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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.

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Presentation on theme: "The Failed Hallux Valgus Instructionnal Course Lecture Canadian Orthopaedic Association Halifax June 2, 2007 André Perreault M.D. Montréal, private practice."— Presentation transcript:

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

3 Failed for who? Patient point of view: Patient point of view: –No bump –Straight toe –Cosmetic scar –Good motion…enough 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) Stretching the indications (too big deformity for the procedure) Wrong procedure for the problem Wrong procedure for the problem Bad technique of an adequate procedure 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 An expected complication for that procedure A complication non specific to the procedure A complication non specific to the procedure A misunderstanding of the expected results A misunderstanding of the expected results …….Patient versus Surgeon expectation….

6 The Failed Hallux Valgus Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Complication after Keller Resection Arthroplasty

7 The Failed Hallux Valgus Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Complication after Keller Resection Arthroplasty

8 Post-Chevron

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

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

11 Complications after distal metatarsal osteotomy 1. Chevron * RECURRENT DEFORMITY 1. Plane of osteotomy 1. Plane of osteotomy 2. DMAA 2. DMAA 3. Too big deformity for the procedure 3. Too big deformity for the procedure 4. Loose capsulorraphy 4. Loose capsulorraphy 5. …Lateral soft tissue release 5. …Lateral soft tissue release

12 Chevron- Recurrent deformity 1. Plane of the osteotomy Avoid: 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 Instead : the osteotomy should be done at right angle to the foot But: Avoid shortening 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: 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 So if needed to lenghten the bone: a good fixation needed Remove the Medial Eminence Remove the Medial Eminence parallel to the foot, not the metatarsal. parallel to the foot, not the metatarsal.

14 Chevron- Recurrent deformity 2. The DMAA angle Primo: Primo: –RECOGNIZE Danger: Danger: –Make a straight toe with an incongruent joint out of a valgus toe but congruent joint –With time will displace

15 Chevron- Recurrent deformity 3. Too big deformity for the technique HV angle < 30 ° HV angle < 30 ° IM angle < 14 ° IM angle < 14 °

16 Chevron- Recurrent deformity 4. Too loose capsulorraphy Tension should be just enough to prevent lateral displacement 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. But Too tight capsulorraphy might lead to stiffness. Akin Chevron

17 Capsulorraphy P-1 Capsule Capsule 1 st Metatarsal

18 Chevron- Recurrent deformity 5. … Lateral soft tissue release Multiple studies: Multiple studies: STR with distal osteotomy : Safe STR with distal osteotomy : Safe Incidence of AVN is so low, ≤ 1 % (periosteal stripping is more a concern), Incidence of AVN is so low, ≤ 1 % (periosteal stripping is more a concern), Most expert : Caution… if a STR is needed Most expert : Caution… if a STR is needed The indication is probably stretch… * Proximal osteotomy … * Adding a Akin procedure are safer. * Adding a Akin procedure are safer.

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

20 Complications after distal metatarsal osteotomy 1. Chevron : Mal-Union Improper cuts may lead to instability 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 Otherwise: a more secure fixation

21 Complications after distal metatarsal osteotomy 1. Chevron : Mal-Union Shortening of 1rst Metatarsal: Shortening of 1rst Metatarsal: –Excessive impaction (osteopenic) –Plane of osteotomy too caudal  Transfer Metatarsalgia  Transfer Metatarsalgia Treatment: (beside orthosis) Treatment: (beside orthosis) –Lengthening of 1 st Metatarsal (Rarely) –Shortening lesser Metatarsal ( Better)

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

23 Complications after distal metatarsal osteotomy 1. Chevron : Stiffness If after correction the join is incongruent… If after correction the join is incongruent… Faillure to recognise the elevated DMAA > 10 ° Faillure to recognise the elevated DMAA > 10 ° Do a biplane Chevron Do a biplane Chevron Avoid Dorsal incisions Avoid Dorsal incisions Careful not to damage sesamoid apparatus Careful not to damage sesamoid apparatus Biplane Chevron

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

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

26 Distal soft tissue release and Distal metatarsal osteotomy Avascular necrosis 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 1. Transfer Metatarsalgia –(Shortening of 1 st ) 2. Mal-Union 2. Mal-Union –Dorsi-Flexion –Plantar-Flexion –Medial or Lateral tilt 3. Delay, Non-Union 3. Delay, Non-Union

