Conferences Residency Summit Midwest 2016

Angulation-Rotation Deformity and Other Life-Altering Situations

Guido LaPorta, DPM, MS

Guido LaPorta, DPM, MS discusses how deformity planning aids in surgical planning and procedure selection. Dr LaPorta discusses how to use the graphic method to better plot out your surgical plan.

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Goals and Objectives
  1. Learn to identify rotational deformity in HAV
  2. Understand how deformity planning will result in better outcomes
  3. Understand the graphic method and deformity parameters
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  • CPME (Credits: 0.75)

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  • Author
  • Guido LaPorta, DPM, MS

    Director Podiatric Medical Education
    Community Medical Center
    Scranton, PA

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    Guido LaPorta has nothing to disclose.

  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: Okay. Our next speaker is not a stranger to us all. I have known Dr. LaPorta [phonetics] for too long. Where did he go? In fact, I think I met him when both of our kids were little kids and the years have gone by quite quickly [Indecipherable] [00:00:25]. I've always considered Dr. LaPorta really to be one of podiatry's best educator. He always thinks about his presentation and puts a lot of time and effort into them and always comes out with some insightful comments or different twists to a very common theme. So with that said, Dr. LaPorta is going to be talking about deformity planning as being vital to complex reconstructive surgery. This talk is supported by an unrestricted educational grant from the MedPro group. So let's welcome Dr. LaPorta from Scranton, Pennsylvania.


    Dr. LaPorta: Thank you sir. So I've been asked to give you my thoughts about deformity planning and why it's essential to what we do. And I'm going to do that in a number of ways. One is I'm going to pontificate for a while and then I'm going to show you an example of what I considered a clinical problem and how I, kind of, looked into deformity planning and what it could tell us about that particular deformity. So I would like to start a lot of my talks with take-home points. So after the first three slides if you want to leave, that’s fine with me too. You've got all the take-home points. So just recently I was shown a book written by Dr. Christopher Ahmad who is an orthopedic surgeon, sport medicine specialist from New York City and it's called Skill. It’s the book that gives you 40 tips on how to improve what you do regardless of what you do. Whether you are surgeon or not, it is very generic and gives you a number of tips which I found fascinating and very useful. One of these tips was to continue to develop skills and he likened it to passion. Now, most of you've been here all morning and you've heard Dr. Freiberg [phonetics], Dr. Huddy [phonetics], Dr. Derrick, Dr. Garofalis [phonetics]. And I would think after hearing them that in no way would you question that they have a passion for what they do, for what their subject matter is. Freiberg is like a walking PubMed. If you want to know any article ever written about anything in wound care, all you got to do is ask him. Okay. But you have to avoid the second trap and that’s second trap is misnomer. It says that if you're great at what you do, somehow that was genetically predetermined, that you were born with great hands, that you were born with talent. And you're not born with talent. That’s something you acquire, that’s something you work at. I knew Freiberg when he was functionally illiterate. [Laughing] Alright. He has improved tremendously over the years because he has a passion for his subject matter and that’s something that we all have to develop. And I think we all should develop it because we are in fact and want to be the caretakers of the foot, ankle and leg. And the only way we can do that is have a passion for the subject. Ahmad talks about finding your sweet spot. And what he means by that is you have to push yourself to a point where you're just past where you feel comfortable with what you're doing and what you know. How many times do you have to hear a lecture on the Austin bunionectomy. Okay. They're all the same. Nothing has changed in the last 15 years. So why do you need to hear another one? Why not lectures on how to alter the Austin bunionectomy to handle certain clinical situations.


