The Failed Hallux Valgus

1
The Failed Hallux Valgus

• Instructionnal Course Lecture
• Canadian Orthopaedic Association
• Halifax June 2, 2007
• André Perreault M.D.
• Montréal, private practice

2
Failed for who?

• Surgeon point of view
• Congruent joint
• Joint space (degenerative joint disease)
• Metatarsal length

3
Failed for who?

• Patient point of view
• No bump
• Straight toe
• Cosmetic scar
• Good motionenough to wear high hell
• No pain
• Almost restituo ad integrum

4
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

5
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.

6
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

7
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

8
Post-Chevron
9
Complications after distal metatarsal osteotomy
1. Chevron

• Recurrent deformity
• Malunion
• Stiffness
• Avascular necrosis

10
Complications after distal metatarsal osteotomy
1. Chevron

• Recurrent deformity
• Malunion
• Stiffness
• Avascular necrosis

11
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

12
Chevron- 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

13
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
  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.

14
Chevron- 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

15
Chevron- Recurrent deformity3. Too big
deformity for the technique

• HV angle lt 30
• IM angle lt 14

16
Chevron- 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
17
Capsulorraphy
1st Metatarsal
P-1
Capsule
18
Chevron- 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.

19
Complications after distal metatarsal osteotomy
1. Chevron

• Recurrent deformity
• Malunion
• Stiffness
• Avascular necrosis

20
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

21
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)

22
Complications after distal metatarsal osteotomy
1. Chevron

• Recurrent deformity
• Malunion
• Stiffness
• Avascular necrosis

23
Complications 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
24
Complications after distal metatarsal osteotomy
1. Chevron Stiffness

• Correction of a ?DMAA
• With a biplane chevron

25
Complications after distal metatarsal osteotomy
1. Chevron

• Recurrent deformity
• Malunion
• Stiffness
• Avascular necrosis

26
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
• Resection arthroplasty
• MTP Fusion

27
Post-Mitchell
28
(Modified) Mitchell
29
Complications Post-Mitchell

• 1. Transfer Metatarsalgia
• (Shortening of 1st )
• 2. Mal-Union
• Dorsi-Flexion
• Plantar-Flexion
• Medial or Lateral tilt
• 3. Delay, Non-Union

30
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

31
Classical case post-Mitchell

• 1st Metatarsal shortening
• Dorsi-Flexion mal-union

32
Better do both at initial surgery!
40
14
33
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 IPK, tend to
  displace the BUMP more proximal

34
Weil 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)

35
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)

36
Classical Weil
My Modification Since 2001
Myerson modification
37
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38
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39
Factors in decision making M-2 Shortening
Osteotomy

• Long 2nd metatarsal M2gtM1
• Expected after Mitchell
• Look at M-3

Donnatello
40
Post-Mitchell 2. Mal Union in Dorsi-Flexion
41
Dorsal open wedge
42
Post-Mitchell Mal-Union in Plantar-Flexion
43
Post-Mitchell Mal-Union With rotation

• Healing in medial rotation
• Lateral
  rotation

44
Post-Mitchell 3. Delay Healing

• Rarely non union
• If the alignment is good, be patient, delay union
  (poor fixation) usually heal (in metaphyseal area)

45
Post-Mitchell

• So to avoid all these displacement
• A fixation is needed (not the cerclage wire)

46
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 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)

47
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 (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

49
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 (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

50
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

51
Post-McBride
52
Post-Mc Bride Hallux Varus
53
Hallux 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

54
Hallux Varus TreatmentExtensor Hallucis Brevis
(EHB) My Procedure (Base Proximally)
55
Simple bunionectomy

• Silver Bunionectomy (1923)
• Medial Eminence removal
• Adductor Hallucis divided
• Distal Capsular flap
• Overlapping Plantar Dorsal capsule

56
Simple bunionectomy

• Will it come back Doctor?
• This is one of the reasons of the bad reputation
  of Hallux Valgus surgery

57
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

58
If the joint cannot be salvage (arthrosis) After
Distal Osteotomy(Chevron-Mitchell)

• First MTP fusion
• Modified Keller resection arthroplasty
• (Hamilton modification)
• Valenti arthroplasty

