Although complications sometimes arise following bunionectomies, one can take steps to reduce potential risk and attain a satisfactory outcome for the patient. These authors address patient-dependent risk factors, ranging from obesity to deformity severity, as well as surgeon-dependent risk factors including procedure selection and soft tissue handling.
A man with great wisdom once said, “It’s what you learn after you know it all that counts.” This idea holds true regarding the pitfalls of hallux abductovalgus surgery. After years of attempting to master reconstructive forefoot surgery, it has occurred to the senior author that it is really all about risk.
There are two principles in avoiding risk. First, one must minimize risk exposure. One must recognize the patient-dependent risk factors and select only those patients who have factors favorable for a successful outcome. The second principle is to embrace risk in accordance with one’s capacity and skill level as a surgeon. One should adhere to procedural indications and not veer from them. Complications tend to occur when risk exposure does not match risk capacity.
Evaluating risk factors that lead to postoperative hallux valgus complications breaks down into two categories: patient-dependent risk factors and surgeon-dependent risk factors. As surgeons, when complications arise, we tend to blame the patient dependent factors. It is, however, the surgeon’s responsibility to identify the patient-dependent risk factors when electing to operate on an individual. It is also the surgeon’s responsibility to critically evaluate the surgeon-dependent risk factors that may have contributed to a complication. This may illuminate a flaw of the surgeon in question.
Typically, when discussing postoperative bunion complications, we focus on the actual complications. These include under-correction, over-correction, hallux varus, nonunion, malunion, infection, chronic pain, chronic edema, painful hardware, hardware failure, nerve entrapment, joint stiffness, loss of stability, lesser metatarsalgia, a painful scar, adhesions and recurrence.
In an extensive review, Lehman reported the incidence of hallux valgus recurrence as high as 16 percent.1 He also reported the incidence of hallux varus to be as high as 12 percent. In our experience, 12 percent is high. Lehman states that hallux varus is primarily a cosmetic problem and is often asymptomatic.
Researchers generally regard the incidence range of avascular necrosis (AVN) of the first metatarsal head as low, especially with regard to the chevron osteotomy.2-4
There are different categories of patient-dependent risk factors. The systemic dependent risk factors include obesity, diabetes, rheumatoid arthritis, vascular disease, neuromuscular disease and nutritional deficiencies.5 The social patient-dependent risk factors include smoking, alcohol and illicit drug use. The educational level, hygiene, home support network, job requirements and socioeconomic status of patients can also be factors that influence surgical success.
One may also consider a patient’s expectations as a patient-dependent risk factor. If the patient’s and surgeon’s expectations do not coincide, then a complication is probable.
There is increasing literature to support the importance of the patient’s psychological disposition with regard to the ability to heal. Catastrophizing and fear of movement disorders have been important factors in poor patient outcomes.6 Medicare and third party payers are recognizing and analyzing these factors more.
The musculoskeletal patient-dependent risk factors include deformity severity, chronicity and the extent of degenerative changes. Associated deformities can also contribute to a patient’s successful outcome. These deformities include a medial column fault, equinus, hammertoes, hypermobility and central ray deformities.
One must also look at a patient’s history. If the surgery is a revisional hallux valgus repair, then there is an increased risk for a complication.
The focus of this discussion will be the surgeon-dependent risk factors that lead to complications because one can modify these factors. Evidence has shown that procedure selection for hallux abductovalgus deformity is critical.1,5,7,8 The procedure should be based on the patient’s risk capacity and the surgeon’s capacity level. The procedural execution should match the surgeon’s risk capacity. This can be evident in performing an Austin bunionectomy on a patient with a high intermetatarsal angle, hypermobility, pes plano valgus and equinus. This would result in failure. The surgeon should not become lax on a procedure’s indications because the procedure is less complex or the rehabilitation is shorter.1,5,7,8
Performing a simple bunionectomy on a complex deformity is not always the primary pitfall. Certain procedures have an inherent biomechanical risk, especially when surgeons perform them on the wrong patient. This will lead to a complication. A Keller bunionectomy on a 22-year-old female will cause a destabilizing effect on the first metatarsophalangeal joint (MPJ) and result in an unsatisfied patient and surgeon. A transverse closing base wedge osteotomy in an obese patient is also highly risky. If the patient falls and breaks the hinge, then a nonunion or malunion will form.