    So if you feel comfortable when you leave a lecture or hear a lecture, you probably didn't learn anything. All you did was reinforced what you already knew and already do and that doesn't make you more skillful. You want to become more skillful. What you want to do after you know what's in the box is think outside the box and have those clinical situations that give you a problem and continue to give you a problem and how can you address them and answer those particular problems. I had a laugh before when Dr. Freiberg quoted [Indecipherable] [00:05:49] because it is in my lecture too. It’s a statement that I've always remembered. When he said it, you see what you look for and you recognize what you know. Well, that’s not good enough. You know that’s akin to if all you have is a hammer, everything looks like a nail. You've just got to expand somewhat in order to become more skillful. And what I tell my residents is failing to plan is planning to fail. And they hate me. I'll be the first to admit that. Okay. I am pain in the rear end to most of my residents and that’s okay because the majority of them come out well trained and are very successful and push the envelope and that’s the only way you get better. But I tell them the deformity planning, evaluating the situation is the only way that they can develop a problem list. And that doesn't mean you have to address every problem, but it means that you can't make that decision until you know those problems are there. Somebody might have the limitation of dorsiflexion. You may not have to address it in that particular patient. Or you may address it nonsurgically as opposed to surgically. But you have to know the problem exist before you can make a rationale decision on what to do for it. I told them to anticipate all the problems that they can imagine might occur during a surgical encounter and think about it preoperatively when they have time to plan what they're going to do about it. Okay. That’s one decision you don't want to have to make in the heat of battle. You know what can go wrong in surgery. How you're going to deal with it. And when you're sitting down and you have time to think about it, you have time to look up references and determine what you can do or what the best course of action might be, that’s when you should plan how you're going to manage them. [Indecipherable] [00:08:05] when they hit. We have a preoperative conference a week before my scheduled surgery day in Scranton. And that’s when I find out what residents are assigned in my cases. Anyone who expects to do the case, I send them to my office and I say dictate a detailed operative report of that case. The usual question at least in the beginning is why? It is usually because I want to make sure that you understand what you're going to do. I want to make sure you understand the sequence of events, the instruments that you're going to use. If you have to strip periosteum, I want to know what you're going to use. Some of them in the beginning say, well it doesn't matter what I use. I can use any one of a number of things. And I assume that’s probably true. What you're going to ask the surgical tech for. You know, hand me the it-doesn't-matter. I want to know what you plan to use and I want a smooth transition in this case. There is more time wasted in the operating room because you didn't think about what you were going to do sequentially. And you are hemming and hawing. And if you thought about it, it would make a smooth transition during the case so that while you're doing one step, you can be telling the surgical tech to prepare the instrumentations for the next one. Okay. I think that's very important. I also think it's essential for you as a surgeon to grade your surgery honestly.


    Okay. Honestly. And the reason for that is that you want to be able to improve your performance. And you can't do that unless you're honest about how you perform during the past surgery. You spent too much time looking at your good results. You learned nothing from your good results. You need to evaluate your bad results so that you can avoid those bad results in the future. And then once you think you have got it, teach another surgeon. Teach a resident how to do it. Nothing codifies your skill and your appreciation of the knowledge of a particular subject until you try to teach it to somebody else. Or you have to prepare a presentation on that particular subject for someone else. And I tell all the residents I want you to think of this presentation of this gentleman or lady that you're going to teach it to is going to go into the next room when you're done and take an exam. I want you to make sure they know everything they need to know to pass the exam on that particular subject. There is some random traps that I think you should avoid. Mention the first one. Talent is genetically predetermined. It's not. It's an acquired skill and you need to learn how to acquire it. Here is another trap. Practicing something before you learn how to do it right. I'm not sure what you're doing, but it's not practice. You are wasting time. You have no traction. You are spinning your wheels. You got to learn how to do something correctly first, then you can practice it. And doing it correctly, you may not get that the first time around. You may have to work at it, but once you understand it and know how to do it correctly, then you can practice it. I think you're foolish if you don't scour the literature before you do surgery especially the first time because you may find out certain pitfalls and traps that other surgeons have encountered. You may find out ways to address that. You may find out how to build a better mouse trap. How to do that surgical procedure better than you might have done it just going in there on a whim. And the last two are very important to me. I constantly hear we're the best. We know what we're doing. Orthopedic foot and ankle surgeons aren't that good. They're not that talented. They don't know biomechanics. And I'm here to tell you're dead wrong. Absolutely dead wrong. They're well trained. They're in many cases the best in their profession. And if you continue with that thought in mind, we're going to be second class a lot sooner than you would hope for. So realize the strength of the opposition and take the steps accordingly to make sure that doesn't happen. The one thing that our group has, I think, more so than they is passion. But remember they have all the hospitals. They get many of the referrals. They're in the lot of systems we're not in and consequently that feeds their knowledge of these various pathologies. And the last one is just as important. Somebody else mentioned -- yesterday afternoon speaker mentioned that you would make a huge mistake if you think plaintiff's attorney is a bozo and doesn't know anything podiatry or how to provide care for your patient. Think of this, all the planning you should have been doing before you did a surgery or rendered care, plaintiff's attorney has now had months and in some cases years to understand what you did or didn't do. In my experience doing expert work, I have found that plaintiff's attorney are as well versed and in many cases better versed than the physician in whom they're bringing the suit against. They know every aspect of that case inside and out, have had all types of expert explained it to them. They come in to a case with a theory of why you didn't provide a standard of care.


