Current Concepts With Revisional Bunion Surgery

Author(s): 
Neal Blitz, DPM, FACFAS

Following hallux valgus surgery, patients may end up with complications or undesirable results, including bunion recurrence, nonunion or hallux varus. This author focuses on revision bunion surgery techniques that keep the big toe joint functional and provides several case example strategies for revision surgery.

Bunion surgery is not always successful. Sometimes the end result is less than optimal and revision bunion surgery may be necessary.1 The key to revision bunion surgery is to understand what caused the “poor outcome” in the first place and provide a surgical plan to undo or revise the index operation.2,3

   “Failed bunion surgery syndrome” is a loose term that I use to describe a patient’s perspective of an unsatisfactory outcome after the initial bunionectomy. There are various reasons that a patient may consider the bunion surgery failed. Some reasons commonly include: bunion recurrence, malunion, nonunion, hallux varus, an excessively short big toe, hallux rigidus and a new onset of pain.

   As surgeons, we have the full scope perspective that a poor outcome is not necessarily a failed surgery or a complication. When it comes to bunion surgery, many problems that a patient may consider a postoperative “complication” are better termed an undesirable and/or an unexpected result.

   Nonetheless, revision bunion surgery can often correct a majority of the underlying causes a patient may complain about.

How To Rectify The Return Of A Bunion

Recurrence of a bunion is always a possibility, even in the best hands. However, the timeframe for a bunion to return is often many years and not months. It is my experience that bunions tend to “recur” because the index operation did not fully address the needs of that particular foot in the first place. An example of this is performing a distal osteotomy in a foot with an extremely high intermetatarsal angle and/or not addressing hypermobility properly.

   When it comes to treatment, the Lapidus bunionectomy is often a go-to procedure for recurrent bunions after a distal metatarsal osteotomy.4 Correcting the bony malalignment (an increased intermetatarsal angle) proximally avoids a secondary bone cutting surgery distally (especially with concerns for bone vascularity) and can also address any hypermobility issues. It is also important to address any residual adductor tendon contracture between the first and second toes, and one usually performs a revision McBride procedure as well.

   “Recurrence” after Lapidus is uncommon but can occur with unaddressed hypermobility in the naviculocuneiform joint. Sometimes concomitant fusion of the first metatarsal base to the second metatarsal base can address this issue.5

   In the photo on the right, a patient had an abnormally positioned first metatarsal bone and a bunion 20 years after having a Lapidus bunionectomy with screw fixation. Complicating matters is that the first metatarsal had been shortened excessively. The revision bunion surgery involved a distraction Lapidus to lengthen the segment and laterally position the bone into a rectus position. I performed a revision capsulotomy as well as an Akin osteotomy.

Essential Pearls For Addressing Malunions

A malunion can cause several clinical problems for patients, depending on the plane of the deformity. While malunions may be multiplanar, they often involve a single plane, making the revision less complex.

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