Title: The Failed Hallux Valgus
1The Failed Hallux Valgus
- Instructionnal Course Lecture
- Canadian Orthopaedic Association
- Halifax June 2, 2007
- André Perreault M.D.
- Montréal, private practice
2Failed for who?
- Surgeon point of view
- Congruent joint
- Joint space (degenerative joint disease)
- Metatarsal length
3Failed for who?
- Patient point of view
- No bump
- Straight toe
- Cosmetic scar
- Good motionenough to wear high hell
- No pain
- Almost restituo ad integrum
4Why did the original procedure failed?
- Stretching the indications (too big deformity
for the procedure) - Wrong procedure for the problem
- Bad technique of an adequate procedure
- Inadequate Medial capsule plication
- Inadequate soft tissue release ( Transverse lig.,
ADD.H.) - Inadequate post-op. dressing
5Why did the original procedure failed?
- An expected complication for that procedure
- A complication non specific to the procedure
- A misunderstanding of the expected results
- .Patient versus Surgeon expectation.
6The Failed Hallux Valgus
- Complications after distal metatarsal osteotomy
- Complications after proximal osteotomy
- Complication after Scarf osteotomy
- Complications after Lapidus procedure
- Complication after Keller Resection Arthroplasty
7The Failed Hallux Valgus
- Complications after distal metatarsal osteotomy
- Complications after proximal osteotomy
- Complication after Scarf osteotomy
- Complications after Lapidus procedure
- Complication after Keller Resection Arthroplasty
8Post-Chevron
9Complications after distal metatarsal osteotomy
1. Chevron
- Recurrent deformity
- Malunion
- Stiffness
- Avascular necrosis
10Complications after distal metatarsal osteotomy
1. Chevron
- Recurrent deformity
- Malunion
- Stiffness
- Avascular necrosis
11Complications after distal metatarsal osteotomy
1. Chevron RECURRENT DEFORMITY
- 1. Plane of osteotomy
- 2. DMAA
- 3. Too big deformity for the procedure
- 4. Loose capsulorraphy
- 5. Lateral soft tissue release
12Chevron- Recurrent deformity1. Plane of the
osteotomy
- Avoid
- Doing the osteotomy in line at right angle with
the first metatarsal - It is more unstable et tend to go back to its
previous position - Tend to ? the bone length
- (Stiffness)
- Instead the osteotomy should be done at right
angle to the foot - But Avoid shortening
13Errors in Chevron Osteotomy
- Here the osteotomy was done to done in the axis
of the bone, instead of the foot - Result 4 weeks post-op distal fragment back to
its original position - So if needed to lenghten the bone a good
fixation needed - Remove the Medial Eminence
- parallel to the foot, not the metatarsal.
14Chevron- Recurrent deformity2. The DMAA angle
- Primo
- RECOGNIZE
- Danger
- Make a straight toe with an incongruent joint out
of a valgus toe but congruent joint - With time will displace
15Chevron- Recurrent deformity3. Too big
deformity for the technique
- HV angle lt 30
- IM angle lt 14
16Chevron- Recurrent deformity4. Too loose
capsulorraphy
- Tension should be just enough to prevent
lateral displacement - With Akin no over correction
- Without Akin minimal overcorrection
- But Too tight capsulorraphy might lead to
stiffness.
Akin
Chevron
17Capsulorraphy
1st Metatarsal
P-1
Capsule
18Chevron- Recurrent deformity5. Lateral soft
tissue release
- Multiple studies
- STR with distal osteotomy Safe
- Incidence of AVN is so low, 1
(periosteal stripping is more a concern), - Most expert Caution if a STR is needed
- The indication is probably stretch
Proximal osteotomy - Adding a Akin procedure are safer.
19Complications after distal metatarsal osteotomy
1. Chevron
- Recurrent deformity
- Malunion
- Stiffness
- Avascular necrosis
20Complications after distal metatarsal osteotomy
1. Chevron Mal-Union
- Improper cuts may lead to instability
- Dorsiflexion or Plantarflexion
- Lateral tilt if the translation too big
- If the cut is at right angle to the foot or
slightly caudal (shortening) usually these are
very stable and some do not fix them - For more security a fixation is advisable.
