Practice Case

[ldsrmdude]

So if you're like me when I was a student, you need a little break from studying sometimes. Since I have a case like this coming up, I figured I would try to post something somewhat educational and try to stimulate a little discussion here. To start off, if any students want to just read the x-rays, tell us what you see and if you feel inclined, list off some angles and what they mean. Then we can move on to what options we have for non-surgical treatment followed by surgical treatment. Once we go over that, we can open it up to residents/attendings if they want to discuss pearls, hints, tips, their favorite technique, etc. This will only work with some participation on your part.

Yes, the x-rays are crappy and no, they aren't mine. Get used to looking at crappy x-rays, you'll have them in real life and also on your board exams. Feel free to ask questions as if you're examining the patient and I'll answer them when I have a chance to post. This can basically be seen as a practice oral board exam question if you want, even though we no longer have those.

The case:
This is a 35-year old female who presents to you complaining of pain around the right big toe joint. It hurts more in tight shoes. It started a few years ago but seems to be getting worse over time. She has noticed a "bump" on the side of her foot that is making it hard to wear the shoes she wants.

GO

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[de Ribas]

Normal angles should be: for HVA <15 and for IMA <9

On first x-ray HVA is about ~25 and IMA is about ~ 15. Which indicates mild condition. IMAs of 2nd and 3rd are also increased, due to 1st phalanx pushing laterally on 2nd and 3rd phalanx.


EDIT: phalanx has a valgus deviation which also causes varus deviation of metatarsal.

Metatarsal I head is positioned medically thus positioning sesamoids laterally which contributes to more issues such as transfer metatarsalgia. Since sesamoids are deviatiated laterally it will affect foot functions since FHB is connected to sesamoids.

 

[GreenHousePub]

A1c is 16, I book her for immediate surgery. I decide for a lapidus. Pack wound open, we'll go back later for closure. She smokes 10 packs a day, we both share a pack together at her first follow up. It's relaxing. At that moment I decide she'll need an arizona brace for her left side, and a balance brace for her right. Don't worry about her credit card, just leave it on file. After the BKA we decide to get a custom orthotic for her prosthesis.

 

[ldsrmdude]

A1c is 16, I book her for immediate surgery. I decide for a lapidus. Pack wound open, we'll go back later for closure. She smokes 10 packs a day, we both share a pack together at her first follow up. It's relaxing. At that moment I decide she'll need an arizona brace for her left side, and a balance brace for her right. Don't worry about her credit card, just leave it on file. After the BKA we decide to get a custom orthotic for her prosthesis.

You’re not obligated to participate in the discussion, so if you don’t have anything to contribute, please don’t.

 

[ldsrmdude]

Normal angles should be: for HVA <15 and for IMA <9

On first x-ray HVA is about ~25 and IMA is about ~ 15. Which indicates mild condition. IMAs of 2nd and 3rd are also increased, due to 1st phalanx pushing laterally on 2nd and 3rd phalanx.


EDIT: phalanx has a valgus deviation which also causes varus deviation of metatarsal.

Metatarsal I head is positioned medically thus positioning sesamoids laterally which contributes to more issues such as transfer metatarsalgia. Since sesamoids are deviatiated laterally it will affect foot functions since FHB is connected to sesamoids.

Ok, thanks for being the brave soul to start us off.

Anyone else have anything to add? Agree or disagree with @de Ribas ?

 

[Podstar]

I see a HAV deformity with metatarsus adductus of the R foot. The IMA 1-2 is about 15 degrees. Normal is 8-12 degrees in a rectus foot type and 8-10 degrees in an adducted foot type (our pt. foot type). This measurement is a bisection of the 1st and 2nd mets. The HAA (HVA) is about 25 degrees, with normal being 10-15 degrees. This is a bisection of the 1st met and proximal phalanx of the hallux. The MAA is hard to measure with this AP radiograph as the tarsal bones are cut off, however it is pretty obvious that the patient does have metatarsus adductus just from looking at the image. For the MAA 5-17 degrees is normal, with 20+ degrees being pathological. Now, for a pt. with met. adductus to get a true measurement of the IMA you should use, IMA+(MAA-15)=true IMA, but since I could not really measure the MAA I could not use this. The HIPA is about 10 degrees, which is normal. The normal range for HIPA is 0-10 degrees. This is measured bisecting the proximal and distal phalanx of the hallux. The PASA is about 5 degrees and the DASA is about 5 degrees, which are both normal. Tibial sesamoid position is 5, maybe 6, but it is hard to see, with normal being 1-4.

