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Board Review Foot Conditions

The Management and Comprehension of Hallux Valgus Complications

Stanley Kalish, DPM

Stanley R. Kalish, DPM, FACFAS reviews surgical approaches to Hallux Valgus (HAV), complications, and avoiding unsuccessful outcomes.

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Goals and Objectives
  1. Define Hallux Valgus
  2. Review surgical options for Hallus Valgus (HAV)
  3. List possible complications of HAV surgeries and ways to avoid these
  • Accreditation and Designation of Credits
  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.5 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Stanley Kalish, DPM

    Senior Staff Surgeon
    Dekalb Medical Center
    Atlanta, GA

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    Stanley Kalish Stanley R Kalish, DPM has disclosed that he receives Honorarium/Expenses, is a Consultant to and serves on the Speaker's Bureau for Pfizer and Merck. He will be speaking on the investigational products dalbavancin and telavancin.

  • Lecture Transcript
  • Male Speaker: Hallux valgus. Okay, alright. No you're fine. This is slower than that. Okay, I’ll be talking about hallux valgus. I’ll do a little research here. I’ve done this lecture but why not make it more interesting for you? He coined the term in 1871. Interestingly, women have it more than men, we knew that and 27 reported a three-generation history of hallux valgus. A three generation, and of course we don’t help ourselves with some of the shoe gear we wear. Twenty two hundred procedures for hallux valgus, why? Everyone knows a breast of a Vietnamese gourd, but when we see that breast we say, “Wow, look at that thing.” When we look down, we see that it’s just a plant. We think we know everything about bunions. We were perceiving that this is what we know. We don’t understand how to fix bunions. Maybe what Guido’s lecture was so interesting is to get us to the point mechanically to have a better prediction from our x-rays before we jump in there and do the stuff that we think we’re experts. We don’t have a standard recipe. We all have big egos. You have to be a surgeon and cut on someone. We are all like kids and only learn from our mistakes. There is no wisdom available to count on. Come on, we know how to fix bunions, we’re podiatrists. It’s my concept of what’s going on here and yet I will tell you the complications always occur between the ears of the surgeon and not the bones of the feet. That’s been my experience. Don’t blame the patient. Don’t blame the hospital. Don’t blame the osteotomy. Don’t blame anything but yourself. You’re in control of the ship. “I don’t have one faith with bunion procedure” says LaPorta. But he has a system based on CORA. He says, “All procedures are good,” I disagree with that. “All procedures can be performed better,” I agree to that. “It helps to understand CORA act in osteotomy principles for prediction preoperatively,” I absolutely agree with that. “All you need is a pencil and a paper and a mathematical inclination,” I partially agree with that. The core is proximal. Ergo all principle should follow osteotomy principle too, angulation and translation. You need to be able to look at this more scientifically with either CT scans as you seen or x-rays that help you to predict the core and the act before you go on and start just randomly picking your bunion operations. Where do you start with the operations? Where do you go with hallux valgus surgically? You need regardless of the procedure to have an access guide. Either you use an .062 Kirschner wire to predict your access and mark the foot up with blue marking sterile pencils in surgery right on the bone, get some prediction. Hopefully, you’ll become more skilled in marking up your x-rays in getting a good prediction or having your residents give you a good prediction of the type of procedures that will work better surgically. But remember, you still have to cut the bone and the tissues. Here is simple K-wire works or you can go and get yourself a fancy one like the apical axis guide [indecipherable] [03:34] and determine exactly where you’re going to put your cuts. Once you put these axis guides on, we get so excited with the bone saw that we just cut them anywhere. Follow the axis guide precisely. Don’t make an axis guide cut and not use it, that’s ridiculous. When you’re doing some of these osteotomies, remember what I said before. Get simple, use simple fixation devices. The cortical bones screws standard whenever possible create the simplest osteotomy. Also remember, don’t help the body create a failure by degloving all the soft tissue so you have this beautiful long osteotomy. Maybe that’s why I’m so afraid of the SCARF procedure and don’t know anything about it and don’t do it and can’t talk about it. Because I’m afraid of all this long exposure and I’m absolutely afraid of multiple osteotomies regardless of the fact that I’m an expert on fixation. You must have enough real estate to accept two screws certainly for this long dorsal arm osteotomy. Here are some complications of the most commonly utilized procedures in podiatric surgery. Again everyone, this topic is a lecture of an hour of itself.