59
1st 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

60
Complications Post-1st MTP Fusion
61
If the joint cannot be salvage (arthrosis) After
Distal Osteotomy(Chevron-Mitchell)

• First MTP fusion
• Modified Keller resection arthroplasty
• (Hamilton modification)
• Valenti arthroplasty

62
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
63
If the joint cannot be salvage (arthrosis) After
Distal Osteotomy(Chevron-Mitchell)

• First MTP fusion
• Modified Keller resection arthroplasty
• (Hamilton modification)
• Valenti arthroplasty

64
Valenti 1st MTP ArthroplastyExtensive
Cheilectomy

• NB. The lower part of the joint and sesamoid
  apparatus are left intact

65
WHY Keller for HV without Arthritis was done on
that young patient ???
66
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, 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

67
A Podiatric Surgeon in Montreal

• After more than 90 minutes of surgery

68
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 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)

69
1st Ray Hypermobility

• Radiologic signs
• Dorsal elevation 1st Meta
• (Plantar gap)
• - Thickening 2nd Metatarsal medial
• cortical shaft
• - Arthritis of 2nd TM joint

70
1st 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

71
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

72
Crescentic Proximal Osteotomy
73
Crescentic Proximal Osteotomy
At 1 Year Metatarsalgia
After Weil Shortening
74
Crescentic Proximal Osteotomy
1 Year post-op
75
Crescentic Proximal Osteotomy
1 Year Post-op
76
Ludloff Osteotomy
77
Modified Ludloff
78
Modified LudloffComplications
79
Modified LudloffComplications
Plantar-flexion Lost of Fixation
80
Hallux Valgus with Arthrosis

• What would you do?

81
Recurrence after Proximal Chevron

• 5 Months after

82
Complication after Proximal osteotomy

• Mal-Union
• Dorsi-Flexion
• Plantar-Flexion
• Non-Union
• Excessive Shortening
• Under-correction
• Over-correction

83
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.

84
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

85
Complication after Proximal osteotomy

• Mal-Union
• Dorsi-Flexion
• Plantar-Flexion
• Non-Union
• Excessive Shortening
• Under-correction
• Over-correction

86
Complication after Proximal osteotomy

• Excessive Shortening
• Can be a significant problem
• Similar as after Mitchell Oseotomy
• Sometimes Lengthening 1st meta
• Generally Shortening 2nd ( ? 3rd )

87
Complication after Proximal osteotomy

• Mal-Union
• Dorsi-Flexion
• Plantar-Flexion
• Non-Union
• Excessive Shortening
• Under-correction
• Over-correction

88
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

89
Complications 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)

90
Hallux Varus after proximal osteotomy
91
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

92
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

93
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 doesnt need to be cut

94
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
95
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 doesnt need to be cut

96
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
97
EHL
ABD.Hallucis
ADD. Hallucis
FHL
Fibular Sesamoid
Metatarso-sesamoid Suspensor Lig.
98
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

99
Scarf Osteotomy

• General Indications
• Same as Proximal Osteotomy IM gt14-18
• More versatile
• More stable
• More demanding

100
SCARF OSTEOTOMY
101
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 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)

102
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
  lt40)
• 2 Superficial infections
• 1 Dislocation of distal
  fragment

103
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

104
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

105
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 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)

106
Scarf 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

107
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

108
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

109
The Failed Hallux Valgus

• Complications after distal metatarsal osteotomy
• Complications after proximal osteotomy
• Complication after Scarf osteotomy
• Complications after Lapidus procedure
• Complication after Keller

110
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 gt18
• OA 1st TMT
• Sometime in adult flatfoot from PTTD
• Should not be done if 1st Metatarsal is short
  (or Open Epiphysis

111
Complications after Lapidus Procedure

• 1. Non-union
• 2. Mal-Union Dorsi-Flexion (mostly)
• 3. Excessive Shortening

112
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)

113
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

114
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

115
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

116
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

117
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), FU74 monhs
• AOFAS score 46/90 Non-Satisfied 61
• Cock-up 67 Recurrence39
  Rigidus11
• Conclusion Fusion much better, but more
  demanding

118
Recurrent 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

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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

120
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

121
The number 1 complication of Hallux Valgus
surgery is not on the first ray !
122
Transfer 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

124
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.

125
The 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

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