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Syndesmosis Procedure for Hallux Valgus and Bunion Deformities Correction

Discussion in 'Foot Surgery' started by danielywu, Jan 15, 2014.

  1. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    I will be returning to this discussion, very soon. In the meantime, I am preparing an article to chronicle my HK experience. If the submission is accepted this information will be widely accessible to the USA Podiatry community.

    In the meantime I gladly invite questions from this community.
     
  2. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Hello Dieter:

    Attached are some photos and x-rays of the patient you saw in my clinic and were interested in having. Hope you have received F-Scan studies and other photos and x-rays that were emailed to you by Rachel for your usage.

    You were particularly fascinated by how her left second clawed toe could have corrected itself spontaneously after syndesmosis procedure and its MTPJ soft tissue release. I believe it was simply due to removal of its deforming forces by restoring normal function of the first ray. The latter was evidenced by disappearance of metatarsalgia callus and much improved F-Scan study.

    The particulars of this patient were a 62 y/o female had had painful second claw-toe and metatarsalgia of her left foot caused by a severe hallux valgus deformity. She could again walk long distance completely without pain and even wear occasional high heels when she was allowed since 6 months after surgery. She was obviously very happy and satisfied with her result.

    Best,

    Daniel
     

    Attached Files:

  3. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    I have to agree, this is of particular interest. Please clarify how far out this patient is from the operation?


    Dieter

    p.s. I have not yet received the additional information
     
  4. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dieter:

    These follow-up images were taken on Oct. 27, 2014 when you met her in HK, more than 2 years and three weeks after her surgery. Her follow-up F-Scan, lateral-view x-ray and other photos that Rachel sent (double checked) to you were also done on the same day.

    Daniel
     
  5. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    I can now confirm the images were sent. Thank you, and Rachel, for taking the time and trouble. I know, also there are at least two more new patients I met who will have the surgery. And who I would love to follow up.

    Dieter
     
  6. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    It will be my pleasure if they do return for surgeries. I can show you in the meantime others if you want with equally severe deformities while we are waiting for them to show up.

    Daniel
     
  7. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    I saw many good examples during my visit, but the wider readership may be interested. What is even more significant, to me, in addition to the corrected bunion, is the secondary effect. Restoration of the first metatarsal to its' native anatomical position has a powerfully stabilizing action on the forefoot, possibly beyond. This has, perhaps, only limited impact in the written word, even with pictorial representation. The reality, of meeting the patient with an examination of the 'repaired' and surgically rehabilitated foot, is quite another story.

    Dieter
     
  8. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    I will present a series of cases of what syndesmosis procedure can and cannot do. I hope they will be as thought-provoking as the ones you saw in my office. What I now often say "Food or really Foot for Thought". You are welcome and encouraged to make comments.

    Attached are standing x-rays of a 57-year old wife of a dentist. She has enjoyed more than 4 years of ballroom dancing without pain in high heels after her surgery. She has felt also much improved power and balance of her feet, and no recurrence.

    As you know, I believe it was probably due to the true sesamoid, intermetatarsal space (not just its angle) and metatarsocuneiform joint reductions without osteotomy, arthrodesis, adductor hallucis tendon release or fibular sesamoid resection and also regaining full 90° dorsiflexion movement of the MTPJ.

    Daniel
     

    Attached Files:

  9. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    Thank you for submitting the XR images. A typical representation of the power of the syndesmosis.

    You mention ideas of what the procedure can and cannot do. Would you please care to elaborate? It is an important caveat. Also, in addition to the promotion of the concept to the surgeon is the challenge of implementation. How can a surgeon, unfamiliar with the procedure, avoid potential pitfalls and failures.

    This question, in particular, fuelled my decision to make the trip. Our prior discussions, and the review material, serves as a good foundation. But, the benefit of OR time, and the opportunity to free base and discuss in person, case-by-case, that is invaluable. It was afterwards, that I was truly able to connect the dots and fully appreciate the nuances of the procedure, the importance of correct follow up, and the adjustments in the post-operative protocol.

    And, I have to be honest, the trip also served as a personal evaluation of outcomes. The syndesmosis concept is a head on challenge to my personal conviction and faith in the osteotomy approach. I arrived with an open mind. I left duly impressed. The experience compels a surgeon to re-evaluate firmly entrenched beliefs.
     
  10. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    What syndesmosis procedure cannot do and does not seek out to do is changing the individuality of each foot. Individuality is the hallmark of normality, not abnormality, of all creatures and also each individual bone in human.

