Sharing Perspectives On Bunion Surgery Complications And Limb Length Discrepancies

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

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