    So underestimate plaintiff's attorneys. They do what they do well and you would be well to recognize that. Okay, enough pontificating. Okay. Let me show you a clinical problem that I had to address. I have often thought as early as 2000 so that probably 10% of bunion patients that I see have a rotational component severe enough that it needs to be addressed. Then I looked at all the procedures that I was performing and said none of them addressed rotation. Okay. And you've all seen it, have you not? You do an osteotomy, you correct the bunion and sesamoid and the metatarsal still don't match up. The IM angle is reduced, toes straight. Toe may or may not move. Alright, but you didn't address rotation because there is a disassociation between the metatarsal and sesamoid. That means there is a possibility that one out of every 10 bunions you do won't turn out too well. Alright. So if you're in a big system in a big city, you may be able to hide that, but I practice in Scranton. I have practiced for 45 years. I do a 100 bunions a year. Okay. So that means if I didn't address this problem, I'd have 5000 people walking around Scranton with the result they weren't real thrilled about. Okay. In effect, I only have 2000, but alright it could have been 5000. Alright. So this is something I had to address. I had to look into and see how other specialties handle the problem of rotation. So I figured it out using a banana. This is a right banana. Okay. And it has two deformities. One is obvious just like bunion deformities. The increase in intermetatarsal angle is obvious. You can see that. What may not be so obvious is that in fact when you look at this head on, you can see that the sticks representing the articular surfaces are actually rotated to each other. So not only is there a 60-degree angle in this banana, but there is a 45-degree rotation torsion whatever you want to call it between the articular surfaces. So one end of the bone is rotated relative to the other. So knowing that I asked the question. Can we correct angulation and rotation with one osteotomy, one stable osteotomy? And the short answer to that question is yes. And here I want to outline something for you. If you consider this tie and if I fold it on itself, I've created a 90-degree angle, have I not? But now, the bottom of the tie is looking forward. It's no longer underneath, it's on top. Alright. So rotating around my finger which is the axis of motion corrected angulation rotation around one axis. All you have to do is to be able to find out where is that axis. Alright. And if you can place the axis correctly or if you cut the osteotomy correctly, then you can correct angulation rotation with the same osteotomy very easily. So what we're dealing with is what's called angulation rotation deformity very common in the orthopedic world.