    A case in point for hallux valgus deformity is the distal metatarsal articular angle (DMAA). High DMAA results in physiological hallux valgus or a normal variance in my book. A physiological hallux valgus will become abnormal only if the foot starts to develop metatarsus primus varus (MPV) due to its incompetent ligaments this are mostly precipitated by estrogen and heredity.

    I hope you can agree that high DMAA has 1) never been proven any guiltier than high-heel shoes as a main player in causing MPV or pathological hallux valgus, 2) never been proven incompatible with normal hallux function of normal feet and 3) pronation of first metatarsal can easily result in apparent but not real high-DMAA on x-rays.

    Daniel

    Pre-op x-ray: A 30 y/o female, no family history, c/o sore leg muscles and low back pain in long walks, balance becoming poorer. Her left DMAA was 90-60.3=29.7° and right was 90-81.8=8.2°. Her left first metatarsal did look different from right, why?

    Post-op x-ray: This standing x-ray was taken 2 years after surgery. She is now more than 5 years and still has not returned for her free 5-year follow-up due to her busy schedules and possibly the fact of no recurrence of deformity and symptoms yet. Her left DMAA remained high at 90-63.6=26.4° (although in theory it should really be greater than pre-op). Many may heroically suggest an osteotomy to make it look even better despite possible additional risks. But both patient and I were quite content to accept it as a normal variance. After all she was already more than happy with its cosmetic result, and especially its functional result of pain-free high heel shoes.
     

    Attached Files:

  11. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    That DMAA presents as a normal variant is an interesting theory. Unfortunately, it is only a theory, as it has never been proven. Also, some might ask, what is a physiological hallux valgus (PHV). Are there patients who have PHV and never develop MPV?

    An alternative explanation

    In gait, the abducted hallux can create retrograde pressure, that may cause increased soft tissue stress on the medial aspect of the 1st MTPJ ligamentous structure which, in time, progresses to produce chronic inflammation and soft tissue attrition.

    Continued retrograde pressure eventually overpowers the damaged ligaments to propel the segment into MPV / MPA. The mechanical model may explain the chronic deterioration found in the histological analysis, in the structures, perhaps better than genetics (which doesn't explain much except predisposition) and gender.

    For the latter are there any studies to know the true incidence of hallux valgus in the general male population. Most studies extrapolate female preponderance based on the sex ratio of operated cases only.

    For the estrogen theory, Kilmartin's work on prepubescent school children suggests the problem arises, and is detectable, in early childhood, before estrogen can exert the effect. That noted, 86% of the cohort (6000 children evaluated) were female.

    From the same study it can be extrapolated the prevalence of HAV in the population is somewhere between 2.5-5% - however this ignores extrinsic factors that may play an additional role e.g. activity level, footwear etc.

    Also from the same study, the finding and suggestion that MPV/MPA precede the development of hallux valgus.

    Other workers comment there is a higher incidence of metatarsus adductus in females, and yet this is contradicted elsewhere. There is an abundance of written material and yet still no consensus to know specifically what causes HAV.

    What can be agreed is that no true bone deformity exists within the shaft of the first metatarsal that might require the bone to be cut and alignment altered. However, this is largely the accepted, globally practiced standard of care, in most cases.

    To understand why, perhaps it is necessary to consider the evolution of the surgical management of hallux valgus - metatarsus primus adductus.
     
  12. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    I hope not but it seems that I have failed to properly upload the x-ray example of the DMAA impasse. Here let me try again.

    Daniel
     

    Attached Files:

  13. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel,

    I saw the XR just fine in your last post. My point, I guess, is that DMAA / HV is a chicken and egg problem. Some would consider DMAA reactive due to long standing hallux deviation. Could it be a normal variant? Possibly. Are there any other examples in the human body where articular cartilage can be so magnificently deviated as a normal variant?

    Dieter
     
  14. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    What I hear you and others saying is that either the shape of human bone can still be changed after its growing or the "magnificent deviation" was developed in kids during their bone growth from "long-term hallux deviation" by wearing unlikely pointed or high heels.

    I have always found DMAA as difficult to measure as osteotomy to cut accurately. In addition, don’t forget that DMAA can be exaggerated often by pronation of the first metatarsal due to the shape of its head. It just like the metatarsocuneiform joint orientation in standing AP-view x-ray can be influenced by a number of variables such pes planus, pronation, calcaneovalgus, MPV and angle of x-ray beam besides the normal variations of the joint itself.

