David Davidson, DPM reviews the causes, symptoms and the radiographic appearance of bunion deformities. Dr Davidson discusses the opening and closing base wedge osteotomies as potential treatments of a symptomatic bunion, highlighting the indications of each procedure. Intra-operative slides are presented.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
David Davidson, DPM
Center for Wound Care & Hyperbaric Medicine
Erie County Medical Center
Buffalo, New York
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David Davidson Dr. Davidson has disclosed that he is a Consultant/Advisor and is an independent contractor for Vilex, KCI and Advanced BioHealing
Moderator: Our next presenter is good friend of mine, it is Dr. David Davidson. He is the chief of Podiatric section, Department of Orthopedics at Kaleida Health System, I believe I pronounced that correctly in Wound Care Hyperbaric Oxygen in Buffalo, New York. And I have asked him to speak on opening versus closing wedge osteotomies in hallux abducto valgus. Please welcome Dr. Davidson.
Dr. David Davidson: Thank you. My name is not Ryan Fitzgerald. Allan Sherman called me last night about 9:30 and said if Ryan is delayed could you do your 5 o�clock lecture at 9:30, it is little bit later than that and I said sure, what Dr. Sherman failed to tell me that I was going to follow Warren Joseph. Warren is a good friend of mine, he has been a friend of mine for 40 years of more and I will try not to follow him again. In the event, I have just a quick question, how many of you because I�m not involved directly in the Residency Program although we have a really good one in Buffalo, how many of you are involved in � out of the [Indiscernible][0:01:16] in clinic practice, you guys have a chance to spend time in doctor�s offices? Anybody, yes, no � obviously nobody has really had a chance to participate in how do you evaluate a patient for what type of procedure? We talked about this little bit last night informally, I think you guys need to put pressure on your directors to get some clinical experience because you are been trained to be really wonderful surgeons, I think you need to be trained to be surgical podiatrist or general podiatrist and the only way you can really do that is to do that in the clinical setting.
I ask to do this lecture because I�m reminded about a year ago, one of the surgical companies went out to California because they said � we have this new opening osteotomy plate we would like you to use and the response was well, why would I need an opening osteotomy plate when I am having a lot of success with the closing osteotomy plates and screws and so forth. I found that really hard to believe because the truth is I�m not sure there should not be a controversy and that�s the comment that that rep was given and relayed it that to me and that was maybe over a year ago and I�m kind of not over that.
I use this article The Journal of Foot and Ankle Surgery in 2003 had a whole bunch of articles on hallux valgus and hallux rigidus limitus and I suggest that all of you put all these articles in your armamentarium. When we talk about hallux valgus bunions obviously this is pretty simple stuff, we need to get an adequate history, is there family history and most of the time there is. When is the patient getting pain, how progressive is that deformity and Dr. LaPorta gave a great presentation on that. We are generally going to find any or all of these medial prominence, there is usually a deviation, there may or may not be abnormal range of motion. There may or may not be pain versus inflammatory like bursitis and there may or may not be neuritic pain and you could have any of these associative findings, which includes by the way, �I get this chronic ingrown toenail.�
Radiographic findings, again medial prominence, you may or may not have joint space abnormality, you will or will not have high hallux abducto valgus angle, increased metatarsal angle, is there displacement of sesamoids, first metatarsal length. You are going to hear this from me, I�m giving a couple of more lectures this morning. Choosing the right procedure for the right patient at the right time and if you do that especially in hallux valgus surgery you won�t have to call your malpractice insurance carrier.
What procedure for what bunion? You have to evaluate all of these and I wonder why I highlighted the length of the first ray. We talk about metatarsal protrusion distance which basically you know this from first year Podiatry school is the comparison of first and second metatarsal relative length. We need to look at the x-rays and say is the first metatarsal longer than the second or is the second longer than the first, seems to be pretty basic but when you are in the operating room and the patients is wheeled in on the gurney, you may not even have the chance to see the x-rays. Choose the right procedure for the right patient at the right time. I suggest that if you do a closing base osteotomy on this particular patient what are you going to do. You are actually going to shorten it even more. Somebody tell me, I agree with Dr. Joseph, I can�t see anybody here, somebody tell me if you do a closing osteotomy on this particular patient, you may get a great result from the hallux valgus resolution but what is the scenario? What are the possible consequences in a year or two? Anybody yell it out.
