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

3. Too big deformity for the procedure 4. Loose capsulorraphy 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 With Akin : no over correction Without Akin : minimal overcorrection But Too tight capsulorraphy might lead to stiffness. Akin Chevron

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 Avoid Dorsal incisions Careful not to damage sesamoid apparatus Biplane Chevron

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: Resection arthroplasty 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 Since 2001 Myerson modification

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)

AOFAS-Hallux MTP Score Compare to author 4 categories 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 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 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

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 >20°

Complications Post-1st MTP Fusion

Modified Keller resection arthroplasty (Hamilton modification) 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 Cut EHB proximally Free up Dorsal capsule 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 Signs of Ligamentous Laxity (Breighton criteria) 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

Metatarso-sesamoid Suspensor Lig. EHL ABD.Hallucis ADD. 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 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 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 Transfer Metatarsalgia is the No. 1 problem after bunion surgery. Usually 2nd Metatarsal.

64% : Lesser metatarsal neck Osteotomy 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 IPK, tend to displace the “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 : 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 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

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

Overall satisfaction at 21 y. FU: Excellent +Good: 65% 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