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Male Speaker: Dr. Trepal is a Professor of Surgery at NYCPM and Vice-President of Academic Affairs. In addition, heâs a Clinical Professor at the Department of Surgery at New York Medical College and a Clinical Assistant Professor in the Department of Orthopedic Surgery at SUNY Downstate. Dr. Trepal serves as the Residency Director for SUNY Downstate Podiatric Residency Program and has authored multiple scientific articles, as well as many textbooks and is an excellent resource.
Heâs going to have two back-to-back talks for us and the first one will be Hallux Valgus Oseteomtomies -- When and Where, followed by Forefoot Epiphyseal Injuries, and then I will be trying to wrap this afternoon up early after Dr. Trepal.
So please give a warm welcome to Dr. Trepal.
Michael Trepal: Thank you. Thanks very much and I appreciate everyone being here on a sunny afternoon on Sunday in mid-August. So weâre going to try to be respectful of your time.
And the first talk, Hallux Valgus Distal Osteotomies -- When and Where. So these are the learning objectives. Weâre going to discuss the various types, general indications for them, and to describe some of the techniques. I have no related disclosures pertinent to this talk.
And so, here we go. The bunion. I can remember as a student back in around -- I would say the turn of the century, but it -- around 19 -- early 80s and well, the book at the time has just gotten out of print, some of you remember it. Kelikianâs textbook on bunion surgery of hallux valgus and associated disorders. And if you read that book -- I still have a copy of it, but I donât know if you can get it anywhere anymore. You open it up and you see hundreds of different bunionectomies there. I mean, everything that you can imagine. There was over 200 different procedures for bunions. So I said, âOh my god. How can, you know, how am I going to memorize all of this?â
Then I remembered just going across the street to, which is at the time, was hospital for joint diseases. And I sat like -- somehow, I got friendly with the chief of surgery there and he looked at me and he said, âKid,â he says, âremember one thing.â He says, âIf someone has appendicitis, itâs this one operation.â Well, back then, there was no laparoscopic. He says, âIf you have a -- thereâs one operation for appendicitis. Everybody does it pretty much the same way.â He says, âWhy? Because it works.â He says, âWhenever you see multiple procedures for the same condition, thatâs a clear kickoff that no one procedure works all the time and many procedures will work most of the time.â And Iâd never forget that and I still look back.
So we got lots of different ways to approach a bunion. We can cut it at every which way with proximal, distal, we can fix it with screws, plates, staples, ex-fixes, you name it, we can do all of these things. And really, what it comes down to is there is indeed more than one way to skin a cat when doing this. There are clearly wrong ways, but you have a couple of choices.
And, you know, weâve all sat at lectures and you hear someone get up here and talk about this particular bunionectomy and then you got a feel at the end of it, âGod. If Iâm not doing that bunionectomy, Iâm committing malpractice because this doctor, this respected doctor, said, you know, thatâs the only way to do it. And if you have to do it this way, and look at -- âHereâs my -- you know, I did it six times and all the patients were happy, so therefore, as my research and time after time.ââ So we need to not look like the blind men and the elephant to each of these people because they are blind. Theyâre feeling a different part of the elephant thinking itâs a different thing. So if someone feeling the trunk -- feeling a rope and someone feeling the leg, itâs a tree trunk, and someone feeling the ear, think itâs a leaf, but itâs all the same elephant.
Francis Bacon said sometimes the remedy is worse than the disease.
Hereâs a 24-year-old woman who had a bunionectomy done. She wishes -- this is how she ended up. She wishes she had her bunion back. So as this patient here, wishes that they could get their bunion back.
So what we need to do is minimize risk unlike this proud parent who didnât minimize risk and turned around to Mother Hen surprised over there to see her little ducklings down through the -- great.
Not everything works all the time. Okay, to have a recurrence or a failure of a bunion doesnât mean that you did something wrong. But again, we have to recognize there is risk inherent into whatever we do. Thereâs risk inherent to you getting home from here today. You can walk outside the building and something falls off the roof and hits you in the head. You can get hit by -- I mean, thereâs all sorts of things that we do in the course of everyday life. So what we try to do is minimize risk. You can never totally eliminate it -- eliminate.
So we need to have several decision points in approaching bunion surgery. Number 1, you need to have the proper indications for surgery. You got to do it in the appropriate patient, which means that they have both pedal deformity and the rest of them, north of the ankle is also amenable to surgeries. So again, selecting them the appropriate procedure and many times thereâs more than one way. So maybe I donât say, âSelect âtheâ appropriate procedure.â I should modify that to say, âSelect âanâ appropriate procedure.â You got to perform the procedure properly, perform post-operative -- proper post-operative care, and throughout the way, proper communications. And when any of these things fall apart, this is when someone knocks on your door and hands you one of those things.
