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i have a 70 year old,moderately active patient presenting for hallux valgus correction.his medical history is umremarkable.the deformity can be summed up as follows: HA angle 35,pasa 8,HIA 10,ima of 18,with no evidence djd and no shortening of the metatarsal.my dilemma is in deciding whether this patient could be better served with a base wedge osteotomy,along with a distal soft tissue correction.
i am also debating as to the possibility of an austin with possibly a distal akin(although i realize the cut off on the ima is 16);or possible a reverdin-green-liard osteotomy and the akin.i just don't feel this patient would do well with the post-op rigors of a base wedge.
any suggestions from other colleagues would be helpful.

rick

Rick,

If you are not comfortable with BWO you may wish to consider a rotation scarf - akin osteotomy. This allows for agressive correction of the IMA and with 2 point AO screw fixation is very stable allowing for early ambulation.

dieter,

are you concerned about the possibility of avascular necrosis and non-unions associated with these procedures.recent literature in the states hasn't very kind on the rotational scarf.

rick

Rick,

In short: no. Seems to me every procedure attracts bad press at times and this is cyclical. I am not aware of any good RCT's favouring one over the other.

I use both OBCWO and Scarf-Akin/ rotation - Scarf Akin. (S/A) I have not encountered significant problems with respect to AN / instability, with either procedure. 1st metatarsal dorsal displacement can occur with the OBCWO but it is not so much a problem if 2 screws are used.

Post-op S/A I have to say I usually do not allow patients to weight-bear quite so early, or aggressively. Even though the osteotomy for S-A has been designed to promote good interfragmentary compression, bone still takes 6 weeks to heal and I just don't trust the patient not to get too enthusiastic too quickly. I am aware of colleagues who allow very early ambulation, some even immediately and in sneakers, and patients seem fine with it and in experienced hands the scarf-akin is undoubtedly a powerful procedure.

With the rotation S-A the longitudinal cut can be placed slightly oblique from dorsal to plantar so the risk of severing the nutrient artery can be reduced. Also, I try to limit dissection around the metatarsal head to essential work only, and preserve the plantar proximal soft tissue surrounding the 1st metatarsal base as much as possible.

Also, I prefer to screw the Akin osteotomy.

Hello Rick

I agree with Deiter that the Scarfe/Akin is a good procedure. However, I don't believe that it's a good idea to get too arbitary about 'cut off' angles on X ray etc. It's much more important to set out your objectives based on the patient in front of you. Are they elderly, what is the PVS, do they suffer from osteopoenia, are you seeking to achieve good mechanical function as opposed to a perfectly straight medial column, is the 1st ray plantar/dorsiflexed, is the first ray short or long etc etc? I carried out a study a few years ago which showed that even a Keller reduced the IM angle by at least 2 degrees, simply by reducing the bowstring effect of TEHL, so that should be borne in mind with other procedures too.
Having said that, I have never (as far as I am aware) had a patient suffer from aeseptic necrosis follwing a Scarfe but I am never over enthusiastic in using a Kalish or McGlamry elevator to mobilise the sesamoids.

All the best

Bill

Rick,
A 70 y.o. patient is not going to respond to an aggressive correction such as you are advocating in my opinion.Technically,the scarf is more difficult, and whether you perform either of those osteotomies, physiologically, the bone of that patient remains elderly.Recognize that you are not treating an xray and in this case,do what is in the patients' best interest.In all probability the patient will be happy if the bump is removed.Can an aggressive procedure be performed? Certainly.Consider the co-morbidities and potential complications for this individual.Bone requires 6-8 weeks to heal in the mature adult.This patient may have normal bone density on xray,but you may want to consider bone densiometry as well. You may be surprised by additional information from that exam.A younger foot surgeon wants to develope and perfect his technique.The only good thing about age is wisdom.The other responses about early ambulation with aggressive osteotomies is sheer folly.Can it be done? Of course.....then evaluate your patient several months or years later.It is doubtful to me that your patient will ever return.Explain to your patient that you are attempting to do what is in his best interest(not testing your technical surgical skill).Consider alternative procedures that are less aggressive and less debilitating to your patient.A McBride with fibular sesamoidectomy and phalangeal osteotomy in a flexible foot-type will go a long way.You could transfer the adductor tendon for additional reconstruction and correction.Will the toe be perfectly straight? Probably not, but, you will get a reasonable correction and a happy patient.Both of you will ultimately be happier.Good luck.
dlbdpm

PODRICK,
if you feel she wouldn't do well with the base wedge then don't do it. You state she is only moderately active. Often times less is better. You don't always need a complete correction and you certainly don't always need to strictly go by the textbook "cut off" limits of angles when planning bunion surgery.

I deal with situations such as this on a daily basis. We have a rather diverse population of patients, athough we tend to lean more towards reconstructive procedures. First and formost, I would evaluate the pateient as a whole. Does the patient WANT that type of correction, or merely just want the "bump" gone. What is the bone stock like. Could the pateint handle the rigors of the post operative care. These are all things to consider when tailoring your surgical decision making.

In the majority of the cases such as this, I tend to err on the side of destructive procedures such as the Keller or Keller/Mayo (with a long first met). They tend to have little discomfort as compared to the osteotomy types of correction. No incidence of non union (logical), and should recover to full weightbearing and shoe gear rather quickly, although they aren't the greatest cosmetically due to shortening of the toe. This may be acceptable to the patient, and should be addressed. Without the Mayo component, you shouldn't have to worry about lesser metatarsalgia developing either.

If you are truly prone to providing the correction, I would suggest a Lapidus type fusion. If a base wedge doesn't heal you are going to have a real mess on your hands, but by the same token, if a Lapidus doesn't heal, it will progress to a non union which is usually asymptomatic and can easily be controlled with orthotics if need be.

Best of luck in your decision making

i appreciated the input.however,in the end i opted for an austin/akin combination.i was able to achieve 2.5 im reduction which elinated her deforming force and prominence of course.i also believe that this type of patient is somewhat more difficult to catagorize.
they are elderly,however in good health and very active.although i do feel that a keller with proper tendon attachment would have served her well too.
the latest update is a happy patient and a satisfied surgeon.

thank you all for the helpful input