    For instance, from this patient’s x-rays, can you tell me:
    1. Why are her left and right DMAAs different? Which one is real? Which one is apparent?
    2. Why did her left DMAA decrease by first metatarsal realignment instead of increase as would be expected?
    3. Why is her high-DMAA left foot as happy as her normal-DMAA right foot?

    I think for hallux valgus surgery we cannot afford worrying about the many apparent (vs real) radiological abnormal findings until we can first do our job well in first metatarsal re-alignment and re-stabilization. One thing at a time is already challenging enough for me.

    Daniel
     
  15. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    What I hear you and others saying is that either the shape of human bone can still be changed after its growing or the "magnificent deviation" was developed in kids during their bone growth from "long-term hallux deviation" by wearing unlikely pointed or high heels. Adaptive changes in response to altered anatomical position is consistent with the laws of Wolff's & Davies. Because it is biologically plausbile and logically coherent this theory cannot be dismissed. And, of course, in the case of the child, ill fitting shoes will not be a driving factor. But in the adult it can be

    I have always found DMAA as difficult to measure as osteotomy to cut accurately.Agreed In addition, don’t forget that DMAA can be exaggerated often by pronation of the first metatarsal due to the shape of its head.Agreed It just like the metatarsocuneiform joint orientation in standing AP-view x-ray can be influenced by a number of variables such pes planus, pronation, calcaneovalgus, MPV and angle of x-ray beam besides the normal variations of the joint itself. Agreed

    One reason surgeons are impressed with DMAA is the very startling presentation found on exposure when performing the osteotomy

    For instance, from this patient’s x-rays, can you tell me:
    1. Why are her left and right DMAAs different? Which one is real? Which one is apparent?No, I cannot with certainty, but I can theorize it is a response to the greater magnitude of hallux abduction
    2. Why did her left DMAA decrease by first metatarsal realignment instead of increase as would be expected?By the same argument how can we know the angle decreased and how much? This measurement cannot be reliably extrapolated from XR. A softer XR will be more indicative (and your XR, by the way, are excellent, much better than those commonly obtained from outside imaging services
    3. Why is her high-DMAA left foot as happy as her normal-DMAA right foot? The concern here is this: if this positional hallux valgus and DMAA persists this may continue to generate pathological mechanical forces in gait - not apparent in the short to mid-term but only in the long term. Also, there will be a good many patients potentially dissatisfied with physiological hallux valgus and in part this will be a factor predicated by the patient population requesting elective surgery - the PHV will be perceived, by some, as an ugly residual 'deformity'. I believe at least one (American) patient expressed dissatisfaction because of that, and had hoped for a 'straighter toe'

    I think for hallux valgus surgery we cannot afford worrying about the many apparent (vs real) radiological abnormal findings until we can first do our job well in first metatarsal re-alignment and re-stabilization.I disagree, to an extent. This is not only a radiological issue but clinical issue. I think we do have to worry on account of patient satisfaction One thing at a time is already challenging enough for me.Let me be of assistance!
     
  16. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    What I understood from Wolff’s law was that stress can change bone density but not so much as bone shape. Even if it were the case it would probably take a lot of stress for a long time but then how do you explain DMAA in kids. I still believe DMAA is mostly congenital and most of them are normal variance. This is probably why we don’t see high-DMAA only or mostly in older patients. I agree that feet with true high-DMAA are more susceptible to developing MPV deformity but not always (as you know why). Again, it has never been proven high-DMAA without MPV is incompatible with normal hallux function. On the other hand, our patients with high-DMAA after MPV correction by syndesmosis procedure could return to normal hallux function proven by F-Scan study. I regrettably have to say that DMAA has been kind of being used as the end to justify the means.

    BTW, more than 80% of my patients (mostly Chinese) never wore much hi-heels at all but more than 80% of my patients do have positive family history (weak stabilizing ligaments and vulnerability). This defective gene is the main reason for juvenile HV, not estrogene nor pointed or high heel shoes yet, neither acquired high-DMAA.

    Daniel
     
  17. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel,

    I cannot dispute the fact that DMAA is associated with the juvenile bunion. One source quotes an incidence of 50% of high DMAA in the juvenile HAV, in contrast to 10% of adult HAV. But, there is evidence of a 1-3 degree increase in DMAA with every decade of life, suggesting an adaptive, acquired process. (Elsaid, 2006). Be that as a consequence of Wolff's law or disuse entropy, either way it is then not being used as a means to justify an end.

