CHAPTER IO

COMPLICATIONS OF HALLUX VALGUS SURGERYA Challenging Case Scenario

Jobn A. Ruch, D.P.M.

It is no surprise that any surgery, including some-thing as familiar and common as hallux valgussurgery, can result in any number of possible com-plications. As much as we hope that complicationsonly occur in conjunction with complex cases, theypotentially can occur following any procedure per-formed by any surgeon. It is strongly recommendedand helpful to inform your patients of the possiblerisks of the surgery before they arise. It is impofiantlo realize that surgery is not the answer to all prob-lems. Offering different treatment options(non-surgical as well as surgical) to your patients is

recommended. Disclose the risks and benefitsinvolved with surgical treatment options. If you are

thorough and truthful with your patients, they willbe more cooperative if complications occur.

Most people would agree that building a goodrelationship with the patient is beneficial and impor-tant. Your efforts in taking true interest in yourpatients will reassure them of your compassion andempathy, as well as professionalism and compe-tence. The goal of this article is to presentsystematic approaches for implementing thoroughevaluations in an attempt to minimize surgicalcomplications. Keep in mind that surgical complica-tions do not equal malpractice unless you neglect toinform your patients properly, or practice abandon-ment when faced with complications. A unique case

involving multiple complications following halluxvalgus surgery will be presented.

PRELIMINARY EVALUAIIONOF THE DEFORMITY

Prior to making any ffeatment decisions, a thoroughhistory of the chief complaint should be taken. A11

clinical and radiographic findings should beevaluated and documented. Formulate some differ-ential diagnoses before being tunneled into theobvious diagnosis. It is important to ascefiain thedetails in an initial work-up for analysis andcomparison of the effectiveness of any treatment

modality. Be aware that most deformities desele a

course of conselative treatment before surgery is

suggested. Try to build a good relationship with yourpatients during this period of time. For hallux valgusdeformities shoe modification, orthotics, NSAIDs,and splints should be considered. Once the non-sur-gical modality proves itself to be of minimal benefit,one can then advance to discussing surgical options.

SURGICAL DISCUSSION

The first task in presenting surgical options is actu-ally making cefiain the patient understands thediagnosis of the deformity. Clearly state theobjectives and goals to be achieved through surgery.Present to your patients the different acceptablesurgical options. In cases of hallux valgus deformi-ties, discuss capitalversus base procedures, differenttypes of fkation devices, and joint preservationversus joint destruction scenarios. Go into details

about the postoperative course such as the expectedhealing time for each of these options. Make surepatients understand their responsibilities in beingcompliant with weight bearing restrictions, follow-up dressing changes, and possible required time offfrom work, spolts, or school. Discuss the topic ofpain management including intraoperativeanesthetic options and postoperative analgesicagents. Finally, no surgical presentation would becomplete without disclosing the risks of complica-tions. Begin with general risks associated with anyinvasive procedure, then expand on complicationsspecific to the procedure to be performed.

RISKS AND COMPLICAIIONS/INFORMED CONSENT

General risks affiliated with arry Lype of surgicalprocedure include infection, allergic reaction to anymedication given, disfiguring scars from the inci-sions, loss of blood which may require transfusion,loss of function of any limb or organ, paralysis,

58 CHAPTER 10

paraplegia or quadriplegia, brain damage, cardiacarrest, or death. These are very serious complica-tions which should be disclosed. Make it clear thataithough these are not probable complications inelective podiatric procedures, they are still possiblerisks for any invasive procedure.

Nex1, discuss the more specific risks relatedto the surgery to be performed including scars,infection, recurrence of pait/deformily, worseningof pain/defofmity, ovef-correction, stiffness, weak-ness, neurovascular damage, hematoma, deep veinthrombosis and pulmonary embolism, bone orftxation device failure, prolonged swelling and heal-i.g, malunion or nonunion of osteotomy,dehiscence of wound, difficulty walking or loss offunction, etc. Make sure the patient is clear that thesurgery would only be performed if the benefits out-weigh the probable risks. Be honest in disclosing thepossible complications, yet reassure the patient thatmeasures will be taken to avoid complications. Forexample, the risk of DVT can be minimized by earlymobilization and anticoagulation therapy. Let themknow that if complications occut you will managethe said complication or make appropriate refemal toa physician more skilled in the management of thespecific complication.

MEDICAL CI.EARANCE FOR SURGERY

Detailed Review of Medical HistoryObtaining a thorough history will help dererminewhether the patient is an acceptable candidate forsurgery. An important factor in avoiding unneces-sary complications is the proper selection ofpatients for surgery. It is important to recognize the"red flags" and follow through with appropriateconsults for further work up. The goal is to ensurethere are no contraindications for the requiredanesthesia, the surgical procedure, and the post-operative healing capabiliq. A thorough hisroryincludes solicitation of the patient's currentand past medical history, prior history of hospital-izations, past surgical history, family history, socialhistory, allergies, current medications, and a reviewof systems.