- Orthosorb If only translational instability
- Otherwise a more secure
fixation
21Complications after distal metatarsal osteotomy
1. Chevron Mal-Union
- Shortening of 1rst Metatarsal
- Excessive impaction (osteopenic)
- Plane of osteotomy too caudal
- ?Transfer Metatarsalgia
- Treatment (beside orthosis)
- Lengthening of 1st Metatarsal (Rarely)
- Shortening lesser Metatarsal ( Better)
22Complications after distal metatarsal osteotomy
1. Chevron
- Recurrent deformity
- Malunion
- Stiffness
- Avascular necrosis
23Complications after distal metatarsal osteotomy
1. Chevron Stiffness
- If after correction the join is incongruent
- Faillure to recognise the elevated DMAA gt 10
- Do a biplane Chevron
- Avoid Dorsal incisions
- Careful not to damage sesamoid apparatus
Biplane Chevron
24Complications after distal metatarsal osteotomy
1. Chevron Stiffness
- Correction of a ?DMAA
- With a biplane chevron
25Complications after distal metatarsal osteotomy
1. Chevron
- Recurrent deformity
- Malunion
- Stiffness
- Avascular necrosis
26Distal soft tissue release and Distal metatarsal
osteotomy
- Avascular necrosis
- Less than 1 after STR
- In fact, it is the excessive periosteal
stripping, but - Difficult salvage
- Resection arthroplasty
- MTP Fusion
27Post-Mitchell
28(Modified) Mitchell
29Complications Post-Mitchell
- 1. Transfer Metatarsalgia
- (Shortening of 1st )
- 2. Mal-Union
- Dorsi-Flexion
- Plantar-Flexion
- Medial or Lateral tilt
- 3. Delay, Non-Union
30Post-Mitchell -1 TRANSFER METATARSALGIA
- If there is no malunion but only metatarsalgia
from a short first metatarsal - Lengthening of 1rst Metatarsal
- Rarely indicated (risk ?? of stiffness and
osteoarthrisis) - Shortening Lesser Metatarsal
- Important to restore the normal cascade pattern
- Usually M2, but always check M3 for shortening
osteotomy - Weil osteotomy
31Classical case post-Mitchell
- 1st Metatarsal shortening
- Dorsi-Flexion mal-union
32Better do both at initial surgery!
40
14
33Classical Weil osteotomy
- Osteotomy parallel to the sole of the foot
- Ex. 5 mm shortening
- 2 mm plantar displacement
- The problem in rigid foot with IPK, tend to
displace the BUMP more proximal
34Weil Myersons modification
- With a wedge resection above the 25 cut
- 5 mm shortening
- 0.8 mm plantar displacement
- The problem the toe is higher and do not touch
the ground - (but no functional signification cosmetic
concern only)
35Weil My modification
- A complete removal of 2 to 3 mm slice
- At an angle of 15 to 20
- Can correct sub-luxation MTP and IPK in many
cases. - Not indicated in very osteoporotic patients)
- All healed, except 1 ( screw loosening or
fracture)
36Classical Weil
My Modification Since 2001
Myerson modification
37(No Transcript)
38(No Transcript)
39Factors in decision making M-2 Shortening
Osteotomy
- Long 2nd metatarsal M2gtM1
- Expected after Mitchell
- Look at M-3
Donnatello
40Post-Mitchell 2. Mal Union in Dorsi-Flexion
41Dorsal open wedge
42Post-Mitchell Mal-Union in Plantar-Flexion
43Post-Mitchell Mal-Union With rotation
- Healing in medial rotation