    The deviated joint, with the deviated hallux can be more problematic to a patient than simply a cosmetic road bump. It is not at all unusual, to have a patient produce symptomatic lesions when the hallux abuts the second digit. Progressively this becomes more a problem when the joints stiffen, as they commonly will do, in advancing years to produce painful hyperkeratotic lesions. When this is superimposed on a foot with compromised vascular flow and / or diabetes, the problem will be more emergent. So, I can't agree that we should ignore and accept as a normal variant a malalignment that can predispose a patient to future pathology. Not when there are prophylactic remedies available. Can this be done, concurrently with a syndesmosis procedure, when this is indicated? Of course it can, and with little additional surgical burden or risk to the patient. An alternative strategy is to address the problem later, although co-morbidity can mitigate against an uncomplicated recovery.

    As for high heels: perhaps in your survey you simply asked the wrong question. There is a well established association of footwear and HAV. Most will agree, footwear is a catalyst, rather than cause but there are studies to show an increased incidence of bunion, in populations that have transitioned from traditional footwear to Western style shoes. From China, no less (among other).

    Dieter
     
  18. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    I am glad to learn more about the DMAA-Wolff connection. I look forward to seeing the reverse-effect by Wolff's law on DMAA after the realignment of hallux and MTPJ by syndesmosis procedure. Possibly that is why I haven’t seen any consequences of uncorrected DMAA yet.

    I am relatively conservative when it comes to any surgery. Prophylactic surgery is still a rather foreign concept to me especially for cosmetic foot surgery. I don't think we need to worry too many theoretical problems before we can first solve the most fundamental pathology (MPV) and first ray function properly.

    There have been indeed plenty studies connecting unspecific shoes in general to HV /MPV deformity. But do let me know if you know of any studies connecting high-heel shoes to MPV deformity.

    Daniel
     
  19. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    The reverse effect is a reasonable proposition when the DMAA is secondary to hallux valgus, and assuming the hallux valgus has been addressed. You may have to wait a few decades to see it! Spontaneous correction of a congenital DMAA will be unlikely.

    I envy the fact you have the luxury to not worry about the effect of a residual hallux valgus. In our clinics it is, all too often, a problem that requires an answer. Perhaps the patient population, location and focus on the syndesmosis procedure allows you to enjoy the natural cushion to the many related podiatric ailments commonly seen in our clinics.

    I have to emphasize here, again, that I remain impressed with the power of the syndesmosis to correct MPV, and the secondary stabilizing effect on the foot. I do feel, the residual HAV, seen sometimes but not always, is a weakness of the procedure. Perhaps we have to agree to disagree, on that point.

    In response to your question. Let me first ask you: when does a heel become high? My second question will be, why do you feel the height of the heel is an important factor? What of the shape of the shoe, and the position and size of the heel print? My third point, to your patient reported self audit is, how reliable is such an audit? I simply wonder, if you were to open the closet to inspect the footwear, would you still agree with this information? I am reminded of the obese patient who will insist they hardly eat anything, and it is their 'hormones' that is making them fat.
     
  20. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Arthritis Care & Research

    Characteristics Associated With Hallux Valgus in a Population-Based Foot Study of Older Adults, Alyssa B. Dufour, Virginia A. Casey, Yvonne M. Golightly, Marian T. Hannan
    First published: 24 November 2014

    Abstract

    Objective

    Hallux valgus (HV) is common in older adults, but limited studies of risk factors have reported conflicting results. This cross-sectional analysis examined the association of HV with foot pain and other characteristics in older adults.
    Methods

    The population-based Framingham Foot Study assessed HV, foot pain, foot structure (planus, rectus, and cavus), current and past high-heeled shoe use, age, and body mass index (BMI). Sex-specific logistic and multinomial logistic regression examined the association of HV and HV with pain with study variables.
    Results

    Of 1,352 men and 1,725 women (mean ± SD age 66 ± 10.5 years), 22% of men and 44% of women had HV, and 3% of men and 11% of women had HV with pain. Foot pain increased the odds of HV in both sexes (P < 0.05). In women, older age and past high-heeled shoe use increased the odds of HV by 27% and 47%, respectively (P < 0.01), and cavus foot structure decreased the odds of HV by 26% (P = 0.02). BMI >30 kg/m2 decreased the odds of HV by 33% in men and 45% in women (P < 0.05). In women only, odds of pain and HV versus no pain and no HV were greater with older age and planus foot structure.

