How To Solve The Dilemma Of The Jumbo Bunion

William Fishco DPM FACFAS

When it comes to surgical treatment of very large bunion deformities, I think we all scratch our heads a little and have to ponder what to do. For the average run-of-the-mill deformity, it is pretty much a slam dunk. You do whatever you are comfortable with such as an Austin bunionectomy, Scarf bunionectomy, distal-L osteotomy, etc.

What I want to talk about is the jumbo bunion. I recently had a patient come into the office because his daughter just had bunion surgery by me and it was one of those run-of-the-mill Austin bunionectomies. He told me he had been to a couple of other podiatrists for treatment of his bunion. He was told that nothing could be done and he would just have to live with it.

Now I don't know about you but I feel like I can fix anything. Unless there is some other medical reason such as heart disease or peripheral arterial disease, I do not tell people that nothing can be done. I do, however, explain the difficulty and sometimes prolonged recovery with such a reconstruction. I do want to give options to patients. Ultimately, it is their decision if they want to live with it.

So what do you do with jumbo bunions? If there is a long first metatarsal, then a Lapidus may be a good option since you can get excellent proximal correction. If the first metatarsal is short, however, then you are probably looking at shortening the central metatarsals as well if you are doing a Lapidus.

Certainly age, activity level, relative stiffness of the joint/first ray and typical shoe gear play a role in decision making. I have found that geriatric patients can do well with a McBride bunionectomy if the main goal is to get a shoe on the foot without pain. I personally avoid the Keller bunionectomy with the exception of an arthritic joint in a geriatric patient with a low demand for activity.

When Should You Consider Fusion?

What about the scenario of a jumbo bunion in an active patient? Do not forget about the age-old fusion of the great toe joint. The beauty of the surgery is that you can take the most severe bunion deformity and reduce it so the toe is straight and the bump is gone. It works for rigid joints and extremely flexible joints. I always get nervous with very flexible joints because of the "boing" effect. It may look great on the table but in six weeks, the bunion is back.

When doing a fusion of the great toe joint in the active geriatric patient, a non-union occurs with some fair amount of frequency. Fortunately, most of these patients tend to get an asymptomatic pseudoarthrosis. Even though the X-rays may be ugly, the patient is generally happy.

In a properly positioned great toe joint fusion, patients can continue running and playing sports. With arthroplasty of the great toe joint, there is vulnerability for stress and strain, leading to implant failure or other problems such as lesser metatarsal overload due to first ray instability.

Most of these patients with jumbo bunions already know they have a severe deformity and they are not going to get the “typical” bunionectomy. I feel it is important to impress upon them the severity of their condition, which you can easily illustrate with X-rays of the "normal" foot and X-rays of a "typical" bunion. Now your patients can understand that due to the necessity of an advanced reconstruction technique, they may require a prolonged recovery including six weeks of non-weightbearing. This may be a far cry from the patient's daughter or friend who was back in a sneaker four weeks after surgery.

We learn that we should avoid fusions in the foot for various reasons. Maybe it is rigidity of the foot, development of neighboring joint arthritis or just a stigma that a fusion is a salvage procedure (end of the road technique). When it comes to the great toe joint, I personally do not feel there is much risk of developing arthritis elsewhere like in a hindfoot or ankle joint fusion.

If you think about the common condition of hallux rigidus, how different is that from a fusion of the joint? Generally, the worst "compensation" condition is hallux extensus (interphalangeal joint hyperextension), which tends to be asymptomatic. At least in a fusion, the great toe is in a better position than it is with hallux rigidus. As you know, the toe with hallux rigidus tends to be plantarflexed relative to the first metatarsal (hallux equinus) due to a spasm of the short flexor tendons.

So think of the surgery as removing the bunion and creating a hallux rigidus (without the arthritis pain) in which the toe is in optimum position for walking and running. Now you have created a stable first ray, a reconstruction that will rarely fail due to recurrence of deformity, and the likelihood of developing arthritis in the joint is nil.

Now on the other side of the coin, with the condition of hallux limitus or rigidus, I tend to be more willing to try a cheilectomy or decompression osteotomy than a fusion. The reason is simple. If the joint preservation surgery fails, then you can always do a fusion later. The postoperative course is easier for patients with joint preservation techniques. Return to function is quicker and there are fewer potential complications.