Conservative tx:
-shoes with a wide toe box
-bunion padding or silicone sleeve to offload pressure
-OTC orthotic (Powerstep) to help foot position when ambulating
-NSAIDs/APAP PRN as long as comorbidities/meds allow for it, if not, topical steroid/capsaicin, maybe medrol dose pack if the pain is acute and debilitating?
-Rest, ice, warm soaks, massage, weight loss if obese.
-Injection as a last resort conservative tx.

Surgical tx:
-Austin bunionectomy

 

[Weirdy]

Surgical tx:
-Austin bunionectomy

Indications and contraindications for Austin?
Since you're on a roll.

 

[Podstar]

Indications and contraindications for Austin?
Since you're on a roll.

Indications:
-Pain with hallux valgus deformity with inability to function comfortably in conventional footwear.
-HAA greater than 16 degrees, but less than 40 degrees with a congruous to deviated 1st MTPJ, normal or abnormal PASA (can correct abnormal PASA with modifications), and an elevated IMA as great as 16 degrees.
-Appropriate metatarsal width to achieve appropriate transposition and good bone stock for fixation.

Contraindications:
-PMH/social hx./conditions that do not make the pt. a good candidate for elective surgery.
-Limited ROM in the 1st MTPJ.
-OA on the radiographs.
-HAA greater than 40 degrees.
-IMA greater than 16 degrees.
-Poor bone quality or cystic changes.
-Narrow 1st met.
-Geriatric pt.

 

[ldsrmdude]

I see a HAV deformity with metatarsus adductus of the R foot. The IMA 1-2 is about 15 degrees. Normal is 8-12 degrees in a rectus foot type and 8-10 degrees in an adducted foot type (our pt. foot type). This measurement is a bisection of the 1st and 2nd mets. The HAA (HVA) is about 25 degrees, with normal being 10-15 degrees. This is a bisection of the 1st met and proximal phalanx of the hallux. The MAA is hard to measure with this AP radiograph as the tarsal bones are cut off, however it is pretty obvious that the patient does have metatarsus adductus just from looking at the image. For the MAA 5-17 degrees is normal, with 20+ degrees being pathological. Now, for a pt. with met. adductus to get a true measurement of the IMA you should use, IMA+(MAA-15)=true IMA, but since I could not really measure the MAA I could not use this. The HIPA is about 10 degrees, which is normal. The normal range for HIPA is 0-10 degrees. This is measured bisecting the proximal and distal phalanx of the hallux. The PASA is about 5 degrees and the DASA is about 5 degrees, which are both normal. Tibial sesamoid position is 5, maybe 6, but it is hard to see, with normal being 1-4.

Conservative tx:
-shoes with a wide toe box
-bunion padding or silicone sleeve to offload pressure
-OTC orthotic (Powerstep) to help foot position when ambulating
-NSAIDs/APAP PRN as long as comorbidities/meds allow for it, if not, topical steroid/capsaicin, maybe medrol dose pack if the pain is acute and debilitating?
-Rest, ice, warm soaks, massage, weight loss if obese.
-Injection as a last resort conservative tx.

Surgical tx:
-Austin bunionectomy

Nice job. Sorry for the cut-off x-ray, but yes on the met adductus.

So we've got a few angles that are abnormal (IM, HAA, MAA). Does an Austin (distal chevron) bunionectomy address them all? If not, do we need to address them?

(By the way these questions are for all to answer)

 

[air bud]

Omg as an attending my brain hurt with all those abbreviations and numbers. Here is what an attending thinks when they see that xray. Try wider shoes, more supportive shoes, some OTC (not custom you crooks) orthotics. Make sure shoe has fabric overlying medial eminence as it stretches and causes less pain as opposed to more constructive leather which will rub. Already did those? Ok let's do surgery. I don't care about angles, looks like a small bunion to me, let's do an Austin.

 

[air bud]

Of course you don't get to this point without understanding all the stuff you guys are pointing out so good. I didn't learn this stuff until residency since I just memorized everything in school and never had to apply anything (and this worked perfectly during school...).