- Lateral
rotation
44Post-Mitchell 3. Delay Healing
- Rarely non union
- If the alignment is good, be patient, delay union
(poor fixation) usually heal (in metaphyseal area)
45Post-Mitchell
- So to avoid all these displacement
- A fixation is needed (not the cerclage wire)
46Modified Mitchell
- Selective Indications and Principles
- Metatarsal length absolute importance
- Need a long 1st Metatarsal or
- Need to shorten at the same time the 2nd ( and
3rd PRN If the 1st is not longer than the 2nd or
3rd - HV angle lt40 ( 30-40)
- IM angle lt14
- Need a Internal fixation
- ________________________Ideal Indication
- H Valgus with some degenerative changes
- That some decompression is needed
- Might be osteoporotic ( witch is a
contra-indication for screw fixation like in
Ludloff, Scarf, Mann osteotomies)
47Late results of Modified Mitchell Procedure for
the Treatment of Hallux Valgus Fokter,
Samo Karl Foot Ankle Int. Vol.5
May 99
- Long term FU (Mean21 years) n105
- 72 Totally satisfied
- 16 Reservation Pain, 6 Look, 3 ROM
- AOFAS-Hallux MTP Score Compare to author 4
categories - Excellent group AOFAS score 95.2 ?37
- Good 86.3
?28.2 - 65 Excellent Good
- 92.4 would agree to undergo the operation again
48- Salvage treatment of failed Hallux Valgus
operation with proximal first metatarsal
osteotomy and distal soft- tissue reconstruction - Journal Foot Ankle Int. Volume 19 number 3
March 1998 - Harold B. Kitaoka, Gary l. Pazer
- 15 patients after failed Distal proceducre (
Silver or Chevron) - TX Crescentic Mann Osteotomy and Soft-tissue
release - HV angle 33 ? 14 IM angle 12.6 ? 5.7
- Complications 44
- 3 Transfer Metatarsalgia
- 2 Mal-Union
- 1 Hallux Varus
- 1 Non-Union
49Late results of Modified Mitchell Procedure for
the Treatment of Hallux Valgus Fokter,
Samo Karl Foot Ankle Int. Vol.5
May 99
- Long term FU (Mean21 years) n105
- 72 Totally satisfied
- 16 Reservation Pain
- 6 Reservation Apparence
- 3 Reservation ROM
- 4 Not satisfied
- AOFAS-Hallux MTP Score Compare to author 4
categories - Excellent group AOFAS score 95.2 ?37
- Good 86.3
?28.2 65 Exc.Good - Satisfactory 67.7
?21.4 - Poor 55.4
?13.6
50Late results of Modified Mitchell Procedure for
the Treatment of Hallux Valgus Fokter,
Samo Karl Podobnik Foot Ankle
Int. Vol.5 May 99
- Initially At
FU - Mean HV angle 33 17
- Mean IM angle 22.5 7.7
- 21 recurred over medial eminence
- 13.3 IPK under 2nd Metatarsal
- Overall satisfaction at 21 y. FU Excellent
Good 65 - 92.4 would agree to undergo the operation again
51Post-McBride
52Post-Mc Bride Hallux Varus
53Hallux Varus TreatmentExtensor Hallucis Brevis
(EHB) Procedure (Myerson)
- K. Johnson Classical EHL tranfert
- IP Fusion
- Total EHL cut distal
- Modification
- Half of EHL
- No need to fuse IP joint
54Hallux Varus TreatmentExtensor Hallucis Brevis
(EHB) My Procedure (Base Proximally)
55Simple bunionectomy
- Silver Bunionectomy (1923)
- Medial Eminence removal
- Adductor Hallucis divided
- Distal Capsular flap
- Overlapping Plantar Dorsal capsule
56Simple bunionectomy
- Will it come back Doctor?