As you know, joint preservation techniques for hallux limitus and rigidus work well. When it comes to jumbo bunions, however, I do not think joint preservation surgeries have the same high rate of success rate as in hallux limitus/rigidus. Otherwise, I would leave the fusion technique for jumbo bunions as my back-up procedure.

Comments

It is interesting to see that a big deformity can be corrected without a Lapidus procedure.
This confirms the primary role of 1st MPJ rather than the met-cuneiform joint in the pathology of HAV.

Vladimir Gertsik, DPM

There are situations where the met cuneiform does play a role in HAV pathology.

The "famous" example is hypermobility along the 1st ray which somehow shows up in every board exam every year. The other one is the atavistic cuneiform. These both affect the integrity of abductor hallucis tendon/muscle, which will ultimately imbalance the 1st MPJ.

I agree that the met-cuneiform joint may play a role in the pathology of HAV but its role is secondary, usually representing an adaptation to years of medial metatarsal deviation.

Congenital problems affecting cuneiforms are rare and met-cuneiform hypermobility is a myth in most cases. If any hypermobility is present, it is usually more proximal. It interesting to see that Hansen views pes planus as lateral peritalar subluxation.

Lapidus was wrong, and McBride was correct.

My main point is that Lapidus procedure is indicated only rarely.
If I am wrong, 1st MPJ fusion should not work for severe bunions and it does.

If in fact "met-cuneiform hypermobility" is a myth, please explain the biomechanics of a severe flatfoot induced bunion.

The classic definition of hypermobility is that motion occurs when it should not. This in and of itself explains the pathology of the above.

I'm interested in your theories however.

Jumbo bunion - interesting and appropriate term! I enjoyed reading this blog.

In my practice, I am not convinced that a big toe fusion is the best treatment for a large bunion — especially in the absence of arthritis, previous surgical misadventure, and/or a sedentary lifestyle. If executed properly, and in the absence of medial column hypermobiity, I can see the benefits.

However, I believe a poorly positioned big toe joint fusion can be quite unforgiving and be a functional disaster for a patient. Additionally, a nonunion of big toe joint, in my experience, tends to be more symptomatic than a nonunion of other common foot fusions (say, a 1st TMT), due to the loads placed on that joint, but I am unaware of any supporting research.

I also don't particularly think that a symptomatic nonunion of a first MTPJ Fusion for bunion correction is equivalent to that of a patient who has an essential "hallux rigidus psuedoarthrosis" simply because the latter is developed over may years and the patient probably has adapted with other gait compensations. A newly acquired nonunion can surely hurt.

Some surgeons may choose to attack the large bunion with a fusion of the big toe, simply because they want to allow patients post-op weightbearing, rather than performing a proximal metatarsal procedure or Lapidus bunionectomy due to non-weightbearing protocols postoperatively.

Recently, published research on Lapidus bunionectomy early weightbearing protocols demonstrate healing rates similar to that of non-weightbearing protocols.1

If there is no big toe joint arthritis, the 1st MTPJ subluxation in not massive and the patient is moderately active, then a Lapidus should indeed be considered as a first line option for your Jumbo Bunion.

Neal M. Blitz, DPM, FACFAS
Chief of Foot Surgery
Bronx-Lebanon Hospital Center
nealblitz@yahoo.com

Reference

1. Early weight bearing after modified lapidus arthodesis: a multicenter review of 80 cases. Blitz NM, Lee T, Williams K, Barkan H, DiDimenico LA. J Foot Ankle Surg. 2010 Jul-Aug;49(4):357-62.

Neal, thanks for adding to the blog. I appreciate your comments. I do agree the Lapidus procedure is indeed appropriate for the Jumbo bunion. However, I personally try to avoid it when there is a short first ray. I understand that surgical stiffening of the first ray minimizes lesser metatarsal overload, however, the risk is there for lesser metatarsalgia. Also, shortening and plantarflexion (plantar transposition) of the first metatarsal that is already short can lead to a floating hallux (non-purchasing great toe), EHL contracture with mallet toe, etc.