Past medical history such as diabetes mellitusmay require further labs to ascertain glycemiccontrol. It is important to obtain a current medica-tion list and withhold appropriate medications suchas Glucophage. Make sure the patient is clear onwhat to do with adjustments of medication with the

NPO status preoperatively, to prevent dangeroushypoglycemic situations. For a patient with hyper-tension, a baseline blood pressure is important.Once again, order appropriate lab work such as achemistry panel to check for electrolyte imbalance(especially potassium for patients on diuretics).Make sure the patient's hypertension is stable andcontrolled on hypertensive medication. Do nothesitate to consult their primary care physician forassistance and to solicit afiy perioperativemanagement recommendations. Patients withcoronary arterial diseases or history of myocardialinfarctions/ischemia will need clearance from acardiologist. It is helpful to obtain copies of anyrecent EKGs, stress test results, and echocardio-gram results for documentation. If there is a historyof myocardial infarction, find out the elapsed timeframe, and cancel or postpone elective cases asnecessary.

Patients with respiratory problems such asasthma or emphysem may need chest x-rays,discussions of modification or cessation of smokingperi-operatively, and precautions with inhalationanesthetic agents. These patients are likely to needincentive spirometry postoperatively. Patients witha history of gastrointestinal problems such as GERDmay require aspiration precautions with generalanesthesia. These are medical issues which are ofsurgical concern and deserve special attention.Although most of the medical history will bedisclosed in this portion of the investigation, beaware that patients often inadvertently leave outinformation. Correlate their previous medicalhistory section with their current medication list.

Following the medical history portion,continue with the past surgical history, socialhistory, and family history. Document not only thetypes of surgery, but learn of any complications withanesthesia, healing, scarring, blood clots, or anyother problems. In obtaining the social history, beaware that someone with a history of alcohol abusemay need precautions for continued abuse or with-drawal. Il may be a good idea to check the liverfunction. Smokers may benefit from a detailed dis-cussion of its negative effects on bone and woundhealing. It is not unreasonable to recommend cessa-tion. Once again, chest x-rays may be indicated,especially if the lungs appear compromised. Socialhistory also involves finding out if the patient hasgood family suppofi or assistance postoperatively. Ifneeded, long-term rehabilitation facilities or nursinghomes can be arranged prior to surgery to avoid the

CHAPTER 10 59

complication of falling due to lack of assistance. Interms of family history, ask about deep vein throm-bosis, keloid formation, and myocardial infarctions(if the patient has CAD). Take appropriate measureswith any positive findings.

Review a complete list of the medications.Look for any discrepancies with the previousmedical history, and also look for medicationswhich may need to be adjusted or withheld peri-operatively. For example, consider stress dosingpatients on long termlroutine steroids. VithholdGlucophage and cover with insulin sliding scale asindicated. Other pertinent concerns are drug-to-drug interactions when you prescribe anyadditional medications. Document all drug allergiesand find out what type of reactions are triggeredwith these allergies.

A review of the systems should be performedbefore advancing to the physical examination.Make certain the patient does not have any recentillnesses such as urinary tract infections, upper res-piratory tract infections, etc. that would requirecanceling or postponing the surgery.

Physical Exam\7hen performing the physical examination to cleara patient for surgery, the physician should bereminded that one of the goals is the prevention ofsurgical complications. Start out the physical evalu-ation with the vital signs. Look for any grossabnormalities. Make sure the patient does not haveunexplained skin rashes. Even if you are not thephysician doing the medical clearance, be compre-hensive and perform an evahntion on your own.

The lower extremity evaluation is alsoperformed in a very systematic manner. Make surethe vascular supply is adequate. Take precautionswhen arteial disease is in question especially indeciding what to use for hemostasis. Neuromuscularexams will be especially important in neuropathicpatients such as in diabetics. Dermatological examsare crucial with ulcers for determining the depth, size,and infectious state. Other dermatological findingssuch as hyperkeratosis can reveal bio-mechanicalabnormalities. Structural evaluations will help indeciding whether the pathology is more soft tissue orosseous which is important in determining the typesof procedures. Radiographic findings will play anadjunctive role in determining surgical options.

By completing a thorough evaluation of the

deformity, implementing different treatmentoptions, determining the need for surgical treat-ment, disclosing all risks and benefits in signing aninformed consent, and participating in making surethe patients are medically cleared for surgery, thephysician can feel eveqzthing has been done togive the patient the best care. Complications maystill arise, however, if they do, the patient will feelmore confident in your care so you can better seleyour patients.

The following is a unique case scenario inwhich the patient underwent multiple surgeriessecondary to complications. The stepwise approachin dealing with each of the complications will bedetailed.

