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Recurrent Hallux Valgus Why did it happen and What to do Now? - - PowerPoint PPT Presentation
Recurrent Hallux Valgus Why did it happen and What to do Now? - - PowerPoint PPT Presentation
Recurrent Hallux Valgus Why did it happen and What to do Now? Robert B. Anderson, MD OrthoCarolina Charlotte, North Carolina Director, Foot and Ankle Titletown Sports Medicine and Orthopaedics Associate Team Physician, Green Bay Packers
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Bunion surgery is not for sissies!!!
- Humbling...
- My experience has
been that 10% fail no matter how good they look immediate postop
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Complications - types
- Infection
- Delayed/nonunion
- Malunion
- Transfer lesions
- Neuroma/neuritis
- Wound healing
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Complications - types
- Avascular
necrosis
- Hallux varus
- Stiffness
- Scar hypertrophy
- Pain
- Recurrence
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Complications
- Incidence 11-39%
–Recurrent hallux valgus most common type (10- 15%)
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Avoiding Recurrence?
- Many have gone to
doing more “primary” Lapidus procedures to avoid recurrence
–Not that easy…
- Recurrent hallux valgus
- Recurrent metatarsus
primus varus
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Lapidus to Avoid Recurrence?
- Think again
Preop 6 weeks 1st revision 2nd revision
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Lapidus Complications
Not just recurrence
–Lapidus nonunion = 2 - 20% –Dorsiflexion malunion
- Transfer
metatarsalgia
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Recurrent Hallux Valgus
- Where did it fail?
–Preoperative evaluation –Intraoperative technique –Postoperative management
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Why did the surgery fail?
- Deformity too
severe for procedure chosen
- Procedure not
performed correctly
Silver
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Why did the surgery fail?
- Complications
inherent to the procedure
- Poor fixation
- Inadequate postop
management
Nonunion – loss of correction
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Failed Bunion Surgery
- Sometimes
its just bad luck!
Bilateral nonunion with loss of correction
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Failed Bunion Surgery
- Once we determine
why it failed…
–Surgery or not? –Avoid surgical cripple
- Operate on
symptoms and not xrays
- Think pedorthics
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Recurrent Hallux Valgus
- If revision surgery
chosen then...
–Reconstruction vs. salvage thru fusion?
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Recurrent Hallux Valgus
- Revision vs. Fusion
–Is joint preserved and salvagable? –Can intrinsic deforming forces be corrected?
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Recurrent Hallux Valgus
- Revision vs. Fusion
–Hallux MP joint
- Passively
correctable?
- Crepitance?
– Grind test
- Sesamoid pain?
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Recurrent Hallux Valgus
- Revision vs. Fusion
–1st TMT joint
- Hypermobility?
- Lesser metatarsal
- verload?
- Pes planus?
- Achilles contracture?
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Revision Opportunities
- Assuming the hallux MP
is salvagable…
– Soft tissue reconstruction – Phalangeal osteotomy – Double/biplanar
- steotomy
– Proximal Metatarsal Osteotomy – Modified Lapidus
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Revision Opportunities
- Option: distal soft
tissue reconstruction and joint realignment +/- Akin
–Assuming IM angle corrected and no hypermobility
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Revision Opportunities
- Example =
“simple” recurrent hallux valgus
–Modified McBride –Akin
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Revision Opportunities
- Bone problems
–Under-correction –Malunion –Nonunion –AVN –Over-correction
Under-correction = Failed Akin
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Revision Opportunities
- Undercorrection
–Failed Akin
- Revision with
distal MT
- steotomy
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Revision Opportunities
- Undercorrection
–Distal osteotomy to salvage a failed PMO
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Revision Opportunities
- Undercorrection
–More common is the recurrent hallux valgus with significant increased IM 1-2
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Revision Opportunities
- Undercorrection
with large IMA
–Re-do osteotomy
- vs. proximal fusion
- Distal
- Double
- Proximal
- Scarf
- Lapidus
8 weeks postop
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Revision Opportunities
- Undercorrection
–Proximal after a failed distal
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Revision Opportunities
- Undercorrection
–Proximal after a failed distal
- Beware of hallux
varus from prior excessive head resection or
- vercorrection
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Revision Opportunities
- Undercorrection
–My current preference is a modified Lapidus
- Especially if
large IMA or hypermobile with lesser metatarsalgia
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Revision Opportunities
- Modified
Lapidus for recurrent hallux valgus
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Revision Opportunities
- Recurrence with
hypermobility and pes planus
–Modified Lapidus –MDCO –Gastroc recession
Failed Silver
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Revision Opportunities
- However, what if
recurrent hallux valgus but stiff
–Failed Akin –Joint pain
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Revision Opportunities
- Recurrent hallux
valgus with joint pain/DJD/stiff/etc
–Think hallux MP fusion!
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Revision Opportunities
- I try to find a
reason to do a hallux mp fusion in recurrent situation
– Especially in a man
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Revision Surgery
- Postoperative
management as important as the surgery
–WB forces → need to protect and follow closely –Corrective dressings –Cast vs. boot vs. sandal
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Recurrent Hallux Valgus
- Minimize failures/complications from
the start!
–Acknowledge the potential complications –Address each patient individually –Avoid stretching the indications –Address the pathologic anatomy –Adhere to the surgical technique
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Recurrent Hallux Valgus
- My preferred revision options are
hallux MP fusion and a modified Lapidus
–Careful preop assessment to determine if joint salvagable –Lengthy discussion with patient about goals/expectations –Proper technique and postop care
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We are all still Seeking the Holy Grail
- f Bunion Surgery
- Simple to do
- Reproducible
- Heals quickly
- Weight bear early
- Back to work quickly
- Lasting correction...
Not in my lifetime...
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