- This is one of the reasons of the bad reputation
of Hallux Valgus surgery
57Simple bunionectomy
- McBride (1928)
- Medial Eminence removal
- Release of Conjoint tendon
- TRANSFER Conjoint tendon to 1st Meta. Head
- Removal of fibular sesamoid
- Duvries-Mann modification of McBride
- Adductor tendon cut and transfer to 1st Meta,
head ( not the Conjoint tendon) - Suture Medial capsule of 2nd Meta to lat. Capsule
of 1st Metatarsal head - No fibular sesamoid excision
58If the joint cannot be salvage (arthrosis) After
Distal Osteotomy(Chevron-Mitchell)
- First MTP fusion
- Modified Keller resection arthroplasty
- (Hamilton modification)
- Valenti arthroplasty
591st MTP Arthrodesis
- Dorsi-Flexion 10-15 to the floor
- 20-30 to the 1st
Meta - Valgus 10 - 15
- Fusion rate 88 after failed H. Valgus surgery
- 94 100 at initial
surgery - 94 2 Steinmann
pins - 96 2 (3.5mm)
cross screws - 97 Multiple
threaded K-wirws - 100 conical
reamming and plate - Less with Interpositionnal Bone Graf after
Failed Keller - Late IP Degeneration 15 (3 time more in Women)
- increase with HV angle gt20
60Complications Post-1st MTP Fusion
61If the joint cannot be salvage (arthrosis) After
Distal Osteotomy(Chevron-Mitchell)
- First MTP fusion
- Modified Keller resection arthroplasty
- (Hamilton modification)
- Valenti arthroplasty
62Excise ¼ Proximal P-1
1/3 resection for Regular Keller
Cut EHB proximally
Free up Dorsal capsule With EHB slide it
down To FHB
Bill Hamilton Capsular interposition
(modification of Keller resection arthroplasty
63If the joint cannot be salvage (arthrosis) After
Distal Osteotomy(Chevron-Mitchell)
- First MTP fusion
- Modified Keller resection arthroplasty
- (Hamilton modification)
- Valenti arthroplasty
64Valenti 1st MTP ArthroplastyExtensive
Cheilectomy
- NB. The lower part of the joint and sesamoid
apparatus are left intact
65WHY Keller for HV without Arthritis was done on
that young patient ???
66Failed Keller
- Salvage of a failed Keller Resection
Arthroplasty - MACHANECK JR., FELIX EASLEY, MARK E
GRUBER,FLORIAN RITSCHL, PETER TRNKA, HANS-JORG - JBJS A June 2004, Volume 86-A, Number 6
1131-1138 - They recommend fusion ( they do not lengthen with
a bone graft. 15 of valgus, 20Dorsiflexion (
M1-P1) - With 2 cross cannulated 3.0 mm screws
- Often associated with metatarsal shortening
osteotomy (mostly Weil osteotomy) - NB. Fusion rate with interposition graft is
lower more difficult
67A Podiatric Surgeon in Montreal
- After more than 90 minutes of surgery
681st Ray Hypermobility
- Some controversy
- Classical Lapidus fusion 1st M-Cuneiform STR
- Signs of Ligamentous Laxity (Breighton criteria)
- D-Flex small finger 1 point per
side - Thumb-Forearm
- Elbow hyperextension gt10
- Knee hyperextension gt10
- Palm-Floor 1 point
- Value gt5 LIGAMENTOUS LAXITY
- Squeeze test You grab the patient foot at
Metatarsal Head level - If there is a total correction of the Hallux
Valgus? suggest Hypermobity - Otherwise more rigid deformity
- Tarso-Metatarsal Clinical Test gt4 in Saggital
plane - Klaue device ( M.Caughlin) gt9 mm (sagittal
plane)
691st Ray Hypermobility
- Radiologic signs
- Dorsal elevation 1st Meta
- (Plantar gap)
- - Thickening 2nd Metatarsal medial
- cortical shaft
- - Arthritis of 2nd TM joint
701st Ray Hypermobility
- Some recent studies didnt show any difference
with Osteotomy (proximal or distal) and Lapidus
procedure ! - Faber, Frank W.M., Mulder, Paul, Verhaar, Jan
- Role of first Ray Hypermobility in the outcome of
the Hohmann and the Lapidus Procedure. A
prospective Randomizeial Involving One Hundred
and One Feet - JBJS March 2004 Volume 86-A, number 3
71The Failed Hallux Valgus
- Complications after distal metatarsal osteotomy
- Complications after proximal osteotomy
- Complication after Scarf osteotomy