When we looked at the success rates of various procedures for hallux valgus in the literature, we found one of the most extensive comparative studies performed by Lagaay and colleagues.9 They performed a multicenter, retrospective chart review of 646 patients who had either a modified chevron-Austin osteotomy (270 patients), a modified Lapidus arthrodesis (342 patients) or a closing base wedge osteotomy (34 patients) to correct hallux valgus deformity. Complications included recurrent hallux valgus, iatrogenic hallux varus, painful retained hardware, nonunion, postoperative infection and capital fragment dislocation.
The rates of revision surgery after Lapidus arthrodesis, closing base wedge osteotomy and chevron-Austin osteotomy were similar with no statistical difference between them.9 The total rate for re-operation was 5.56 percent among patients who had a chevron-Austin osteotomy, 8.82 percent among those who had a closing base wedge osteotomy and 8.19 percent for patients who had a modified Lapidus arthrodesis. Among the patients who had the chevron-Austin osteotomy procedure, the rates of reoperation were 1.85 percent for recurrent hallux valgus and 1.48 percent for hallux varus. Among patients who had the modified Lapidus arthrodesis, rates of reoperation were 2.92 percent for recurrent hallux valgus and 0.29 percent for hallux varus. Among patients who had the closing base wedge osteotomy, rates of reoperation were 2.94 percent for recurrent hallux valgus and 2.94 percent for hallux varus.
The high amount of success that occurred in all three of these procedures is because the surgeons adhered to the procedural indications. It is also likely that they only selected patients who were willing to follow the postoperative instructions.
In the literature, there are more studies that analyze the success of individual procedures. Choi and colleagues performed the scarf osteotomy for hallux valgus on 51 patients (53 feet), who had at least one year of follow-up with an average follow-up of 24 months.10 The overall complication rate was 15 percent (8/53), attributable to four feet with symptomatic hardware, two feet with hallux varus and two feet with progression of first MPJ arthritis. Reoperations occurred in four feet (8 percent) for removal of symptomatic hardware. In this study, the researchers deemed the scarf osteotomy to be a reliable technique for the correction of moderate to severe hallux valgus, and had low rates of complication or recurrence.
Preoperative assessment of the degree of degenerative joint disease is paramount to selecting a procedure. An attempt at performing joint preserving osteotomies in patients with painful degenerative disease will result in poor functional results and failure. Painful degenerative joints need fusion. It has been our experience that one needs to satisfy four key elements when selecting a procedure:
1) The intermetatarsal angle needs reduction to 8 degrees or less.
2) The sesamoids need realignment.
3) The medial column needs stabilization.
4) The first MPJ needs decompression.
If there is a lack of intermetatarsal correction, the patient will not be satisfied. Malaligned sesamoids lead to a lateral hallux drift as well as poor MPJ motion and function. An unstable medial column will lead to pain and recurrence. Procedures designed to lengthen the first ray will lead to more joint jamming, pain and failure.
Poor operative techniques will also lead to complications. This factor is very difficult to quantify and therefore is not often evident in the literature. Soft tissue handling is of the utmost importance to avoid scarring, dysvascular episodes, avascular necrosis and periarticular imbalances. The lack of familiarity with an anatomical location may result in soft tissue destruction and is a common finding when learning to perform a new or more demanding procedure.
Another important component of preventing hallux abductovalgus surgery complication is the use of a sound fixation construct. Whether it be an osteotomy or a fusion of the first ray, the emphasis should be on principles of fixation over the type of fixation. Screws, plates, pins and staples are all satisfactory if one utilizes them properly. The key to a good construct is one that provides compression, stabilization in all planes and allows for neovascularization at the healing site.
An overlooked surgeon-dependent risk factor can be the actual facility where one performs the surgery. The lack of familiarity with equipment or the staff can lead to unforeseen complications. The facilities that tend to cut costs or do not allow into their facility new fixation devices or technologies impact the standard of care, and can lead to poor outcomes.
