To Radiograph Or Not To Radiograph A Bunion Deformity: What The Intraoperative Findings Reveal

In the discussion of whether or not you really need to use X-rays in bunion surgery, there seem to be more posted comments in my camp (see see http://www.podiatrytoday.com/blogged/emphasizing-the-importance-of-radio... and http://www.podiatrytoday.com/blogged/can-you-select-a-bunion-procedure-b...). I have always considered the radiographic evaluation an important component of both the preparation for and execution of bunion surgery. While there may be others who are a little more cavalier and believe that radiographs are not an absolute necessity, the patient profile that I have been unfolding to you over this blog has illustrated a classic case in point.

While this case appeared as a “jumbo IM bunion” clinically (see figure 1), and seemed rather bland radiographically (see figures posted previously in http://www.podiatrytoday.com/blogged/emphasizing-the-importance-of-radio...), it turned out to be more than that. Those who commented on the blogs suspected a hallux limitus and treatment suggestions have ranged from first MPJ fusion to decompression osteotomy.

For this blog entry, I am revealing the intra-operative findings that underlie the fact that more preoperative work is always better.

The patient’s serologic studies were within normal limits at the time of his last examination when he was in a significant amount of pain in his bunion area. While I had not confirmed the diagnosis, I suspected gout as a culprit for his extreme structural abnormality without an increased intermetatarsal angle.

I prepared the patient for surgery by consenting him for everything from a decompression osteotomy to an arthrodesis procedure depending upon the intra-operative findings. Given his participation in weight lifting, the patient expressed the distinct desire to avoid permanently locking up the joint. I suggested looking at this as a staged procedure and that I could always perform the fusion if he was dissatisfied with his outcome.

Take a look at figure 2, which reveals the large intra-capsular mass mimicking an enlarged medial eminence. Figure 3 reveals evidence that one can lift and reflect the capsule from around this unusual soft tissue mass. With close inspection, figure 4 reveals a giant, well organized tophaceous deposit. In figure 5, it is easy to appreciate that the joint has been completely eroded and is shut down. There is a hardened chalk white margin to the joint that represents the acidic destruction of concentrated uric acid crystal deposition.

I think the readers can agree there was no radiographic evidence of the large erosive changes that one typically sees in chronic gout. However, one could appreciate end stage joint space narrowing. Without the benefit of the radiographs, the treating DPM may not have appreciated the generalized osteopenia, osteophyte degeneration and metatarsus adductus. Is there any chance that a podiatric surgeon would select a proximal astronomy without obtaining radiographs?

When I perform proximal procedures, I generally do the proximal work first as it often precludes the need for interspace release. I would have been in a heap of trouble with that approach in this case.

Figure 6 simply illustrates that chalky in-growth of uric acid deposition interspersed over a completely degenerative first metatarsal head. Figures 7 and 8 show the end result after excision of the mass, an aggressive debridement of the joint and sodium bicarbonate lavage. In the end, I performed a modified cheilectomy and the patient began range of motion exercises within the first week of surgery.

I would be interested in what the readers of this blog predict will happen in this case in the short term. I performed the procedure in February 2010. I will provide seven-month post-op radiographs, clinical photos and subjective evaluations in the next blog update. Thank you in advance for your interest and continued participation in this case.

Figure 1. This case appeared as a “jumbo IM bunion” clinically and seemed rather bland radiographically.
Figure 2. Here one can see a large intra-capsular mass mimicking an enlarged medial eminence.
Figure 3. This photo reveals evidence that one can lift and reflect the capsule from around this unusual soft tissue mass.
Figure 4. With close inspection, this photo reveals a giant, well organized tophaceous deposit.
Figure 5. Here it is easy to appreciate that the joint has been completely eroded and is shut down. There is a hardened chalk white margin to the joint that represents the acidic destruction of concentrated uric acid crystal deposition.
Figure 6. This simply illustrates the chalky in-growth of uric acid deposition interspersed over a completely degenerative changes in the first metatarsal head.
Figures 7. Here is a medial view of the end result after excision of the mass, an aggressive debridement of the joint and sodium bicarbonate lavage.
Figure 8. This is a frontal view following excision of the mass. The author performed a modified cheilectomy and the patient began range of motion exercises within the first week of surgery.


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