Case Study: A Surgical Option for Failed MIS Bunionectomy with Nonunion
Minimally invasive surgery (MIS) of the foot, particularly for correction of hallux abducto valgus (HAV), has become increasingly popular in recent years.1 Correction for HAV, whether open or minimally invasive, may present with surgical complications including nonunion or malunion, amongst others.2 MIS techniques in the correction of HAV claim to allow less trauma to soft tissue structures of the first ray, decreased surgical times, and quicker overall recovery, while maintaining a similar rate of correction and clinical outcomes.2,3 Surgeons must be aware of the complications of MIS as well as open surgical techniques and be prepared to address these if and when they arise in the postoperative setting.
The authors present a case report of a failed MIS bunion correction with subsequent nonunion and a technique guide for the surgical interventions they implemented in the revision surgery.
What You Should Know About the Patient Presentation and Surgery
A 41-year-old female presented to the clinic for a second opinion regarding continued right foot pain following a minimally invasive chevron bunionectomy and subsequent hardware removal. She was evaluated and, based on radiographic and computed tomography (CT) findings (Figure 1), was found to have a nonunion. Interventions were discussed with the patient and she elected to proceed with a repair of the first metatarsal nonunion site with calcaneal autograft.
A standard dorsomedial incision was used for the surgical approach. Dissection and reflection of the soft tissue structures revealed a gapped osteotomy site at the distal metatarsal, corresponding to the site of nonunion as demonstrated on radiographic imaging (Figure 2). Fibrous tissue was noted within the osteotomy site, which was mobilized with an osteotome, followed by resection of all nonviable tissues.
Attention was then directed to the lateral heel where a curvilinear incision was placed anterior to the insertion of the Achilles tendon and posterior to the peroneal tendons and sural nerve (Figure 3). Subperiosteal dissection yielded the lateral calcaneal wall, where two K-wires were inserted, functioning as cut guides for harvest of the structural calcaneal bone graft: one anterior to the insertion of the Achilles tendon and the second 1 cm anterior to the first. The graft was cut and excised—measuring 1.0 x 1.5 x 1.0 cm in its entirety (Figure 3). The site was flushed, backfilled with cancellous bone chips, and appropriately closed.
Attention was redirected to the first metatarsal and a Weinraub distractor was applied distal and proximal to the nonunion site, holding the metatarsal out to length and maintaining the metatarsal parabola (Figure 4). The nonunion sites were curetted and fenestrated with a drill to bleeding bone. A Y-plate was placed medially and secured with locking screws proximally and distally. The autogenous calcaneal bone graft was then tamped into the site, ensuring a secure fit. Cancellous bone chips and cellular bone matrix were both used to fill any remaining deficit. This was followed by placement of a T-plate dorsally and secured again with locking screws, completing the dual 90-90 plate construct (Figure 5). The surgical site was irrigated thoroughly and layered closure was attained, followed by placement of the extremity in a padded posterior splint. The patient progressed well in the postoperative period. She advanced well through a progressive weight-bearing protocol and completed physical therapy, and was discharged approximately 4 months after the date of revisional surgery with final X-rays showing good bone healing (Figure 6).
Final Thoughts
The incidence of complications is generally similar in open versus MIS for the correction of a HAV deformity.1 In MIS, decreasing the incidence of nonunion may be addressed by decreasing thermal injury to the bone; this is often conducted by implementing high torque, lower speed, and sharp burrs, which are often rinsed for cooling.1 The authors recommend use of autogenous structural calcaneal bone graft to preserve metatarsal length when dealing with bone loss, which may be augmented further with cellular bone matrix. Calcaneal bone graft has been implemented with good success in first metatarsophalangeal joint distraction arthrodesis and can similarly maintain length to the first ray in cases of nonunion.5
The authors recommend a stronger fixation construct in revision cases such as these; in this case, utilization of a medial locking plate enhanced with a dorsal locking plate. Double plate techniques have been described and implemented with good results for comminuted distal fibular fractures for additional rigidity and decreased risk of fixation failure.6,7 This construct has also been reported with good outcomes for fixation of a comminuted second metatarsal fracture in an overweight patient with diabetes.7
A dual 90-90 plate construct with implementation of structural calcaneal bone graft is a viable and replicable option for stable open reduction and internal fixation (ORIF) for the described revision surgery. The authors recommend a thorough evaluation of patients undergoing revisional surgery and determining the best possible intervention and techniques for each individual case, and additionally weight the options of conservative versus surgical intervention.
Zuhair Irfan, DPM, AACFAS is the current Reconstructive Rearfoot and Ankle fellow at the Foot and Ankle Specialists of Central Ohio Fellowship. He is board qualified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle Surgery.
https://www.linkedin.com/in/zuhair-irfan-b2101882/
Andrew Mastay, DPM, FACFAS is Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot/Ankle Surgery as well as by the American Board of Podiatric Medicine. He is affiliated with the Henry Ford Health System in Detroit and is the President-elect for the Michigan Podiatric Medical Association.
References
1. Toepfer A, Strässle M. 3rd generation MICA with the “K-wires-first technique” – a step-by-step instruction and preliminary results. BMC Musculoskelet Disord. 2022;23(1):66. Published 2022 Jan 18. Doi:10.1186/s12891-021-04972-5
2. Hochheuser G. Complications of minimally invasive surgery for hallux valgus and how to deal with them. Foot Ankle Clin. 2020 Sep;25(3):399-406. Doi: 10.1016/j.fcl.2020.04.002. Epub 2020 Jun 18. PMID: 32736737.
3. Kaufmann G, Dammerer D, Heyenbrock F, et al. Minimally invasive versus open chevron osteotomy for hallux valgus correction: a randomized controlled trial. International Orthopaedics (SICOT). 2019; 43(2):343–350. https://doi-org.sladenlibrary.hfhs.org/10.1007/s00264-018-4006-8
4. Malagelada F, Sahirad C, Dalmau-Pastor M, Vega J, Bhumbra R, Manzanares-Céspedes MC, Laffenêtre O. Minimally invasive surgery for hallux valgus: a systematic review of current surgical techniques. Int Orthop. 2019 Mar;43(3):625-637. Doi: 10.1007/s00264-018-4138-x. Epub 2018 Sep 14. PMID: 30218181.
5. Kindred KB, Wavrunek MR, Blacklidge DK, Wadehra A. First metatarsophalangeal joint distraction arthrodesis with bicortical calcaneal autograft. J Foot Ankle Surg. 2020 May-Jun;59(3):568-576. Doi: 10.1053/j.jfas.2019.09.017. PMID: 32354513.
6. Samrendu S, Wilson MG. A double plate technique for the management of difficult fibula fractures. Techniques Foot Ankle Surg. 2005; 4(4):235-239. Doi: 10.1097/01.btf.0000176001.88953.fb
7. Chesser A, Saltrick K. Dual plating technique for comminuted second metatarsal fracture in the diabetic obese patient: A case report. Foot and Ankle Online Journal: 2017
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