Addressing Complications Of Hallux Valgus Surgery

Mark Hofbauer, DPM, FACFAS, and Alexander J. Pappas, DPM, AACFAS

Although complications sometimes arise following bunionectomies, one can take steps to reduce potential risk and attain a satisfactory outcome for the patient. These authors address patient-dependent risk factors, ranging from obesity to deformity severity, as well as surgeon-dependent risk factors including procedure selection and soft tissue handling.

A man with great wisdom once said, “It’s what you learn after you know it all that counts.” This idea holds true regarding the pitfalls of hallux abductovalgus surgery. After years of attempting to master reconstructive forefoot surgery, it has occurred to the senior author that it is really all about risk.

   There are two principles in avoiding risk. First, one must minimize risk exposure. One must recognize the patient-dependent risk factors and select only those patients who have factors favorable for a successful outcome. The second principle is to embrace risk in accordance with one’s capacity and skill level as a surgeon. One should adhere to procedural indications and not veer from them. Complications tend to occur when risk exposure does not match risk capacity.

   Evaluating risk factors that lead to postoperative hallux valgus complications breaks down into two categories: patient-dependent risk factors and surgeon-dependent risk factors. As surgeons, when complications arise, we tend to blame the patient dependent factors. It is, however, the surgeon’s responsibility to identify the patient-dependent risk factors when electing to operate on an individual. It is also the surgeon’s responsibility to critically evaluate the surgeon-dependent risk factors that may have contributed to a complication. This may illuminate a flaw of the surgeon in question.

   Typically, when discussing postoperative bunion complications, we focus on the actual complications. These include under-correction, over-correction, hallux varus, nonunion, malunion, infection, chronic pain, chronic edema, painful hardware, hardware failure, nerve entrapment, joint stiffness, loss of stability, lesser metatarsalgia, a painful scar, adhesions and recurrence.

   In an extensive review, Lehman reported the incidence of hallux valgus recurrence as high as 16 percent.1 He also reported the incidence of hallux varus to be as high as 12 percent. In our experience, 12 percent is high. Lehman states that hallux varus is primarily a cosmetic problem and is often asymptomatic.

   Researchers generally regard the incidence range of avascular necrosis (AVN) of the first metatarsal head as low, especially with regard to the chevron osteotomy.2-4

Managing Patient-Dependent Risk Factors

There are different categories of patient-dependent risk factors. The systemic dependent risk factors include obesity, diabetes, rheumatoid arthritis, vascular disease, neuromuscular disease and nutritional deficiencies.5 The social patient-dependent risk factors include smoking, alcohol and illicit drug use. The educational level, hygiene, home support network, job requirements and socioeconomic status of patients can also be factors that influence surgical success.

   One may also consider a patient’s expectations as a patient-dependent risk factor. If the patient’s and surgeon’s expectations do not coincide, then a complication is probable.

   There is increasing literature to support the importance of the patient’s psychological disposition with regard to the ability to heal. Catastrophizing and fear of movement disorders have been important factors in poor patient outcomes.6 Medicare and third party payers are recognizing and analyzing these factors more.

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