There are three major considerations I utilize when evaluating surgical outcomes after a bunionectomy. First, the procedure must allow pain relief. Regardless of any radiographic success, if the patient continues to experience pain, the procedure has failed. Secondly, one must achieve deformity correction, acutely and chronically. Lastly, cosmetic improvement is expected by patients and is important in most deformity correcting surgeries.
The choice of bunion procedures is seemingly endless in comparison to any other foot and ankle operation. The options span soft tissue exposure, osteotomy location, osteotomy type, fusion procedures, fixation types and location, and post-op protocol. Many of the known bunion procedures may have similar outcomes and succeed in accomplishing my checklist. My daily goal with bunions is to address the characteristics of the deformity but keep the decision-making process as simple as possible. I do not choose from the hundreds of procedure choices available. I choose from a handful that I have attempted to master and that accomplish my checklist demands.
I utilize three bunion operations on a routine basis. The SCARF bunionectomy is my most commonly utilized procedure. I find the SCARF to be a great utilitarian bunionectomy. The versatility is noticeable. The technicalities of this procedure allow for differences in soft tissue exposure. The SCARF allows for correction of PASA by rotating the capital fragment. The IM angle correction ability is surprisingly large. The lengthening and shortening ability are straightforward and stable. The blood supply is preserved to the metatarsal. As a bonus, the osteotomy stability allows for immediate post-op weightbearing.
My second most common choice is the Lapidus. The indication is specific for medial column instability. We can go around in circles about the reproducibility of determining tarsometarsal instability but if I find it on clinical or radiographic exam, I make the Lapidus decision. The lateral X-ray will show a plantar gapping at the first tarsometatarsal joint, indicating instability in the sagittal plane. Although realigning the first ray with a SCARF procedure corrects for some of this instability, I feel more confident in addressing the tarsometatarsal joint directly in these cases. Medial column collapse may also warrant the Lapidus choice, with or without adjunctive procedures, such as an extended medial column fusion. Technique improvements, biologics and hardware improvements have brought the Lapidus into focus as a great bunion treatment option.
My final bunion correction choice is the opening base wedge (OBW) osteotomy. Recent locking plate technology has allowed this procedure to move up the ranks of popularity. For a large IM angle and a noticeably short first metatarsal, the opening base wedge osteotomy is a great choice. This procedure sufficiently allows the IM angle and there is typically a noticeable gain in the first metatarsal parabola length post-operatively. I typically employ a biologic here, whether I harvest an autograft or utilize an off-the-shelf product. This bunionectomy has a straightforward indication in my hands and I have been having great results.
I should note that there is also a role for adjunctive Akin osteotomies in my surgical tool chest. I may add this osteotomy on an as needed basis with any of the aforementioned procedures. In rare cases, I may use it as a stand-alone correction. The first MPJ fusion is also a valuable asset in certain instances and surgeons should consider it as an option for bunions, particularly severe varieties and revision cases.
Each of these bunion procedure choices meets my checklist criterion. I realize others may choose a different set of procedures for their own reasons. That is a beautiful merging of art and skill set. If you are achieving the results you desire, then you are making the correct choice. As time moves along, I likely will add or remove from my short list of bunion procedures. For now, I feel confident I can offer my patients pain relief, deformity correction and aesthetically pleasing results.