Postoperative Protocol After Bunion Surgery: In Search Of A Standard
Hallux abductovalgus (HAV) surgical correction has inspired debate on techniques and postoperative protocols among foot and ankle surgeons protocols since its initial consideration for painful bunions. This debate continues in present day as surgical techniques and our understanding of HAV deformities advance. There are hundreds of described open procedures, most commonly including the distal chevron osteotomy, Scarf osteotomy, and first tarsometatarsal arthrodesis (Lapidus). Additionally, minimally invasive bunion surgery, first popularized in 1990 by Bosch and colleagues, has gained substantial momentum in the past few years.1 While United States adoption of minimally invasive surgical methods is slower relative to other countries, the literature shows very positive results and many now recognize the benefits of this surgical approach.2,3 Such benefits include a cosmetic incision, minimal dissection, low energy osteotomy, shorter and more accommodating recovery, as well as improved patient satisfaction.2
In our experience, a substantial piece of patient satisfaction is the comfort experienced during a patient’s postoperative course. Postoperative courses depend highly on surgeon preference and the surgical procedure of choice, making it exceptionally variable. One surgeon may recommend transition to a sneaker within one week postop while another may advise non-weight bearing for up to eight weeks. Without an existing standard for postoperative weight bearing, a critical piece of patient satisfaction and outcomes are left to chance.
Pertinent Points With The Chevron And Scarf Osteotomies
The distal chevron osteotomy has undergone several modifications including most recently a minimally invasive method. Long-standing criticism of the open distal osteotomy includes disruption of the soft tissue capsule, inability to perform triplanar correction and debate on its effectiveness for severe hallux abductovalgus deformities. Conversely, surgeons like the ease and reproducibility of the procedure. In our observation, patients often perform full or heel-touch weight bearing postoperatively in a surgical shoe. Most frequently, suture removal takes place at two weeks postop and patients often remain in the postoperative shoe or a CAM boot until approximately four to six weeks after the procedure.4
Discussions of the Scarf osteotomy characterize it as an extremely inherently stable with its large overlap of cancellous bone, there across mild to severe deformities.5 Postoperative protocol for the Scarf osteotomy enables immediate weight bearing in a surgical shoe immediately with ability to return to sneakers at one week and full bathing.5 However, this surgical approach does require a large incision with lateral soft tissue release that while rare, may place the metatarsal head at risk of avascular necrosis and disrupts the joint capsule.6 Other sources critique its technical demand, large learning curve and requirement of sufficient width of the first metatarsal.6 Intraoperative complications such as troughing and fracture are also of concern, which can cause elevation of the first ray and transfer metatarsalgia.6 An often highlighted benefit is return to work at approximately six weeks postop and return to sports activity at eight weeks.6 This early weight bearing and return to activity enables first metatarsophalangeal joint range of motion, helping to prevent long-standing stiffness.
What Does The Literature Reveal Regarding Tarsometatarsal Arthrodesis?
Advocates for tarsometatarsal arthrodesis for HAV correction stress the opportunity for triplanar correction with argument for correction at the anatomic center of rotation of angulation (CORA).7 Postoperative protocol for this procedure varies greatly from immediate weight bearing in a CAM boot to six-to-eight weeks of non-weight bearing before converting to a CAM boot. Consideration of extended non-weight bearing for this procedure is to allow for primary bone healing, preventing elevation of the first ray and prevention of complications associated with possibly poor fixation constructs.8 Even in the study completed by Ray and team that looked at the effects of immediate weight bearing, surgeons within the study varied between weight bearing immediately or advising non-weight bearing for two weeks before transitioning to weight bearing, with an average of partial weight bearing at postoperative day 10.7
Nonunion rates after first tarsometatarsal arthrodesis do not appear to correlate with early weight bearing (prior to 21 days, as compared to after 21 days).9 Partial weight bearing at an average of postoperative day 12 also did not impact nonunion rates in another study that looked at a two crossing screws technique.8 Nonunion rates in these early weightbearing studies have ranged between 1.6 to 7.1 percent with variation in fixation, and one study reported a recurrence rate of 3.2 percent with biplanar locked plates.7-9 Variation in constructs and surgical technique still makes these comparisons difficult and often debated among surgeons.
