Addressing Complications Of Hallux Valgus Surgery

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

   In the literature, there are more studies that analyze the success of individual procedures. Choi and colleagues performed the scarf osteotomy for hallux valgus on 51 patients (53 feet), who had at least one year of follow-up with an average follow-up of 24 months.10 The overall complication rate was 15 percent (8/53), attributable to four feet with symptomatic hardware, two feet with hallux varus and two feet with progression of first MPJ arthritis. Reoperations occurred in four feet (8 percent) for removal of symptomatic hardware. In this study, the researchers deemed the scarf osteotomy to be a reliable technique for the correction of moderate to severe hallux valgus, and had low rates of complication or recurrence.

Further Insights On Procedure Selection

Preoperative assessment of the degree of degenerative joint disease is paramount to selecting a procedure. An attempt at performing joint preserving osteotomies in patients with painful degenerative disease will result in poor functional results and failure. Painful degenerative joints need fusion. It has been our experience that one needs to satisfy four key elements when selecting a procedure:

1) The intermetatarsal angle needs reduction to 8 degrees or less.
2) The sesamoids need realignment.
3) The medial column needs stabilization.
4) The first MPJ needs decompression.

   If there is a lack of intermetatarsal correction, the patient will not be satisfied. Malaligned sesamoids lead to a lateral hallux drift as well as poor MPJ motion and function. An unstable medial column will lead to pain and recurrence. Procedures designed to lengthen the first ray will lead to more joint jamming, pain and failure.

   Poor operative techniques will also lead to complications. This factor is very difficult to quantify and therefore is not often evident in the literature. Soft tissue handling is of the utmost importance to avoid scarring, dysvascular episodes, avascular necrosis and periarticular imbalances. The lack of familiarity with an anatomical location may result in soft tissue destruction and is a common finding when learning to perform a new or more demanding procedure.

   Another important component of preventing hallux abductovalgus surgery complication is the use of a sound fixation construct. Whether it be an osteotomy or a fusion of the first ray, the emphasis should be on principles of fixation over the type of fixation. Screws, plates, pins and staples are all satisfactory if one utilizes them properly. The key to a good construct is one that provides compression, stabilization in all planes and allows for neovascularization at the healing site.

How The Surgical Facility Can Influence The Success Of The Procedure

An overlooked surgeon-dependent risk factor can be the actual facility where one performs the surgery. The lack of familiarity with equipment or the staff can lead to unforeseen complications. The facilities that tend to cut costs or do not allow into their facility new fixation devices or technologies impact the standard of care, and can lead to poor outcomes.

   The surgeon-dependent risk factors that increase the risk of complication generally occur in the operating room. There are, however, certain postoperative course concerns that may arise. Non-adherence is a surgeon-dependent risk factor in that the surgeon may be at fault for poor patient selection. There are times when unforeseen events occur. However, most complications that occur in the postoperative period are complications that manifested themselves in the preoperative planning period or within the operating room.

   We believe the most difficult complication is an unsatisfied patient. The answer to this complication is often complex and a solution is often not available.

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