Tackling Revision With MIS for Hallux Valgus
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Transcript
Tyler Gonzalez, MD, MBA, FAAOS: Let's go into—because everyone's always worried about the burns. They're worried about the necrosis. They're worried about nonunions. Well, nonunions happen in every bunion, right? They happen in every bunion. So this is nothing new, but people are worried. I've revised one. I mean, I think just like any surgeon, it's the same thing. You go in there, you bone graft, you plate it. And mine healed great. For you too, Oliver, you said you've revised one. Brian, I don't know if you had to revise yours, but Oliver, anything different besides going in there, taking out the screws, bone grafting it, adding stability, whether it's a staple or plate. I mean, what's kind of—again, we have an “N” of probably 3 in this group of thousands of bunions. So we don't have a large number, but I don't think it's it's an annoying problem and none of us want it, but it's so rare. But if it happens, I don't think it's that difficult of a fix. But Oliver and then Brian, I'd like to know your experiences with how you fixed yours.
Oliver Schipper, MD: Sure. So the one I actually revised, I did 90-90 staples, smaller nitinol staples on her with calcaneal bone autographed In there and she held up really well. The other option you can do is a dorsal locking plate—sorry, or a dorsal plate, I apologize—if you're locking but I use that one time. It's totally, it's not a nonunion, but I had a lady fall. Four weeks out and she had a sagittal fracture right through or—sorry, it was an axial plane fracture—through the first metatarsal shaft that exited out the osteotomy site and just put a dorsal plate on top and hold it. The awkward part about that is you can only get like kind of 2 screws on the proximal segment 'cause obviously part of it is kind of floating. You can even go to a longer plate, probably get 3, but that's the only challenging part there is, you're a little limited on fixation on both sides. But again, she did great, was able to heal. But those are kind of the 2 options I see for this.
Brian Loder, DPM, CWS, FACFAS: Yeah, I didn't have to revise my nonunions. Two of them, the patients decided to just live with them. And over time, they just tolerated it. The pain wasn't that bad. So I didn't have to revise them at all, the two that I had. I've had a few displaced osteotomies by over-aggressive people and at the beginning a little bit too distal of a screw throw in that cortex, which is extremely important and that's why you'll get blow out through that cortex and windshield wiping.
The funny part is, is that when the osteotomy goes back, it doesn't completely go back to where it was and the patients were mostly satisfied. I had to repair two of those and I didn't open them. I did what I did is pull the screws out and I went to the SERI technique. And I actually percutaneous pins them a wires and had them. Yeah, I used I went back to the old technique of just fixing it with the wire and that the patient was very satisfied with that reduction state so those are my complications that I had to deal with.
Dr. Schipper: Tyler, I think because he just alluded to it or a little bit here, but you know in terms of, and this goes back to one or two screws as well. But, you know, the complication of fracture, right? Or, you know, breaking through your fixation is, I would put that also as an exceedingly rare, you know, 1%, no more than that. And in my experience, it's not 'cause the times I've seen it is someone falls, right? And if they fall, they're gonna fracture early on. I mean, there's no way around that. It's not a, you know, oh, they walked on it and it just fell apart. You know, I think we kind of, you know, in teaching consistent concepts, having that proximal screw exit a centimeter from the lateral cortex, you know, that was the key to reduce risk of fracture or loss of fixation, as Brian was describing.
But I just wanted to touch on that, because outside of that, right, you really don't see it unless someone falls early on. And if they fall, I mean, there's no way that's not going to fracture. It doesn't matter, you know, what kind of screw construct you have.
How do you handle iatrogenic fractures?
Dr. Gonzalez: So Brian alluded to it. I've had one iatrogenic fracture and the capital fragment went back, but not all the way. And their toe clinically looked very straight and very good. You know, given this, you know, I got a CT scan, looked at it, but I felt overall that it was not that displaced. The toe clinically looked good. I treated it nonoperatively. I eliminated their weight-bearing for, I think, about a month, 4 to 6 weeks until it consolidated, and then let them get back to walking. And they did great. Is there anything you guys do differently? I think, obviously, if it's really displaced and shifts, you have to fix it. But has your guys’ been experience similar where you can treat these nonoperatively in these iatrogenic fractures?
Dr. Loder: Yeah, mine definitely. I haven't gone back and treated—the only, I only did one where the gentleman like Oliver said, literally took the shoe off and was climbing a ladder and walking on his roof in the first postop day number 2. So he broke his through, and then I went back and repaired it. But the remainder of them, I did not repair. I just, I treated them nonoperatively. The patient was satisfied. For some reason, the shift, you lose it, but the sesamoids still stay in a really good position. And they follow the head at that point. And so their toe stays relatively straight and their bunion is significantly better than ever was and they choose not to go back into surgery, giving them the options.
Dr. Schipper: Yeah, I think the only part, I agree with Brian and Tyler and my experience too, I just usually have to remove like 1 or 2 of the screws because they do, you know, they can sometimes be prominent, approximately, because again, what happens is the screws kind of move back with the head, right? And so those screws are then typically medial, but I agree with Brian. I mean, it's like typically it clinically still looks pretty good. And these are like usually 60-, 70-year-old patients. They're not, they're not typically young patients. And again, it's not usually bad enough where they want to go back and kind of have you put a plate on top or something like that.
