When Bunion Surgery Fails

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What To Include In Patient Consent Forms

I am sure your surgical consent form is similar to mine. I write out the name of the proposed surgery (i.e. Austin bunionectomy) and describe it in lay terms. I am going to shave bone, cut bone, reposition bone and use internal hardware. I also have a paragraph for all patients stating that, “I will do any additional surgery or modify the proposed surgery if necessary to obtain the best possible result.” I feel it is important to do whatever it takes to get the surgery done right.

As long as the additional surgery is reasonable, there is nothing to worry about regarding your consent form. For example, I have done an opening base wedge osteotomy and needed to add a Reverdin osteotomy to get a congruous joint. I have also obtained patient consent for an Austin procedure and then realized that I needed to do an Akin procedure (which was not included on the consent form). That is completely acceptable.

Certainly, there is a limitation to what you can do without consent. For example, it would not be appropriate to obtain consent for an Austin bunionectomy and then decide to do an arthrodesis of the joint. To address that potential problem, I will often obtain patient consent with an “either/or” procedure. For example, I may obtain patient consent for an Austin or a closing base wedge osteotomy. Certainly, the postoperative protocol is different. I will tell patients they may wake up with a soft dressing on their foot with a surgical shoe or a cast. They are prepared to be non-weightbearing after surgery if necessary.

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Author(s): 
By William Fishco, DPM, FACFAS

There are many procedures for hallux valgus and there are varying definitions of what constitutes a successful procedure. Accordingly, this author examines why bunionectomies fail, expounds on pertinent factors that impact healing and reduce recurrence risk, and explains how to advise patients on potential pitfalls of their surgery.

Hallux valgus reportedly occurs in 23 to 35 percent of the shoe-wearing population.1 We know that bunions are more prevalent in shoe wearing populations, older people and in women.1 To that end, bunion surgery is commonplace for the podiatric surgeon. In the literature, more than 100 procedures have been reported in the correction of hallux valgus, which means that there is no “gold standard” surgical approach to the correction of the deformity. Many of those 100 procedures have fallen out of favor. However, many options and their variations are well accepted and surgeons utilize them regularly.

   A common question that patients ask me is, “What is the success rate for bunion surgery?” That is a good question that I have trouble answering.

   The best I can tell my patients is that it works most of the time. Certainly, there are subjective and objective parameters to consider when deeming a bunion surgery successful. Most of us will opine that the surgeon is much more critical than the patient when determining good results. For the patient, pain must resolve and the appearance should be acceptable. From the surgeon’s perspective, success is based on a combination of appearance, function, range of motion of the great toe joint, and radiographic analysis.

   Just like any other surgery, bunion surgery can fail. A list of the more common complications leading to failure include: loss of correction, under- or over-correction, delayed union, malunion or non-union of osteotomy or fusion, joint stiffness, nerve entrapment, and excessive shortening of the first metatarsal leading to lesser metatarsal overload. As we all know, other complications may include hardware failure/irritation, infection, prolonged swelling, deep venous thrombosis and complex regional pain syndrome. Luckily, most of these serious complications are relatively rare.

   The most popular techniques that podiatric surgeons employ include distal metatarsal osteotomies, which are popular due to their consistent good results and uncomplicated postoperative protocol. Unfortunately, this type of technique, which we all feel very comfortable and confident with, cannot fix all bunion deformities. If an Austin type bunionectomy can fix 95 percent of bunion deformities, then you will have at least a 5 percent failure rate. This assumes that you have no complications every time you perform an Austin bunionectomy.

   Of course, this is all theoretical and the point that I am making is that to be a skilled surgeon, you have to know when you can do your “favorite” procedure and when you need to do something that you are less comfortable performing. Remember the old adage: if all you have is a hammer, then everything is a nail.

Keys To Appropriate Procedure Selection

So how do you choose the appropriate bunion procedure to perform? Is it based on evaluation of the intermetatarsal angle on X-ray? Do you take measurements? Do you use templates? How does the clinical exam play a role in your decision making?

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Dr.Adam Katzsays: October 12, 2013 at 8:08 pm

Nice article on bunion surgery and yes it can fail! But surgical correction should always in my book be the last resort. Too many treatments to utilize before putting someone under the knife. Please stop by our blog at www.premierpodiatrygroup.com .

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