FASXXX10.1177/1938640016640403Foot & Ankle SpecialistFoot & Ankle Specialist 640403research-article2016 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 DOI: 10.1177/1938640016640403. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2016 The Author(s) Downloaded from fas.sagepub.com by guest on April 24, 2016 160 Foot & Ankle Specialist April 2016 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.