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Addressing Multiple Failed Attempts At First Ray Surgery
Emphasizing the importance of a contingency plan, these authors discuss revision surgery for a patient who had two bunionectomies, a first metatarsophalangeal joint fusion and subsequent hardware removal.
On occasion, surgery in everyone’s hands does not meet the expected results. Every surgeon should have a contingency plan should these complications or failures occur.
A first-time recurrent bunion will typically entail revision bunion surgery of various types. If revisional surgery fails, first metatarsophalangeal joint (MPJ) fusion may likely be the next step. But what if this fails? If one has already performed all the above procedures, the surgeon may pursue a second opinion. However, we see patients from other providers as well who have already attempted these measures. How does one take it from here?
A 53-year-old male presented to the office with a history of four surgeries. He had two bunionectomies followed by a first MPJ fusion and subsequent hardware removal at an outside facility. Nonunion was evident both clinically and radiographically. The patient had a low vitamin D level at 16 ng/mL and supplementation corrected this to 33.9 ng/mL. He had a bone block arthrodesis with calcaneal autograft, bone marrow aspirate and external bone stimulator. Despite radiographic union, the patient continued to have pain to the great toe. We discussed hardware removal versus hallux amputation with the patient. He elected hallux amputation, which did relieve his pain.
A Closer Look At The Revision Rate After Failed MPJ Surgery
Although first-time first MPJ nonunions are rare at about 5 percent, the indication for surgery may have an influence on the rate of nonunion.1 In one retrospective study, nonunion rates for hallux valgus, inflammatory arthropathies and hallux rigidus were 14.3 percent, 12 percent and 0 percent respectively.2
Additionally, revisional first MPJ surgeries have more complications.3 Myerson and colleagues found about a 20 percent nonunion rate in 24 patients with substantial bone loss following failed hallux valgus or hallux rigidus surgery with revisional bone block arthrodesis utilizing structural autograft or femoral head allograft.4 In a similar case series of 11 patients failing first MPJ arthroplasty for hallux rigidus, surgeons performed revisional bone block arthrodesis.5 Of the 12 arthrodesis sites, five had a delayed union and two went on to a nonunion. Revisional bone block arthrodesis also required a longer time to fusion at 6.9 months in comparison to 2.5 months for primary arthrodesis. Malhorta and coworkers reported three nonunions after the use of interpositional bone block arthrodesis with autogenous iliac crest bone graft in in 24 patients (25 feet).6 Interestingly, all nonunions in this study occurred at the distal interface of the fusion.
Recognizing The Potential Causes And Challenges With Nonunions
There are many different possible causes of nonunions. When it comes to failed bone healing, causes may include age, higher body mass index (BMI), smoking, poor adherence, poor vasculature/soft tissue envelope, diabetes, neuropathy, previous infection, inflammatory arthritis, steroid use, nonsteroidal anti-inflammatory drug (NSAID) use, vitamin D deficiency, poor fixation, poor joint preparation, alcohol use and other factors. (See the table “A Closer Look At Fusion Failure Factors” at left.)
In multiple revision cases/failed fusions, one must consider likely contributors to the outcome. Separate factors into modifiable or non-modifiable as the patient will likely have multiple possible contributing factors. Certainly, one should address all modifiable risks. Correct low vitamin D, initiate smoking cessation, control hemoglobin A1c, etc.
However, recognize that even when correcting nearly all of these factors, the patient will still carry an increased risk of failed fusion in comparison to those without a history of these risk factors. For example, after treatment of open tibial fractures, an increased risk of osteomyelitis exists even after a patient has quit smoking, albeit that risk is reduced in comparison to the risk for active smokers.7
How Vitamin D Deficiency Can Be A Contributing Factor In Nonunions
Recent studies have found vitamin D deficiency to be a risk factor for nonunion. Researchers have found an association in both elective lower extremity fusions and traumatic fractures with nonunions.8,9 This is concerning, considering about two-thirds of patients who have hindfoot or ankle fusion have low vitamin D.10
However, animal studies have not shown a consistent benefit of vitamin D supplementation on fracture healing.11 Only one human randomized, placebo -controlled trial is published on this topic to our knowledge.12 In this study, a significant increase in bone mineral density was present at week six in patients with healing humeral fractures. However, this is not conclusive evidence that healing is improved (all patients healed) and the trial suffers from small sample size. In part, the hesitation to state that vitamin D indeed improves healing stems from the general lack of evidence vitamin D supplementation has for any outcome.
In a large review and meta-analysis of over 100 systematic reviews and meta-analysis, researchers found very little evidence to vitamin D supplementation but did find associations with vitamin D status with some outcomes.13 Furthermore, in a meta-analysis of vitamin D supplementation on bone mineral density, only a small benefit occurred at one site: the femoral neck but the study authors also noted a potential publication bias, confounding the result.14
Thus, vitamin D deficiency may be more than just a deficiency that requires correction but a warning of overall health that in turn has a link to bone healing. However, to truly determine this, a randomized controlled trial would need to occur with fusion as an outcome. Randomized controlled trials on bone fusion are extremely difficult as large numbers of patients would be required to have relatively few nonunions.
