Key Elements: Bunion Correction Pati tient t Goals: That it was - - PowerPoint PPT Presentation

Bunions: Osteotomy is

Necessary to Achieve Balance

Gregory C Berlet MD, FAOA, FRCS(C) Orthopedic Foot and Ankle Center

Key Elements: Bunion Correction

Pati tient t Goals:

• That it was worth the cost and time

– Perception of improvement – Appealing cosmetic appearance

• Functional motion
• All in a time frame that does not sig

compromise work / family responsibilities

Key Elements: Bunion Correction

Surge geon Considerations:

• 1. IM angle correction
• 2. Sesamoid reduction
• 3. Articular congruity
• 4. Rotation
• 5. Functional motion
• 6. Medial column stability

Medial Column Instability

Fundamental Biomechanical Flaw of the Foot Isolated Deformity Requiring Re-Balancing

• r

Controversy: Is a Bunion a …….

1st TMT Instability

• Hansen commenting on Bunions:

– Bunion is a symptom of a greater and more complex dysfunction of the extremity – Bunion is one of the most common manifestations of gastroc contracture and mobile 1st ray – Management by means of dozens of techniques in literature is simplistic

Hansen: Functional Reconstruction of the Foot and Ankle 2000

Fundamental Flaw: One Operation for Bunions

LAPIDUS FUSION

Bunion as an Isolated Condition

Coughlin and Jones (2007):

• Hallux Valgus and First Ray Mobility
• Proximal osteotomy for bunion outcomes:
• 90 – 95% good to excellent
• Systematically evaluated the atavistic traits
• How common ?
• Influence on outcome of bunion surgery?

Coughlin MJ, Jones CP: JBJS 89(9) , 2007

HV and 1st Ray Mobility

• 103 patients, min 2 year follow up
• Proximal crescentic osteotomy + DSTP
• Outcome parameters:

– AOFAS – Ankle range of motion – Harris mat prints – 1st TMT motion – Klaue device – Radiographs

Coughlin MJ, Jones CP: JBJS 89(9) , 2007

Hypermobility ∞ Alignment

Increased preoperative mobility of the first ray:

• Regularly and consistently reduced to a

NORMAL range without fusion

• Stability of the first ray is a function of the

ALIGNMENT of the first ray and is not an intrinsic characteristic of the first metatarsocuneiform joint.

Coughlin MJ, Jones CP: JBJS 89(9) , 2007

Coughlinites: Save the Joint

Before After Proximal Metatarsal Osteotomy

State of Practice: 2006

Hypothetical Case: Severe Bunion Deformity

 50 year old female  IM 20 0 ; HVA 420

• 105 orthopedic academic foot and ankle

– 52% metatarsal osteotomy * * – 26% 1st MTP arthrodesis – 24% 1st TMT arthrodesis ( lapidus ) – Secondary procedures: Akin 30%

Pinney, Song, Chou: FAI 27(12); 2006

My Approach : 2017

Metatarsal Osteotomies:

• Scarf almost exclusively

– Short arm when I used to use chevron – Long arm for greater IM angle correction

• Proximal wedge removed to

allow for angular correction at the DMAA ( preserve congruity)

Sesamoid Reduction is the KEY

Sesamoids Not all the Same

Kim et al, FAI 36(8), 2015 26% of specimens with HV there was abnormal metatarsal pronation with absence of sesamoid deviation from articular facet

My Approach: 2017

Pre Operative Planning Sesamoid View:

• Reduced Sesamoids ( pronation deformity
• f the metatarsal) = Derotational Lapidus

with no DSTP

• Malreduced Sesamoids
• Mild deformity = short arm Scarf
• Significant deformity = regular Scarf
• In combination with a DSTP

My Approach : 2017

Peri articular Osteotomies:

• Akin 50% of the time

–Driven by hallux valgus interphalangeus –Position of toe relative to 2nd –Occasionally by rotation of hallux

• Oblique osteotomy secured by headless

compression screw

My Approach : 2017

Motion and Physical Therapy:

• Early joint mobilization is key
• No strapping, believe in your correction
• PT at 2 weeks to teach passive and

active assisted joint mobilization

• Intrinsic and extrinsic strengthening at 6

weeks

Osteotomies Most of The Time

• Get obsessed with sesamoid

position –Soft tissue balancing ( DSTP / capsule ) –Metatarsal angular correction including rotation

• Osteotomy is the answer in at

least 75% of my bunion cases

THANK YOU