Practical Keys To Improving Fluency In Foot And Ankle Surgery

By Luke D. Cicchinelli, DPM, FACFAS

Key Considerations In Digital And First Ray Surgery

Lesson two: There is nothing worse than a perfectly straight fused lesser toe. Perfectly fused interphalangeal joints look great on X-rays but can be problematic for patients with shoegear.
   Practical experience: Perform flexed toe fusions for hammertoe or clawtoe correction. The result is more cosmetic and more functional. Normal flexion in a digit at the proximal interphalangeal joint is about 20 degrees. Strive to achieve that in your post-op results. I prefer fixation using an absorbable pin that allows adjustment of the final position of the toe in all planes prior to applying the dressing.
   Translation to patient: Yes, your toe will be stiff after surgery. Stiff in a functional position and slightly bent is better than stiff in a bad position that rubs in your shoes.
   Lesson three: Never commit to your proposed bunion procedure until you have performed the soft tissue releases. The key to bunion surgery is the flexibility or lack thereof in the first ray. Researchers have described over 130 procedures and they likely all have worked at some time for someone. Lasting correction comes from a congruent first MPJ and the metatarsal head well positioned over the sesamoids.
   How one achieves this is secondary. First consider whether an osteotomy is required at all. There are repositional options of the first and second metatarsals via screws, sutures or tape that work well in many cases. This of course depends on the flexibility of the first ray.
   Practical exercise: Always consider PASA correction and decompression via a distal osteotomy with rotational corrections of the intermetatarsal angle. A relative lengthening occurs. The difference between a good bunion correction and a great bunion correction is attention to PASA and more frequent use of the Akin.
   Learn to do a Scarf bunionectomy correctly and well. It is the most versatile and secure osteotomy available that still allows immediate weightbearing, secure fixation and multiplanar correction including PASA. It also resists shortening. Do not forger the Keller. An 88-year-old grandma will do just fine and heal in 10 days with a well-done Keller bunionectomy. Tag the flexors to the remaining proximal phalanx to improve toe purchase.
   Translation to patient: No, we cannot guarantee your bunion will never come back nor that your toe will be perfectly straight. Mild residual abduction of the great toe is preferable to hallux varus and fits in shoes better.

Addressing Severe Forefoot Deformity

Lesson four: Utilize Barouk’s approach to forefoot longitudinal and mediolateral decompression. By the time all the toes are pointed in 12 different directions and the hallux underlaps the third toe, the soft tissues are trying to tell us something. They have adaptively contracted beyond the length permitted by the osseous structures. In a sense, the bones have become too long for the foot.
   Practical exercise: One needs to decompress the forefoot bones in order to relax the soft tissues. Lengthening extrinsic tendons and pinning MPJ joints often do not last. The intrinsics are shortened as well. One needs to ensure the central metatarsals are harmonized with the first ray and that the whole forefoot is “relaxed.” Shortening Scarf and Weil osteotomies are the most effective options to achieve these results. Panmetatarsal head resection with digital fusions remains a very viable option for severe forefoot deformity as well.
   Translation to patient: Some toes may not fully touch the ground post-op. That is okay. They did not start off touching the ground either. We are looking for relief of painful metatarsalagia and toes less likely to ulcerate dorsally.


Great article.
I sense the very same thing going on, possibly to an even greater extent (Think the Tower of Bable) in biomechanics.
Do you agree?

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