Sharing Perspectives On Bunion Surgery Complications And Limb Length Discrepancies

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   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 or “Current Insights On The Use Of Orthotics For Limb Length Discrepancy And Morton’s Syndrome” at .

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