How Can Surgeons Best Correct All Three Planes In Hallux Valgus?

I made up my mind based on the literature. I painstakingly put together a lecture titled, “The Death of the Austin Bunionectomy.”¹ The first part of the lecture examines the 10 steps in the pathogenesis of the hallux abducto valgus deformity. The middle section of the lecture is a thorough look at the absurd “long-term” follow-up for the Austin bunionectomy and the shockingly high recurrence rates.

The conclusion of my presentation discussed a series of landmark articles by Dayton and colleagues about the triplane nature of hallux abducto valgus deformity with the center of rotation of angulation (CORA) located at the first metatarsocuneiform joint.^2-5 Dayton and colleagues extol the importance of varus rotation of the first metatarsal to adequately realign the valgus rotated sesamoids directly beneath the metatarsal head. The Lapidus procedure is the only procedure, according to these articles, that can fully address all three planes of hallux abducto valgus at the CORA, resulting in deformity correction without translation.

It made sense to me and therefore is what I use as my methodology for treating hallux abducto valgus deformities over the past three years. I utilize first metatarsophalangeal (MPJ) arthrodesis to treat severe hallux abducto valgus or arthritic hallux abducto valgus deformities additionally. Basically, of 130-plus bunion surgery options, I narrowed it down to two options for my patients.

One article in my presentation challenges the location of the CORA for hallux abducto valgus deformity. LaPorta and colleagues propose the CORA lies in the proximal tarsus at the dorsolateral proximal corner of the medial cuneiform.⁶ The authors submit that the result of any bunion procedure produces translation to achieve colinear axes. The article left some degree of doubt in my mind about the true location of the CORA for hallux abducto valgus.

Then I lectured at the American Society of Podiatric Surgeons meeting in Baltimore. At this meeting, LaPorta and Siddiqui presented a third option that made sense. Well, sort of. I had to wrap my head around it first. They spoke of a percutaneous distal first metatarsal osteotomy just proximal to the sesamoids for mild to moderate hallux abducto valgus. LaPorta and Siddiqui argue that this osteotomy allows for triplanar correction — consistent with Dayton’s assertion — provides realignment of the mechanical axis of the first ray, and does not invade the MPJ, thereby maintaining range of motion. There is extensive literature by authors such as Magnan, Giannini, Bosch, Maffulli, Markowski, Oliva, and their colleagues.^7-20 Conversely, Kadakia and colleagues’ study on the procedure showed unacceptable rates of complications.²¹ The argument by those supportive of the procedure is the surgical technique deviates from the standard technique for the percutaneous distal first metatarsal osteotomy.

The argument piqued my curiosity and I began my research on the topic. The literature is significant but as Trnka and coworkers discovered in their critical review of the literature, the majority were Level IV articles with one Level II and three Level III studies.²² The review consisted of 21 articles with 1,750 patients with 2,195 procedures.

Two days after I returned from the meeting, I had a middle-aged female patient come in with a symptomatic mild to moderate hallux abducto valgus. The patient is the perfect candidate for the percutaneous distal first metatarsal osteotomy. We discussed the treatment options and the patient has elected to undergo the procedure.

I have done well over 1,000 Austin bunionectomies during my career but I essentially stopped doing the Austin procedure about three years ago. Is this the beginning of a new era? We shall see.

References

1. DeHeer P. The death of the Austin bunionectomy. Wisconsin Podiatric Medical Association Annual Scientific and Membership Meeting. Wisconsin Dells, WI, Oct. 1, 2016.

2. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013; 52(3):348-354.

3. Dayton P, Kauwe M, Feilmeier M. Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy. J Foot Ankle Surg. 2015; 54(1):102-111.

4. Dayton P, Feilmeier M, Kauwe M, et al. Observed changes in radiographic measurements of the first ray after frontal and transverse plane rotation of the hallux: does the hallux drive the metatarsal in a bunion deformity? J Foot Ankle Surg. 2014; 53(5):584-587.

5. Dayton P, Kauwe M, Kauwe JS, et al. Observed changes in first metatarsal and medial cuneiform positions after first metatarsophalangeal joint arthrodesis. J Foot Ankle Surg. 2014; 53(1):32-35.

6. LaPorta GA, Nasser EM, Mulhern JL, Malay DS. The mechanical axis of the first ray: a radiographic assessment in hallux abducto valgus evaluation. J Foot Ankle Surg. 2016; 55(1):28-34.

7. Magnan B, Bortolazzi R, Samaila E, et al. Percutaneous distal metatarsal osteotomy for correction of hallux valgus. J Bone Joint Surg Am. 2006; 88(Suppl 1 Pt 1):135-148.

8. Magnan B, Samaila W, Viola G, Bartolozzi P. Minimally invasive retrocapital osteotomy of the first metatarsal in hallux valgus deformity. Oper Orthop Traumatol. 2008; 20(1):89-96.

9. Magnan B, Pezze L, Rossi N, Bartolozzi P. Percutaneous distal metatarsal osteotomy for correction of hallux valgus. J Bone Joint Surg Am. 2005; 87(6):1191-1199.

10. Giannini S, Ceccarelli F, Bevoni R, Vannini F. Hallux valgus surgery: the minimally invasive bunion correction (SERI). Techniques Foot Ankle Surg. 2003; 2(1):11-20.

11. Giannini S, Vannini F, Faldini C, et al. The minimally invasive hallux valgus correction (SERI). Interactive Surg. 2007; 2(1):17-23.

12. Giannini S, Faldini C, Vannini F, et al. The minimally invasive osteotomy “SERI” (simple, effective, rapid, inexpensive) for correction of bunionette deformity. Foot Ankle Int. 2008; 29(3):282-286.

13. Giannini S, Faldini C, Nanni M, et al. A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI). Int Orthoped. 2013; 37(9):1805-1813.

14. Giannini S, Cavallo M, Faldini C, et al. The SERI distal metatarsal osteotomy and Scarf osteotomy provide similar correction of hallux valgus. Clin Orthoped Rel Res. 2013; 471(7):2305-2311.

15. Bösch P, Wanke S, Legenstein R. Hallux valgus correction by the method of Bosch: a new technique with a seven-to-ten-year follow-up. Foot Ankle Clin. 2000; 5(3):485-98.

16. Maffulli N, Longo UG, Oliva F, et al. Bosch osteotomy and scarf osteotomy for hallux valgus correction. Orthoped Clin N Am. 2009; 40(4):515-524.

17. Markowski HP, Bosch P, Rannicher V. Surgical technique and preliminary results of a percutaneous neck osteotomy of the first metatarsal for hallux valgus. Foot. 1992; 2(2):93-98.

18. Maffulli N, Oliva F, Coppola C, Miller D. Minimally invasive hallux valgus correction: a technical note and a feasibility study. J Surg Orthoped Adv. 2005; 14(4):193.

19. Oliva F, Longo UG, Maffulli N. Minimally invasive hallux valgus correction. Orthoped Clin N Am. 2009; 40(4):525-530.

20. Maffulli N, Longo UG, Marinozzi A, Denaro V. Hallux valgus: effectiveness and safety of minimally invasive surgery. A systematic review. Br Med Bull. 2011; 97(1):149-167.

21. Kadakia AR, Smerek JP, Myerson MS. Radiographic results after percutaneous distal metatarsal osteotomy for correction of hallux valgus deformity. Foot Ankle Int. 2007; 28(3):355-360.

22. Trnka HJ, Krenn S, Schuh R. Minimally invasive hallux valgus surgery: a critical review of the evidence. Int Orthoped. 2013; 37(9):1731-1735.

23. Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg Am. 2011; 93(17):1650-1661.