So what are the indications for surgery? In -- where people get criticized for the legal system, for insurance companies that buy all the claims or for regulatory bodies, for whatever the reason that their care has been criticized, many times, theyâll say, âUnindicated surgery. No indication for surgery.â So what is the indications for surgery?
Number 1, there needs to be some thought of deformity thatâs there that youâre looking to manage. There has to be, in most cases, symptoms or functional impairment.
Now, this comes into the case of, you know, cosmetic surgery on there -- thatâs -- there is some debate on there. Iâve taken the position that, you know, cosmetic surgery or operating on non-painful bunions is okay so long as thereâs proper information thatâs exchanged. The patient has to know what theyâre getting into. They have to know that this is purely cosmetic and therefore, the risk is that you can take up deformity thatâs non-painful and convert it into something which is painful, right?
Plastic surgeons do cosmetic surgery all the time. And the people are entitled to have plastic surgical procedures done on their body, as long as all the proper information is appropriately now delineate to the patient. Now that being said, I very rarely if ever will do that because I think the risk outweigh the potential gains of that but -- so in general, you want have a deformities, itâs should be causing some symptom or functional impairment. Also a major criticism is that there was inadequate non-surgical management.
Now I ask you if you take a 23-year-old individual who goes to professional -- is a professional work and they have to wear stylish shoes to work because thatâs part of the job. And say, âWhat conservative management is going to alleviate that problem?â Fine, you got to have to wear, you know, your grandmotherâs shoes for six months and then come back and say, âWell, the bunion still here.â So surgical treatment needs to be disclosed to the patient. Say, âThese are the options that you have.â
And the patient may say, âNo, I decline that. Thatâs not -- I donât want to have you shooting cortisone into my joint. I donât want to wear grandma shoes. I want to have a foot because this is my lifestyle and this is what I need.â And of course along the whole way, there should be a proper informed consent.
Picking your appropriate patients. Now patients donât like this. Theyâll walk into the office and sometimes you got to wonder, is this the type of patient that I wanted? Again, I think that you need to -- you need to call the shots here in conjunction with the patient. How many times do I hear doctors who get into a problem that will say like, âYou know, this is what the patient wanted.â Well, true. Patients, as their foot, they have a -- they have something to say in the matter there, certainly. They got skin in the game so to speak but not to the point where you do something where it violates your principles.
Now in looking at a deformity, which a bunion is a deformity in general, weâre not talking about major lecture on a deformity correction here, but you usually try to correct a deformity at its apex. Most of the so-called core or apex of the deformity and when you look at it the bunions or and the bunion is real proximal in the in the in the mid foot. Youâre not going to do an osteotomy for the most part throughout the cuneiforms or into the mid-tarsal joint to go with the real crux of where the deformity is. So therefore, we are doing a procedure at a level which is not at the apex of the deformity.
Deformity is not just in the transverse planes, thatâs clearly what we look at. We have to be cognizant of where that metatarsal is sitting in the sagittal plane as well. Is it truly elevated? Again, that needs to be part of our clinical examination on x-ray and want to know kind of whatâs happening in the frontal plane. Thereâs a lot of misinformation out there, itâs truly whatâs happening in the frontal plane, particularly now with this is a vogue topic about the rotating and everything else.
Remember that the foot was once a grasping object and if you look at all forbearers, the first ray, plantar flex and everted to grab the case and the same thing in the human foot as Hick showed this many years ago that on plantar flexion, the ray will evert on it, so people who like to evert the ray may be doing the wrong thing as well.
Ops, sorry. And if you have any doubt that one of dorsiflexes and inverse, just look at it intra-operatively. Okay, clearly thatâs a dorsiflex metatarsal and you can see that that is -- thatâs inverting there. So actually, if youâre going to plan to flex it, itâs going to evert a little bit, but you may want to do that a little bit more and be cognizant to where that metatarsal is sitting in the transverse plane.