- Complications after Lapidus procedure
- Complication after Keller Resection Arthroplasty
72Crescentic Proximal Osteotomy
73Crescentic Proximal Osteotomy
At 1 Year Metatarsalgia
After Weil Shortening
74Crescentic Proximal Osteotomy
1 Year post-op
75Crescentic Proximal Osteotomy
1 Year Post-op
76Ludloff Osteotomy
77Modified Ludloff
78Modified LudloffComplications
79Modified LudloffComplications
Plantar-flexion Lost of Fixation
80Hallux Valgus with Arthrosis
81Recurrence after Proximal Chevron
82Complication after Proximal osteotomy
- Mal-Union
- Dorsi-Flexion
- Plantar-Flexion
- Non-Union
- Excessive Shortening
- Under-correction
- Over-correction
83Complications after Proximal Crescentic Osteotomy
(Mann)
- Mal-Union the most common complication
(Dorsi-Flexion,Recurrence - 1. Incorrect orientation of the osteotomy
- When patent lie supine Hips are in external
Rotation the cut tend to be PROXIMAL-MEDIAL to
DISTAL-LATERAL ? elevation of Metatarsal head - 2. Positioning of the Osteotomy (ideal 10-12
mm) - Too distal cortical bone Heals less readily
- Narrow shaft . More
unstable - Too Proximal Fixation is difficult or impossible
- _ 3. Fixation of the Osteotomy
- Fixation is problematic
- Proximal cancellous, short. Distal Hard
cortical - Screw best but sometime unstable
and recurrence not rare. -
-
-
84Complications after Proximal Osteotomy- Treatment
- Mal-Union
- Dorsi-Flexion Sometimes difficult to correct
- TX Some type of plantar osteotomy
- If excessive shortening BONE GRAFTING
- - Plantar-Flexion
- Dorsi-Flexion osteotomy
- To avoid shortening a crescentic
osteotomy can be done in the sagittal plane - Non-Union rarely. If occurs Bone grafting
85Complication after Proximal osteotomy
- Mal-Union
- Dorsi-Flexion
- Plantar-Flexion
- Non-Union
- Excessive Shortening
- Under-correction
- Over-correction
86Complication after Proximal osteotomy
- Excessive Shortening
- Can be a significant problem
- Similar as after Mitchell Oseotomy
- Sometimes Lengthening 1st meta
- Generally Shortening 2nd ( ? 3rd )
87Complication after Proximal osteotomy
- Mal-Union
- Dorsi-Flexion
- Plantar-Flexion
- Non-Union
- Excessive Shortening
- Under-correction
- Over-correction
88Complication after Proximal osteotomy
- Under-correction (of IM angle)
- TX another Crescentic Osteotomy
- or an Open wedge Osteotomy
- Over-correction
- Often result in a HALLUX VARUS
-
89Complications after proximal osteotomyKey
Prevention
- Indications for Proximal Osteotomy
- IM angle gt 14 (13-15 ) STR
- HV angle gt 40 (30-40 )
- Goal To correct the intermetatarsal angle)
- Contraindication
- 1st MTP Osteoarthritis
- DMAA gt15-20 ( Unless Double osteotomy)
- (Severe H Valgus with Hypermobility)
90Hallux Varus after proximal osteotomy
91Hallux Varus after HV Correction
- Excessive Lateral Soft Tissue Release
Interruption of Lateral Conjoint Tendon - (Overpull of Abductor Hallucis)
- Excision of Lateral sesamoid
- Excessive medial capsule tightening
- Excessive Medial Eminence removing
- Overcorrection of IM angle
- Excessive Overcorrection with Postop dressing
92Hallux Varus after HV Treatment
- Excessive Lateral Soft Tissue Release
- Interruption of Lateral Conjoint Tendon
- (Overpull of Abductor Hallucis)
- Excision of Lateral sesamoid
- Excessive medial capsule tightening
- Excessive Medial Eminence removing
- Overcorrection of IM angle
- Excessive Overcorrection with Post-op dressing
93MTP Lateral Soft tissue Release
- TECHNIC 1
- 1. Adductor Hallucis
- Identified and isolated from Flexor Hallucis
Brevis with Hemostat clamp. - No need to relocate on Meta. neck
- (Conjoint tendon Add. Hallucis FHB)
- 2. Metatarso-Sesamoid suspensor Lig.
- (to free the fibular sesamoid, that can after be
relocated under the Metatarsal head - Not cutting the Metatarso-Phalangial Lig.
