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 Green Bay, Wisconsin
Disclosures Wright Medical/Arthrex/DJO/Zimmer Biomet: Consultant, Royalities Amniox, Diamond Orthopaedic: Consultant No off-label uses of materials are presented during this lecture
Bunion surgery is not for sissies!!! • Humbling... • My experience has been that 10% fail no matter how good they look immediate postop
Complications - types • Infection • Delayed/nonunion • Malunion • Transfer lesions • Neuroma/neuritis • Wound healing
Complications - types • Avascular necrosis • Hallux varus • Stiffness • Scar hypertrophy • Pain • Recurrence
Complications • Incidence 11-39% – Recurrent hallux valgus most common type (10- 15%)
Avoiding Recurrence? • Many have gone to doing more “primary” Lapidus procedures to avoid recurrence – Not that easy… • Recurrent hallux valgus • Recurrent metatarsus primus varus
Lapidus to Avoid Recurrence? • Think again Preop 2 nd revision 1 st revision 6 weeks
Lapidus Complications Not just recurrence –Lapidus nonunion = 2 - 20% –Dorsiflexion malunion • Transfer metatarsalgia
Recurrent Hallux Valgus • Where did it fail? –Preoperative evaluation –Intraoperative technique –Postoperative management
Why did the surgery fail? • Deformity too severe for procedure chosen • Procedure not performed correctly Silver
Why did the surgery fail? • Complications inherent to the procedure • Poor fixation • Inadequate postop management Nonunion – loss of correction
Failed Bunion Surgery • Sometimes its just bad luck! Bilateral nonunion with loss of correction
Failed Bunion Surgery • Once we determine why it failed… –Surgery or not? –Avoid surgical cripple • Operate on symptoms and not xrays • Think pedorthics
Recurrent Hallux Valgus • If revision surgery chosen then... –Reconstruction vs. salvage thru fusion?
Recurrent Hallux Valgus • Revision vs. Fusion –Is joint preserved and salvagable? –Can intrinsic deforming forces be corrected?
Recurrent Hallux Valgus • Revision vs. Fusion –Hallux MP joint • Passively correctable? • Crepitance? – Grind test • Sesamoid pain?
Recurrent Hallux Valgus • Revision vs. Fusion –1st TMT joint • Hypermobility? • Lesser metatarsal overload? • Pes planus? • Achilles contracture?
Revision Opportunities • Assuming the hallux MP is salvagable… – Soft tissue reconstruction – Phalangeal osteotomy – Double/biplanar osteotomy – Proximal Metatarsal Osteotomy – Modified Lapidus
Revision Opportunities • Option: distal soft tissue reconstruction and joint realignment +/- Akin –Assuming IM angle corrected and no hypermobility
Revision Opportunities • Example = “simple” recurrent hallux valgus –Modified McBride –Akin
Revision Opportunities • Bone problems –Under-correction –Malunion –Nonunion –AVN –Over-correction Under-correction = Failed Akin
Revision Opportunities • Undercorrection –Failed Akin • Revision with distal MT osteotomy
Revision Opportunities • Undercorrection –Distal osteotomy to salvage a failed PMO
Revision Opportunities • Undercorrection –More common is the recurrent hallux valgus with significant increased IM 1-2
Revision Opportunities • Undercorrection with large IMA –Re-do osteotomy vs. proximal fusion • Distal • Double • Proximal • Scarf • Lapidus 8 weeks postop
Revision Opportunities • Undercorrection –Proximal after a failed distal
Revision Opportunities • Undercorrection –Proximal after a failed distal • Beware of hallux varus from prior excessive head resection or overcorrection
Revision Opportunities • Undercorrection –My current preference is a modified Lapidus • Especially if large IMA or hypermobile with lesser metatarsalgia
Revision Opportunities • Modified Lapidus for recurrent hallux valgus
Revision Opportunities Failed Silver • Recurrence with hypermobility and pes planus –Modified Lapidus –MDCO –Gastroc recession
Revision Opportunities • However, what if recurrent hallux valgus but stiff –Failed Akin –Joint pain
Revision Opportunities • Recurrent hallux valgus with joint pain/DJD/stiff/etc – Think hallux MP fusion!
Revision Opportunities • I try to find a reason to do a hallux mp fusion in recurrent situation – Especially in a man
Revision Surgery • Postoperative management as important as the surgery –WB forces → need to protect and follow closely –Corrective dressings –Cast vs. boot vs. sandal
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
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
We are all still Seeking the Holy Grail of Bunion Surgery • Simple to do • Reproducible • Heals quickly • Weight bear early • Back to work quickly • Lasting correction... Not in my lifetime...
Thank You!
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