This week we will focus on the types of surgical procedures used to correct for rigid and progressed bunion deformities. It is important to keep in mind when reviewing these procedures that your Podiatrists will select a procedure based on their clinical knowledge, one they deem the most appropriate and one that will provide the longest lasting results. The procedures as they are described are clear-cut, but no patient is clear-cut and decisions are also based on the patient’s subjective presentation, physical examination and radiographic evaluation.
Capsule Tendon Balance Procedures (CTB): Can be performed as a sole procedure in cases of mild deformity, but are always performed in conjunction with more corrective procedures.
• Most Common CTB: “Modified McBride Procedure”
• Indications: Mild deformity, with medial bump pain and no deep joint pain; slightly increased Intermetatarsal (IM) Angle on X-ray; minimal joint range of motion restriction
• Procedure: Dorsomedial skin incision over the hallux; release of the metatarsal-phalangeal joint (MPJ) capsule; resection/removal of the medial bone prominence; release of the adductor hallucis and flexor hallucis brevis conjoined tendon; medial capsulorrhaphy (removal of a wedge of capsule from the medial side); closure
• Complications: Hallux Varus (the opposite of HAV); recurrence of deformity; stiffness
• Recovery Period: 2 weeks in a surgical shoe; transition to a sneaker
Metatarsal Osteotomies: Procedures that make cuts into the 1st metatarsal. Some procedures make through-and-through cuts, while others remove or add a wedge of bone. All metatarsal osteotomies are performed in conjunction with a CTB, but not all CTB are performed with a metatarsal osteotomy.
• Most Common Osteotomy: “Austin”
• Indications: Mild to moderate deformity; mild increase in the IM Angle; good range of motion with no arthritic changes.
• Procedure: Dorsomedial incision; release of the MPJ capsule; release of the adductor hallucis tendon; V-cut made through the bone at a 60 degree angle; shifting of the head of the metatarsal laterally; fixation with a Kirschner wire; medial capsulorrhaphy; closure.
• Complications: Non-union; shortening of the metatarsal; fracture of the metatarsal; transfer metatarsalgia.
• Recovery Period: 4 weeks in a surgical shoe; transition to sneaker and normal activity by 8 weeks.
Phalangeal Osteotomies: Often performed in conjunction with other HAV procedures when the proximal phalanx is a contributing factor in the deformity.
• Most Common Phalangeal Osteotomy: Akin
• Indications: Depending on the location of the osteotomy cut, this procedure can be used for abnormal DASA (radiographic angle), a high hallux abductus interphalangeal angle (radiographic angle) or an abnormally long proximal phalanx.
• Procedure: Dorsomedial skin incision; release of the MPJ capsule; reflection of periosteum; osteotomy cuts made; fixation with a Kirschner wire; medial capsulorrhaphy; closure.
• Complications: Displacement of the bone fragments; stiffness; non-union; fracture.
• Recovery Period: 4 to 6 weeks in a surgical shoe.
Arthrodesis of the 1st Metatarsal-Phalangeal Joint: Fusion of the joint, which ultimately prohibits movement and eliminates pain.
• Most Common Arthrodesis: McKeever
• Indications: Hallux Rigidus/Limitus; failed previous HAV surgery; Neuromuscular disorders
• Procedure: Medial-linear incision; resection of cartilage from the base of the proximal phalanx and the head of the 1st metatarsal; fixation with Kirschner wires; joint alignment in 5-10 degrees of abduction in relation to lesser digits and 5-10 degrees of dorsiflexion off the weight-bearing surface; closure
• Complications: Poor positioning; lack of 1st toe purchase; fracture; degenerative joint disease of the proximal and distal joints.
• Recovery Period: Cast immobilization for 6 weeks with transition to a surgical shoe and eventually sneaker.