- (Collateral lig.) re. Risk
of H. Varus - N.B. Deep Transverse Metatarso-phalangial
Ligament doesnt need to be cut
94MTP Lateral Soft tissue
Conjoint tendon PIB
MTP Lateral collateral Lig.
Metatarso-sesamoid suspensor Lig
Fibular Sesamoid Sesamoid
Adductor Hallucis
Flexor Hallucis Brevis
PIB Phalangial Insertion Band
95MTP Lateral Soft tissue Release
- TECHNIC 2
- 1. Conjoint tendon (PIB Phalangial
Insertion Band) - 2. Metatarso-Sesamoid suspensor Lig.
- (to free the fibular sesamoid, that can after be
relocated under the Metatarsal head - Not cutting the Metatarso-Phalangial Lig.
- (Collateral lig.) re. Risk
of H. Varus - N.B. Deep Transverse Metatarso-phalangial
Ligament doesnt need to be cut
96MTP Lateral Soft tissue
Conjoint tendon PIB
MTP Lateral collateral Lig.
Metatarso-sesamoid suspensor Lig
Fibular Sesamoid Sesamoid
Adductor Hallucis
Flexor Hallucis Brevis
PIB Phalangial Insertion Band
97EHL
ABD.Hallucis
ADD. Hallucis
FHL
Fibular Sesamoid
Metatarso-sesamoid Suspensor Lig.
98The Failed Hallux Valgus
- Complications after distal metatarsal osteotomy
- Complications after proximal osteotomy
- Complication after Scarf osteotomy
- Complications after Lapidus procedure
- Complication after Keller Resection Arthroplasty
99Scarf Osteotomy
- General Indications
- Same as Proximal Osteotomy IM gt14-18
- More versatile
- More stable
- More demanding
100 SCARF OSTEOTOMY
101Scarf Osteotomy
- Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS
CORRECTION - Foot and Ankle Clinics, Volume 3, September
2000, 525-580 - Results (123 feet, 76 patients) FU 3 to 46
months (13) - HVA 35.2 ?16.4
- IMA 17.4 ? 10.2
- ROM 75 (DF 65 PF 10)
- Complications
- 2 Stress fractures ( at proximal osteotomy site)
- 4 Recurrences (HVA gt25) 2 need capsuloplasty
- 5 Over-correction?Hallux Varus (Learnig curve
8?3) - 3 Prominent Hardware, less with Threaded head
screws. - 3 Osteonecrosis ( 2 need arthrodesis)
- Rare Under-correction or Stiffness (early
mobilization) -
-
102Scarf Osteotomy
- Results Complications
- KH. Kristen, C. Berger, S. Steizig, E.
Thaihammer, M. Posch, A. Engel - The SCARF Osteotomy for the Correction of
Hallux Valgus Deformities - Foot and Ankle surgery Volume 23 Number 3
220-228, March 2003 - 89 patients Post-op HV 19 IM 6.6
- Return to Work 6 weeks, to Sports 8.3 weeks
- Complications 7 Recurrence 6
- 4 Hallux Limitus (ROM
lt40) - 2 Superficial infections
- 1 Dislocation of distal
fragment
103Scarf Osteotomy
- Results Complications
- Rippstein, P ZUnd, I Clinical and radiological
midterm results of 61 scarf osteotomies for
hallux valgus deformity. Synopsis book, Second
internat. AFCP spring meeting, Bordeaux May, 2000 - 2 years FU
- HV angle 32?11
- IM angle 14?6
- Complications 1 Osteonecrosis Meta. Head
- 1 Painful Over-correction
104Scarf Osteotomy
- Results Complications
- Valentin, B Leemrijse, Th Scarf osteotomy of
the first metatarsal A review of the first 56
cases (5 years follow-up) and improvement of the
surgical technique. Synopsis book, Second
internat. AFCP spring meeting, Bordeaux May, 2000 - 56 patients 5 years FU
- HV 38.5 ? 19
- IM 16.6 ? 11
- Complications
- 15 Hallux Limitus
105Scarf Osteotomy
- Results Complications
- Wagner, A Fuhrmann, R Abramovsky, I Early
results of Scarf osteotomies using differentiated
therapy of hallux valgus. Foot and Ankle
surgery 6105-112, 2000 - 53 cases 14 months FU
- HV angle 43 ?23
- IM angle 16?8
- Complications
- 2 Fractures of 1st Metatarsal ( at distal screw
level)
106Scarf Osteotomy
- Wagner, A Fuhrmann, R Abramovsky, I Early
results of Scarf osteotomies using differentiated
therapy of hallux valgus. Foot and Ankle surgery
6105-112, 2000 - Rippstein, P ZUnd, I Clinical and radiological
midterm results of 61 scarf osteotomies for
hallux valgus deformity. Synopsis book, Second
internat. AFCP spring meeting, Bordeaux May, 2000 - Valentin, B Leemrijse, Th Scarf osteotomy of
the first metatarsal A review of the first 56
cases (5 years follow-up) and improvement of the
surgical technique. Synopsis book, Second
internat. AFCP spring meeting, Bordeaux May, 2000 - The SCARF Osteotomy for the Correction of Hallux
Valgus Deformities KH. Kristen, C. Berger, S.