    [05:00]

    You’ll excuse me if we missed. Metatarsal nonunions come from all of them. Go pick a procedure, a Mao, a Ludloff, over a SCARF or Reverdin or Watermann. Every single one of these procedures have the potential for nonunion. With the most common procedures is a muscle tendon balancing procedure and if you understand one thing about the fixation, the fixation is our enemy. What? What are you talking about? It’s your enemy. It’s the enemy because once you fixed a bone with cortical bone screws, it’s not moving. When we did impaction osteotomies, when we created hallux varus with soft tissue, Washington Monument incisions on the capsule. As soon as they walked on it, the fixation slipped back into good position and the foot look great. That doesn’t happen with rigid fixation. When you add soft tissue balancing to it, to a rigidly fixated osteotomy, you’re going to get at least the hallux adductus and most probably a varus. First, choose the right procedure. The enemy of good is better. Anybody here remember the derotation on transpositional osteotomy? I always said, that probably was a pretty good osteotomy. The fixation wasn’t up-to-date to it. The nonunion rate was terrific. Now, I’m back to my original concept that I don’t like multiple osteotomies on that little metatarsal bone or on the proximal phalanx doing the same day on the same patient. First, do no harm. Where is my bunion, please give me my bunion back doctor. Okay? Can you find it for me? When you’re in there, use joint motion assessment. Reduce the IM angle. See how flexible it is. Go in and dissect. Do a rod, do a Rock anatomical dissection release of fibular sesamoids, the fibular sesamoid or ligament then put your finger down into this and see what the metatarsal looks like sitting at the base on the head and getting a congruous position. Look at the cartilage to determine. Well, do I need an osteotomy? Do I need a Reverdin? Well, I certainly think I do from reviewing my preoperative x-rays and looking at the act and the core of these patients and looking at all the angulations I marked up on the x-rays, but here I’m looking at it. What do I need to do to correct that? A low the MPJ, straighten the sagittal motion, stop. This is where I want to be. This is where I wanted to stay. Don’t add anything that doesn’t need to be added. But I told her I was going to do an osteotomy. It’s not necessary, don’t do it. What’s the lateral deviation? Do I need further release? I take my thumb and I put it right behind the bunion. I put a tiny amount of pressure on the skin. If the toe comes over, I’ve done enough in the interspace. If it doesn’t, I go back in and do more. It’s automatizing the flexor hallucis brevis if you need to. Transferring the adapter, no. Not unless you’re doing a pure soft tissue non-osteotomy procedure. Don’t do it universally on patients that have low IM angle. You could use it for a cheater procedure, meaning you need additional intermetatarsal correction because you did a metaphyseal osteotomy and you didn’t do a Lapidus or a base wedge and you want a little bit more. That’s when you add some of your tenotomies and you add your adductor transfer. But you’re controlling the situation based on looking on it, looking on the feel, feeling it. Look at the fact whether you need indeed to have distal osteotomies or proximal osteotomies. What is your deformity beforehand? Absolutely. I just adore listening to some of these technical axis on x-rays. Understand that that is only helping you with that information on the right side of your brain but the left side of your brain is saying okay, that really is correct. Technically, I can make this bunion work. Look for the dynamic imbalances and understand when you’re dealing with this disaster called hallux varus that you have to go and undo everything that you’ve done to get it back in position and do it fast because if you do it slow, the joint goes to hell in a handbasket within six months. Looking at some of these failures that you see classic historical McBride with a fibular sesamoidectomy, a stake metatarsal excess of medial capsulotomy, there’s nobody sitting in this room that would do that.

    [10:03]

    Nobody. Nobody who’s had four years of podiatric medical school and residency training. I’m not worried about those but I do see them, where do they come from. Again, understand the etiology of this and understand that the hallux varus occurs a failure between the surgeon ears. A very, very prominent orthopedic surgeon in South Florida did this to a plastic surgeon’s wife. I try to fix it. Still unhappy 10 weeks later. We’re not gods. In 35 years of practicing medicine, I’ve only come to too hard and incontrovertible facts. There is a god and I’m not him or her. Reasons for failure for bunions are poor inappropriate procedural selection, poor planning, poor x-ray planning, inadequate exposure or too much exposure creating avascular necrosis, suboptimal executional experience, decreased healing potential, unworthy patient, poor compliance. There is a whole host of situations. Don’t operate on a patient that’s not worthy of you. Here is a great surgeon, wonderful surgeon. Does an osteotomy. Invented the osteotomy, put the screw on the second toe little too long. But what the hell happened here? Poor dissection, overzealous, maybe I was filming this, maybe I was showing off. I don’t know what I was doing, but all I can tell you is looking at this is the design was good. The fixation was good. Instrumentation was good. The brain wasn’t good because I tucked in the glove the whole metatarsal wound up with this. What idiot would convert a simple bunion to this? I confess, it was me. Okay. Ache and failures, I’m not going to talk about them but again, they are all failures. Anyway you cut the bone, I’m not going to talk it all about, you know the nakedness, the medial closing wedge osteotomy, ache and complication. But you’ll see this guy in the upper right corner here. Mike Trepal is going to talk totally on this later today on ache and osteotomies and the failures and complications associate. I don’t want to certainly steal his thunder. But I can talk to you about the procedure that is near and dear to me and what happens and what are the complications. The technique of compression with screw fixation enhances bone healing. It’s not a fantasy. It’s not mystical as Meyer said. Early ambulation and range of motion is acceptable. Who wants to be in a cast for eight weeks like they used to be? Hallux varus is diminished by judicious use of the adductor transfer when you need it. A cheater type of a procedure. Add a little bit, a flexor digitorum longus tenotomy, brevis tenotomy, adductor transfer when you need it. Anatomical dissection works. Get one of Rock’s films, they are beautifully done. Two weeks post Kalish osteotomy, happy patient. No, I’ve had over the years of patients give me one thing, but I don’t think they were talking about one week. I think they were talking about something else. But here 25 years postoperative. I’ve seen a lot of lectures on failures of this osteotomy, like people who don’t do the osteotomy. I wonder where the failures come from. If you don’t do it, you’re going to fail. It can work well and usually does. Here on a patient who in 25 years later, I can be critical in saying, look, there’s a little plantarflexory limitus but I know we get that because we’re hell bent on plantarflexing the first metatarsal with axis guide concept. When you do that, you almost always get a plantarflexory limitus. Dorsiflexion is perfect. Here, 25 years later, trauma screws 273 and 3.5 trauma screws, 25 years after this operation with good joint position. Don’t blame the operation if you fail. You’ve failed on the indication. You failed on the preoperative planning. That osteotomy stinks. Of course, it stinks. You used it for the wrong indication. Here are some failures I can show you with hallux varus. Overstaking of the bone, the tibial sesamoid peaking, the osteotomy negative correction, failure, a disaster. Winds up with a silastic implant.