Pertinent Pointers On Addressing The Failed Union
After correcting all modifiable factors, one still needs to determine how to repair this nonunion. If the patient still appears to be at high risk for nonunion even after optimization, then consider an arthroplasty with or without an implant, or even possibly hardware removal. Some studies have found hardware removal highly successful for first MPJ nonunion pain.15 If one pursues revision arthrodesis, then aggressive resection of nonviable bone until bleeding bone is necessary on both the proximal and distal aspects of the first MPJ.
One may be tempted to perform minimal resection as this will inevitably create a large defect. However, in a patient with risk factors for nonunion, this would be a disservice. No autograft or expensive biologic will work without viable bone ends. Consider previous surgeries and the possible interruption of normal vasculature from other attempts. If one uses power instruments first, finish preparation by removing thermonecrotic bone/tissue with manual tools. At least in amputations in patients with diabetes, manual tools appear to be associated with regrowth of bone in comparison to power instruments.16 Although we recommend more aggressive resection of bone, one should also ensure minimal interruption of the periosteum. Consider the use of a transverse periosteal/capsule incision and placing a locking plate superficial to the periosteum.
Debating Autograft Versus Allograft
When choosing between allograft and autograft, frequently one ponders whether at-risk healing is secondary to a diseased host or a diseased site. Is it better to place diseased bone or dead processed bone In a systematic review, allograft and autograft were not significantly different in regard to healing rates although a slight trend favoring autograft was apparent.17 As this systematic review is comprised of retrospective studies, there may have been a bias to select more complicated and higher risk patients to have autograft, which may explain the lack of statistical superiority in the autograft group. Thus, for high-risk situations such as nonunion cases, autograft is still the gold standard.
Where to harvest the graft becomes the next question. Although iliac crest has been the conventional approach, high complication rates have occurred.18 This has in part led some to harvest from other sites such as the calcaneus.19-21
Assessing The Potential Of Bone Marrow Aspirate For Nonunion
Surgeons have utilized bone marrow aspirate to augment foot and ankle surgeries including arthrodesis, ankle fractures and nonunions.22,23 There are multiple sites to harvest bone marrow aspirate including the iliac crest, distal tibia and calcaneus.22,24 The number of progenitor cells varies based on patient age, comorbidities and harvest location.24,25 The stem cells found in bone marrow aspirate contain the primary element for differentiation into bone-forming cells. These may be present in higher concentrations in the iliac crest than in the proximal tibia or calcaneus.26 Others have suggested that bone marrow aspirate from the calcaneus offered a “healthy source” of multipotent mesenchymal stem cells.27
Technique may also influence the concentration. Hernigou and colleagues demonstrated that using a 10 mL syringe had a higher yield in comparison to a 50 mL syringe and that the first milliliter aspirated from the 10 mL syringe had more cells in comparison with 5 mL from the 50 mL syringe.28
However, McAlister and colleagues quantified the mean osteoprogenitor cell colony-forming unit concentration along with the radiographic union of foot and ankle arthrodesis surgeries.29 They found no association between bone marrow aspirate concentration and the incidence of fusion, and suggested a minimum concentration is needed for successful arthrodesis. Regardless, a systematic review of bone marrow aspirate in long bone healing in animals found that all studies showed increased bone formation in the bone marrow aspirate groups.30 Furthermore, 90 percent of the studies reported a statistically significant increase in new bone formation in comparison to the controls.30
In summary, the evidence for bone marrow aspirate is still fairly elementary but potentially appears to improve bone healing or, at the very least, is unlikely to do harm, something not all products have shown.31 However, there is still reason to be wary of placing new products in a fusion site without any research.
In Conclusion
The revision first MPJ arthrodesis case should certainly include a thorough review of potential causative factors for nonunions. One should address each modifiable risk factor but should also consider non-modifiable risk factors. Additionally, one should recognize that even with attempts to address modifiable risk factors, there is still an elevated risk of failure although hopefully this will be lower.
Dr. Thorud is board-certified by the American Board of Podiatric Medicine and is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Thorud is affiliated with Mercy Health System in Illinois.
Dr. Patel is a second-year resident in the Department of Podiatric Medicine and Surgery at Baylor Scott and White Health at Texas A&M Health Science Center.
Dr. Yuhas is a second-year resident in the Department of Podiatric Medicine and Surgery at Baylor Scott and White Health at Texas A&M Health Science Center.
Dr. Kyprios is a third year resident in the Department of Podiatric Medicine and Surgery at Baylor Scott and White Health at Texas A&M Health Science Center.
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