complications of surgery of hallux valgus
TRANSCRIPT
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M.Thomas Department of Foot& Ankle Surgery
Hessingpark- Clinic
Augsburg- Germany
Forefoot Complications Complications of surgery of Hallux
valgus
Copenhagen 2015
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Disclaimer
No benefits in any form have been received or will be received by the author from a commercial party, directly or indirectly, related to the subject of this talk
Consultant: • Wright medical • DePuy Synthes • Medartis GmbH
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Hallux valgus surgery- aims
– Restoring or maintaining normal weight bearing mechanism and gait pattern
– Retention of functional ROM of MTP I – Congruent joint with realignement of the
sesamoids – Correction of transversal and sagittal deformity
of first ray – Resection of medial pseudoexostosis – No Recurrence of Hallux valgus
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Hallux valgus complications- overview
soft tissue complications:
– Impaired wound healing – Nerve dammage or irritation – infection – Instability of MTP I – arthrofibrosis – Recurrence of Hallux valgus – Transsection of FHL – CRPS
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Hallux valgus complications- overview
bone and hardware complications
– Malunion- pseudarthrosis – Hardware failure – Overcorrection- hallux varus – Undercorrection- recurrence – Head necrosis – Failure in Length ratio
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Hallux valgus complications- literature
Rates of revision surgery using chevron-Austin osteotomy, Lapidus arthrodesis and closing base wedge osteotomy for correction of hallux valgus deformity Lagaay PM, Hamilton GA, ford LA, Williams ME, Rush SM, Schuberth JM J Foot Ankle Surg 2008 Jul- Aug;47(4):267-272
Multicenter study with 646 patients: Chevron-Austin: 270 Pat., Lapidus arthrodesis; 342 Pat., Closing base wedge osteotomy: 34 Pat.
Rate of revision surgery similar for all 3 methods, no statistical significance
Total rate: 5,56% Chevron-Austin, 8,82% closing base wedge osteotomy, 8,19% for Lapidus procedure
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Hallux valgus complications- literature
Complications of first ray osteotomies A consecutive series of 475 feet with first metatarsal Scarf osteotomy and first phalanx osteotomy Hammel E, Abi Chala ML, Wagner T Rev.chir. Reparatrice Appar. Mot 2007 Nov;93(7):710-719 Most frequent complication: MTP I- stiffness- reduced by time!
41,7% after 6 weeks 5,7% after 4 mths Others: late wound healing:5,7% Secondary dislocation of osteotomy:1% CRPS: 1,3% Infection< 1%
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Hallux valgus complications- literature
Angular correction and complication of proximal first metatarsal osteotomies for hallux valgus deformity Schuh R, Willegger M, Holinka J, Ristl R, Windhagen R, Wanivenhaus AH Int Orthop 2013 Sep; 37(9):1771-1780 Metaanalysis of 62 primary studies: Total amount of 2843 feet Overall complication rate 18,7% Most common major complication: Hallux varus (4,3%) Recurrence (3,5%) Dorsiflexion malunion (2,5%)
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Total number of procedures Foot & Ankle:
n= 5510
2 surgeons
Complications of surgery of Hallux valgus
• Review of all surgical procedures of primary Hallux valgus
• Exclusion criteria: all kind of HAV revision case
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Primary HAV surgery n = 1255 Time period: 1/2004 – 1/2014 Age at Surgery : Ø 54,0 yrs
female: n= 948 male: n= 307
Gender distribution
Complications of surgery of Hallux valgus
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Surgical techniques HAV Correction
Complications of surgery of Hallux valgus
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Surgical procedures
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Chevron/ Austin Procedure
Complications of surgery of Hallux valgus
Resch S, Operationsatlas Fuß und Sprunggelenk 1998, Enke Verlag 1998. S. 11
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Scarf procedure
Complications of surgery of Hallux valgus
Dutoit M, Operationsatlas Fuß und Sprunggelenk (Wülker N), Enke Verlag 1998,S. 31
Sabo D, in Vorfußchirurgie ( Sabo D),2010, Springerverlag
Authors own patient documentation
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Proximal displacement osteotomy
Complications of surgery of Hallux valgus
Thomas M. Die proximale Verschiebeosteotomie mit winkelstabiler Plattenosteosynthese 2009, Fuß& Sprunggelenk, Elsevier
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Lapidus arthrodesis
Complications of surgery of Hallux valgus
Thomas M. in: Vorfußchirurgie (Sabo D),2010, Springer Verlag
