Addressing Complications Of Hallux Valgus Surgery
- Volume 27 - Issue 5 - May 2014
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Proper delicate handling of soft tissue and perfect soft tissue balancing can lead to successful outcomes and help avoid complications. It is the construct and not the actual type of hardware that will influence a positive or negative outcome. Being comfortable with the type of fixation you use and understanding how to utilize it to maximize stability are also key.
We cannot overstate the preoperative assessment of risk factors, both patient-dependent and surgeon-dependent factors. Patient education appears to be overrated in that the literature supports the fact that our patients only comprehend 25 percent of what we tell then.11
One must also realign the sesamoids. A critical analysis of poor hallux valgus outcomes will reveal that in a majority of cases, the sesamoids are part of the problem.
In our experience, fibular sesamoidectomy is the number one culprit of hallux varus. It is also involved in cases of avascular necrosis and creating abnormal joint mechanics. The patient who has a radiographic intermetatarsal angle of 0 degrees, in which the joint is stiff and painful, likely has degenerative sesamoids. The sesamoids can become hypertrophied and adhere to the first metatarsal.
When performing a Lapidus arthrodesis, if you are unable to reduce the intermetatarsal angle to 0 degrees, it is usually due to the lateral interspace fibular sesamoid interposition. Lateral hallux drift is due to malaligned sesamoids. If there is intraoperative difficulty with positioning of a first MPJ fusion, it is usually due to hypertrophied sesamoids interfering with bony apposition of the plantar third of the fusion site.
We want to emphasize that painful arthritic joints need fusion. Attempts to avoid fusing degenerative joints in the hope of restoring joint function lead to angry patients and difficult revisions.
Finally, we must not solely rely on postoperative X-ray appearance. The patient may have the greatest looking X-ray but that does not mean that the patient is happy. We must fully understand patient expectations preoperatively or an unsuccessful outcome will result.
Avoid the temptation to perform a high-risk procedure in a high-risk patient. Patients with multiple risk factors that require multiple procedures will have inherent biomechanical risk, which will increase the likelihood of complications exponentially. Furthermore, these types of patients and complications are a nightmare to fix when things go bad.
Eliminate risk by evaluating your patient properly. Select your procedure with risk capacity and risk exposure in mind. Execute the procedure perfectly. Follow the basic principles. Conceptualize your fixation contract and keep things simple.
Dr. Hofbauer is a Diplomate of the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He is a member of The Orthopedic Group in Pittsburgh.
Dr. Pappas is a Fellow of the Monongahela Valley Foot and Ankle Reconstructive Fellowship in Monongahela, Pa. He is an Associate of the American College of Foot and Ankle Surgeons.