So this thread is good.

 

[DexterMorganSK]

So we've got a few angles that are abnormal (IM, HAA, MAA). Does an Austin (distal chevron) bunionectomy address them all? If not, do we need to address them?

For this case just the IM and HAA?

Imo, we should address whatever is not corrected by Austin because one operative procedure can complicate another deformity.

 

[ldsrmdude]

For this case just the IM and HAA?

Imo, we should address whatever is not corrected by Austin because one operative procedure can complicate another deformity.

Ok, so if you're saying we should address the met adductus, how would we do that?

And is there anyone who would do another procedure besides an Austin for this bunion? Where are all the Lapidus lovers? Should we get a sesamoid axial x-ray?

 

[Weirdy]

Ok, so if you're saying we should address the met adductus, how would we do that?

And is there anyone who would do another procedure besides an Austin for this bunion? Where are all the Lapidus lovers? Should we get a sesamoid axial x-ray?

Any 1st ray hypermobility?

 

[ldsrmdude]

Any 1st ray hypermobility?

How would you define 1st ray hyper mobility? 🙂

 

[heybrother]

I'll take the lapidus bait, but not if students are still chiming in. We haven't done anything like this in a long time - I still remember FOREVER ago Jonwill (sp) doing a thread on a young child who slid into a base and then ended up with a hot, red, swollen, ankle who would not tolerate any sort of ROM/motion of the joint.

 

[ldsrmdude]

I'll take the lapidus bait, but not if students are still chiming in. We haven't done anything like this in a long time - I still remember FOREVER ago Jonwill (sp) doing a thread on a young child who slid into a base and then ended up with a hot, red, swollen, ankle who would not tolerate any sort of ROM/motion of the joint.

Yep, that was a great thread. Maybe I’ll try to find it tonight and link to it.

Edit: Nevermind, I found it. It was part of the epic stories from Podiatric residency thread. Hard to believe that was 7 years ago

True Stories From Podiatric Residency

We had a case today of a DM neuropathic ankle fx that was way underfixated at StElsewhere and went into bad Charcot valgus. We did tibiotalocalc fusion with a BioMet Phoenix IM nail, platelet concentrate, and then an OrthoFix Ilizarov style ring fixator to protect it all. A lot of fixation, but...

forums.studentdoctor.net

Let’s let this be a student discussion until tomorrow night, and then you can lay the Lapidus smack down on us all😀

 

[air bud]

Ok didn't really look at xray I admit.....@heybrother coming in hot with some truth.
Also I promise I look more at x-rays of my patients okthanksbye

 

[air bud]

@jonwill? Wow blast from the past. Remember when @Feli popped his head above ground?

 

[Podstar]

Ok, so if you're saying we should address the met adductus, how would we do that?

And is there anyone who would do another procedure besides an Austin for this bunion? Where are all the Lapidus lovers? Should we get a sesamoid axial x-ray?

With the met adductus there is a greater risk of recurrence of the bunion. A Lapidus would correct the deformity at the TMTJ, where as with a distal osteotomy like an Austin the deformity might be more likely to recur due to the met adductus. As far as correcting the met adductus surgically, you could do a 2nd and 3rd metatarsal osteotomy, giving you more room to correct the bunion and decreasing the chance of recurrence. I haven’t had very much clinical exposure to the Lapidus procedure (3rd year only through 3 months of rotations).

As far as the sesamoid axial view it gives you a more accurate view in determining sesamoid position and allows you to appreciate the met adductus and met heads from another view point.

 

[GreenHousePub]

Taking a recovery time of 4 wks WB in a boot, and turning it into 4-6 wks NWB in a cast is going to be a hard sell. It's a right foot, in a lot of states she won't be able to legally drive until that boot is off. 35 year old women still care about their appearance and a bunch of scars on the foot won't look nice. Plus many women have kids at that age, good luck chasing them around with a cast.

This is a very, very mild bunion, easily correctable with an austin and then an akin to get it looking phenomenal.

I'd rather defend myself in court with doing a lapidus on a flatfoot or an IM angle of 25, then having to defend myself using hypermobility as an excuse. Also it takes me 60 min to do a lapidus and an akin and then the cost of the screws on top of it. Austin/Akin with kwires and a bit of cerclage wire is 45 mins and cheap.