30 If there is no malunion but only metatarsalgia from a short first metatarsal: If there is no malunion but only metatarsalgia from a short first metatarsal: –Lengthening of 1rst Metatarsal Rarely indicated (risk  of stiffness and osteoarthrisis) Rarely indicated (risk  of stiffness and osteoarthrisis) –Shortening Lesser Metatarsal Important to restore the normal cascade pattern Important to restore the normal cascade pattern Usually M2, but always check M3 for shortening osteotomy Usually M2, but always check M3 for shortening osteotomy –Weil osteotomy Post-Mitchell -1 TRANSFER METATARSALGIA

31 Classical case post-Mitchell 1 st Metatarsal shortening 1 st Metatarsal shortening Dorsi-Flexion mal-union Dorsi-Flexion mal-union

32 Better do both at initial surgery! 14° 40°

33 Myerson modification My Modification Since 2001 Classical Weil

34

35

36 Factors in decision making: M-2 Shortening Osteotomy Long 2nd metatarsal M2>M1 Long 2nd metatarsal M2>M1 –Expected after Mitchell Look at M-3… Look at M-3… Donnatello

37 Post-Mitchell 2. Mal Union : in Dorsi-Flexion

38 Dorsal open wedge

39 Post-Mitchell Mal-Union in Plantar-Flexion

40 Post-Mitchell: Mal-Union: With rotation Healing in medial rotation Healing in medial rotation Lateral rotation Lateral rotation

41 Post-Mitchell: 3. Delay Healing Rarely : non union Rarely : non union If the alignment is good, be patient, delay union (poor fixation) usually heal (in metaphyseal area) If the alignment is good, be patient, delay union (poor fixation) usually heal (in metaphyseal area)

42 Post-Mitchell So to avoid all these displacement: So to avoid all these displacement: –A fixation is needed (not the cerclage wire)

43 Modified Mitchell Selective Indications and Principles Selective Indications and Principles –Metatarsal length absolute importance Need a long 1 st Metatarsal or Need a long 1 st Metatarsal or Need to shorten at the same time the 2 nd ( and 3 rd PRN If the 1 st is not longer than the 2 nd or 3 rd Need to shorten at the same time the 2 nd ( and 3 rd PRN If the 1 st is not longer than the 2 nd or 3 rd –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 That some decompression is needed Might be osteoporotic ( witch is a contra-indication for screw fixation like in Ludloff, Scarf, Mann osteotomies) Might be osteoporotic ( witch is a contra-indication for screw fixation like in Ludloff, Scarf, Mann osteotomies)

44 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 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 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 92.4 % would agree to undergo the operation again

45 Salvage treatment of failed Hallux Valgus operation with proximal first metatarsal osteotomy and distal soft- tissue reconstruction 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) 15 patients after failed Distal proceducre ( Silver or Chevron) TX: Crescentic Mann Osteotomy and Soft-tissue release TX: Crescentic Mann Osteotomy and Soft-tissue release –HV angle 33°  14 ° IM angle 12.6 °  5.7 ° –Complications: 44% 3 Transfer Metatarsalgia 3 Transfer Metatarsalgia 2 Mal-Union 2 Mal-Union 1 Hallux Varus 1 Hallux Varus 1 Non-Union 1 Non-Union

46 Post-McBride

47 Post-Mc Bride: Hallux Varus

48 Hallux Varus –Treatment * Extensor Hallucis Brevis (EHB) Procedure (Myerson) Hallux Varus –Treatment * Extensor Hallucis Brevis (EHB) Procedure (Myerson) K. Johnson Classical: EHL tranfert: K. Johnson Classical: EHL tranfert: –IP Fusion & –Total EHL cut distal Modification: Modification: –Half of EHL –No need to fuse IP joint

49 Hallux Varus –Treatment *Extensor Hallucis Brevis (EHB) My Procedure (Base Proximally)

50 Simple bunionectomy Silver Bunionectomy (1923) Silver Bunionectomy (1923) –Medial Eminence removal + –Adductor Hallucis divided + –Distal Capsular flap + –Overlapping Plantar & Dorsal capsule

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

52 Simple bunionectomy McBride (1928) McBride (1928) –Medial Eminence removal + –Release of Conjoint tendon –TRANSFER Conjoint tendon to 1 st Meta. Head + –Removal of fibular sesamoid Duvries-Mann modification of McBride Duvries-Mann modification of McBride –Adductor tendon cut and transfer to 1 st Meta, head ( not the Conjoint tendon) –Suture Medial capsule of 2 nd Meta to lat. Capsule of 1 st Metatarsal head –No fibular sesamoid excision