    Conclusion

    Our work showed different associations in participants who had HV with pain compared to those without foot pain. In both men and women, strong associations were observed between HV and foot pain and inversely with BMI. Older age was associated with HV in women only, as were protective associations with cavus foot structure.
     
  21. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    Thank you for bringing this article to my attention. I often enjoy epidemiology studies more for their practical information. Without reading its full version I can’t tell what criteria they used for a positive hi-heel history definition. In other words, what kind of hi-heel history would be damaging and make a significant impact on the development of HV. Obviously, a proper study is still needed to dispel the hi-heel myth once and for all (My published survey study with the Baptist University of Hong Kong in 2008 of over 1,000 Chinese women revealed >80% hallux valgus sufferers did not wear much or any hi-heels at all.).

    From just reading the abstract I can’t help conclude that the much higher incidence of hallux valgus deformity in old age (both female and male) than average is most likely due to degeneration/failure of the soft tissue supporting structures and thus instability/hypermobility of first metatarsal. As the head of first metatarsal is one of the two pillars for both transverse and longitudinal arches of the foot, they can both can collapse when first metatarsal becomes unstable and hypermobile especially in sagittal/vertical plane. Collapsed transverse/metatarsal arch results in metatarsalgia. Collapsed longitudinal/medial arch results in flatness and fatigue of foot as reported in the article.

    I agree to disagree that American women would still mind mild residual/physiological hallux valgus when they can again wear any shoes and undertake any activities after syndesmosis procedure and without Akin or DMAA osteotomies.

    Daniel
     
  22. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel: in your study, what criteria did you use to define high heel? You have not yet addressed my last but one reply. I am not sure about the 'high heel myth' but would again ask, why do you think high heels are the important factor. But I agree, when all of the material pertaining to footwear is evaluated globally, there remain more questions than answers.

    I don't know if ALL syndesmosis patients can agree they can wear any shoe or undertake any activity. I certainly want to believe they do, and know from my own evaluation of a cohort of your patients, that a high percentage are very satisfied indeed. But, I believe you mentioned, in your penultimate paper, this requires more work and using a robust outcome measure, such as the Manchester Foot Score. BTW, I just obtained a license for the MFS.

    Merry Christmas!

    Dieter
     
  23. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    Did not mean to sidestep your questions.

    Q1: When does a heel become high?
    A1: I don't know but really like to know. Women may know better.

    Q2: Why do you feel the height of the heel is an important factor?
    A2: Actually I don’t believe high heel or even estrogen is an important factor if the critical stabilizing ligaments are genetically competent. Similarly, they shouldn’t be important factors after surgery if the surgery is capable of producing a permanently competent mechanism to help stabilize the first metatarsal against the external deforming forces. Syndesmosis procedure may just be able to do that.

    Q3: What of the shape of the shoe, and the position and size of the heel print?
    A3: My wife told me Jimmy Choo is closer to figuring that out than anyone else.

    Q4: Your patient reported self audit is, how reliable is such an audit?
    A4: As reliable as you can believe in the Visual Analogue Pain Scale and the person.

    Since you are licensed to use the Manchester Foot Score, you are welcome to use it for a study of my patients if you want.

    BTW, this 61-year old lady Ms. Lee whom you saw in my office on Oct 28th and liked to follow up if she had surgical treatment. Attached are her pre- and recent 10-day post-op x-rays for your attention. Take note of her left clawed second toe and metatarsocuneiform joint. I will try to remember sending her later x-rays and other images. But feel free to remind me if necessary.

    Daniel
     

    Attached Files:

  24. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    I remember the lady well. Phenomenal outcome
     
  25. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Q1: When does a heel become high?
    A1: I don't know but really like to know. Women may know better.
    Q1a:The reason I ask is that this becomes relevant when you state your patients don't wear high heels but have bunion. If we cannot answer that question, can we reliably make the statement
    A1a: Indeed, does any podiatrist or orthopedic surgeon know how high a heel should be considered too high? It is much less relevant to me than estrogen and heredity.


    Q2: Why do you feel the height of the heel is an important factor?
    A2: Actually I don’t believe high heel or even estrogen is an important factor if the critical stabilizing ligaments are genetically competent. Similarly, they shouldn’t be important factors after surgery if the surgery is capable of producing a permanently competent mechanism to help stabilize the first metatarsal against the external deforming forces. Syndesmosis procedure may just be able to do that.
    Q2a: In you research questionnaire you asked about pregnancies. Were you able to correlate pregnancy with HAV?
    A2a: Yes, indeed just like the pubic symphysis dysfunction/subluxation is correlated to pregnancy(ie:high estrogen) not trauma.