    I mentioned yesterday for those of you who were here that pediatric orthopedist who treat Blount's disease surgically deal with this day in and day out. So they have a three-part deformity, do they not? They have a varus angulation, procurvatum angulation and internal rotation of the tibia, distal on the proximal part. And they do one osteotomy, one cut through bone and straighten that. How do they do that? Well, they have to deformity plan. They have to find out where to put that osteotomy. So angulation rotation is present in longstanding first ray hypermobility with hallux valgus. When you see uncovered sesamoid in hallus abducto valgus, this is probably a rotational deformity. I mentioned this yesterday, did I not? Why does hallus valgus form? Because it has to and it can. Okay. It has to and it can. So what do I mean by that? I mean that the joint has limited motion. How does the body compensate for limited motion? How does the body compensate for an equinus. The foot pronates, does it not? You get dorsiflexion out of other joints when the ankle can't move. The first MTP joint can't do that. Okay. It can't do that. So if the first metatarsal can get out of the way, it will. It uncovers the sesamoid. That freeze up dorsiflexion and you've seen that, have you not? You go in, somebody has the worst bunion you've ever seen. You look at the x-ray. The metatarsals are over here. The sesamoids are over here. You put the hallux through a range of motion and it has 80 degrees of dorsiflexion because the sesamoids are uncovered. What limits the motion? You correcting it. Alright. You bring the metatarsal back. You put it over the sesamoids. You cinch up on the medial capsule. And now, everything is so tight in there because you reduce the internal cubic content of the joint that now the hallux can't move. I mean I've had patients telling me great job doc. That toe is straight as it can be. How come it doesn't move like my other foot? Alright. Well, we did a few things. It's no longer like your other foot. Okay. So there has got to be a way then to address rotation without doing those maneuvers. Most osteotomy procedures that we do reduce the IM angle but osteotomies that address rotation are through and through osteotomies. Alright. And other than the chevron, we have an aversion to through-and-through osteotomies. Scarf is through-and-through osteotomy. Lot of scarfs done in Chicago area. Yes. Chevrons are done all over the world. Distal Ls, they're all through-and-through, but they're stable. Because of the construct of the osteotomy, they're stable. You can't address rotation with a scarf. You can't address rotation with a chevron. You have to do a less stable through-and-through osteotomy and that’s why I think most people have sighed away from those particular procedures. So definition of terms, we won't spend any time on this. We went over this yesterday. Rotation is an angulation around axial axis. Okay. Oblique plane deformity, I talked about yesterday also. We describe hypermobility is a biplane deformity. We describe it is the metatarsal moved over and up. In fact, it didn't do that, did it? It moved that way. Alright. It moved in that plane, that’s oblique plane. It's not one of the cardinal body planes. It's in between two cardinal body planes. We know what CORA is. It's the apex. We know what the osteotomy principles are. The axis I just showed you, didn’t I? with my tie. It's the points around which one part rotates around another in order to correct the deformity.


    There are only four types of osteotomies we can do, okay, regardless of whose name is attached to it. There is only angulational; opening, closing or neutral wedge. Translational; translational where you slide one part relative to the other. Linear osteotomy which is shortening, take out a piece of bone, add a graft to lengthen. Or rotational osteotomy. So when I saw that rotational osteotomy, so what the heck are they talking about? How do you rotate something? So I looked into it. We know the osteotomy principles. I'm not going to bore you with that again, but the goal here is to do the simplest osteotomy that will correct rotation and angulation without having to remove intricate pieces of bone that destabilize the metatarsal. What we want to avoid is osteotomy rule 3. This is osteotomy rule 3, call it anything you want. This is an arcuate or crescentic ostetotomy. It's rotated within the osteotomy. You noticed that the CORA is not where the two true CORA is. So you created deformity to correct the deformity. You want to avoid that if you can. Every base wedge opening or closing even Lapidus and certainly cuneiform osteotomy that doesn't translate is osteotomy principle 3. You created deformity to create the deformity. And that served us for years, hasn't it? But the point is you can do it better. All you need to know is that you need a little translation. Alright. So how do we figure all this stuff out? Let's look at the graphic method. For most cases, our deformities don't approach 40 degrees. Certainly, the IM angle doesn't and the rotational deformity doesn't approach 40. There are lower numbers. So you can use this simple graphic method. And the graphic method means on a graph, you let one degree equal one millimeter. Okay. So if we plot angulation against rotation. And yes I had to go back to my trig stuff because I had forgotten all of this. Alright. Because nobody told me why it was important while I was studying this. It happens to be important. So one degree equals one millimeter. So I'll plot 45 millimeters of rotation in my banana and I'll plot 60 millimeters of angulation in my banana. And the simplest thing I have to do is then looking at that banana and that deformity, I complete the parallelogram, very simple. Alright and then I draw the resultant vector from the zero point to the point on the parallelogram. I have a green line now and what does that green line tell me? It tells me two things. One, it tells me that my deformity is really 65 degrees. Alright. The resultant deformity is always larger than any one of the component deformities. So my 60 and 45 millimeter deformity is really a 65 millimeter deformity. That line is 65 millimeters long. More importantly, it tells me that it is 50 degrees from the horizontal. So my osteotomy needs to be 50 degrees from the horizontal in order to correct the angulation and the rotation in that banana or in that metatarsal or in that mid tarsus or in that heel or in that tibia. Anything that you plot. Alright. So the osteotomy angle is 50 degrees. Now that may be boring and childish for you. So you may be a trigonometric wiz. Alright and you want to do it in trigonometry fashion.