53 If the joint cannot be salvage (arthrosis) After Distal Osteotomy(Chevron-Mitchell) First MTP fusion First MTP fusion Modified Keller resection arthroplasty Modified Keller resection arthroplasty –(Hamilton modification) Valenti arthroplasty Valenti arthroplasty

54 1 st MTP Arthrodesis Dorsi-Flexion: ° to the floor Dorsi-Flexion: ° to the floor 20°-30 ° to the 1 st Meta 20°-30 ° to the 1 st Meta Valgus : 10 ° - 15° Valgus : 10 ° - 15° Fusion rate : 88 % after failed H. Valgus surgery Fusion rate : 88 % after failed H. Valgus surgery 94% – 100 % at initial surgery 94% – 100 % at initial surgery 94 % 2 Steinmann pins 94 % 2 Steinmann pins 96 % 2 (3.5mm) cross screws 96 % 2 (3.5mm) cross screws 97 % Multiple threaded K-wirws 97 % Multiple threaded K-wirws 100% conical reamming and plate 100% conical reamming and plate Less with Interpositionnal Bone Graf after Failed Keller Less with Interpositionnal Bone Graf after Failed Keller Late IP Degeneration: 15 % (3 time more in Women) increase with HV angle >20° increase with HV angle >20°

55 Complications Post-1 st MTP Fusion

56 If the joint cannot be salvage (arthrosis) After Distal Osteotomy(Chevron-Mitchell) First MTP fusion First MTP fusion Modified Keller resection arthroplasty Modified Keller resection arthroplasty (Hamilton modification) (Hamilton modification) Valenti arthroplasty Valenti arthroplasty

57 Cut EHB proximally Excise ¼ Proximal P-1 Free up Dorsal capsule With EHB slide it down To FHB Bill Hamilton Capsular interposition (modification of Keller resection arthroplasty 1/3 resection for Regular Keller

58 If the joint cannot be salvage (arthrosis) After Distal Osteotomy(Chevron-Mitchell) First MTP fusion First MTP fusion Modified Keller resection arthroplasty Modified Keller resection arthroplasty –(Hamilton modification) Valenti arthroplasty Valenti arthroplasty

59 Valenti 1 st MTP Arthroplasty: Extensive Cheilectomy NB. The lower part of the joint and sesamoid apparatus are left intact NB. The lower part of the joint and sesamoid apparatus are left intact

60 WHY Keller for HV without Arthritis was done on that young patient ???

61 Failed Keller Salvage of a failed Keller Resection Arthroplasty 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 –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

62 A Podiatric Surgeon in Montreal After more than 90 minutes of surgery… After more than 90 minutes of surgery…

63 1 st Ray Hypermobility Some controversy Some controversy Classical: Lapidus fusion 1 st M-Cuneiform+ STR Classical: Lapidus fusion 1 st M-Cuneiform+ STR Signs of Ligamentous Laxity (Breighton criteria) 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 Value >5 : LIGAMENTOUS LAXITY Squeeze test: You grab the patient foot at Metatarsal Head level; Squeeze test: You grab the patient foot at Metatarsal Head level; If there is a total correction of the Hallux Valgus  suggest Hypermobity If there is a total correction of the Hallux Valgus  suggest Hypermobity Otherwise: more rigid deformity Otherwise: more rigid deformity Tarso-Metatarsal Clinical Test: >4° in Saggital plane Tarso-Metatarsal Clinical Test: >4° in Saggital plane Klaue device ( M.Caughlin) >9 mm (sagittal plane) Klaue device ( M.Caughlin) >9 mm (sagittal plane)

64 1 st Ray Hypermobility Radiologic signs: Radiologic signs: –Dorsal elevation 1 st Meta –(Plantar gap) - Thickening 2 nd Metatarsal medial - Thickening 2 nd Metatarsal medial cortical shaft - Arthritis of 2 nd TM joint - Arthritis of 2 nd TM joint

65 1 st Ray Hypermobility Some recent studies didn’t show any difference with Osteotomy (proximal or distal) and Lapidus procedure ! 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

66 The Failed Hallux Valgus Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Complication after Keller Resection Arthroplasty

