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					   The Failed Hallux Valgus
  Instructionnal Course Lecture
Canadian Orthopaedic Association
       Halifax June 2, 2007


       André Perreault M.D.
       Montréal, private practice
       Failed for who?

 Surgeon      point of view
 – Congruent joint

 – Joint space (degenerative joint disease)

 – Metatarsal length
      Failed for who?

 Patient    point of view:
 – No bump
 – Straight toe
 – Cosmetic scar
 – Good motion…enough to wear high hell
 – No pain
 – Almost: restituo ad integrum…
    Why 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
Why 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….
        The 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
         The 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
Post-Chevron
Complications after distal
metatarsal osteotomy 1. Chevron

    Recurrent deformity
    Malunion
    Stiffness
    Avascular necrosis
Complications after distal
metatarsal osteotomy 1. Chevron

  Recurrent       deformity
    Malunion
    Stiffness
    Avascular necrosis
Complications 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
Chevron- Recurrent deformity
1. 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 it’s
                         previous position
                       – Tend to  the bone length
                          (Stiffness)
                      Instead : the osteotomy
                       should be done at right
                       angle to the foot
                        But: Avoid shortening
Errors 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 it’s
                     original position
                 So if needed to lenghten
                  the bone: a good fixation
                  needed
                 Remove the Medial Eminence
                  parallel to the foot, not the
                  metatarsal.
Chevron- Recurrent deformity
2. 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
  Chevron- Recurrent deformity
   3. Too big deformity for the
              technique


 HV   angle < 30 °

 IM   angle < 14 °
       Chevron- Recurrent deformity
       4. Too loose capsulorraphy
    Tension should be just enough to prevent lateral
       displacement
              Akin



              Chevron




    – With Akin    : no over correction
    – Without Akin : minimal overcorrection

    But Too tight capsulorraphy might lead to stiffness.
      Capsulorraphy


                      1st Metatarsal

P-1



       Capsule
      Chevron- Recurrent deformity
      5. … 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.
Complications after distal
metatarsal osteotomy 1. Chevron

    Recurrent deformity
  Malunion
    Stiffness
    Avascular necrosis
Complications 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
Complications 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)
Complications after distal
metatarsal osteotomy 1. Chevron

    Recurrent deformity
    Malunion
  Stiffness
    Avascular necrosis
 Complications after distal metatarsal
 osteotomy 1. Chevron : Stiffness

                     If after correction the join
                      is incongruent…
                     Faillure to recognise the
                      elevated DMAA > 10 °
                     Do a biplane Chevron

Biplane Chevron
                     Avoid Dorsal incisions
                     Careful not to damage
                      sesamoid apparatus
Complications after distal metatarsal
osteotomy 1. Chevron : Stiffness




                          Correction of a
                           DMAA
                           – With a biplane
                             chevron
Complications after distal
metatarsal osteotomy 1. Chevron

    Recurrent deformity
    Malunion
    Stiffness
  Avascular      necrosis
Distal 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:
                         Resectionarthroplasty
                         MTP Fusion
Post-Mitchell
(Modified) Mitchell
Complications Post-Mitchell

     1. Transfer Metatarsalgia
      – (Shortening of 1st )
     2. Mal-Union
      – Dorsi-Flexion
      – Plantar-Flexion
      – Medial or Lateral tilt
     3. Delay, Non-Union
Post-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
Classical case post-Mitchell
    1st Metatarsal shortening
    Dorsi-Flexion mal-union
Better do both at initial surgery!




          40°

    14°
                       Classical Weil




                       My Modification
Myerson modification      Since 2001
         Factors in decision making:
         M-2 Shortening Osteotomy


   Long 2nd metatarsal M2>M1
    –Expected after Mitchell

   Look at M-3…


                                Donnatello
Post-Mitchell 2. Mal Union: in Dorsi-Flexion
Dorsal open wedge
Post-Mitchell Mal-Union in Plantar-Flexion
Post-Mitchell: Mal-Union: With rotation


                 Healing in medial rotation




                                    Lateral rotation
Post-Mitchell: 3. Delay Healing

                     Rarely : non union

                     If the alignment is
                      good, be patient,
                      delay union (poor
                      fixation) usually
                      heal (in
                      metaphyseal area)
               Post-Mitchell

