January 2013

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Which Bunionectomy Technique Provides The Most Advantages?

By Brian McCurdy, Senior Editor

What type of bunionectomy do you most commonly perform? A recent Podiatry Today online poll reveals a range of preferences for the best surgery for hallux valgus (see www.podiatrytoday.com/polls/what-type-bunionectomy-do-you-most-commonly-... ).

   Out of 415 respondents, 41 percent (169 votes) perform the standard Austin bunionectomy, while 35 percent (144 votes) prefer the long-arm Austin. Seven percent favor the scarf bunionectomy, 6 percent perform the Lapidus and 11 percent voted for “other.”

   About 90 percent of the time, William Fishco, DPM, performs a traditional Austin with a 3.0 mm screw, using it for average-sized bunions. He chooses that type of bunionectomy due to its inherent stability, the fact that the osteotomy is centered into the metaphysis (which has the best potential for rapid healing), and because the technique is straightforward.

   For Bradly Bussewitz, DPM, the scarf bunionectomy is a “go-to procedure,” accounting for about 70 percent of the bunionectomies he performs. The other 30 percent of his bunionectomies are either the opening base wedge osteotomy or the Lapidus, which he will perform when indicated. He uses the Akin osteotomy as an adjunct to all three of these on a PRN basis.

   The Austin bunionectomy’s advantages include less dissection and stripping of periosteum in comparison to midshaft osteotomies and base wedge procedures, according to Dr. Fishco, a Fellow of the American College of Foot and Ankle Surgeons, who practices in Phoenix. He notes that complications of over-shortening the first metatarsal bone are less likely with the Austin than with base wedge procedures or the Lapidus. Dr. Fishco says the fact that Austin patients can bear weight immediately is the main advantage over base wedge or Lapidus procedures.

   Dr. Bussewitz cites versatility and stability as main advantages of the scarf procedure. He notes the scarf can lengthen or shorten the first ray with ease, and its corrective ability is significant. As he opines, the Lapidus can be a better choice in cases of gross medial column instability and/or first tarsometatarsal joint osteoarthritis. The opening base wedge osteotomy, explains Dr. Bussewitz, is an additional option for the short first metatarsal.

   “The primary advantage for the patient should always be pain relief and the scarf can offer that for a variety of hallux abducto valgus presentations,” says Dr. Bussewitz, a fellowship-trained foot and ankle surgeon who practices in Iowa City, Iowa.

   As Dr. Bussewitz says, the scarf offers “impressive” correction of deformity and post-op first metatarsophalangeal joint range of motion. He adds that patients usually take note of this as they return to activities. Dr. Bussewitz cites the procedure’s early weightbearing capability as a plus as patients attempt to return to work or the activities of daily living. Furthermore, he says the lack of prominent hardware in the scarf, in comparison to the Lapidus and opening base wedge procedures, improves patient tolerance.

   “Implant technology has made all of these bunionectomies great options for today’s surgeon. I want to feel confident the patient isn’t going to disrupt the corrected position during the early postoperative course and all three of these procedures allow me this confidence,” says Dr. Bussewitz.

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