Hallux Valgus CONTRIBUTORS Matthew D

FASXXX10.1177/1938640016640403Foot & Ankle SpecialistFoot & Ankle Specialist research-article6404032016

vol. 9 / no. 2 Foot & Ankle Specialist 159 〈 Roundtable Discussion〉

Hallux Valgus CONTRIBUTORS Matthew D. Sorensen, DPM Weil Foot and Ankle Institute Are We Really Getting It Correct? Chicago, IL Truitt M. Cooper, MD Assistant Professor o say that the topic of bunions understand that each bunion deformity is Department of Orthopedics comes into play in all of our different with its own set of University of Virginia T practices would be stating the idiosyncrasies. I think the subsets are Charlottesville, VA obvious. Whether you deal with them few and therefore enable us to make often and find enjoyment in the cases, or educated decisions when it comes to Paul Dayton, DPM you see them rarely and hide in your picking the appropriate procedure for Unity Point Clinic office when a patient shows up with a any given bunion deformity. I would Fort Dodge, IA bunion complaint, they affect our practice. strongly submit that a “one trick pony” Assistant Professor My major frustration with bunions has approach to correcting a bunion is Des Moines University CPMS often been the unpredictability of the probably not appropriate. Des Moines, IA outcomes. I felt this was an area I was not Cooper: Not really. When we work with ROUNDTABLE MODERATOR happy about in my own practice. My the residents and try to help them get thought was, “Come on, I’m the foot and ready for the board exams, we make sure W. Bret Smith, DO, MS ankle guy in my practice, I should be they know how to measure intermetatarsal Director of Foot and Ankle Division knocking this out of the park.” (IM) angles and hallux valgus angles, as Moore Center for Orthopedics So I thought I would assemble a team of well as to look for congruency at the Columbia, SC innovative, forward-thinking surgeons to metatarsophalangeal (MTP) joint. educate me on how they get great results SECTION EDITORS However, it may be more important to with their bunion patients. I think you look at the pronation deformity and what will find their discussion very W. Bret Smith, DO, MS is occurring at the first tarsometatarsal enlightening. They have opened my eyes Director of Foot and Ankle Division (TMT) joint (these are probably related). to ways that can hopefully improve my Moore Center for Orthopedics own understanding of the bunion Dayton: Simply put, I do not think we Columbia, SC deformity and therefore outcomes for my can ever achieve mastery of hallux Stephen A. Brigido, DPM patients. I am hoping this discussion will abducto valgus (HAV) surgery with such a Section Chief—Foot and Ankle Reconstruction stimulate interest in pursuing improved wide variation in process. It has been Coordinated Health answers in our understanding of the shown by multiple industries, such as the Bethlehem, PA hallux valgus deformity. airlines and auto manufacturing, that Professor of Surgery control of the process and strict adherence The Commonwealth Medical College Help me out with this, we have to protocols are what drive quality. The Scranton, PA over 100+ bunion correction concept of every surgeon performing his or her own individualized procedure goes procedures, do we really against all that is accepted in quality idea. However, it is becoming very evident understand the deformity? management. Some say that in medicine that medicine and surgery are more like Sorensen: Interestingly I think we are procedures must be individualized, and the airlines than we may have thought. finally reaching the point where we we are to some degree comforted by this That is, ultimately quality follows