   So to avoid all these displacement:
    – A fixation is needed (not the cerclage wire)
                 Modified 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 <40° ( 30-40)
    – IM angle <14°
    – 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)
    Late results of Modified Mitchell Procedure for
    the Treatment of Hallux Valgus
          Fokter, Samo Karl
          Foot & Ankle Int. Vol.5 May 99

   Long term FU (Mean:21 years) n=105
     – 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
   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
Post-McBride
Post-Mc Bride: Hallux Varus
Hallux Varus –Treatment
*Extensor 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
Hallux Varus –Treatment
*Extensor Hallucis Brevis (EHB) My Procedure
     (Base Proximally)
     Simple bunionectomy

   Silver Bunionectomy (1923)

    – Medial Eminence removal +
    – Adductor Hallucis divided +
    – Distal Capsular flap +
    – Overlapping Plantar & Dorsal capsule
Simple bunionectomy

           Will it come back
            Doctor?

           This is one of the
            reasons of the bad
            reputation of
            Hallux Valgus
            surgery
          Simple 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
If the joint cannot be salvage (arthrosis)
 After Distal Osteotomy(Chevron-Mitchell)

      First MTP fusion

      Modified Keller resection arthroplasty
       – (Hamilton modification)


      Valenti arthroplasty
               1 st    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 >20°
Complications Post-1st MTP Fusion
If the joint cannot be salvage (arthrosis)
 After Distal Osteotomy(Chevron-Mitchell)

      First MTP fusion

      Modified Keller resection
       arthroplasty
         (Hamilton modification)

      Valenti arthroplasty
                     Excise 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
If the joint cannot be salvage (arthrosis)
 After Distal Osteotomy(Chevron-Mitchell)

      First MTP fusion

      Modified Keller resection arthroplasty
       – (Hamilton modification)


      Valenti arthroplasty
Valenti 1st MTP Arthroplasty:
   Extensive Cheilectomy
    NB. The lower part of the joint and
     sesamoid apparatus are left intact
WHY Keller for HV without
Arthritis was done on that
    young patient ???
                     Failed 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, 20°Dorsiflexion
      ( 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
        A Podiatric Surgeon in Montreal

   After more than 90 minutes of surgery…
                      1st 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 >10° :    “
     –   Knee hyperextension >10° :      “
     –   Palm-Floor                : 1 point

   Value >5 : 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: >4° in Saggital plane


   Klaue device ( M.Caughlin) >9 mm (sagittal plane)
            1st Ray Hypermobility
   Radiologic signs:
    – Dorsal elevation 1st Meta
           – (Plantar gap)




   - Thickening 2nd Metatarsal medial
        cortical shaft




   - Arthritis of 2nd TM joint
           1st Ray Hypermobility

   Some recent studies didn’t 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
        The 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
Crescentic Proximal Osteotomy
Crescentic Proximal Osteotomy


 At 1 Year:
Metatarsalgia




  After Weil
 Shortening:
Crescentic Proximal Osteotomy




                   1 Year post-op
Crescentic Proximal Osteotomy




     1 Year Post-op:
Ludloff Osteotomy
Modified Ludloff
Modified Ludloff…Complications
Modified Ludloff…Complications




                        Plantar-flexion
                        Lost of Fixation
Hallux Valgus with Arthrosis

                What would you do?
Recurrence after Proximal Chevron

                        5 Months after
       Complication after
      Proximal osteotomy
   Mal-Union
    – Dorsi-Flexion
    – Plantar-Flexion
   Non-Union
   Excessive Shortening
   Under-correction
   Over-correction
    Complications 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.
           Complications 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
       Complication after
      Proximal osteotomy
   Mal-Union
    – Dorsi-Flexion
    – Plantar-Flexion
   Non-Union
 Excessive Shortening
 Under-correction
 Over-correction
       Complication after
      Proximal osteotomy
   Excessive Shortening