The surgeon-dependent risk factors that increase the risk of complication generally occur in the operating room. There are, however, certain postoperative course concerns that may arise. Non-adherence is a surgeon-dependent risk factor in that the surgeon may be at fault for poor patient selection. There are times when unforeseen events occur. However, most complications that occur in the postoperative period are complications that manifested themselves in the preoperative planning period or within the operating room.
We believe the most difficult complication is an unsatisfied patient. The answer to this complication is often complex and a solution is often not available.
Proper delicate handling of soft tissue and perfect soft tissue balancing can lead to successful outcomes and help avoid complications. It is the construct and not the actual type of hardware that will influence a positive or negative outcome. Being comfortable with the type of fixation you use and understanding how to utilize it to maximize stability are also key.
We cannot overstate the preoperative assessment of risk factors, both patient-dependent and surgeon-dependent factors. Patient education appears to be overrated in that the literature supports the fact that our patients only comprehend 25 percent of what we tell then.11
One must also realign the sesamoids. A critical analysis of poor hallux valgus outcomes will reveal that in a majority of cases, the sesamoids are part of the problem.
In our experience, fibular sesamoidectomy is the number one culprit of hallux varus. It is also involved in cases of avascular necrosis and creating abnormal joint mechanics. The patient who has a radiographic intermetatarsal angle of 0 degrees, in which the joint is stiff and painful, likely has degenerative sesamoids. The sesamoids can become hypertrophied and adhere to the first metatarsal.
When performing a Lapidus arthrodesis, if you are unable to reduce the intermetatarsal angle to 0 degrees, it is usually due to the lateral interspace fibular sesamoid interposition. Lateral hallux drift is due to malaligned sesamoids. If there is intraoperative difficulty with positioning of a first MPJ fusion, it is usually due to hypertrophied sesamoids interfering with bony apposition of the plantar third of the fusion site.
We want to emphasize that painful arthritic joints need fusion. Attempts to avoid fusing degenerative joints in the hope of restoring joint function lead to angry patients and difficult revisions.
Finally, we must not solely rely on postoperative X-ray appearance. The patient may have the greatest looking X-ray but that does not mean that the patient is happy. We must fully understand patient expectations preoperatively or an unsuccessful outcome will result.
Avoid the temptation to perform a high-risk procedure in a high-risk patient. Patients with multiple risk factors that require multiple procedures will have inherent biomechanical risk, which will increase the likelihood of complications exponentially. Furthermore, these types of patients and complications are a nightmare to fix when things go bad.
Eliminate risk by evaluating your patient properly. Select your procedure with risk capacity and risk exposure in mind. Execute the procedure perfectly. Follow the basic principles. Conceptualize your fixation contract and keep things simple.
Dr. Hofbauer is a Diplomate of the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He is a member of The Orthopedic Group in Pittsburgh.
Dr. Pappas is a Fellow of the Monongahela Valley Foot and Ankle Reconstructive Fellowship in Monongahela, Pa. He is an Associate of the American College of Foot and Ankle Surgeons.
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2. Edwards WH. Avascular necrosis of the first metatarsal head. Foot Ankle Clin. 2005;10(1):117-27.
3. Sammarco GJ, Idusuyi OB. Complications after surgery of the hallux. Clin Orthop Relat Res. 2001; 391:59-71.
4. Rothwell M, Pickard J. The chevron osteotomy and avascular necrosis. Foot (Edinb). 2013;23(1):34-8.
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9. Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM, Schuberth JM. Rates of revision surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy for correction of hallux valgus deformity. J Foot Ankle Surg. 2008;47(4):267-72.
10. Choi JH, Zide JR, Coleman SC, Brodsky JW. Prospective study of the treatment of adult primary hallux valgus with scarf osteotomy and soft tissue realignment. Foot Ankle Int. 2013;34(5):684-90.
11. Godwin Y. Do they listen? A review of information retained by patients following consent for reduction mammoplasty. Br J Plast Surg. 2000;53(2):121-5.