Second and third, they are going to come in with pain, they are going to come in with callus so we don�t want to shorten that metatarsal, we need to recognize the short first ray; the right procedure for the right patient at the right time. Closing base wedge osteotomy, wedge a bone, we will achieve reduction at that angle but we will in fact shorten the osteotomy. Now, you can, and I make my proximal osteotomies very oblique, the more oblique the cut, the less shortening you are going to get, the less bone you have to remove, it�s just basic mathematics. Closing base osteotomy, I�m going to go through quickly because I don�t have an awful lot of time here.
I do an L-flap for capsular correction, I do locate the adductor tendon and release that, that�s controversial, remove the eminence, here I do an oblique cut at the base and I pre-measure this, I use fluoroscopy. This is the Vilex screw set that I�m using. I use fluoroscopy to make sure that the proper length is achieved, proper measurement, countersink, appropriate screw fixation, closure, confirmation with fluoro, closure of the skin. The more oblique the osteotomy, the better.
Now, let�s talk about the opening osteotomy. This is really important, probably the opening osteotomy is certainly little bit technically more difficult to do. I have a partner that generally likes to brag that he can do an closing osteotomy in 17 minutes. This is an opening osteotomy and it needs a little bit more time and little bit more care. Locating the first metatarsal cuneiform joint is extremely important. I do this before we prep the foot with fluoroscopy and we mark it so now I know where I�m going. Initial skin incision extending to the capsule. Again, I use the L-flap incision because I think we need capsular correction. This is controversial, it�s become a little bit controversial, do you need to an adductor release, do you need to do a lateral capsulotomy? In my experience, if it�s not broken don�t fix it so I do this procedure. I want to confirm and reconfirm the first metatarsal cuneiform joint and I basically can do that with a K wire or a blade and again visualize it with fluoroscopy.
Using an open osteotomy plate, I mark the position of where the osteotomy is going to be. Resection of the medial eminence and now we are going to the base osteotomy. Here with an opening, you are doing a medial cut osteotomy and this is the most important part of this procedure. You need to preserve the lateral cortex. Again this is a procedure that needs to be done with care. You need good exposure, you need to know where the first metatarsal cuneiform joint is so you can isolate that. Now, one other comment here, you know, when I said we need to evaluate the patient and the x-rays and part of that evaluation is the quality of the bone. If there is some evidence of osteoporosis/osteopenia, that osteotomy cut does not have to be carried so lateral because the bone is a little bit weaker. Make sure the lateral cortex is intact. Gently open that osteotomy with an osteotome and we can use a spreader to maintain that site open and we confirm with fluoroscopy to determine have we gotten the appropriate intermetatarsal correction.
Once we have done that, we put a sizer in and we place the wedge plate, the correct wedge plate and I also use K wires as was mentioned earlier in the lecture to temporarily fixate the plate to the bone. Then we use � this particular is the Vilex set, this particular that I use is 1.1 mm K wire and then a drill over that and we use fluoroscopy to confirm the length. Measure for the screw, place the first screw, use fluoroscopy to confirm that, placement of the second wire, measure and put the second screw and here�s the plate in place with all four screws. Again we have used fluoroscopy several times during this procedure to confirm the proper length of the screws and the amount of IM angle closure. Here�s the plate in place. We fill in the void with bone paste and that�s the end of the procedure. That�s our final fluoroscopy; preoperative, postoperative.
I am suggesting that this is a pretty closed procedure, whether we can do opening or closing, I still think this metatarsal is slightly short. This patient � if I recall correctly � this patient already had some second and third MP joint issues, I did not want to shorten that bone any further so that�s why I chose the opening osteotomy set.
The truth is as I mentioned I don�t think there is controversy, I think there is a place for both. Metatarsal length determines do you do opening, do you do closing. If it is a relatively normal metatarsal parabola you can do the closing, if there is a first ray, I don�t think there is a choice. Short first ray, high intermetatarsal angle, I don�t think there is a choice.
Now I�m not mentioning any of these other procedures, the Lapidus procedure was mentioned earlier, it is an excellent procedure to be used. Why would we choose Lapidus? Basically, what kind of the first ray pathology would there be in order to choose a Lapidus, what do you need to have? Flexibility, hypermobility, correct. If it is a rigid first ray, did not hyperbola enough, again the opening osteotomy is the procedure of choice.
I want you to open your eyes here and again I hope you would go to your directors and say we really would like to take an active part in how the surgeon chooses what procedure for what patient. If I have anything to close with, I would say, there is no controversy here, there�s an opening osteotomy procedure which is excellent, there is a closing osteotomy procedure which is time tested and an excellent procedure; metatarsal length determines which procedure to use. Thank you.