Steizig, E. Thaihammer, M. Posch, A. Engel Foot
Ankle International Volume 23 number 3 march
2002
107Revision of Failed Foot Surgery a critical
analysis KILMARTIN, TE. J. Foot Ankle Surg. 41
309-315, 2002
- Off 244 patients refer by GP after all type off
failed foot surgery, 218 treated with revision
surgery - 152 (66 ) Failed first ray Surgery
- 42 After Mitchell Procedure
- 14 After Keller
- 14 After First MTP Fusion
- 8.6 After Silver ( Bumpectomy STR)
- Diagnosis ( 244 patients)
- 34 Transfer Metatarsalgia
- 26 Recurrent H. Valgus
- 18 Lesser digit deformity
- 5 Continued pain over 1 MTP
108Revision of Failed Foot Surgery a critical
analysis KILMARTIN, TE. J. Foot Ankle Surg. 41
309-315, 2002
- Revision surgery
- 32 Lesser Metatarsal surgery
- Weil or Schwartz
- 23 Lesser Toe surgery
- 21 First Metatarsal-Phalanx
- Scarf-Akin
- 4 First Lesser Metatarsal
- Scarf-Akin and Weil or Schwartz
- 86 Might have been avoid
109The Failed Hallux Valgus
- Complications after distal metatarsal osteotomy
- Complications after proximal osteotomy
- Complication after Scarf osteotomy
- Complications after Lapidus procedure
- Complication after Keller
1101st Metatarsal-Cuneiform arthrodesis The
Lapidus Procedure
- Indication for Lapidus Procedure
- Severe Hallux Valgus, With Hypermobility
(Instability of the Metatarso-Cuneiform joint) in
saggital plane, particularly with Generalize
Ligamentous Laxity mostly in
Hallux Valgus Juvenile with High 1-2
Inter-Metatarsal angle IM angle gt18 - OA 1st TMT
- Sometime in adult flatfoot from PTTD
- Should not be done if 1st Metatarsal is short
(or Open Epiphysis
111Complications after Lapidus Procedure
- 1. Non-union
- 2. Mal-Union Dorsi-Flexion (mostly)
- 3. Excessive Shortening
112Complications Lapidus Procedure
- 1. Non-UNION (10-12....7 to 50!!)
- Significantly more common than Mal-Union
- Very high rates
- Frequently symptomatic
- Need Multiple screw fixation and
- Cast Immobilisation and
- A period of non-weight bearing ( 4-6
weeks) - (Union rate better with Bone Grafting)
113Modified Lapidus procedure
- Popularize by Sig. Hansen
- Minimal articular resection
- C1? M1
- M1? M2
- Big Screws (4.0-4.5)
- Lag Screw tech.
- Local Bone Graft
114Fusion rate of 1st TMT arthrodesis in MODIFIED
Lapidus and Flatfoot Reconstruction
- Ian M. Thompson Donald R. Bohay John G.