Key Considerations Regarding Minimally Invasive Bunion Correction
As demonstrated, postoperative protocol for many procedures depends on surgeon preference. Minimally invasive bunion surgery is no exception. Further discussion surrounding postoperative protocol is necessary for optimal patient outcomes. In our experience, one must consider several factors including the incision, osteotomy stability and fixation selection. Due to the minimal incisions, only a few sutures are necessary for closure, making incisional concerns a small component of postoperative decision-making. With less soft tissue disruption, we find patients often have substantially less pain and opioid use.
One concern to those new to minimally invasive bunion surgery is that for stability of the transverse osteotomy technique as employed and described by Siddiqui and colleagues.10 A recent publication by Aiyer and coworkers looked at biomechanical stability of the minimally invasive approach via a chevron or transverse osteotomy.11 In this cadaveric study, the authors found no statistically significant difference between methods of osteotomy for failure after cyclic loading. Though not statistically significant, the transverse osteotomy performed slightly better when it came to failure when compared with the chevron method of correction.11 In addition to this report, Siddiqui and team had no nonunions and excellent radiographic outcomes in their on 218 feet that underwent minimally invasive transverse osteotomy for bunion correction at four weeks.12
The initial technique employed with no internal fixation and use of a 2.0 mm Steinman pin saw more callus formation from secondary bone healing, but still allowed for immediate postop weight bearing.12 However, there was a higher risk noted for pin site infection.13 Internal fixation provides direct fixation of the capital fragment, yielding less callus formation, but enhanced direct stability. Additionally, with inherent minimal dissection associated with a minimally invasive approach, the soft tissue structures surrounding the osteotomy provide enhanced stability.13 The capital fragment maintains the tibial and fibular sesamoid ligament attachments along with the dorsal and plantar capsule/soft tissue attachments normally disrupted in open surgery.13 The literature and the authors experience support that it is safe for patients to ambulate immediately postop in these minimally invasive cases.
One Team’s Approach Towards A Standard Postoperative Protocol
The authors’ standard postoperative protocol for minimally invasive bunion surgery cases include immediate weight bearing in a postoperative shoe. Patients’ postoperative dressings, which consist of 4x4 gauze, ABD pads, cast padding and an Ace bandage stay intact until their first postoperative follow-up appointment in one to two weeks. After this dressing removal, patients can begin showering with regular soap and water. We instruct them to place a silicone gel toe spacer in the first interdigital space at the time of their first visit and to begin gentle range of motion exercises of the first metatarsophalangeal joint. Siddiqui and colleagues describe, that unlike with open surgery with capsular dissection, this extracapsular dissection supports early first metatarsophalangeal joint range of motion, further preventing capsular scarring or adhesions.12 This also contributes to why patients rarely report first metatarsophalangeal joint stiffness postoperatively with these minimally invasive techniques.14
Dependent on edema, patients may be able to transition to tennis shoes any time between two to four weeks postoperatively. Once doing so, patients can continue with low-impact activity and walking. Light exercise can begin generally between four to six weeks postop and return to full impact activity between eight to twelve weeks, pending patients’ clinical presentations. If patients do not have pain at the osteotomy site with palpation, at eight to 12 weeks postoperatively we transition them to full activity.
It is imperative to note that one must evaluate postoperative radiographs for alignment and osseous bridging, however one will not be able to visualize full radiographic union at the time one releases the patient to full activity. The clinical exam is still the most important piece of the postoperative course progression, in our experience. We advise patients to keep their silicone gel insert in the first interdigital space until 12 weeks postop, as the soft tissue structures realign to the corrected anatomic location. We obtain postoperative radiographs at two weeks, four weeks, eight weeks, and 12 weeks postoperatively.
Concluding Thoughts
Foot and ankle surgeons continue to debate hallux abductovalgus deformity and surgical procedure selection, as well as postoperative protocol. Current pathways continue to depend on surgeon technique and patient considerations, which enables surgeons to make postoperative protocol specific to each patient’s needs.
Dr. Millonig is an Associate of the American College of Foot and Ankle Surgeons and is a Fellow with the Foot and Ankle Deformity Correction and Orthoplastics Fellowship at the Rubin Institute for Advanced Orthopedics.
Dr. Siddiqui is a Fellow of the American College of Foot and Ankle Surgeons and is the Director of Podiatric Surgery at the Rubin Institute for Advanced Orthopedics. He is the Director of the Foot and Ankle Deformity Correction and Orthoplastics Fellowship also at the Rubin Institute for Advanced Orthopedics.
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