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.

By William Fishco, DPM, FACFAS

   Over-shortening of the first metatarsal can lead to serious problems. The patient may be thrilled that the bunion is gone (i.e. bump gone and toe straight), but the resultant pain under the second metatarsal head can be challenging to treat. Typically, the first and third metatarsal should be about the same length with the second metatarsal slightly longer. When the first metatarsal is the same length as the fourth metatarsal, there is a likelihood of lesser metatarsalgia. Over-shortening may be a result of osteopenia, inadequate fixation of the osteotomy, a poorly executed osteotomy or the patient started out with a short first metatarsal prior to surgery. Of course, it may be a combination of many factors. Certain osteotomy types, such as the Mitchell procedure, are known to cause excessive shortening.

   In my experience, delayed union and non-unions are relatively rare even with a Lapidus procedure. Certainly, risks for this complication are higher in smokers, patients with diabetes and those with vitamin D deficiency.

   Malunion of a distal metatarsal osteotomy occurs on occasion. It typically involves excessive dorsiflexion or plantarflexion. In both cases, a non-purchasing toe may develop. Malunions typically occur after the patient starts to walk altwhough a poorly executed osteotomy and fixation can certainly be the cause.

   When a patient presents to the office with a failed bunion surgery, the most important elements of evaluation should include: what failed (loss of correction, malunion, shortening, stiff joint, etc.) and why? Certainly, the “why” is your best educated guess after examining the patient and looking at before and after X-rays. Often, we do not have the luxury of preoperative X-rays. Sometimes, I will take an X-ray of the contralateral foot to get an idea of what the normal anatomy looks like.

   When I have to repair a sagittal plane malunion of the first metatarsal, my go-to procedure is usually the sagittal Z osteotomy. It affords correction in the sagittal plane where I can raise or lower the first metatarsal head. In addition, I can lengthen the bone at the same time if necessary. Rarely would I need to shorten the bone but I can do that if necessary.

   If I need to fix the malunion in the transverse plane and alter length, I will consider a Mau/Ludloff oblique-type osteotomy. These osteotomies are not very stable and require immobilization but are very versatile. You can shorten, lengthen, translate and swivel. Not many osteotomies allow one to manipulate the bone in that many directions.

   A challenging scenario involves patients who are happy with their bunionectomy but have developed lesser metatarsalgia. If the great toe joint is moving well, the patient is happy with the results and the joint is congruent, I find it difficult to address the first metatarsal surgically. I learned never to destroy normal anatomy but rather fix the abnormal anatomic segment. So the “textbook” answer would be to lengthen the first metatarsal versus shortening the second metatarsal.

   My experience with lengthening the first metatarsal is that it is fraught with complications and leads to stiffening of the great toe joint. Therefore, I tend to shorten the “relatively long” second and third metatarsal (if necessary). Shortening lesser metatarsals leads to other problems such as floating toes due to the lack of flexor power. Certainly, we try to minimize this with postoperative splinting and physical therapy. I make it a priority to explain to patients that pain will resolve under the second metatarsal head but the toe may float. They need to be aware of that. The last thing that you want to hear from your patient after surgery is that, “You never told me ...” (see the sidebar “What To Include In Patient Consent Forms” at right).

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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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