Hallux Varus After Bunion Surgery Why Did It happen And What To Do - PowerPoint PPT Presentation

Hallux Varus After Bunion Surgery Why Did It happen And What To Do Now James A Nunley, MD Duke University

DISCLOSURE I am a consultant for Wright Medical, Stryker, Exactech, DT Medsurg, Orthofix, Treace Medical I receive royalties from Exactech I receive fellowship support from Integra, Breg and Acumed I have no conflicts related to this presentation

Hallux Varus Several factors contribute to Hallux Varus s/p Hallux Valgus corrective surgery: Removal of fibular sesamoid 1. Excessive resection of medial eminence 2. Excessive medial capsuloraphy 3. Malalignment of the osteotomy site 4. Overcorrection via excessive lateral release 5. Overcorrection with the post-operative bunion 6. dressing Foot & Ankle Zahari et al. J of Foot Surg. 1991

Hallux Varus Treatment Prevention: Since advent of modified McBride, post-op hallux varus s/p hallux valgus corrective surgery is rare (routinely less than 1%). Thus, the etiology now the result of excessive lateral release, overcorrection of valgus deformity, and inappropriate post- op dressings.

Hallux Varus Treatment Early post-op identification of a hallux varus deformity may be treated with aggressive dressing changes to correct the deformity

Hallux Varus Treatment Longstanding deformity and/or conservative therapy fails – MP joint must be assessed: No MP DJD – soft tissue correction, preserves motion MP DJD Present – First MP joint fusion

Hallux Varus Treatment – No MP DJD Johnson, et al. JBJS. 1984

Hallux Varus Treatment – No MP DJD Miller’s Review of Orthopaedics. 2008

Case Presentation

Case Presentation Miller’s Review of Orthopaedics. 2008 www.Arthrex.com

Case Presentation

Case Presentation

Case Presentation

9 month followup after my bunion correction. Ugh. Now what? Tell her it is her mission to promote peace? Keep taping? Of course not; this is a surgical course!

FYI: I did not over-release on original procedure! No dorsolateral incision for lateral release

Hardware Removal and Medial Release

Complete Medial Release

Fluoroscopy after Medial Release

Recut Distal 1 st MT

Reverse Chevron

Reverse Proximal Osteotomy

Medial Closing Wedge

Lateral Capsular Tightening

Improved…

Still too much medial pull of EHL

Reverse Akin with Bone Graft

Improved pull of EHL

Medial Capsule Left Open

One Year Followup

One Year Followup

Hallux Varus Summary Hallux varus is a rare condition. Hallux varus occurs most commonly as a complication of hallux valgus corrective surgery. The most common reason for hallux varus is excessive lateral release with overcorrection of valgus deformity. However, other etiologies include fibular. sesamoidectomy (i.e. McBride procedure), excessive resection of medial eminence, overplication of medial capsular structures, malalignment of osteotomy site, and overcorrection with post-op dressing.

Hallux Varus Summary Clinically apparent – patients may have cosmetic complaints or pain when wearing shoes. Evaluate ROM, and if deformity is flexible or rigid. Evaluate radiographs, measure IMA and HVA. If found early may be able to treat conservatively. Likely will require tendon transfer if no MP joint DJD present. However, if MP joint DJD present then fusion is indicated. Use of Mini Tightrope as augmentation to EHB soft tissue reconstruction?