    Well, it's easy then. You can figure out where the axis is. By the way, all your smart phones allow you to do this. You don't even have to be good. Just punch in the number. So you can figure out the angle of the axis by doing an arctan function of rotation divided by angulation. But as soon as you do that, then you've to think the second step. Well, if that’s the axis, then osteotomy has to be perpendicular to the axis. So why not just figure out the osteotomy. Okay. And if you do that the formula is arctan of angulation divided by rotation or osteotomy angulation rotation. Alright. The arctan of angulation of rotation, you can figure out the angulation of your osteotomy. So as it turns out because of hallux valgus deformity and because you usually want the metatarsal to internally rotate because it's externally rotated that you have to drop your hand so the procedure that corrects osteotomy angulation and rotation in any IM angle deformity is a Mau. It is the simple Mau osteotomy. You just have to know what angle to drop your hand from the perpendicular so that you make the Mau at the right angle. And then here I'm cutting a Mau osteotomy through the banana. And then I rotate it. Right within that one cut, I rotate the distal fragment. Okay. And you can see that that’s the axis. I could have figured that out right from that formula and then made my osteotomy at right angle to that axis or I just figure out the axis to the osteotomy and after the rotation is complete, then I have greatly reduced the angulation and more importantly I've reduced the rotation of both ends of the bone. So one cut, Mau osteotomy, rotate. So in that cut, I can do angulational correction, I do a rotational correction and I can translate the distal fragment. You may say what if that is unstable. Walk through the exhibitor area. There are at least 17 plates out there that you can use that will make this a stable construct. So it's no longer a matter of can I fix this? The problem is going to be to figure out which one you like best to fix it. You can make this a stable construct. Okay. And there is the rotation reduced. Alright. All it took was the right angle of the osteotomy. Alright. What about oblique plane because all I did was reduce the IM angle, didn't I? What happens if your metatarsal is elevated too? Do you see that in a lot of HAV deformity? I think you do, not every one. But if you look at the lateral view, your first ray is higher than two. So do you want to bring that down to the wedge supporting surface? I think you do. If you did that, you can't make that osteotomy like you just did. You're going to have to angle it to one side. You're going to have to angle it laterally or medially. How do you figure that out? Alright. So let's look at an oblique plane deformity. Here is a normal typical hallux valgus patient. In the transverse plane, the literature says anything between 0 and 8 degrees is normal. You figure that out on the AP x-ray. And on this particular case, you measure a 17 degree IM angle. Alright. You don't want to bring it to 0 usually. Let’s say we want to bring it down to 5, so that’s a 12-degree deformity. I wanted to be 5, why? Because the nonbunion foot IM angle is 5. Alright. So the first thing I do is look at the patient's other foot. If the patient's other foot is abnormal, then I have to use population normal.