And then just to raise on the thought that the deformity is not in the metatarsal itself. This is a study. We did a cadaver dissection about 15 years ago where we actually -- what we were looking at is contouring the metatarsal cuneiform joint to see if thereâs anatomical differences at the metatarsal cuneiform joint between the foot bunions and rectus feet. I think clearly, if you look at these two pictures, these two cadaver feet like, you know, I donât think thereâs any disagreement as to which foot has the bunion. Okay. But if you take out those two metatarsals and you look at them, I defy everyone here of absolute accuracy to tell me which foot has the bunion in the metatarsals. So the deformity itself as we said from the beginning, is really not within the metatarsal itself. What with the deformity is positional, more proximal but yet we, for practical reasons, osteotomized or perform the procedures on the metatarsal. And again, we can do it at various places.
You can do it the phalange, we can do it in the metatarsal head, we can do it mid shaft, we can do a proximal osteotomy, we can do it the cuneiform joint, we can open up wedge osteotomy, we can close wedge osteotomy, we can do translatory osteotomies, we can do the rotational osteotomies. This is where it starts to get crazy and this is where, again, more than one way may solve the problem.
If we look at what the literature states also, there are preferred practice guidelines that are in generalities. And again, these are not necessarily the standard of care. Theyâre just broad based practice guidelines to put things within guidelines both in our profession, these acts that has them, the orthopedic foot and ankle surgery has them too. Again, we got to be careful in doing this because once you make this dogmatic and say this is the standard of care, any violation of that means that you violated the standard of care.
So again, we can look at -- for the topic of this choice, where in the -- what are the indications for the classic procedures which deal with and osteotomize the metatarsal disc leak.
Well generally, you want to have an IM angle thatâs mild to moderate. Okay, you can push this a little bit. Thereâs no hard and fast absolute number here. They may or may not be some articular cartilage deviation which we refer to as a -- as a PASA. You may need the -- in conjunction of the osteotomy, the plantar flexion. If the metatarsal is long, you may want to shorten it a little bit. You may want to rotate it or de-rotate it in the frontal plane. You need to take into consideration how wide that metatarsal is because thatâs how much real estate you have to work with if youâre doing a transliteration osteotomy.
And lastly, in constructing the design of the osteotomy, how much inherent stability is there? If thereâs not a lot of inherent stability, then you got to provide it in whatever form of fixation youâre going to use.
So letâs look at a bunion like that which would be mild to moderate deformity.
We can do a transpositional, which means we cut the metatarsal through and through and across bicortical, and take one portion of it, just the distal capital fragment, and move it laterally, or transpose it laterally. We can take a wedge either opening or a closing, and we can angulate it, the osteotomy, or we can go through and through again and rotate the bone as well. Or you can, in some cases, do combination of all three, depending upon it.
More often than not, a translation osteotomy, the Austin or the Chevron is performed. The x-ray on the left obviously is very extreme, and I donât think that will -- a Chevron type osteotomy would be my choice in an osteotomy like that.
But for arguments sakes, what Iâm showing you here, the point of this is itâs inherently a stable osteotomy where you take the capital fragment and translate it laterally. But the rate-limiting step that you have there is with the metatarsal, because that is how much real estate you have to move that capital fragment laterally. And if the IM is too high and you move it too far, laterally, itâs going to fall off the cliff and youâll get something like this.
When you push the limits of the osteotomy, you donât have enough bone to bone contact there to stabilize it, and you end up getting, well, one type of complication. You can end up getting is -- a hallux varus because you dislocate the joint and then many others that are happening.
So again, the rate-limiting step again, another example of pushing it too far. Well, when we get to that in a second, Iâll talk about -- but again, remember, whenever youâre doing a translatory osteotomy, you rate them, I donât care what you do in proximal.
And this is where I have some disagreement before the scuff proponents about doing that extra little cut that you can get actually more correct. Still, itâs at that apex. The distal apex, how far you need to move that head laterally is a function of how much bone there is. I donât care whatâs happening with the cut upstream.
The Austin or the Chevron type was described in the early -- initially, in the early 60s. Itâs originally done as via osteotomy of 60 degrees. When I was a student and the early resident, we used to do this, we didnât fixate them, we put them at a little 4-foot cast, not all of them did well. Most of them did do well, but not all.
So the indications for the Chevron type, as I said, in general, the joint has to be functional. You donât want to do this in the arthritic joint. You can push the IM angle, but recognize, okay, recognize what your saving instability, youâre losing in the amount of correction that you can get. And itâs -- this is where discussion happens with the patient. You say, âLook, you know, Mrs. Jones here, you have such a big deformity.â To make this straight, I need to back up, you know. You either have to do a proximal osteotomy or a lapidus, and thatâs going to give me the ability to make it straighter although this is the downside in it. Okay, it comes with a price that you need to pay.