Authors own patientdocumentation
Compression screw Medial locking plate
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Akin Osteotomy
Complications of surgery of Hallux valgus
Author`s own patient documentation
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Soft tissue release
Complications of surgery of Hallux valgus
Barouk L S, Forefoot Reconstruction Springer Verlag 2003 Hallux valgus correction using transarticular lateral release with distal chevron
osteotomy Choi YR, et al et al. F&A Int., 33(10):838-843;2012
Transarticular approach No adductor tenotomy
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Complications of Surgery of Hallux valgus results
1/2004- 1/2014
n =1255, 2 surgeons
1. Chevron-Austin Osteotomy 2. Scarf Osteotomy 3. Lapidus Arthrodesis 4. Proximal Metatarsal Osteotomy 5. Proximal+Distal Osteotomy MT I 6. Akin Osteotomy
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Complications of Surgery of Hallux valgus results
1/2004- 1/2014
Chevron-Austin Osteotomy:
– n= 567 – Infection:0 – delayed woundhealing: 0 – Hallux varus: 3 (0,5%) – Headnecrosis: 4 (0,7%) – Recurrence: 3 (0,5%) – Revision surgery: 5 (0,9%): • 1x recurrence • 2x hallux varus • 2x head necrosis (stiffness, swelling,pain)
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Complications of Surgery of Hallux valgus results
1/2004- 1/2014
Scarf Osteotomy:
– n= 155 – Infection:0 – delayed woundhealing:1 – Hallux varus:3 (1,9%) – Fracture prox cut:1 (0,7%) – Head necrosis: 0 – Recurrence: 4 (2,6%) – Revision surgery: 3 (1,9%) • hallux varus: 2x • recurrence: 1x
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Complications of Surgery of Hallux valgus results
1/2004- 1/2014
proximal metatarsal osteotomy:
– n= 49 – Infection:0 – delayed woundhealing: 1 (1,3%) – Hallux varus: 1 (1,3%) – Hardware failure:3 (6,1%) – Head necrosis: 0 – Recurrence: 3 (6,1) – Pseudarthrosis: 0 – Reoperation: 2x • hallux varus: 1x • hardware failure: 1x
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Complications of Surgery of Hallux valgus results
1/2004- 1/2014
proximal + distal metatarsal osteotomy: – n= 245 – Infection: 0 – delayed woundhealing: 5 (2,0%) – Headnecrosis:3 – Hallux varus:6 (2,4%) – Hardwarefailure:8 (3,3%) – Recurrence : 5 (2%) – Reoperation:10 (4,1%) • hardware failure :4x • recurrence: 1x • hallux varus: 4x • head necrosis/ stiffness: 1x
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Complications of Surgery of Hallux valgus results
1/2004- 1/2014
TMT- Fusion – n= 239 – Infection:0 – delayed woundhealing: 3x – Hallux varus:4x – Hardwarefailure: 5x – Headnecrosis: 0x – Recurrence: 1x – Reoperation: 6x • hallux varus 3x • hardwarefailure: 2x • Hallux varus+ hardwarefailure: 1x
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2x lesion of the FHL Tendon after AKIN Osteotomy!!!!
Additional Complications of Surgery of Hallux valgus
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2014: What are our conclusions?
- Headnecrosis : minor problem - Lateral release: Less is more - Check indications: more Scarf osteotomies? - Hardware problems with locking plates? - Check for neurological problems - Treat soft tissue carefully (FHL-lesions!)
Complications of Surgery of Hallux valgus
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What have we changed?
If neurological problem (parkinson, insult,…):
prefer arthrodesis Stable osteosynthesis Watch out for delayed union
Complications of Surgery of Hallux valgus
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What have we changed?
Don´t operate on heavy smokers
Complications of Surgery of Hallux valgus
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What have we changed?
Check for bone density If osteoporosis rather plate than screw
Complications of Surgery of Hallux valgus
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What have we changed?
Only transarticular lateral release No adductor tenotomy! Less is more!
Complications of Surgery of Hallux valgus
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Complications of Surgery of Hallux valgus
Hallux varus Treatment-Algorythm bone soft tissue
Arthrotic MTP II no arthrosis
Extensor hallucis split-Arthrodesis Re-osteotomy transfedr
of metatarsal mini- Tight-Rope or reverse akin lateral collateral - ligament tightening medial capsule release
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What have we changed?
If plate does not fit: change it or bend it!
Complications of Surgery of Hallux valgus
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What have we changed?
PASA does influence recurrence- rate Always check with fluoroscopy
Complications of Surgery of Hallux valgus
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Thank you for your attention