    Alright. But I want to make it like the other foot, so I have a 12-degree IM angle deformity. I look in the sagittal plane, lateral view. The normal metatarsal declination is somewhere between 18 and 22 degrees. In this particular case, we measure 15, our goal is 20, so we have a 5-degree deformity. Okay. And in the frontal plane, the metatarsal can be rotated anywhere from 10 to 13 degrees bottom facing laterally. We have a misnomer that the bottom of the metatarsal is facing down against the floor, it's not. It's rotated with the bottom facing laterally. So in this example, I say that the metatarsal has rotated away 1 degree. So I have 11-degree deformity because I wanted to bring it to 10 degrees internal. So I know what my deformity is. Alright. I have three planes of deformity here. I have 12 degrees, 5 degrees and 11 degrees. What do I do with that information? Well, the first thing to do is to find out the oblique plane. Okay. So in this particular case, I think of my foot like I'm looking at it. Okay. So I'm looking down at the right foot, dorsal on top, plantar on the bottom, medial to the inside, lateral to the outside. And I plot my deformity. So dorsally, I had a 5-degree deformity. Medially, IM angle I had a 12-degree deformity. Do the same thing. Plot the parallelogram, completed. What it means is that I have a 15-mm deformity 30 degrees from the horizontal. Okay. So in the last case, I took my blade and angled it down 50. Now, I've got to angle it 30 degrees in the direction I want the metatarsal to move. Alright. Can you do that? Of course you can. If I asked any one of you to approximate 45 degrees with a blade, you'd be surprised how close you come. 30 degrees with a blade, you'd be amazed that how accurate you would be because you've been doing all this crap for years, right? You're learning how to do it. You have to visualize that. If I ask you to drill or wire it right angle to the bone, you can all do that. Don't sell yourself short. And I don't want to hear, x-rays aren't accurate. Don’t measure angles on them. Because the same people who tell me that take x-rays with angles postop to show me what a great job they did. So it's either good both times or not good at all. Alright. And my take on that is x-rays are very accurate. You take them the same way every time. Okay. Most of them now are digital. You calibrate them. They're as accurate as can be. So that's the spinning on that. So 30 degrees what does that mean? That means if I want to reduce the IM angle and plantar flex the metatarsal, the blue line is my axis for proximal osteotomy. Alright. It's 30 degrees angle to the horizontal and the black line at right angles to that is the apex for my chevron. In both cases, when I cut the osteotomy and slide the distal fragment, it will move 30 degrees. Alright. And it will move down that plane and you will correct dorsiflexion and IM angle at the same time. Then you can plot that against rotation and you know exactly 50 degrees. So if I'm going to do a Mau, alright, I start with my blade right angles to the metatarsal. I drop my hand 50 degrees. I rotate it towards the side I wanted to turn 30 degrees and cut.


    Pretty simple. Alright. It’s the same cut you made without thinking about it just cutting through the bone. All we're doing is given you a parameter of where to face the blade. So now, you just rotate it. Okay. Translate it, put a plate on it, two screws, whatever you want. And fortunately, it’s a Mau and not a Ludloff which in the Mau just by its very nature is more stable. So that’s my schpiel. And my schpiel is you can do this for every deformity that you ever address; tailor's bunion, hallux valgus, callus foot, flat foot, supramalleolar deformity. All you need is the draping on the table and a marking pen and you can map this out. Alright. And you should. Because you should want to do this as accurately as possible. Alright. Learn deformity planning. I think it's extremely important. Once you deformity plan, then you can make a rationale decision, that’s not important, that’s important, I'm going to address it. But before you know what the deformity is, you can't make that decision. Okay. Then all you are is a carpenter. You're cutting bone, putting screws and et cetera, et cetera. Thanks for your attention.


    TAPE ENDS - [41:46]