67 Crescentic Proximal Osteotomy

68 At 1 Year: Metatarsalgia After Weil Shortening:

69 Crescentic Proximal Osteotomy 1 Year post-op

70 Crescentic Proximal Osteotomy 1 Year Post-op:

71 Ludloff Osteotomy

72 Modified Ludloff

73 Modified Ludloff…Complications

74 Plantar-flexion Lost of Fixation

75 Hallux Valgus with Arthrosis What would you do? What would you do?

76 Recurrence after Proximal Chevron 5 Months after 5 Months after

77 Complication after Proximal osteotomy Mal-Union Mal-Union –Dorsi-Flexion –Plantar-Flexion Non-Union Non-Union Excessive Shortening Excessive Shortening Under-correction Under-correction Over-correction Over-correction

78 Complications after Proximal Crescentic Osteotomy (Mann) Mal-Union: the most common complication (Dorsi-Flexion,Recurrence 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 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: mm) Too distal: * cortical bone… Heals less readily Too distal: * cortical bone… Heals less readily * Narrow shaft.… More unstable * Narrow shaft.… More unstable Too Proximal: Fixation is difficult or impossible 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. Screw best but sometime unstable and recurrence not rare.

79 Complications after Proximal Osteotomy- Treatment Mal-Union Mal-Union –Dorsi-Flexion: Sometimes difficult to correct TX: Some type of plantar osteotomy TX: Some type of plantar osteotomy If excessive shortening: BONE GRAFTING If excessive shortening: BONE GRAFTING - Plantar-Flexion: * Dorsi-Flexion osteotomy To avoid shortening : a crescentic osteotomy can be done in the sagittal plane To avoid shortening : a crescentic osteotomy can be done in the sagittal plane * Non-Union: rarely. If occurs: Bone grafting

80 Complication after Proximal osteotomy Mal-Union Mal-Union –Dorsi-Flexion –Plantar-Flexion Non-Union Non-Union Excessive Shortening Excessive Shortening Under-correction Under-correction Over-correction Over-correction

81 Complication after Proximal osteotomy Excessive Shortening Excessive Shortening –Can be a significant problem –Similar as after Mitchell Oseotomy –Sometimes: Lengthening 1 st meta –Generally: Shortening 2 nd ( ? + 3 rd )

82 Complication after Proximal osteotomy Mal-Union Mal-Union –Dorsi-Flexion –Plantar-Flexion Non-Union Non-Union Excessive Shortening Excessive Shortening Under-correction Under-correction Over-correction Over-correction

83 Complication after Proximal osteotomy Under-correction (of IM angle) Under-correction (of IM angle) –TX: another Crescentic Osteotomy or an Open wedge Osteotomy Over-correction: Over-correction: Often result in a HALLUX VARUSOften result in a HALLUX VARUS

84 Complications after proximal osteotomy Key: Prevention Indications for Proximal Osteotomy Indications for Proximal Osteotomy –IM angle > 14 ° (13-15 °) + STR –HV angle > 40 ° (30-40 °) Goal: To correct the intermetatarsal angle) Goal: To correct the intermetatarsal angle) Contraindication: Contraindication: –1 st MTP Osteoarthritis –DMAA >15-20° ( Unless Double osteotomy) –(Severe H Valgus with Hypermobility)

85 Hallux Varus after proximal osteotomy

86 Hallux Varus after HV Correction Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon (Overpull of Abductor Hallucis) (Overpull of Abductor Hallucis) Excision of Lateral sesamoid Excision of Lateral sesamoid Excessive medial capsule tightening Excessive medial capsule tightening Excessive Medial Eminence removing Excessive Medial Eminence removing Overcorrection of IM angle Overcorrection of IM angle Excessive Overcorrection with Postop dressing Excessive Overcorrection with Postop dressing

87 Hallux Varus after HV Treatment Excessive Lateral Soft Tissue Release Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon (Overpull of Abductor Hallucis) (Overpull of Abductor Hallucis) Excision of Lateral sesamoid Excision of Lateral sesamoid Excessive medial capsule tightening Excessive medial capsule tightening Excessive Medial Eminence removing Excessive Medial Eminence removing Overcorrection of IM angle Overcorrection of IM angle Excessive Overcorrection with Post-op dressing Excessive Overcorrection with Post-op dressing