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consistency. A good example is the World I found myself having to explain how not in the metatarsal or in other words the Health Organization presurgical checklist. this was “normal” to the patient and metatarsal is deviated and not deformed. I This simple but strict process has been using the typical rationalizations to make think we have put so much reliance on shown to reduce countless operative myself feel better. Worse yet, from time transverse plane radiographic angles to complications by removing variability. to time hallux varus showed up. decide on which procedure to pursue for Hundreds of procedures with thousands Complications are normal, a little drift is bunion correction that we have of individual variations cannot lead us to acceptable, and the patient caused the overlooked the basic anatomy of the mastery and consistent outcomes. problem come to mind as comforting deformity. The fact is in a bunion rationalizations. With fractures I could deformity both the hallux and metatarsal My biggest issue with bunions nearly always succeed. I just put it back components are deviated in 3 dimensions. is patient dissatisfaction. where it was supposed to be. That is A 3-dimensional problem cannot be when I realized that with bunions I was solved with a 2-dimensional solution. Why am I getting so many not putting it back where it was The simple answer is that I do not cut issues with recurrence? supposed to be, I was cutting a normal the metatarsal and create a new and Sorenson: Again, I think it comes back metatarsal and making a new deformity, unpredictable deformity. I strive to put to treating each individual deformity as a which was completely unpredictable. My the metatarsal back where it is supposed unique entity. I think assessing things like quest for better outcomes has now to be. The deformity can be completely hypermobility, intrinsic metatarsal turned to understanding the anatomic corrected with angulation in the deformity, coronal plane rotation, sesamoid basis of the deformity in an attempt to transverse and sagittal planes, and varus malposition, hallux/phalanx deviation, find the “one” reliable HAV procedure rotation in the coronal plane. This puts other global foot deformity and how all of and reduce the variation in my approach. the metatarsal and first MTP joint back to these affect one another plays a more normal alignment without having to rely significant role that we have historically Let me get inside your brain. What on capsular balancing. thought in our capacity to predictably treat tips/pearls can you give us about bunions with long-term success. I think I have seen a great deal of new how you approach your bunions? missing any one of these components in information on the coronal procedure selection or execution of the Sorenson: The biggest 2 components plane aspect as it relates to selected procedure or both will play into a that have made an impact on outcome bunions; does this influence less than satisfactory outcome. for me over the past couple of years is addressing the hypermobile state and, your approach when selecting Cooper: Many (if not all) of those 100+ even more compelling but strongly a technique to fix the bunion? surgeries you mentioned above are what connected, addressing coronal plane Sorenson: As alluded to previously, I would call “work-arounds,” meaning rotational deformity of the first ray on this component strongly influences that they do not necessarily address the the cuneiform. The hypermobility procedure selection in my current primary issue. The ultimate example of component is really most effectively practice. When I see a rotated first ray in this would be to simply shave the medial assessed during the clinical exam. The the coronal plane, which is not every eminence, even though we know this is coronal plane deviation of the first ray is case, based largely on the sesamoid axial not an abnormal growth of bone. The assessed clinically, but also importantly view I think it is difficult to argue for any same is true for most metatarsal through plain film radiographic exam procedure that does not actively reduce osteotomies; the first metatarsal is not including an AP film and sesamoid axial the rotational deviation in addition to deformed; yet we cut it. In cases where view. These assessments then direct correcting for any transverse plane or the soft tissues are great and we get a procedure selection and execution of the sagittal plane deformity. powerful correction, it works. chosen procedure. Unfortunately, that is not always the case Cooper: It does. It makes me lean and the margin for error is small. Cooper: I am very wary about males more toward a first TMT fusion with hallux valgus. Although Nery, procedure. In the past we have used Dayton: I realized a decade ago that I Coughlin et al1 have shown similar Akin proximal phalanx osteotomies to was not delivering on my patient’s results in males treated with osteotomies, try and correct this, which may help with expectations for deformity correction. I I have a lower threshold to move to a the callus on the medial side of the toe, performed a variety of osteotomies first MTP arthrodesis in males, especially but again, this does not really address according to accepted protocols and if there is any loss of motion at the joint the root of that deformity. always using soft tissue balancing to get preoperatively. that final correction of the hallux and Dayton: The new data on the coronal sesamoids. Unfortunately, in far too Dayton: A deformity always has a position is exciting because it explains so many cases the hallux began to drift CORA (center of rotation of angulation) many of our previous questions and weeks to months after the procedure and or an anatomic basis. In HAV the CORA is complications. For the last 3 years I have