 

[ldsrmdude]

Taking a recovery time of 4 wks WB in a boot, and turning it into 4-6 wks NWB in a cast is going to be a hard sell. It's a right foot, in a lot of states she won't be able to legally drive until that boot is off. 35 year old women still care about their appearance and a bunch of scars on the foot won't look nice. Plus many women have kids at that age, good luck chasing them around with a cast.

This is a very, very mild bunion, easily correctable with an austin and then an akin to get it looking phenomenal.

I'd rather defend myself in court with doing a lapidus on a flatfoot or an IM angle of 25, then having to defend myself using hypermobility as an excuse. Also it takes me 60 min to do a lapidus and an akin and then the cost of the screws on top of it. Austin/Akin with kwires and a bit of cerclage wire is 45 mins and cheap.

So I take it you don’t buy into the early protected weight bearing after a Lapidus philosophy? If we did have a sesamoid axial that showed frontal plane rotation of the 1st met, would that change your plan? Thanks for bringing up cost, because I think we overlook that aspect of it too often. In a perfect world cost wouldn’t be a factor, but it is.

Again, questions for anyone to answer.

 

[air bud]

Taking a recovery time of 4 wks WB in a boot, and turning it into 4-6 wks NWB in a cast is going to be a hard sell. It's a right foot, in a lot of states she won't be able to legally drive until that boot is off. 35 year old women still care about their appearance and a bunch of scars on the foot won't look nice. Plus many women have kids at that age, good luck chasing them around with a cast.

This is a very, very mild bunion, easily correctable with an austin and then an akin to get it looking phenomenal.

I'd rather defend myself in court with doing a lapidus on a flatfoot or an IM angle of 25, then having to defend myself using hypermobility as an excuse. Also it takes me 60 min to do a lapidus and an akin and then the cost of the screws on top of it. Austin/Akin with kwires and a bit of cerclage wire is 45 mins and cheap.

You're going to use k wires and cerclage wire to avoid a few cheap synthes screws? And 15 mins? other than the non-weight-bearing factor which obviously is the biggest part of all of this, saving literally a few dollars and 15 minutes is not worth it to not do it right the first way.

 

[GreenHousePub]

You're going to use k wires and cerclage wire to avoid a few cheap synthes screws? And 15 mins? other than the non-weight-bearing factor which obviously is the biggest part of all of this, saving literally a few dollars and 15 minutes is not worth it to not do it right the first way.

I was more referring to how everyone seems to be using these fancy systems for lapidus these days. Synthes screws are gonna run you a hundred bucks each vs the latest and greatest plate system is 6000 bucks. When hospitals audit how much each case costs their gonna look at that. The time factor isn't a difference I know.

Also when you are paying for it yourself then you definitely weigh the costs vs reimbursement. As well as the time.

So I take it you don’t buy into the early protected weight bearing after a Lapidus philosophy? If we did have a sesamoid axial that showed frontal plane rotation of the 1st met, would that change your plan? Thanks for bringing up cost, because I think we overlook that aspect of it too often. In a perfect world cost wouldn’t be a factor, but it is.

Again, questions for anyone to answer.

I had a disaster one time after using the "latest and greatest" plate system, where the patient broke the hardware and ended with a complete midfoot collapse. The amount of headache and stress with the revision was is not worth it to me, now I NWB all lapidus 4 weeks. Then protected WB in boot.

It's not enough frontal plane rotation to make a difference to me. Doing a good lateral release will get those sesamoids back under the head, and besides the tibial sesamoid is right on the crista still. It'll fall back in place.

This is an Austin and Akin.

 

[heybrother]

I think the most contentious and variable part of this profession is how we do forefoot related procedures. My program was lapidus/1st MPJ heavy. I've had friends who were similar. I've unfortunately had friends who had essentially zero lapidus experience in residency. There are enormous differences in region, technical approach, judgement, fixation, recovery, procedure choice/thought process etc.