As far as weight bearing goes, I am very conservative and non-weight bear my first MTPJ fusions so the post-op course for me is the same for a Lapidus and a first MTPJ fusion.

It has been my experience that if you look at patients that have hallux rigidus/limitus for many years, patients that have a pseudoarthrosis of a first MTPJ fusion, and patients that have had a Keller 10+ years ago, the AP x-rays look pretty much the same (other than the hardware in the fusion case). There is a loss of joint space, remodeling with cupping of the proximal phalangeal base and exostoses. Clinically, the joints are relatively stiff and most often function in a similar fashion.

It is my opinion that no surgery should be "first line" treatment because every patient/x-ray is different. Maybe a better term would be "first consideration." Just like I tell my residents, "in a red, hot, swollen foot in a patient that has diabetes, it is Charcot until proven otherwise."

So in your case, the jumbo bunion should have the Lapidus procedure unless there is a better choice considering the patient's clinical exam, X-ray evaluation and lifestyle. I do agree that the Lapidus and first MTPJ fusion are generally the main considerations I make in these scenarios. I personally do the Lapidus procedure when I have good length of the first metatarsal to work with and with those that have clinical or radiographic signs of DJD of the MTCJ.

I have no problem fusing a normal joint that is grossly unstable. The best analogy is doing a subtalar joint arthrodesis or triple arthrodesis in a severe flexible pes valgus foot. X-rays may show no gross DJD but when the foot is flexible and unstable, the arch is flat and deformed. A hindfoot fusion stands the test of time.

The whole crux of a good outcome with the first MTPJ fusion is optimum position. That sounds silly for me to say that because we always want fusions to be in optimum position.

As far as hypermobility goes, we could have a great blog session on that alone. So what comes first: hypermobility causing the bunion or the bunion causing the hypermobility? We can also throw a little equinus in there for fun. Does hypermobility come from the first MTCJ, the NCJ or both?

I have done some research on first ray hypermobility and have the Glasoe device for objectively measuring first ray mobility. I am currently studying first ray ROM before and after bunion surgery. The study will prove or disprove whether a stable/congruous great toe joint following bunion surgery reduces first ray mobility. So maybe it is possible to do a repositioning osteotomy bunionectomy on a patient with clinical preoperative hypermobility that postoperatively is not hypermobile.

I am not a Lapidus hater. As you know, I trained in Atlanta (not Pittsburgh or Seattle), so maybe we see things a little different. But the bottom line is that there is always more than one way to skin a cat.

Personally, this is what makes podiatry exciting. If everything that we did was "cookbook," then it would get boring.

William D. Fishco, DPM, FACFAS

Let me clarify. There is no first met-cuneiform hypermobility in the vast majority of patients. The first metatarsal moves medially in response to lateral deviation of the hallux. In other words, the primary pathology is at the level of first MPJ. Whatever happens at the met-cuneiform joint is secondary and somewhat reversible even in late deformities.

This is why Lapidus and Dr.Blitz are wrong, and McBride and Dr. Fishco are correct. MPJ arthrodesis will correct severe bunions where McBride procedure has failed.
The Lapidus procedure is pretty much NEVER indicated.
If the first metatarsal refuses to move laterally, where is the hypermobility now? If the met-cuneiform joint has adapted in a medial position and is now rigid after years of HAV, why not do a base wedge?

The Lapidus procedure is nothing more than a re-emerging fad. Let us go back to the basics and see that it is the hallux that drives the metatarsal medially, and not the other way around.

How can flatfoot contribute to HAV? Possibly by altering muscle forces around the first MPJ. Again, nothing primary about the Lapidus joint here. If any hypermobility exists, it is usually more proximal at the TN joint.

Vladimir Gertsik, DPM
New York

Dr.Fishco has far more reasons to avoid the Lapidus procedure than to do it and he is correct. His thinking is ahead of current podiatric dogma. He does not need to apologize for his surgical choices.

There is an interesting article suggesting that "first ray hypermobility may be the result of the deformity, not the cause."1

Vladiir Gertsik DPM, NY

Reference

1. Coughlin, Jones, Viladot et al. Hallux valgus and first ray mobility: A cadaveric study. Foot Ankle Int 2004; 25:537-544.

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