Now I know some of the new plates and everything else, people are proponing that theyâll walk much earlier and that the post-operative healing time isnât quite as much as it is in a distal. Iâm not quite sure outcomes are proving that quite extensively. But nevertheless, you know, you can say, âLook, we can do a lesser procedure as long as you are willing to accept less of a correction. Perfection is not -- itâs the desired outcome but itâs not the realistic outcome that youâre going to get here. And in turn for a less of a correction, this is the trade-off that you are going to get.â
Okay, remember, you need to consider the metatarsal width because thatâs going to be a rate limiting step as to how much correction you can get. Generally, the PASA has to be the normal range because otherwise, you need to rotate to correct it, or do some type of angulational. Normal to, you know, slightly reduced met-protrusion, if you have a real short metatarsal, this could be a problem. And if the PASA is normal, youâre going to have a congruous to deviated MTPJ. And again, youâre just taking that MPJ and youâre sliding it laterally. Youâre just taking that joint and youâre narrowing the foot at that level.
Of course, we all know there are lots of modifications that you can do. You can do bicorrectional Austin by taking at a wedge, you can angulate the cut to get -- correct some elevatus or some shortening. These modifications give you marginal additional -- again, itâs a function of how much youâre moving over. I mean, you can angulate the cut but if youâre only transposing it 2 or 3 millimeters, youâre not going to be able to get any appreciable lengthening or of plantar flexing.
The unique correctional, as we said has been modified in ways that we have moved towards a more rigid internal fixation with screws so you can make a longer plantar cut, or you can make a longer dorsal cut. As long as you understand what youâre looking to do here and youâre modifying the cut so as to accommodate the type of fixation that youâre going to be utilizing.
Again, we -- this is very simplistic but I think, you know, some of the philosophy behind is more important than the actual and everybody in this room are certainly adept and can do this thing.
Again, a big problem I see in many poor results is that the -- itâs taking the head, taking too much bone off. This is where you push the limits of the osteotomy. I said before you can, but the high -- the larger the IM angle, the narrower the bump you want to take. All right? Almost -- if Iâm going to really push the limits of this, Iâm going to take some time just to ever so sliver of a bump there so I have enough bone within the metatarsal, had to move it over laterally, and then pack it still on the shaft.
Soft tissue release and sesamoidectomies, it is somewhat, I would say, controversial. Some would swear by it. Some will condemn it. I tend to shy away from it. I try to put the metatarsal head back on top of the sesamoids. Sesamoidal action is a whole other talk that we donât have time to go on here.
On this original lateral releases and sesamoidectomies were quote-unquote, âcondemnedâ by mostly in the orthopedic community as you are going to devascularize the capital fragment and almost guarantee yourself AVN and those of us who do these procedures with regularity rarely see any clinically significant AVN. Thereâs probably some degree of it but to the point of clinical significance, itâs a very infrequent procedure.
Again, fixating it, we can modify the cut by utilizing a guide pen to plantar flex it, dorsiflex it, but again these results modest at best because itâs dependent upon how much translation youâre doing in it.
The bi-correctional Austin by taking out more of a wedge medially than laterally as we are combining both an angulational and transpositional osteotomy. They have also a sub-modification of the bi-plain, youngâs wick that can also plantar flex it at the same time where you have an elevata.
You can get some appreciable plantar flexion of this. Although, the more of a wedge you take out the more of a shortening youâre going to get and you have to make sure that the shortening that you get is kept -- counteracted by the increase plantar flexion. So, that this is a balancing act that youâre going to get there.
People have most notably, they all take credit for Achilles, Harold Vogla -- itâs called Achilles dorsal ascent -- long dorsal arm.
Basically, this is really extending the dorsal arm. Once again, the amount of lateral transposition that youâre going to get or able to get is limited to the width of the metatarsal but the advantage of doing this is that you can really kind of push the limits there and you can stabilize. It gives you more real state to put more fixation in.
So, where you might only be able to put one screw, now, you can put two or three screws there and stabilize it a little bit more by pushing the limits where you -- now, ideally, you want to have at least 50% contact between the capital fragment and the metatarsal shafts. So, maybe you can push that a little bit more and counteract for it with multiple screws.
