapidus with more correction potential than the Austin. Nonetheless, they are a lot more dissection than the Austin, so you have to do a good eval, know your skills, and select each procedure when it's indicated. Also consider that any bunionectomy will fail to some degree if you don't adress any co-existing condition... equinus, pes planus, met adductus, hallux rigidus, PASA, etc.

The surgeons who are still routinely utilizing basal metatarsal osteotomies for large adult bunions, esp large hypermobile adult bunions, are probably still doing Silastic first MPJs for their hallux rigidus patients also. It might be how they were trained or "it works in my experience," but they're just not practicing evidence based medicine IMO. That may have been just fine for generations, but it's really not the way the future of medicine appears to be headed. Base wedges offer no difference in recovery time vs the Lapidus, and the published results are repeatedly proven to be inferior. The only real indication I see for a base procedure is maybe a base wedge + Riverdin in a big and problematic peds bunion where you can't do a Lapidus yet.

You can look up Graham Hamilton's JFAS articles on Lapidus vs CBWO results for maintaining IM correction and the comparison article on Austin, Lapidus, and proximal osteotomy revisional surgery rates. For the diaphyseal versus basal osteotomies, Hyer also has a good JFAS paper on Mau compared to proximal crescenteric osteotomy. Weil has published extensively on the Scarf technique and results.
 

PADPM

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If you really want to get someone angry, email Kevin Kirby, DPM and ask him any question using the term "hypermobile first ray". Dr. Kirby is a very well respected/well versed DPM regarding biomechanics, though he is also surgically trained. He practices in California and is well published and strongly opinionated regarding biomechanically issues.

His "pet peeve" is the term "hypermobile first ray". There is a way to converse directly with Dr. Kirby. I believe he is a regular "poster" on the Podiatry Arena forum.

You can perform a search on that forum on the term hypermobile first ray, or better yet send him a PM after joining that forum. He's a brilliant guy.
 

NatCh

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There's not enough info here to make an accurate decision of course. We'd need the remainder of radiographic measurements, rehab limitations, expectations for return to activity, concomitant deformities, etc., etc., but for the sake of argument can we just work under the stipulation that in this case either a Lapidus or an Austin would be appropriate? Okay then.

Here in the Pacific Northwest the Lapidus is very popular indeed. I like how much correction I can obtain and I like how the soft tissue structures line up nicely afterwards. I think the Lapidus gives a better overall gross appearance than the Austin for any IM angle over 13 degrees (the foot looks straighter, narrower). Post-op can be difficult, although I usually allow my patients to heel-walk immediately in an Aircast and weightbear as tolerated at 2 weeks.

One of the difficulties with the Lapidus, however, is shortening of the first ray. If you resect too much of the joint then the end result is a very short 1st ray, which sets the patient up for 2nd metatarsalgia, which would make running difficult. You have to discuss this possibility with the patient pre-op. The patient ideally would have a long first met pre-op.

Another option for this hypothetical patient is an Austin/Cotton. The Cotton plantarflexes the first ray and really makes the medial column more rigid. How big of a wedge I use depends on how much metatarsus primus elevatus I see pre-op and how tight the first ray feels intra-op after I've opened the wedge. Arthrex makes Cotton plates in 2mm increments, but I tend to favor using a tricortical allograft wedge because it's rock-solid immediately and I don't have to worry about big screws crossing joints as I do with the plate. I like that this combination of procedures doesn't typically result in a short first ray. Since it spares the 1st TMTJ however, there is a chance the patient may need fusion later. You have to discuss this possibility with the patient pre-op.

Functionally I think patients recover more easily from the Austin/Cotton than from the Lapidus. If the 1st TMTJ is very hypermobile (let's ask K. Kirby!) then I'd favor the Lapidus. If the 1st TMTJ is only a bit hypermobile (where's Kirby?!) then I'd favor the Austin/Cotton. It's subjective on the part of the doctor doing the exam, because it's up for debate what defines hypermobile. You kind of have to do hundreds or thousands of first ray range of motion exams to get a feel for what's "normal." It's good to check it on all patients whether their complaint is a bunion or not. I make a 1st ray ROM exam a part of my initial office visit physical exam on everyone who has a first ray.

In this scenario your patient is an avid runner, and avid runners are notoriously difficult to manage due to their high expectations and desire for impossibly speedy return to activity. Add to that the demands on the foot of running itself. Good luck. I'd make sure to explain that with either option there is a chance that they won't be able to run at the same level.

My personal opinion favors the Austin/Cotton when appropriate. There's less chance of first ray shortening, less chance of nonunion, easier recovery, and a quicker return to athletic activity. Although there's maybe a higher chance of needing another procedure in the future, most athletes (lots around here) have stated they'd trade the time now when they're in their prime for the time later when they're more sedentary. I never promise anyone that they won't need another surgery in the future.