Downloaded from fas.sagepub.com by guest on April 24, 2016 vol. 9 / no. 2 Foot & Ankle Specialist 161 been getting pre- and postoperative its normal position.” You can’t do this with plane deviation at all and no sesamoid axial views on all HAV patients. a metatarsal osteotomy procedure because hypermobility component, I am going to This has led to an infinitely better when you show the postoperative X-ray it the Lapidus. understanding of what we are seeing on does not look normal. Cooper: My favorite is first MTP X-ray and what is really present in 3D. arthrodesis, although I do a fair number of These axial views definitely help me be So you happen to see a bunion scarf osteotomies. Personally, I do very prepared during the procedure. The recurrence in your office (of few traditional chevron osteotomies, more knowledge that the sesamoids can be in course not yours!), the MTP likely I will extend it to a “mini scarf.” normal position medial and lateral to the joint is still healthy, walk me crista yet look dislocated on the AP X-ray through your thoughts? Dayton: This will strike many surgeons because of pronation completely as much too simplistic because we live in changes our mind set about the need for Sorenson: First I ask if the patient is in a world of 130 bunionectomies, but here capsular balancing. We can see that in pain. If he or she is not in pain, then I do it is. If the MTP joint is healthy I do a those cases supination corrects the not necessarily recommend consideration tri-correctional TMT joint fusion deformity. Weight bearing computed for further surgery, but do try to educate correcting all 3 planes simultaneously, tomography scans are now beginning to them on the potential risk factors in their rarely doing any significant MTP joint take our understanding to the next level. current state in the short term and long soft tissue work. If the MTP joint is Once you see the connection between term if they choose to leave it alone. My arthritic, I do a fusion at that joint, also coronal rotation and what we have thought immediately is to try to understand correcting all 3 planes, including very traditionally evaluated on AP why the bunion came back, which is high intermetatarsal angles. That is it, 2 radiographs, it opens up a whole new usually fairly clear, and then make surgical procedures addressing the anatomic understanding of the deformity. recommendations based on that assertion. basis of the deformity and striving for Cooper: This is tough and depends consistency of the basic process. Give me your elevator pitch on why it recurred, what was done when you explain your bunion prior, and what the patient’s goals are. Tell me about your postoperative surgery to your patient? The idea of a “healthy” joint in this regime, this is one of the situation is relative, as it has already Sorenson: Again, this is deformity most often asked questions been violated. Even it is “healthy,” I specific, but I generally do my best to by my bunion patients? offer MTP fusion in a lot of cases. The make recommendations based on giving Sorenson: My patients can put weight really challenging cases are those in them the best long-term outcome that will on the heel of their splint with crutch which some type of mid-shaft or distal be predictable. I educate them on the assist as soon as they are comfortable. osteotomy has been done, but the intrinsic pathology at a layman level and They transition to full weight bearing in a IM angle is still really high, the Distal then illustrate how the correction will long boot at 2 weeks postoperative and metatarsal articular angle (DMAA) is directly address their bunion pathology. begin significant range of motion really off, and they are short. Often in exercises. At 6 weeks they transition out of Cooper: There is no pitch, I make them these I am thinking about first TMT the boot into a regular shoe and gradually beg for surgery and then try to talk them fusion, some sort of distal closing return to all activities as tolerated. out of it. I spend a lot of time trying to wedge to correct the DMAA and then make sure that patients really understand shortening the second and third Cooper: For most, it is 2 weeks heel their problem, as well as what they can metatarsals, as they often have transfer weight bearing in a postoperative shoe or expect. The perceptions are all over the metatarsalgia. short fixed ankle walker using crutches place. Some patients are shocked that I for support. They then can begin weight Dayton: First thing is a sesamoid cannot “just shave it off.” On the other bearing as tolerated with a goal of getting axial radiograph. In many cases the hand, a lot of patients are in terrible pain back to a shoe at 6 weeks. For first TMT metatarsal is severely pronated and but are horrified because they know fusions, I make them non–weight bearing driving the recurrence. In these cases someone who had a bad experience. Last, for 2 weeks, then touch down heel revision is relatively straightforward using although we all want them to look great weight bearing for 2 weeks, then full in a derotation to realign the first MTP joint. when we are done, I really try to make boot at 4 weeks postoperative. sure that they are doing it because it hurts, not simply for aesthetic purposes. Of course I need to ask, Dayton: With first MTP joint fusion I walk the patients in a postoperative shoe what is your go to bunion Dayton: Two X-rays in view, a normal or cast boot from days 2 to 3 or when X-ray and the patient’s X-ray: “This is a procedure, we all have one? they are comfortable. Average time to normal foot, this is your foot. My goal is to Sorenson: More and more, unless the tennis shoes is 5.5 weeks. Full sports put your metatarsal and big toe back into bunion is fairly mild with no coronal around 10 weeks.

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With tri-plane TMT joint fusion I let If you could wish for one thing same time, the fact that there exists such them walk at 2 weeks in cast boot and when it comes to bunions in your variation in the pathology makes it a they are usually in tennis shoes by 8 practice, what would it be? really interesting topic. weeks. Sorenson: That every patient All patients have bandages removed Dayton: Less options. responded perfectly to my surgery and start showering at 4 days. This is not without fail every time. common but strongly supported by the References published literature. We find that Cooper: That everyone would come in and ask for a first MTP fusion. In all 1. Nery C, Coughlin MJ, Baumfeld D, Ballerini splinting of the toe is not needed with FJ, Kobata S. Hallux valgus in males–part 2: tri-plane correction so bandages after the seriousness, part of me wishes that there radiographic assessment of surgical treatment. first few days are not necessary. was one answer for all bunions, but at the Foot Ankle Int. 2013;34(5):636-644.

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