88 MTP Lateral Soft tissue Release TECHNIC 1 TECHNIC 1 1. Adductor Hallucis 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) (Conjoint tendon: Add. Hallucis + FHB) 2. Metatarso-Sesamoid suspensor Lig. 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. Not cutting the: Metatarso-Phalangial Lig. (Collateral lig.) re.: Risk of H. Varus (Collateral lig.) re.: Risk of H. Varus N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut

89 MTP Lateral Soft tissue Flexor Hallucis Brevis Adductor Hallucis Fibular Sesamoid Sesamoid Metatarso-sesamoid suspensor Lig MTP Lateral collateral Lig. Conjoint tendon= PIB PIB= Phalangial Insertion Band

90 MTP Lateral Soft tissue Release TECHNIC 2 TECHNIC 2 1. Conjoint tendon (PIB: Phalangial Insertion Band) 1. Conjoint tendon (PIB: Phalangial Insertion Band) 2. Metatarso-Sesamoid suspensor Lig. 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. Not cutting the: Metatarso-Phalangial Lig. (Collateral lig.) re.: Risk of H. Varus (Collateral lig.) re.: Risk of H. Varus N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut

91 MTP Lateral Soft tissue Flexor Hallucis Brevis Adductor Hallucis Fibular Sesamoid Sesamoid Metatarso-sesamoid suspensor Lig MTP Lateral collateral Lig. Conjoint tendon= PIB PIB= Phalangial Insertion Band

92 Metatarso-sesamoid Suspensor Lig. ADD. Hallucis EHL ABD.Hallucis FHL Fibular Sesamoid

93 The Failed Hallux Valgus Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Complication after Keller Resection Arthroplasty

94 Scarf Osteotomy General Indications: General Indications: –Same as Proximal Osteotomy IM >14-18° –More versatile –More stable –More demanding

95 SCARF OSTEOTOMY SCARF OSTEOTOMY

96 Scarf Osteotomy Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTION Foot and Ankle Clinics, Volume 3, September 2000, Foot and Ankle Clinics, Volume 3, September 2000, * Results: (123 feet, 76 patients) FU 3 to 46 months (13) HVA: 35.2°  16.4 ° HVA: 35.2°  16.4 ° IMA: 17.4°  10.2° IMA: 17.4°  10.2° ROM: 75 ° (DF: 65° PF: 10°) ROM: 75 ° (DF: 65° PF: 10°) Complications: 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)

97 Revision of Failed Foot Surgery: a critical analysis KILMARTIN, TE. J. Foot Ankle Surg. 41: , 2002 Off 244 patients refer by GP after all type off failed foot surgery, 218 treated with revision surgery: 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 42% : After Mitchell Procedure 14% : After Keller 14% : After Keller 14% : After First MTP Fusion 14% : After First MTP Fusion 8.6% : After Silver ( Bumpectomy+ STR) 8.6% : After Silver ( Bumpectomy+ STR) –Diagnosis ( 244 patients) 34% : Transfer Metatarsalgia 34% : Transfer Metatarsalgia 26% : Recurrent H. Valgus 26% : Recurrent H. Valgus 18% : Lesser digit deformity 18% : Lesser digit deformity 5% : Continued pain over 1 MTP 5% : Continued pain over 1 MTP

98 Revision of Failed Foot Surgery: a critical analysis KILMARTIN, TE. J. Foot Ankle Surg. 41: , 2002 Revision surgery Revision surgery –32%: Lesser Metatarsal surgery Weil or Schwartz Weil or Schwartz –23%: Lesser Toe surgery –21%: First Metatarsal-Phalanx Scarf-Akin Scarf-Akin – 4% : First & Lesser Metatarsal Scarf-Akin and Weil or Schwartz Scarf-Akin and Weil or Schwartz 86% Might have been avoid 86% Might have been avoid

99 The Failed Hallux Valgus Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complications after Lapidus procedure Complication after Keller Complication after Keller

100 1 st Metatarsal-Cuneiform arthrodesis: The Lapidus Procedure Indication for 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 1 st TMT –Sometime in adult flatfoot from PTTD Should not be done if 1 st Metatarsal is short ( or Open Epiphysis Should not be done if 1 st Metatarsal is short ( or Open Epiphysis

101 Complications after Lapidus Procedure 1. Non-union 1. Non-union 2. Mal-Union: Dorsi-Flexion (mostly) 2. Mal-Union: Dorsi-Flexion (mostly) 3. Excessive Shortening 3. Excessive Shortening