    Q3: What of the shape of the shoe, and the position and size of the heel print?
    A3: My wife told me Jimmy Choo is closer to figuring that out than anyone else.
    Q3a: Jimmy Choo is probably the last person to ask about shoe design in respect of HAV deformity
    Q3a: However, according to my wife his shoes are by far the most comfortable among all brand name very-high heels. He may just accidently nailed the HV problem by designing the ridiculously high but most comfortable hi-hi-heels.

    Q4: Your patient reported self audit is, how reliable is such an audit?
    A4: As reliable as you can believe in the Visual Analogue Pain Scale and the person.
    Q4a: Maybe, but a patient might not want to divulge this information. A positive response would seem to apply 'blame'
    A4a: Then you just have to make the best interpretation as you believe.


    Daniel
     
  26. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure



    Daniel,

    From your patient questionnaire: is there further data analysis about the role of pregnancy? How many women, from your sample, had prior pregnancy, is there a ratio? How many pregnancies? We might speculate that multiple pregnancy might play a role, for example.

    Dieter
     
  27. Lab Guy

    Lab Guy Well-Known Member

    Re: Syndesmosis Procedure

    I referred my neighbor to a well known Podiatric Surgeon for her HAV deformity. Eight months ago she had the newest version of the mini tightrope procedure and was doing pretty good until she developed a fracture of her second metatarsal about 7 weeks post-op. She is still have difficulty ambulating and only has about 10 degrees of dorsiflexion. I would stick with my simple Austin procedure and soft tissue rebalancing. Six weeks they are in regular shoes and walking very well.

    Steven
     
  28. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steven,

    Sorry about your neighbor, nobody hopes for complications.

    Unfortunately, the Austin (or any other osteotomy) also has its' share of complications.

    This thread discusses the syndesmosis procedure, not the mini-tight rope. The mini-tight rope relies entirely on the mechanical construct for it's correction. The syndesmosis procedure maintains correction from the induction of a new 'ligament'.

    As for 10 degrees of dorsi-flexion, I assume you refer to the 1st MPJ? I had the opportunity to examine many patients s/p syndesmosis procedure. The great majority demonstrate 80+ degrees 1st MTP joint dorsiflexion. Occasionally it is 60 degrees or less, usually when there has been damage to the 1st MH articular cartilage from long standing deformity.

    Dieter
     
  29. Lab Guy

    Lab Guy Well-Known Member

    Re: Syndesmosis Procedure

    My fault Dieter, I sent my post before reading it again and edit feature gone. I was going to add that I would do my Austin procedure over the mini tightrope (MTR) procedure but would have loved to learn the syndesmosis procedure as it appears to be a big improvement over the MTR. I guess I was venting over the MTR procedure.

    I had read the entire thread before and I give you kudos for flying to Hong Kong to learn the nuances of the syndesmosis procedure. The pre and post-op x-rays to me are just incredible. If I was in your shoes and was a total believer, I would consider sub-specializing in this procedure. With good public relations (You could get on the Dr. Oz show) patients with severe bunions will be flying to your office for bunion surgery. I have read many of your posts on here and on Podiatry.com and with your open mind, you are going to be extremely successful after your obligatory residency that you have to suffer through.

    Steven
     
  30. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steven,

    No problem at all! After all, I too was firmly in the osteotomy camp for many, many years and totally understand the reservations. I expect a measure of disbelief, from the foot surgery community, in the same way that I had my own doubts and reservations.

    I debated the syndesmosis concept with Dr. Wu, for over 2 years, before making that trip. I found, in Dr. Wu, a true gentleman, who has no agenda other than help to popularize the syndesmosis procedure. The outcome, as evidenced by the x-rays, is often nothing short of phenomenal. But the XR does not tell the whole story. The patient does.

    The next step is to provide evidence of reproducibility. Different surgeon, working on a different patient cohort. I am working on this with my Residency Director.

    To say I am optimistic, is probably an understatement. This hidden gem of a technique, from our Italian colleagues, has simply slipped under the radar, as have many other innovations over the centuries. What is most remarkable, the fact that Dr. Wu has, for several decades now carried the torch, single handed.