Lapidus is one of those procedures where if you poll a bunch of surgeons the only thing they may share in common is the joint the procedure is done at. I've attached a picture of a lapidus disaster (DP X-ray, sagittal not included - tremendous elevatus). Saying I do lapidus doesn't really mean anything. I'm personally a believer in frontal plane rotation, but I've seen failure to attain any sort of transverse correction(essentially in situ, "fused-in-place" bunion), frontal plane issues, and my worst fear - sagittal deformities. 2nd image - a clinical image of a patient fused transverse in situ with horrible recurrence (have X-ray but I think its in someone else's lecture so I won't share). I have an unbelievable image (not shown) of a failed lapidus with failure to achieve any joint stabilization at the TMTJ in which the surgeon gave up and did an Austin afterwards but not before breaking the 2nd metatarsal (its shocking what is being done out there).

I've done lapidus with the latest and greatest, plate-screw, plate, double screw, triple screw(it was recurring with 2 so we need a 3rd across to pull it together). I've seen a bunch of recurrence. I've seen non-unions. I've seen cases that were a joy to do - large corrections done in literally skin to fixated in sub-30 (so ...29 minutes) and I've scrubbed hellish cases where after the joint resection the surgeon couldn't reduce the joint and you'd have thought we were doing some sort of wild lisfranc dislocation instead of a 30 year old elective case. I've seen lapidus where the correction wasn't achieved and recurrence happened at which point the surgeon decided it just must be stiffness/failure to achieve lateral release at the MPJ - so let's McBride it again and make some more scar tissue and then at the first post-op where the recurrence is already evident tell them it must have been the dressing. I'm well versed in failure so when I tell you I like lapidus I'm not being blase about the complications. I don't really believe in recurrence studies for lapidus done using X-rays because I've seen full blown clinical recurrence with X-rays that looked perfect. And I of course don't believe Austin/Akin recurrence angles at all because the bunion was never actually fixed *wink wink* 🙂

In regards to the case above
-I think there remains substantial correction that can be achieved with lapidus.
-It is entirely possible to have a degree of metatarsus adductus such that there is no correction to be achieved with lapidus.
-Even with admirable lapidus correction + metatarsus adductus the patient may still perceive a contour or curvature to their foot that resembles a bump. Metatarsus adductus sucks.
-The textbook answer for students about metatarsus adductus is that it masks the IM - you'll interpret this to be a smaller bunion than it is.
-My suspicion is that clinically you would appreciate this bunion as being more severe than how it is being described here. I don't think you'll find this to be a small bunion if you were standing in front of the patient without an X-ray.
-My residency performed the full spectrum of recovery ie. some did aggressive weight-bearing and others did variations of WNB. In general though, no cast. When you allow a patient to weight-bear in any shape or form ie. heel only, you are potentially setting yourself up for more than you think. Your gentle partial heel weight bearing is their full time, full weight-bearing out of the boot at 1st visit.
-Patient selection is crucial - but really what does that mean - setting a patient up for true NWB may be setting them up for failure. I've had a few fat old ladies with lapidus who just couldn't stop falling down and therefore all the complications that come of that - broken hardware, non-union. People who are WB fall down less - my experience.
-Read these two lines above and you'll see I'm clearly having it both ways. People will walk all over it and people will fall all over it.
-I don't order sesamoid axial (my nurses can barely take a mortise view) because I don't need to convince anyone frontal plane rotation is going on. Were I to correct a bunion I would attempt to correct this deformity. The main proponent of frontal plane rotation actually used to measure the rotation with a device (essentially a multiple pin measuring construct over the top). My understanding is that he stopped because he ultimately decided he didn't need to measure it - he just needed to correct it.
-Give the 1st MPJ its due when considering lapidus (or hell, any bunion). I have seen some crepitus/limitation/MPJ issues in young patient's who had very well done lapidus. Residents at my program sometimes wondered if young people with progressive bunions had essentially "adapted" the contour of their MPJ to having a bunion. The bunion was their normal. Performing the lapidus essentially placed them into a non-intended position.
-Similarly, I've seen quite a few lapidus done on people who were subluxed/dislocated for so long that they require something bordering on a cheilectomy after the lapidus. When I see people at conferences talking about all manner of 1st MPJ joint surface restructuring I wonder if we're pushing lapidus on people who should have been 1st MPJ fusions (or perhaps they are just heroes going joint to joint saving the patient's foot).