102 Complications Lapidus Procedure 1. Non-UNION (10-12%....7% to 50%!!) 1. Non-UNION (10-12%....7% to 50%!!) –Significantly more common than Mal-Union Very high rates Very high rates Frequently symptomatic Frequently symptomatic Need: Multiple screw fixation and Need: Multiple screw fixation and – Cast Immobilisation and A period of non-weight bearing ( 4-6 weeks) A period of non-weight bearing ( 4-6 weeks) (Union rate better with Bone Grafting)

103 Modified Lapidus procedure Popularize by Sig. Hansen Popularize by Sig. Hansen Minimal articular resection Minimal articular resection C1  M1 C1  M1 M1  M2 M1  M2 Big Screws ( ) Big Screws ( ) Lag Screw tech. Lag Screw tech. Local Bone Graft Local Bone Graft

104 Fusion rate of 1 st TMT arthrodesis in MODIFIED Lapidus and Flatfoot Reconstruction Ian M. Thompson; Donald R. Bohay; John G. Anderson Ian M. Thompson; Donald R. Bohay; John G. Anderson Foot & Ankle Int. Volume 26 Number 9, September 2005 Foot & Ankle Int. Volume 26 Number 9, September 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. Of 201 feet, 25 (12%) had Recurrence after Previous Bunion Surgery. –Out of these: 20% had Non-Union after Modified Lapidus

105 Complications Lapidus Procedure 2. MAL-UNION 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) Some Plantar-Flexion of the ray usually require to compensate the shortening ( too much  sesamoid pain) 3. SHORTENING: 3. SHORTENING: –Relative to joint resection

106 The Failed Hallux Valgus Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Complication after Keller Resection Arthroplasty

107 Complications after Keller Salvage of a Failed Keller Resection Arthroplasty Salvage of a Failed Keller Resection Arthroplasty Machacek Lr., Felix and all. Machacek Lr., Felix and all. JBJS-A Vol. 86-A, Number 6, June 2005 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 90% healed. AOFAS score: 76/90 Needed surgery: 17% need refusion (3 Mal-Union & 2 non-union) Needed surgery: 17% need refusion (3 Mal-Union & 2 non-union) 62% Needed Lesser Metatarsal shortening ( Weil,Helal,etc.) 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% AOFAS score: 46/90 Non-Satisfied: 61% Cock-up: 67 % Recurrence:39% Rigidus:11% Cock-up: 67 % Recurrence:39% Rigidus:11% Conclusion: Fusion much better, but more demanding

108 Recurrent H. Valgus without arthrosis: The Lapidus procedure The Lapidus procedure as salvage After Failed Surgical Treatmen of Hallux Valgus. A Prospective Cohort Study 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 Here it is only recurrent H. Valgus Here it is only recurrent H. Valgus AOFAS score 47.6  87.9 AOFAS score 47.6  87.9 Visual Analog Pain Scale 6.2  1.4 Visual Analog Pain Scale 6.2  1.4 Very satisfied: 77% Satisfied : 4% Somewhat satisfied: 19% Dissatisfied: 0 Very satisfied: 77% Satisfied : 4% Somewhat satisfied: 19% Dissatisfied: 0 C1  M1 & M1  M2 C1  M1 & M1  M2

109 First Metatarsophalangeal Joint Arthrodesis as a Treatment for Failed Hallux Valgus Surgery Grimes, J.S., Coughlin, M. Foot & Ankle InternationalVol.27, No. 11 / / Nov Grimes, J.S., Coughlin, M. Foot & Ankle InternationalVol.27, No. 11 / / Nov The only well documented long-term results of salvage of failed hallux valgus procedures by arthrodesis of the first MTP

110 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 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. 55% recurrence H. Valgus, 24% H. Varus, etc. 82% have Lesser toes complaints 82% have Lesser toes complaints AOFAS score of 73 (Excellent 39%, Good 33% AOFAS score of 73 (Excellent 39%, Good 33% Fair 24%, Poor 3%) Fair 24%, Poor 3%) 79% would have the surgery again 79% would have the surgery again

111 The number 1 complication of Hallux Valgus surgery is not on the first ray !

112 Transfer Metatarsalgia is the No. 1 problem after bunion surgery. Usually 2 nd Metatarsal.

113 Review of All Orthopaedic surgeries witch led to litigation: (USA- Glyn Thomas ) Review of All Orthopaedic surgeries witch led to litigation: (USA- Glyn Thomas ) –Most: Foot surgery : 23 % Out of this: Out of this: 64% : Lesser metatarsal neck Osteotomy 64% : Lesser metatarsal neck Osteotomy

114 Patients Expectations vs Realistic Results Good discussion Good discussion Need to repeat and repeat 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. 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 They tend to underestimate minor warnings So… you need to be clear and need to emphasis mostly on what would be a realistic result. So… you need to be clear and need to emphasis mostly on what would be a realistic result.