    Dieter
     
  31. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dieter:

    Shucks, I did not think of getting pregnancy history before. But I will do now. Thanks.

    Steven:

    One of the things, osteotomy practitioners do not talk about often enough is by what mechanism would osteotomy procedures re-stabilize first metatarsal and prevent metatarsus primus varus (MPV) from recurring when patients return to high-heels.

    Mini-tight rope would rely on one or two single-string suture(s) to re-align first metatarsal and also maintain it until the suture(s) eventually fail and then deformity may recur.

    Then the golden question is why MPV deformity does not recur in many feet after osteotomy and min-tight rope procedures. Some speculate and I concur that it is due to the scar tissue formation between first and second metatarsals in the intermetatarsal space. Syndesmosis procedure has basically expended on that hypothesis. Voila! it worked.

    Daniel
     
  32. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    About the parity status / pregnancy, it's a dilemma. We know HAV affects women more than men, 2:1 odds often cited. Women have babies, men don't (blinding flash of the obvious). Problem here is to know if this correlation is association or causation.

    So, what causes bunions. We can identify risk factors (female, genetics). We may speculate that estrogen affects the integrity of ligaments. This still does not explain why men develop HAV. We can maybe say men suffer because of 'some' unidentified hereditary factor. Can there be a genetic predisposition that can cause soft tissue failure so narrowly confined to the integrity of one anatomical segment? I don't have the answer. Or is this a part of a more general syndrome.

    I like to believe foot mechanics is an additional risk factor. The functional hallux limitus foot, for example. We can theorize that certain foot 'types' can set the mechanical foundation. Heel valgus, forefoot valgus and the plantar flexed 1st metatarsal position, for example. What happens next is predicated on the principle of proximal stability. When the MTJ is flexible any abnormal stress is accommodated, without producing 1st MTPJ pathology. When the MTJ is stiffer there is more stress on the 1st ray segment. Next, in the dynamic chain, the available range of motion of the 1st ray. When there is a large excursional range the axis of the 1st metatarsal head is tilted, as the first metatarsal is elevated and inverted. The hallux must now abduct. When there is increased 1st metatarsal stiffness there is less axial rotational deviation. Instead of developing hallux valgus, this foot generates hallux limitus / rigidus.

    The above, theoretical model is an elegant explanation. Further research is indicated to determine validity of the principles. In examining a patient I will routinely evaluate mid-tarsal joint flexibility. My anecdotal observation leads me to believe a good many HAV patient has a very flexible MTJ. Contrary to the mechanical model. A problem here, there is no instrument available, yet, to measure MTJ range of motion.

    Dieter
     
  33. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dieter:

    Firstly, the prevalence of HV deformity among women is often quoted 9 times greater than men. I believe it is due much more to estrogen than high-heels.

    If you believe hallux valgus is caused by ligaments failure, then what can also make men victims? How about failure of ligaments (medial collateral & medial metatarsosesamoid) caused by heredity (genes) [1,2], attrition (shoes) [3,4], degeneration (aging) and the last and probably the least by excessive external deforming forces (pointed shoes, sports, ballet …etc) in women and also men.
    To me, first metatarsal instability/hypermobility is unmistakably the consequence of MPV and the main killer of the normal biomechanics of the all-important medial column of foot and other secondary problems seen in HV feet.

    My belief of the sequence of events is: 1) failure of the tie-bar system at the medial metatarsosesamoid ligament as described by Stainsby, 2) development of MPV (tansverse/horizontal instability/hypermobility) inducing 3) sagittal instability/hypermobility, then 4) disintegration of normal biomechanics.
    I believe the reasons for syndesmosis procedure can restore normal function of the foot is its effective restoration of not only the normal realignment of first metatarsal but also its stability in both planes.

    Daniel

    1. Hallux valgus inheritance: pedigree research in 350 patients with bunion deformity. J Foot Ankle Surg. 2007 May-Jun;46(3):149-54. Piqué-Vidal C, Solé MT, Antich J.
    2. Hallux valgus in males--part 1: demographics, etiology, and comparative radiology. Nery C, Coughlin MJ, Baumfeld D, Ballerini FJ, Kobata S. Foot Ankle Int. 2013 May;34(5):629-35.
    3. A Comparison of Foot Forms Among the Non-Shoe and Shoe-Wearing Chinese Population, LAM SIM-FOOK M.B., B.S.1 and A. R. HODGSON M.B., CH.B., F.R.C.S. (EDIN.)1 J Bone Joint Surg [Am] 1958;40-A:1058
    4. Foot health and shoewear for women. Clin Orthop Relat Res. 2000 Mar;(372):32-44. Frey C.
     
