Forefoot Surgery: Insights on Procedures and Complications

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When patients present with iatrogenic forefoot deformities, this can be due to factors such as procedure failure, worsening of the condition, non-adherence by the patient, physiological factors and other reasons, Thomas Chang, DPM, FACFAS, noted at this morning’s APMA National session.
 
Dr. Chang supports a systemic approach to repair in the forefoot, noting it is better to start off proximal and work one’s way distal. He said having a stable ankle and hindfoot is the first step to having a stable forefoot. Dr. Chang emphasized the importance of the metatarsal parabola, saying once the parabola is stable, surgeons can build a functional metatarsophalangeal joint (MTPJ) and stabilize the digit.
 
The goals of repair for the iatrogenic forefoot are to balance the metatarsal loading, establish a functional MTPJ, and provide flexor power to a stable digit. He noted one should consider the most predictable approach for the forefoot, adding that cosmesis is a secondary consideration.
 
Daniel Hatch, DPM, FACFAS, noted there are over 130 hallux valgus procedures, and many—from Keller to Lapidus to minimally invasive surgery to AO—have evolved and fallen in and out of favor over time.
 
For Dr. Hatch, current concepts in bunion surgery include an anatomy-based approach rather than a severity-based approach, and frontal plane rotation, which has helped him explain why some patients did well with certain bunion procedures. He noted other considerations include the center of rotation angulation, transverse plane instability, sesamoid position, first tarsometatarsal joint contours as a contributing etiologic factor, and biological healing. Dr. Hatch emphasized that what matters in hallux valgus surgery is attaining an increased intermetatarsal angle, seeing it as more important than the amount of increase.
 
The future of bunion surgery, opined Dr. Hatch, will include patient-specific instrumentation, three-dimensional computed tomography instrumentation, anatomic mapping and 3D printing of anatomic guides.
 
Colin Mizuo, DPM, FACFAS, discussed osteochondral lesions of the talus at the APMA National session. He cited success with arthroscopic procedures, saying they lead to less scarring than open procedures. He does not use microfracture for osteochondral lesions. When using cartilage resurfacing, Dr. Mizuo noted if bone is compromised, it needs to be addressed.
 
Dr. Mizuo offered several pearls for osteochondral lesions of the talus: address structural deformities if present, and prioritize subchondral bone. He has had great results without needing augmentation with platelet-rich plasma or bone morphogenetic protein.
 
Ellianne Nasser, DPM, CWS, FACFAS, addressed first MTPJ arthrodesis, noting its indications in patients with rheumatoid arthritis, failed bunion surgery, and gout. She emphasized paying attention to the second toe when considering positioning.
 
Dr. Nasser said first MTPJ arthrodesis works for hallux valgus and can provide an intermetatarsal angle of 3.7–14º. She emphasized that a bigger intermetatarsal angle will provide greater correction.