Bunions: Are Proximal Osteotomies Necessary?

By John McCord, DPM, and Mark Hofbauer, DPM

Yes, if the procedure is done correctly, it is a valuable adjunct to bunion correction, says John McCord, DPM. Who will ever forget the memorable autistic man played by Dustin Hoffman in the film Rain Man? My favorite scene was when he refused to fly on any airline but Quantas because that carrier had no history of accidents. I reflect on that scene when I talk with colleagues in podiatry who refuse to consider performing proximal osteotomies while correcting bunion deformities. Their logic makes as much sense as the Rain Man in that they will choose a head osteotomy even though it won’t correct the deformity. Proximal osteotomies were the gold standard in podiatry until metatarsal head osteotomies became popular in the mid-‘70s. Mostly, we performed transverse closing wedge procedures to correct high IM angles. We secured these with stainless steel wire and, in most cases, they worked well. Then the hinge/axis concept was introduced and it helped to prevent elevatus of the first metatarsal. Screw fixation was also introduced and this required an oblique Juvara osteotomy. Why Distal Osteotomies Aren’t The Answer With Severe IM Angles Metatarsal head or distal osteotomies were easy to perform and became the favored procedures. You could think two dimension and achieve a relative correction of a high IM angle without much danger of a surgical complication. Proximal osteotomies demand that you think three dimensions and work with templates preoperatively. A poorly executed proximal osteotomy could result in severe elevatus of the first metatarsal and subsequent hallux limitus. A poorly executed head osteotomy just kind of takes care of itself in time. The problem with distal osteotomies is that they don’t really correct the deformity. They are okay when the IM angle isn’t severe but anything over 16 degrees will fail unless you correct the deformity at its source, the proximal aspect of the first metatarsal. There have been variations of the metatarsal head osteotomies with long legs that stretch back to the proximal shaft. If the deformity approaches 18 degrees, these are unstable because of troughing. The solution is that we should all be capable of performing proximal first metatarsal head osteotomies or willing to refer cases with high IM angles to colleagues who can do the job right. I don’t look forward to the patients who come in with high IM angles. These patients tend to be young people who have had juvenile hallux abducto valgus. The best solution is to select a procedure which corrects the hallux valgus plus an appropriate osteotomy to correct the metatarsus primus varus. In these cases, I go by the patient’s apparent needs rather than my limitations or desire for an easy trouble free operation. It is best to correct the deformity and its underlying cause so the patient doesn’t have to face a series of operations. I went for a long period of time in the ‘80s in which I avoided performing the dreaded closing wedged osteotomy. I had created a few elevated metatarsals and had encountered a few non-compliant patients who liked to bear weight before things had healed. I reasoned that it was better to err on the side of caution and risk a recurrence than to do what was needed at a higher risk. Then I looked back at 10 years of my easy metatarsal head osteotomies and was appalled at the numbers of recurrence and unsatisfactory results. The worst results occurred with patients who had IM angles of around 18 degrees. Revisiting The Proximal Osteotomy And Emphasizing Compliance I revisited the proximal osteotomy and took a few internal fixation courses. I made templates by tracing X-rays, AP and lateral views. I now do this with a digital camera which is much easier. I bring the templates into surgery with me. My OR looks like a third-grade art project sometimes with templates hanging everywhere. I take my time getting to know the patients. If any seem like they will be a compliance problem, I counsel them into waiting to have the procedure done. Most are better off being left alone than undergoing surgery, walking too early and winding up crippled. If the patient is compliant, has a bunion with a high IM angle and is in good health, I talk to him or her about a proximal osteotomy as an option. I talk about the risk factors and prepare the patient for at least three months on crutches.

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