Anderson - Foot Ankle Int. Volume 26 Number 9,
September 2005 - 201 feet
- Non-Union 4 ( 8 cases)
- 5 Had previous Bunion Surgery
- 2 Smokers
- 1 diabetic
- Of 201 feet, 25 (12) had Recurrence after
Previous Bunion Surgery. - Out of these 20 had Non-Union after Modified
Lapidus
115Complications Lapidus Procedure
- 2. MAL-UNION
- Technically difficult re. Dorsal incision Poor
visualisation Re. depth of bone ? MEDIAL
INCISION - Some Plantar-Flexion of the ray usually require
to compensate the shortening ( too much ?sesamoid
pain) - 3. SHORTENING
- Relative to joint resection
116The Failed Hallux Valgus
- Complications after distal metatarsal osteotomy
- Complications after proximal osteotomy
- Complication after Scarf osteotomy
- Complications after Lapidus procedure
- Complication after Keller Resection Arthroplasty
117Complications after Keller
- Salvage of a Failed Keller Resection
Arthroplasty - Machacek Lr., Felix and all.
- JBJS-A Vol. 86-A, Number 6, June 2005
- Complications Cock-up toe, Recurrent H Valgus,
Flail toe, metatarsalgia. - Group A- Treated with Fusion (29 feet), FU 36
months - 90 healed. AOFAS score 76/90
- Needed surgery 17 need refusion (3
Mal-Union 2 non-union) - 62 Needed Lesser Metatarsal
shortening ( Weil,Helal,etc.) - Group B- Re-Keller or STR (EHL Z-Lenghtening) (18
feet), FU74 monhs - AOFAS score 46/90 Non-Satisfied 61
- Cock-up 67 Recurrence39
Rigidus11 - Conclusion Fusion much better, but more
demanding -
118Recurrent H. Valgus without arthrosisThe
Lapidus procedure
- The Lapidus procedure as salvage After Failed
Surgical Treatmen of Hallux Valgus. A Prospective
Cohort Study - COETZEE, J.CHRIS, RESIG,SCOTT G.,
KUSKOWSKI,MICHAEL SALEH, KHALED J. - JBJS-A January 2003,Volume 85-A Number 1 60-65
- Here it is only recurrent H. Valgus
- AOFAS score 47.6?87.9
- Visual Analog Pain Scale 6.2? 1.4
- Very satisfied 77 Satisfied 4 Somewhat
satisfied 19 Dissatisfied 0 - C1?M1 M1?M2
119First Metatarsophalangeal Joint Arthrodesis as a
Treatment for Failed Hallux Valgus Surgery
- Grimes, J.S., Coughlin, M.
Foot Ankle
InternationalVol.27, No. 11 / 887-893/ Nov. 2006 - The only well documented long-term results of
salvage of failed hallux valgus procedures by
arthrodesis of the first MTP -
120First Metatarsophalangeal Joint Arthrodesis as a
Treatment for Failed Hallux Valgus Surgery
- Here M.J. Coughlin expose his results for Failed
H. Valgus treated with fusion and not only for
those with arthrosis - 55 recurrence H. Valgus, 24 H. Varus, etc.
- 82 have Lesser toes complaints
- AOFAS score of 73 (Excellent 39, Good 33
- Fair 24 , Poor
3) - 79 would have the surgery again
121The number 1 complication of Hallux Valgus
surgery is not on the first ray !
122Transfer Metatarsalgia is the No. 1 problem after
bunion surgery. Usually 2nd Metatarsal.
123- Review of All Orthopaedic surgeries witch led to
litigation (USA- Glyn Thomas) - Most Foot surgery 23
- Out of this
- 64 Lesser metatarsal neck Osteotomy
124Patients Expectations vs Realistic Results
- Good discussion
- Need to repeat and repeat
- When they listen( i.e. Not looking at their
Question list, or not thinking at their next
question, most do not really understand the
technical explanations. - They tend to underestimate minor warnings
- So you need to be clear and need to emphasis
mostly on what would be a realistic result.
125The Failed Hallux Valgus
- 1. Recognize why the first surgery failed
- Dont repeat the initial error
- 2. Look the Whole Foot (re. Lesser Metatarsals)
- 3. Look if there are Degenerative changes
-
126(No Transcript)