I'm cognizant that even a more aggressive WB recovery for lapidus is still significantly more onerous than ...the MIS being pushed in PM news. Assuredly, I will miss out on "easy" Austin's as patient's choose to skip the recovery. I'm obviously no longer at my residency so I'll have to see if I can duplicate the success I had in residency. Else I may be telling my patients what the locals already tell people in my area. It looks great. No, you must have rheumatoid arthritis. Let me put you on steroids for a year. My area is Austin only. The latest-greatest rep in my area asked the local F&A ortho if she liked doing bunions - she told him that DPMS have F***ed them all up before they get to her. Ha.

Have some more metatarsus adductus pics but I need to format them first.

(1) Terrible lapidus. Also has elevatus so 1st MPJ ruined.
(2) Different patient - lapidus with recurrence. Fused wide open.
(3) A triple fail - Austin, Akin, and Lapidus. 2 Surgeries. Unhappy patient. Soft tissue over 1st ray - ruined. Joint motion, ruined. Patient is sub-30.

Here's my promise to the people more experienced than me - I will reread this post in a year or three and see how I feel.

 

[heybrother]

X-rays are WB. Obviously, clinical pictures are not. Just to throw in some additional pictures of metatarsus adductus (I acknowledge I did not provide sagittal pictures - so you'll have to take my word for it that they aren't also cavus which just makes things worse).

 

[air bud]

Great post

Also, for a different thread but I am a huge fan of mpj fusions for a big bunion. Over 65 overweight? I don't care what joint looks like it's getting fused. Walk right away, fixed the problem, allows them to do everything they want.


Anyways, great post again.

 

[heybrother]

Thanks and 100% with you on 1st MPJ. Powerful, reproducible, reliable - I could keep going.

 

[air bud]

Reproducible and reliable

 

[DYK343]

I have too many 1st MTPJ fusion non-unions. In fact those are the only non-unions I have. I ream it and beat the crap out of the joint. Good bloody subchondral fragmented surfaces. Interfrag screw + locking plate. Great opposition. NWB 4-6 weeks-->Non-union. I have zero lapidus non-unions. I'm revising someone elses 1st MTPJ nonunion next week.

I would never fixate lapidus with staples. Motion too unpredictable. Elevatus or transverse plane mobility easily re-created once you clamp the staple down. Worse once its down its really hard to change unlike a screw. Cross screws or interfrag screw + plate or bust. I love the lapidus. I almost never Austin/Akin. I have my Lapidus <60 min. I did have "the lapidus from hell" a couple weeks ago tho. Those still pop up every now and then.

 

[ldsrmdude]

Since the discussion has died down a little, I went ahead and added a poll at the top of the thread. You can only vote 1 time.

We also will keep this thread going in a few days with some journal articles to discuss that @SLCpod will be posting for us.

 

[josebiwasabi]

i would do a distal metatarsal osteotomy for this one. i think that with a lapidus in isolation without correction of the met adductus can cause issues due to 1st/2nd metatarsal crowding. and no, i am not going to correct the met adductus for a person whose chief complaint was simply bump pain.

 

[DYK343]

i would do a distal metatarsal osteotomy for this one. i think that with a lapidus in isolation without correction of the met adductus can cause issues due to 1st/2nd metatarsal crowding. and no, i am not going to correct the met adductus for a person whose chief complaint was simply bump pain.

I would like to challenge. I've done a few lapidus with minor metaductus. My experience number is admittedly low, but I have seen resolution or at least partial resolution in the metaductus once I get the 1st ray repositioned without correcting the lesser metatarsals. I would call the original case "minor" metaductus. I think the 1st ray drives a lot of the metaductus deformity. Cases like original posted above I feel do fine with Lapidus. Severe metaductus is a different story.

For the record, I do not think anyone would be wrong doing a plantarflexing head procedure for the above case. Everyone has different opinions. Always enjoy listening to others opinions, thoughts, and strategies.

 

[Podstar]

We have recently had quite a few lectures over the Lapidus procedure and I have also seen a few post-op patients in clinic since this was posted. In retrospect, I can definitely appreciate its utility for this case. I really enjoyed this and would like to continue to have case discussions.

 

[ldsrmdude]

We have recently had quite a few lectures over the Lapidus procedure and I have also seen a few post-op patients in clinic since this was posted. In retrospect, I can definitely appreciate its utility for this case. I really enjoyed this and would like to continue to have case discussions.

We’ll definitely do some more. I’ve been meaning to be more active with this, maybe doing one a month.