Addressing Complications Of Hallux Valgus Surgery

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

   The musculoskeletal patient-dependent risk factors include deformity severity, chronicity and the extent of degenerative changes. Associated deformities can also contribute to a patient’s successful outcome. These deformities include a medial column fault, equinus, hammertoes, hypermobility and central ray deformities.

   One must also look at a patient’s history. If the surgery is a revisional hallux valgus repair, then there is an increased risk for a complication.

How You Can Minimize Surgeon-Dependent Risk Factors

The focus of this discussion will be the surgeon-dependent risk factors that lead to complications because one can modify these factors. Evidence has shown that procedure selection for hallux abductovalgus deformity is critical.1,5,7,8 The procedure should be based on the patient’s risk capacity and the surgeon’s capacity level. The procedural execution should match the surgeon’s risk capacity. This can be evident in performing an Austin bunionectomy on a patient with a high intermetatarsal angle, hypermobility, pes plano valgus and equinus. This would result in failure. The surgeon should not become lax on a procedure’s indications because the procedure is less complex or the rehabilitation is shorter.1,5,7,8

   Performing a simple bunionectomy on a complex deformity is not always the primary pitfall. Certain procedures have an inherent biomechanical risk, especially when surgeons perform them on the wrong patient. This will lead to a complication. A Keller bunionectomy on a 22-year-old female will cause a destabilizing effect on the first metatarsophalangeal joint (MPJ) and result in an unsatisfied patient and surgeon. A transverse closing base wedge osteotomy in an obese patient is also highly risky. If the patient falls and breaks the hinge, then a nonunion or malunion will form.

   When we looked at the success rates of various procedures for hallux valgus in the literature, we found one of the most extensive comparative studies performed by Lagaay and colleagues.9 They performed a multicenter, retrospective chart review of 646 patients who had either a modified chevron-Austin osteotomy (270 patients), a modified Lapidus arthrodesis (342 patients) or a closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection and capital fragment dislocation.

   The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevron-Austin osteotomy were similar with no statistical difference between them.9 The total rate for re-operation was 5.56 percent among patients who had a chevron-Austin osteotomy, 8.82 percent among those who had a closing base wedge osteotomy and 8.19 percent for patients who had a modified Lapidus arthrodesis. Among the patients who had the chevron-Austin osteotomy procedure, the rates of reoperation were 1.85 percent for recurrent hallux valgus and 1.48 percent for hallux varus. Among patients who had the modified Lapidus arthrodesis, rates of reoperation were 2.92 percent for recurrent hallux valgus and 0.29 percent for hallux varus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94 percent for recurrent hallux valgus and 2.94 percent for hallux varus.

   The high amount of success that occurred in all three of these procedures is because the surgeons adhered to the procedural indications. It is also likely that they only selected patients who were willing to follow the postoperative instructions.

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