Bunions: Osteotomy Is Necessary to Achieve Balance

Bunions: Osteotomy is Necessary to Achieve Balance

Gregory C Berlet MD, FAOA, FRCS(C) Orthopedic Foot and Ankle Center Key Elements: Bunion Correction Patient 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 Surgeon Considerations: 1. IM angle correction 2. Sesamoid reduction 3. Articular congruity 4. Rotation 5. Functional motion 6. Medial column stability Medial Column Instability

Controversy: Is a Bunion a ……. Fundamental Biomechanical Flaw of the Foot

or

Isolated Deformity Requiring Re-Balancing 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 0 0  IM 20 ; HVA 42 • 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

26% of specimens with HV there was abnormal metatarsal pronation with absence of sesamoid deviation from articular facet

Kim et al, FAI 36(8), 2015 My Approach: 2017 Pre Operative Planning Sesamoid View: Reduced Sesamoids ( pronation deformity of 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