  34. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    I would speculate the syndesmosis procedure can effect a corrective change in all three planes: transverse, saggital and frontal plane. From the correct 1st ray (re)position. In the bunion foot the first metatarsal is often dorsiflexed and inverted, in addition to loss of transverse plane alignment. In correct alignment the inversion component is also corrected. This is facilitated also by the orientation and pull of the cerclage, used for temporary correction, and later maintained by correct casting and, finally, maturation of the syndesmosis.

    Dieter
     
  35. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    Do you mean inversion of the first metatarsal the same as pronation or supination?

    Daniel
     
  36. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    The first ray axis, strictly speaking, does not conform to the pronation-supination model, as compared to the subtalar joint, for example, where pronation is linked to dorsiflexion, abduction, eversion. Supination to plantarflexion, adduction, inversion.

    The first ray axis, by virtue of its' orintation, functions predominantly in the saggital and frontal plane, with dorsiflexion coupled to inversion, plantarflexion to eversion. The transverse plane component is almost negligible, although it is described to have a single axis with triplanar motion.

    At least that's what we are taught.

    Dieter
     
  37. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    Thank you for the more information than I expected.

    My own understanding is that first metatarsal itself can move in three plains through its metatarsocuneiform joint in standing and ambulation, transverse/horizontal (ie. MPV deformity by varus displacement), vertical/sagittal (ie. hypermobility in dorsiflexion) and frontal/axial (ie. inversion/internal rotation) plains.
    First metatarsal of hallux valgus feet can be displaced/deranged in all its three planes. The least noticeable and talked about is its inversion. It happens probably less regularly than the other two. It can accentuate inversion of the hallux and even DMAA. How I try to help correct it is by making my first metatarsal drill holes more in the medial to lateral direction to hopefully pull it towards the second metatarsal with also slight derotation/eversion effect.

    The first metatarsal possible inversion displacement and its correction can now be best investigated by the CurveBeam’s PedCAT Weight-Bearing Scanner. Unfortunately, it has not come to Hong Kong yet. It can probably also be best used to end the age-long debate on the entity of ” metatarsal /transverse arch”, as we have discussed in HK.

    Daniel
     
  38. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    I believe, if cadaver analysis of 1st ray function can be trusted, the transverse plane displacement / component is an effect of pathology. Also, the tri-planar correction is the consequence of anatomically correct metatarsal-cuneiform (re)articulation.

    After returning from HK I spent some time working with an articulated foot skeleton model. Minor 3D adjustments at the MCJ can provide for major effects in 1st metatarsal position. This effect, on metatarsal cuneiform alignment, will be too subtle to detect on XR, I believe.

    I do recall the added step in the M1 drill hole orientation. Your supposition is intuitively correct. Also, this step probably makes for easier passage of the suture.

    I don't know anyone who has the Curvebeam, but certainly this would be an interesting exercise. I also look forward to MRI analysis to investigate the appearance of the biological bridge. Alternatively this can be investigated with ultrasound. It will be useful to have an objective method to know when the process is fully matured.

    Dieter
     
  39. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    Unfortunately, this natural and automatic anatomical 3-planar correction of the first metatarsal through (re)articulation of the metatarsocuneiform joint by syndesmosis procedure would be instead completely lost by osteotomies and even Lapidus procedure. To rediscover the normal 3-planar position for the metatarsal head after osteotomy is a daunting if not impossible task. As the result of possible shortening, dorsiflexion and other malunions, transfer metatarsalgia and suboptimal function restoration of the first ray function may be the sometimes seen consequences.

    Qualitative evaluation of the new connective soft tissue material in the first intermetatarsal space and also the quantitative interpretation of its possible tensile strength by simple MRI and US imaging may be a little challenging but will be extremely useful.

    Daniel
     
  40. Dieter Fellner

    Dieter Fellner Well-Known Member

    Hello Daniel:

    A little update. I have great confidence in the SP, seeing is believing!

    Truthfully, NYC surgeons seem very receptive to the concept. My only concern is they take the trouble to understand the importance of each step. A successful outcome is the aggregate of patient selection, correct execution and proper aftercare. Whenever an opportunity arises I offer a powerpoint presentation and discussion to convey this information. Otherwise, if there should be a poor outcome, it will be a disservice to the reputation of the SP.
     
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