I am a podiatric physician and surgeon, and have been in practice for 43 years. As a past president of the American College of Foot and Ankle Surgeons and professor at the Temple University School of Podiatric Medicine teaching a course in podiatric biomechanics, I have observed many articles that have been written in Podiatry Today.
I need to comment on two articles that I evaluated in the October 2013 edition. The first article was “When Bunion Surgery Fails.” I certainly applaud the author for his insight and experience in complications following bunion surgery. What I think the article needed to be far more inclusive of is the etiology of complication associated with the pathomechanics that led to the deformity in the first place.
It has been pretty well established that hyperpronation syndromes and hypermobility of the first ray in the propulsive phase of gait are clearly associated with the development of the hallux abducto valgus deformities. The surgical procedures performed by most surgeons are distal osteotomies of the first ray such as an Austin bunionectomy, which in no way stabilizes or deals with the original deforming forces related to hyperpronation.
The one original surgical procedure which was identified in the article is a Lapidus with a transsyndesmotic screw and fusion between the base of the first metatarsal and second metatarsal. This was identified as a welding type of procedure to stop this plane of the first ray. The vast majority of surgical cases that we perform as podiatric physicians and surgeons correct deformity on the table but we have the added advantage of understanding the biomechanics and pathomechanics of deformity. Those underlying causes are not corrected on the surgical fields unless a flatfoot procedure is performed concomitantly to stop the hyperpronation syndrome. Failures occur over time for numerous reasons that have been enumerated that are surgically related. My concern is a lack of support by the profession identifying the absolute need for biomechanical control following our surgical procedures to minimize the risk of recurrence of deformity.
The second article that I evaluated dealt with limb length discrepancy (“Current Insights On The Use of Orthotics For Limb Length Discrepancy And Morton’s Syndrome,” Orthotics Q&A). I think this is an important article and it does identify methods to treat limb length deformity. However, I saw no evidence within the article talking about potential scoliosis of the spine, which certainly can and will be associated with limb length discrepancies, and should be carefully controlled if possible through shoe modifications.
It is also possible that no attempt at elevation on one side or the other be utilized when there is scoliosis. I have found minimal amounts of limb length discrepancy, as Dr. D’Amico had pointed out, which can cause hyperpronation syndrome on the long side and a relatively neutral foot on the short side. The etiology of unilateral hallux abducto valgus deformity is often associated with the pronation on the long side. This again would require biomechanical control after surgical procedures are performed.
Limb length discrepancies can occur in various segments. These discrepancies can be due to low back issues such as those associated with scoliosis or occur in the femoral segment or the tibial segment. Scanograms and standing X-rays are often necessary to truly identify the location and the extent of the deformity as well as X-rays of the low back and spine to assess the impact and importance of scoliotic curvatures. It is certainly clear that when attempting to treat limb length discrepancy, it should be done gradually and progressively so no harm occurs as a result of our aggressive attempt to address an imbalance.
I hope these comments that I have made are taken in the right light. They are just suggestions and identifications that I have seen through the years associated with biomechanics and deformity. I cannot emphasize enough that our profession must utilize the knowledge of biomechanics and not let it disappear into the wilderness as our surgical residency programs seem to stress.
— Harold D. Schoenhaus, DPM, FACFAS
Thank you, Dr. Schoenhaus, for your critical review of my article, “When Bunion Surgery Fails.” I think we can all agree that a textbook could be dedicated to the topic of complications and failures of bunion surgery. The insight I was trying to deliver in the article was based on the technical aspects of the surgery.
It was not my intent to belabor the importance of biomechanics associated with bunion formation and “reformation” as our readers should have the basic understanding of how pronation affects the first ray. Moreover, I am sure most of us encourage the use of orthotics after bunion surgery, especially in the patient who may have concomitant pes valgus and/or excessive pronation.
We can also talk about hypermobility all day and I don’t know if at the end of the day, we can really understand exactly how it affects each and every person. I have personally done research on hypermobility of the first ray and published papers on it. As you know, hypermobility is a subjective test with poor inter-rater reliability.
Therefore, there is no standard or absolute measurement that would be necessary to dictate which surgical procedure would be best. The Lapidus has long been revered as the “procedure of choice” for patents with a hypermobile first ray. However, most of the sagittal plane motion of the first ray probably comes from the naviculocuneiform joint.
All podiatrists love to talk about bunion surgery because we do it frequently. We have our favorite procedures because we know what works in our hands. If we ask Lowell Weil, Sr., DPM, what works, he will tell you the scarf bunionectomy. If you ask John Ruch, DPM, he will say a traditional Austin. If you ask Jack Schuberth, DPM, he will tell you the Lapidus. They are all correct.
So from a technical standpoint, which I was trying to deliver in the article, if you have a congruent joint and the metatarsal head is over the sesamoids, then you will have a stable great toe joint that should provide years of correction. Certainly, orthotics would be important to help control excessive pronation, which can ultimately undermine your bunion correction.
In my experience, the majority of “failed” bunion surgeries were the result of the deformity never adequately being repaired versus the bunion coming back because of unrecognized hyperpronation or faulty biomechanics.
A final point about hyperpronation syndrome is that I feel orthotics can handle that most of the time. I do not personally recommend a “flatfoot” reconstruction with bunion surgery unless there is recalcitrant pain in the foot that we cannot manage with stiff-soled shoes and orthotics. The last thing that our profession and patients need is for our patients with excessive foot pronation and bunions to get a gastrocnemius recession, subtalar joint arthroereisis or calcaneal osteotomy and a bunionectomy. Not to sound sarcastic but heel cord stretching, better shoes and orthotics can go a long way.
I think the next logical step with this dialogue is to have a feature article in Podiatry Today entitled, “Biomechanics And Bunion Surgery: What You Need To Know.”
— William D. Fishco, DPM, FACFAS
Editor’s note: For further reading, see “When Bunion Surgery Fails” at http://tinyurl.com/l7yuvdh or “Current Insights On The Use Of Orthotics For Limb Length Discrepancy And Morton’s Syndrome” at http://tinyurl.com/omwqw6a .