115 The Failed Hallux Valgus 1. Recognize why the first surgery failed 1. Recognize why the first surgery failed –Don’t repeat the initial error… 2. Look the Whole Foot (r e. Lesser Metatarsals) 2. Look the Whole Foot (r e. Lesser Metatarsals) 3. Look if there are Degenerative changes 3. Look if there are Degenerative changes

116

117 Weil osteotomy

118 Classical Weil osteotomy Osteotomy parallel to the sole of the foot Osteotomy parallel to the sole of the foot Ex.: 5 mm shortening = Ex.: 5 mm shortening = 2 mm plantar displacement 2 mm plantar displacement The problem in rigid foot with IPK, tend to displace the “BUMP” more proximal The problem in rigid foot with IPK, tend to displace the “BUMP” more proximal

119 Weil: Myerson’s modification With a wedge resection above the 25° cut With a wedge resection above the 25° cut 5 mm shortening = 5 mm shortening = 0.8 mm plantar displacement 0.8 mm plantar displacement The problem: the toe is higher and do not touch the ground (but: no functional signification; cosmetic concern only) (but: no functional signification; cosmetic concern only)

120 Weil: My modification A complete removal of 2 to 3 mm slice A complete removal of 2 to 3 mm slice At an angle of 15 to 20 ° At an angle of 15 to 20 ° Can correct sub-luxation MTP and IPK in many cases. Can correct sub-luxation MTP and IPK in many cases. Not indicated in very osteoporotic patients) All healed, except ~ 1 % ( screw loosening or fracture)

121 Scarf Osteotomy Results & Complications: Results & Complications: KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel The SCARF Osteotomy for the Correction of Hallux Valgus Deformities The SCARF Osteotomy for the Correction of Hallux Valgus Deformities Foot and Ankle surgery Volume 23 Number , March 2003 Foot and Ankle surgery Volume 23 Number , March 2003 –89 patients Post-op HV: 19° IM: 6.6 ° Return to Work: 6 weeks, to Sports: 8.3 weeks Return to Work: 6 weeks, to Sports: 8.3 weeks Complications: 7 Recurrence 6% Complications: 7 Recurrence 6% 4 Hallux Limitus (ROM <40°) 4 Hallux Limitus (ROM <40°) 2 Superficial infections 2 Superficial infections 1 Dislocation of distal fragment 1 Dislocation of distal fragment

122 Scarf Osteotomy Results & Complications 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 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, years FU 2 years FU HV angle 32°  11° HV angle 32°  11° IM angle 14°  6° IM angle 14°  6° Complications: 1 Osteonecrosis Meta. Head Complications: 1 Osteonecrosis Meta. Head – 1 Painful Over-correction

123 Scarf Osteotomy Results & Complications : 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 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, patients 5 years FU 56 patients 5 years FU HV 38.5°  19° HV 38.5°  19° IM 16.6°  11° IM 16.6°  11° Complications: Complications: –15 Hallux Limitus

124 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: , 2000 –53 cases 14 months FU –HV angle: 43°  23° –IM angle : 16°  8° –Complications: 2 Fractures of 1 st Metatarsal ( at distal screw level) 2 Fractures of 1 st Metatarsal ( at distal screw level)

125 Scarf Osteotomy Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6: , 2000 Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6: , 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 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 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 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

126 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 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 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%

127 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 Initially At FU Mean HV angle 33° 17° Mean HV angle 33° 17° Mean IM angle 22.5 ° 7.7° Mean IM angle 22.5 ° 7.7° 21% recurred over medial eminence 21% recurred over medial eminence 13.3 IPK under 2 nd Metatarsal 13.3 IPK under 2 nd Metatarsal Overall satisfaction at 21 y. FU: Excellent +Good: 65% Overall satisfaction at 21 y. FU: Excellent +Good: 65% 92.4 % would agree to undergo the operation again 92.4 % would agree to undergo the operation again


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