How To Manage Postoperative Hallux Varus
Chances are, you have seen patients present to your office with pain after undergoing a bunion surgery, which you may or may not have performed. If you were the operating surgeon, it is easy enough to research the specific procedure that you performed. However, in many cases of hallux varus complications, the patients wind up in another surgeon’s office for reconstruction. Obtaining all the prior operative and post-op information will aid in tailoring the revisional surgery. With this in mind, let’s consider the following case. A 55-year-old female patient returns to the office for a follow-up visit four months after her bunion surgery. The patient is complaining of continued pain in the first metatarsophalangeal joint that occurs mainly with range of motion and ambulatory activities. The patient also expresses some concern about the position of the toe, stating it looks “too straight.” We sent her to get some new films and went back to check the op report, X-rays and post-op notes. The op report discussed a medial skin incision, a standard lateral release of the adductor tendon at the level of the joint as well as a lateral capsulotomy. For the osteotomy, we had performed a standard head procedure, using a long dorsal-arm chevron bunionectomy and fixation with two 2-0 mm screws. We had resected the medial overhang and smoothed the medial first metatarsal as per standard procedure. We also had performed a medial capsulorrhaphy with tightening of the medial capsule. Intraoperative fluoroscopy pictures in the chart revealed great positioning of the sesamoids under the first metatarsal head. They showed good correction of a moderate bunion deformity without overaggressive translocation of the capital fragment or medial resection. The intermetatarsal angle had been corrected from a 14 to an 8 or 9. The initial postoperative visits at one, two, four and six weeks were all uneventful with a normal postoperative course. The patient denied any history of trauma. She was attending some range of motion therapy with a licensed physical therapist specializing in foot and ankle care. She had shown good progress in terms of range of motion. She noted the pain was better but remained persistent. The patient has been in tennis shoes for about six weeks, but can not wear much else. Normally an active person, she has tried to increase her activity but is bothered by the pain. She now raises questions about the cosmetic appearance of the toe. The patient’s films confirm early onset of a hallux varus. The hallux abductus angle is approximately a negative 3 degrees with an IM of 8. The position of the capital fragment on the first metatarsal shaft is good with no visible osteotomy line and no signs of malrotation, collapse or overcorrection. The screws are intact without shifting or signs of loosening. On the DP radiograph, the tibial sesamoid has migrated medially a small amount from the previous films and is now peeking out medially. Emphasizing The Importance Of Informed Consent The patient wants to know what happened and where do we go from here. Informed consent is an important part of the preoperative work-up. We are careful to spend the extra time with patients detailing the procedure and outlining the potential complications with each specific procedure. Iatrogenic hallux varus is an uncommon complication that, according to the literature, occurs in 1 to 5 percent of cases. Since we had informed and educated the patient regarding the possibility of developing hallux varus along with other potential complications, she returned to our office for treatment and possible revision. A Guide To Key Treatment Considerations The literature offers many options for treating iatrogenic hallux varus. Conservative management includes strapping, taping and padding of the hallux in a corrected position. When employing conservative treatment, make sure the patient understands the corrective device needs to be in place all the time. Applying felt padding to the inside of the shoe is a good idea, but keep in mind that most people will be in those shoes for only a third of the day. This will not provide long-term correction. Surgical reconstruction of early hallux varus is directed at correcting the deforming force, but bear in mind that the same procedure will not work for every patient. For example, if the flexors have been destabilized due to a fibular sesamoidectomy, one needs to address this.