    – Can be a significant problem
    – Similar as after Mitchell Oseotomy
    – Sometimes: Lengthening 1st meta
    – Generally: Shortening 2nd ( ? + 3rd )
       Complication after
      Proximal osteotomy
   Mal-Union
    – Dorsi-Flexion
    – Plantar-Flexion
   Non-Union
   Excessive Shortening
 Under-correction
 Over-correction
       Complication 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
Complications after proximal osteotomy
           Key: Prevention

      Indications for Proximal Osteotomy
       – IM angle > 14 ° (13-15 °) + STR
       – HV angle > 40 ° (30-40 °)
             Goal: To correct the intermetatarsal angle)


      Contraindication:
       – 1st MTP Osteoarthritis
       – DMAA >15-20° ( Unless Double osteotomy)
       – (Severe H Valgus with Hypermobility)
Hallux Varus after proximal osteotomy
    Hallux 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
    Hallux 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
MTP 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 doesn’t need to be cut
MTP 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
MTP 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 doesn’t need to be cut
MTP 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
                            EHL



       ADD.                       ABD.Hallucis
       Hallucis
                                  FHL
         Fibular Sesamoid



Metatarso-sesamoid
Suspensor Lig.
        The 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
         Scarf Osteotomy

   General Indications:
    – Same as Proximal Osteotomy IM >14-18°
    – More versatile
    – More stable
    – More demanding
SCARF OSTEOTOMY
                   Scarf 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 >25°) 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)
Revision 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
Revision 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
       The Failed Hallux Valgus

   Complications after distal metatarsal osteotomy
   Complications after proximal osteotomy
   Complication after Scarf osteotomy
   Complications after Lapidus procedure
   Complication after Keller
    1st 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 >18°
     – OA 1st TMT
     – Sometime in adult flatfoot from PTTD
   Should not be done if 1st Metatarsal is short (or
    Open Epiphysis
Complications after Lapidus Procedure



          1. Non-union
          2. Mal-Union: Dorsi-Flexion (mostly)
          3. Excessive Shortening
      Complications 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)
Modified 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
Fusion 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
     Complications 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
       The 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
      Complications 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), FU:74 monhs
      AOFAS score: 46/90 Non-Satisfied: 61%
     Cock-up: 67 % Recurrence:39% Rigidus:11%
Conclusion: Fusion much better, but more demanding
Recurrent H. Valgus without arthrosis:
The 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
    First 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
First 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
     The number 1
 complication of Hallux
Valgus surgery is not on
     the first ray !
      Transfer
Metatarsalgia is the
No. 1 problem after
 bunion surgery.
    Usually 2 nd

    Metatarsal.
   Review of All Orthopaedic surgeries witch
    led to litigation: (USA- Glyn Thomas)



    – Most:   Foot surgery : 23 %

         Out of this:
   64% : Lesser metatarsal neck Osteotomy
Patients 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.
       The Failed Hallux Valgus
   1. Recognize why the first surgery failed
     – Don’t repeat the initial error…

   2. Look the Whole Foot (re. Lesser Metatarsals)



   3. Look if there are Degenerative changes
Weil osteotomy
Classical Weil osteotomy

                Osteotomy parallel to
                 the sole of the foot
                Ex.: 5 mm shortening
                 =
                        2 mm plantar
                 displacement
                The problem in rigid foot with
                    tend to displace the
                 IPK,
                 “BUMP” more proximal
Weil: Myerson’s
 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)
Weil: 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)
                    Scarf 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 <40°)
                               2 Superficial infections
                               1 Dislocation of distal fragment
               Scarf 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
                 Scarf 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
               Scarf Osteotomy

– Results & Complications
– Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf
  osteotomies using differentiated therapy of hallux valgus.
  Foot and Ankle surgery 6:105-112, 2000

– 53 cases 14 months FU
– HV angle: 43° 23°
– IM angle : 16°8°
– Complications:
      2 Fractures of 1st Metatarsal ( at distal screw level)
                    Scarf Osteotomy
   Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies
    using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112,
    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
    Late results of Modified Mitchell Procedure for
    the Treatment of Hallux Valgus
           Fokter, Samo Karl
           Foot & Ankle Int. Vol.5 May 99

   Long term FU (Mean:21 years) n=105
     – 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%
        Late 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

				
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