    [15:02]

    A double disaster. Give me back my bunion, please. Case presentation. Now, if you look at those screws, what are they purchasing? When you push the osteotomy laterally, you have to drop your hand dorsal medial to plantar lateral. If you drop the screws straight down, all you’re doing is purchasing air. The screw is going to back out as you see and you’re going to get motion and you’re going to get a short metatarsal and you’re going to put on nonweightbearing and you got to call the oxygen person or anyone of the bone stimulator. Then you got to go out and get a locking plate. You got to put this on and put them on a cast for three months. Give me back my bunion, please. Go find it in the garbage can. I can’t figure out what this Kalish osteotomy was doing. We call this the ZIP code screw. We sent it to the wrong address. Okay. Where the hell is that screw going? How did it get down there? Some more failures here again. The wrong direction of the bone screws, and failure. At least, use kind of an Iowa [phonetic] type of loop to try to salvage it and get a good result. Some more failures here. With elevatus, just disasters. I showed you this case a few minutes ago. I don't know why it came up again. Again, adequate dissection apical axis guides, strict adherence to AO technique, reviewing the lab and ask a colleague to scrub. Know what to do when it fails. SCARF, I rarely ever do the operation, can’t offer you much on it, sorry. I made a comment on the radio with some master’s meeting and about 10 people called and they said, you don’t know what you’re talking about. I said, you’re right. I shouldn’t have said anything about the SCARF. But you can get complications. I guess I don’t like the SCARF because we never were trained on it. I never learned on it. Nobody ever did it at the institute. The concept of a long bone osteotomy with big exposure does have its advantages mechanically and from a radiological planning point of view but the fixation has to be done perfectly and the patient really has to be careful that the fixation is good and tight. Only you know in surgery and you’ve heard me say over and over, when you put your hand on a bone screw, on a K-wire, you’re going to feel tight, tight, loose, loose, tight, tight. Your brain is being told that the cortical surface is being entered when it’s tight. It gets loose you coming into cortex. It gets tight again when you’re on the opposite cortex. This is something you will judge, postoperative care. If you get good two-finger tight compression and you feel that tight, tight loose, loose, tight, tight. These are the patients that can ambulate. Closing base wedge osteotomies, again we’re running out of time. Shortening elevatus, failed fixation, malunion, nonunion. Here, look at some of these cases of patients who have had failure. Ouch with these people. These people have failures because six-week postop noncompliant. Operation is intrinsically unstable. They have to be nonweightbearing with this. Intrinsically, you can get shortening with this operation. You have to fix these. These are disasters that wind up in unfriendly hands who turn around and sue you. Nonunion, removal of fixation, revision of the site, reduction of the osteotomy, restoration of the length. Holy mackerel, why they ever do this operation? Fixation technique, here talking about the dissection, taking some of the bone that you can use for bone packing, distal lateral exposure to the joint. The nonunion osteotomy, using bone that’s good bone to put back into areas where you had fixation. Provisional fixation, get some x-rays, get an intraosseous wire ankle loop that you can use in combination with bone screws, has multiple applications in failing operations. Good stable fixation and then compression with a simple Cancellous 4.0 screw. Looking at these patients nonweightbearing three weeks, six weeks, two months, three months, four months.

    [20:15]

    To me, that’s a failure to take a bunion operation and let it go that long. External fixators can be used but we’re not going to talk about this and look at these disasters and failures with conventional plating. On your postoperatively, here I showed you this bony reabsorption with a standard plate, a locking plate will avoid it. I’m going stop here because I’ve run out of time in 20 minutes trying to tell you how to deal with hallux valgus. I thank you very much for your great attention.