The disadvantages we mentioned, the limit to the reduction of the IM angle which is dependent upon the metatarsal width. Thereâs no really appreciable frontal plain correction here if you need that. You can overdo it. You can plantar flex too much. If you make the cut too far distal and you impact it, this is not what you want to see happen in the operating room. Youâve got to be careful with that dorsal cortex, it can be very thin. And if you tighten, you know, that one last turn that, you know, the hammock -- the residences say, this is tighten -- let me test it and we go, and then it cracks. So, youâve got to be careful there. You can get stress rises.
All the modifications of the distal are more akin to the Reverdin which is an angulational osteotomy. And it has its modifications as well. And this particular locations, correcting for a deviation of the articular cartilage on the metatarsal head by derotating that and depending upon how you augment the cut, you can laterally transpose it, you can plantar flex it.
All the metatarsal osteotomies that you can -- you can do a through and through. The most flexible osteotomy that we have is a straight linear cut. Cut the bone in two pieces straight across.
You can dorsiflex it, plantar flex it, turn it on the side, rotate it, you can do whatever you want but the price you pay for that is inherent stability. So, the Reverdin is an angulational osteotomy, classically done at the metatarsal head, Donny Green modified it by doing that plantar cut because of what was found to be adhesions -- adhesive sesamoiditis because that cut and if it was through and through, was right over the sesamoidal complex and ending up getting adhesive capsulitis.
So, by doing that plantar cut there, you kind of insulated the sesamoids and it doesnât take much additional skills set to do this. And as you can see in the bottom picture there, it effectively insulates the sesamoids from the cut. You can also modify this by shifting it laterally, like taking that cut and transecting the lateral cortex. So, now, you derotate and you transpose laterally.
So, you can see again why thereâs more than one way to skin a cap on this make sometimes fixation make a little bit more difficult or challenging to do because it doesnât always land itself to nice placement of the screw. Bill Todd modified this by saying, âWell, if I want to plantar flex it, not only can I angulate it, not only can I transpose it laterally but let me -- let me plantar flex it too.â
Now, again, there are different cuts that will do the same effect but the important thing here is for the operating surgeon is to determine whatâs the deformity and what do I need to do to correct it and how am I going to get there?
The Homman, again, variation of the same theme. Homman, is a through and through. Itâs in angulational, shortens it a lot. Can be challenging in terms of your fixation of how you want to go there. Of, late, the percutaneous, the IMS bunion, that is being -- various companies have different devices to help us to do this.
Nowadays, I think the difference of days of your where these were done truly blindly is that these were all done under fluoroscopic control and you can see exactly where you want to be. Thereâs a lot to say on this.
I think there is certainly a fairly significant skill set that it takes to do it -- to do it properly and to get good results but certainly Iâve seen my own and several of us at the college get some really, kind of, like a -- take a double take, âWow, you did that through a small little push,â but it can be done, Iâm not sure, that you necessarily need thousands of dollars of equipment and guides to help you -- to help you get there.
Iâve seen pretty good results with saw blade, freer elevator, and a K-wire as well, not that the other stuff doesnât help is, again, we need to determine, of course, on this tour -- this is a whole other factor which weâre not talking about.
As everything else, it doesnât end when you put the bandage on in the operating room and put the piece of tape on it and send the patient off. Your end result is as good as the proper post-operative care. And that involves part of the patientâs compliance of what you -- what you tell them to do, how you -- when you return them to full function. Bone, you know, still takes -- still takes what it takes to heal. And I know weâre anxious to get the patients back to full function quickly and the patientâs, âOh, I just want to -- can I just go to my nieceâs graduation. I got to go to this wedding. Can I wear this shoe? You know, I have this trip planned to Croatia. And, you know, Iâm going to be good,â and weâve all heard it, okay? But you still got to keep and manage these patients quite properly throughout it until they return to the level of function.
So, thatâs a little bit about some of the osteotomies, the modifications and more importantly than the actual procedures, I think is the -- I think the philosophy that goes behind it. And the one take home point is, understand the deformity that you have. What it needs to be corrected. What you need to do. Shorten, lengthen, plantar flex, dorsiflex, derotate, transpose, angulate, whatever it is and remember, it doesnât usually -- if it doesnât look good on the table, itâs rarely isnât going to look better after the fact, okay?
So, when youâre in the operating room, thatâs the time that you have to get it where you -- where you want to be. And also, itâs critically important that you and the patient be on the same page as to what the expectation is.
I mean, Iâve looked at post-operative bunions over the -- Iâve been doing this close to 40 years now and when I look at it first, oh, my God, the patientsâ really -- thatâs what they expected, thatâs what they wanted and they got what they wanted and theyâre happy. So, itâs all in the communication here as to whatâs going on.
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