CASE PRESENIATION

A 65-year-old woman presented with a hallux valgusdeformi$z as well as a tailor's bunion, and subluxedhammer digit deformity of the second digit. Thedefonnities were bilateral and had become progres-sively worse over 25 years. Conseryative treatmenthad been ineffective, and surgical correction wasscheduled. The medical history was positive forpolymyalgia rheumatica and borderline hyper-cholesterolemia. The medication list consisted ofthree years of prednisone use. The patient reportedan allergy to doxycycline. The patient was deemed anappropriate surgical candidate, and the first surgeryon the right foot was performed in November ofL999.

Surgery #L, Right Foot (LL-99):

A McBride /Austin bunionectomy including adduc-tor tendon transfer, lateral FHB tendon release, andfibular sesamoidectomy was performed. Flxationwas with one 2.7mm screw. The hammertoe repairconsisted of PIPJ arthrodesis with MPJ release,lateral capsulotomy, and flexor tendon transfer.The tailor's bunionectomy was performed using 28gauge wire loop fixation.(Fig. 1) The postoperativeinjection consisted of 1cc Decadron and 70cc 0.5o/o

Marcaine plain. The patient was instructed to bepafiial-weightbearing using a walker for assistance.

On day four, the postoperative x-rays revealeda shift in the capital fragment of the first metatarsal.(Fig 2A) The patient related an unremarkablepostoperative course with the pain being well-controlled.

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Figure 1A. Preoperative x-ray of the right foot

Figure 2A. Dislocated capital liagment of firstmetatarsal, preoperative X ray of right fbot.

Figure 1ts. Postoperative x ray of the right foot

Figure 28. Postoperative x-ray, to correct dislo-cation of capital fragment.

CFIAPTER 10 6l

Surgery #2,Right Foot (L1-99)

The dislocation of the first metatarsal osteotomywas repaired surgically on postoperative day four.No intra-articular fracture or capital fragment frac-ture was noted intraoperatively. The capitalfragment was then relocated and fixated with three0.062" smooth K-wires using the lock-pintechnique. (Fig. 28) C-arm imaging was used inrra-operatively for assistance. The foot was cast andthe patient was instructed to be non-weightbearingon that side using a walker.

Surgery #3,[eft Foot (3-00)

Four months later, the patient presented for surgi-cal correction for similar pathologies on the leftfoot, Identical procedures were performed as thefirst surgery with the exception of the bunion andtailor's bunion fixation techniques. The firstmetatarsal capital osteotomy was fixated using two0.062" smooth K-wires in the lock pin fashion.(Fig. 3) The left foot was casted and the patient wasinstructed to be non-weight bearing on that sideusing a walker.

Surgery #4,Right Foot (7-00)

The patient developed hallux varus bilaterally, withthe left side appearing clinically less severe than theright side. Conservative treatrnent with splinting didnot control the deformities. The right side becamesymptomatic at the metatarsophalangeal ioint withmotion and ambulation. The deformity on the left sideis less symptomatic. Clinical evaluation revealedflexible varus deformities which were both tracking.Minimal pain was elicited with range of motion. Theinterphalangeal joint on both the right and left halluxdemonstrated malleus flexion deformities. The surgicalprocedure selected was a first metatarsophalangealjoint arthrodesis fkated with two parallel 4.0mmpartially-threaded screws.(Fig. 4) There were areas ofsignificant c rtllage erosion noted rntraoperatively.The previous three K-wires were removed. Thepatient was instructed to be non-weightbearing post-opefatively.

Figure JA. Preoperative x-ray of the left lbot Figure lB. Postoperative x-ray

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Figure 4Aright foot.

Preoperative x ray of hallux varus,

Figure 5A. Preoperative vieu', hallux \iarus of theleft foot.

F-igure 48. Postoperative view ofcorrected halluxvarus with MPI athrodesis.

Figure 58. Postoperative x-ray, showing correc-tion usin€l MPJ arthrodesis.

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Surgery #5,[.r-ft Foot (L1-00)

The patient returned for surgical correction ofsymptomatic hallux varus on the left foot. The righthallux varus, which is nearly four months postop-erative, continues to be asymptomatic. The surgicalprocedure selected was also a first metatarsopha-langealjoint arthrodesis. This was fixated using twocrossed partially-threaded 4.Omm screws.(Fig.5)

CONCLUSION

\7ith this case presentation, we can see that multi-ple complications can occur to the same patient.The patient was informed of the risks and compli-cations prior to surgery after thorough clinical and

medical evaluations. The possibility of complica-tions were verbally discussed with each and everyone of the five surgeries. Despite the multiple com-plications, this patient never questioned thesurgeon's competence. The invaluable lesson to belearned is dealing with the complications in a pro-fessional manner. Face the patient and face theproblems. Patients who are well-informed andinvolved in all facets of the decision makingprocess, are more likely to be cooperative andunderstanding should any complications arise.