|
|
Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA |
I don't usually spend a lot of time discussing academic / scientific issues directly related to podiatry. I was originally tasked by the folks at PRESENT e-Learning Systems to talk more about the "social" aspects of being a podiatric physician – a "day in the life of" so to speak. However, sometimes an important topic or concept comes along that requires some attention.
 At the last American College of Foot and Ankle Surgeons (ACFAS) conference in Phoenix, Arizona, there was a lecture track devoted to bunion surgery. Overall, the lectures were excellent, but there was one that was revolutionary. That lecture was given by Paul Dayton, DPM, MS, an assistant professor at the  Des Moines College of Podiatric Medicine. Dr. Dayton is a well – published podiatric researcher and surgeon who, if you look at his publication list, has contributed a lot to our profession. But of all the work he has done his relatively recent work on hallux valgus is, in my opinion, ground-breaking. Dr. Dayton, along with others, has created a body of research that may move hallux valgus surgical treatment to its next level.
In light of good work that deserves attention, let's do a quick journal club covering this revolutionary work of Dr. Dayton and colleagues. We'll look at a few articles that introduce the evolution of bunion surgery to its next logical step.
What is that logical step you ask? Here it comes. Drumroll please...
Addressing the frontal plane component of the hallux valgus pathology.
Anticlimactic, you say? Let's explore his work with the past paradigms in mind before you judge my opinion too harshly.
An All Too Brief History of Bunion Surgery
Without going into too much detail, surgical bunionectomies started with soft tissue releases (the McBride) and joint destruction like the Keller procedure. It then moved to osteotomies of the first ray and eventually to popularization of the Lapidus first metatarsocuneiform arthrodesis (it was around a long time before becoming as ubiquitous as it is today).
Podiatric physicians paid surgical attention to the intermetatarsal angle with the highly popular Chevron-type bunionectomies and the closing base wedge family of procedures. Both of these primarily addressed the transverse plane deformity with a small amount of sagittal correction. As we moved on, we began paying greater attention to the sagittal plane, and the Lapidus became increasingly popular in our profession. This is where many, if not most, podiatric and orthopedic literature resides. For many years the vast majority of papers have discussed modifications of these procedures or various methods of fixation. Success has been generally positive, but as anyone in practice can tell you we've had trouble obtaining consistent correction and still see a significant number of recurrences.
 I said earlier that Dr. Dayton's work is evolutionary because he and his colleagues have taken the next logical step by focusing on hallux valgus treatment as a three-dimensional problem (contrary to the previous one- and then two-dimensional approaches). We've known about the 3D nature of the deformity for quite some time, but have ignored the frontal plane during surgery.
Dr. Dayton and colleagues provide an excellent summation and application of this entire concept in an upcoming article to be published in the Journal of Foot and Ankle Surgery (JFAS).1 In essence these researchers establish that along with the medial transverse displacement of the first metatarsal (metatarsus primus adductus) and dorsiflexion of the first metatarsal (metatarsus primus elevatus) there also exists a concomitant frontal plane valgus rotation of the metatarsal. They address the multiple names for this rotation including pronation, eversion, and external rotation along with valgus. We'll stick with valgus for consistency.
Along with the valgus rotation of the metatarsal comes a relative valgus position of the sesamoids. Dayton has shown that this valgus position of the metatarsal and seasmoids is demonstrated on radiographs as increased intermetatarsal angle, increased tibial sesamoid position, rounding of the lateral aspect of the metatarsal head and lateral bowing of the metatarsal shaft.2,3 They postulate that this may be driven by the valgus position of the hallux.2 Though more work is necessary to determine what truly drives the deformity, this concept has applications to surgery.
Dayton and colleagues argue that the modified Lapidus procedure is the best option to surgically treat HAV due to its ability to correct all three planes of the deformity.1 Additionally, they make the well-known argument that the Lapidus procedure addresses the CORA (center of rotational angulation) or the apex of deformity.
 Combining all of these concepts together, he describes a modification of the Lapidus procedure that allows surgeons to correct this triplanar deformity.1 First, it's important to know that this modification is performed without entering the first metatarsophalangeal joint. There is no capsulorraphy, no sesamoid release, adductor tendon release, or medial eminence resection. Read that sentence again. Dayton proves that with adequate triplanar deformity correction, it is not necessary to violate the 1st MTP joint.
Through an incision over the first metatarsocuneiform joint, Dayton performs the standard joint elimination (take your pick on methods). After correcting the IM angle and sagittal plane, he inserts a Kirschner wire into the 1st metatarsal and uses it as a joystick to rotate the metatarsal into a relative varus position. Dr. Dayton uses intraoperative fluoroscopy to verify reduction of frontal plane deformity via decrease in the lateral 1st metatarsal head rounding (it flattens out a bit as more of the dorsal head is visible), a more rectus appearance of the 1st metatarsal shaft and decrease in the tibial sesamoid position. It's then fixation of the fusion site by dealer's choice.
Lawrence DiDomenico, DPM and colleagues discussed a modified frontal plane reduction approach employing the concepts discussed by Dayton in reference 2. Instead of using a Kirschner wire joystick,, they rotate the hallux itself into varus, which then rotates the sesamoids out of their pathologic valgus rotation.4
Illustrative Cases
As a very small and very unscientific testimonial to the potential of these concepts I'll show my first two experiences with this work. The first is a patient I took care of about three years ago. This was a 17-year-old female on whom I performed a modified Lapidus and Akin without entering her first MTP joint. I did not consider the rotational part at the time.
Figure 1
Preoperative and 13 week postoperative clinical and corresponding radiographic images. |
 |
|
The second is a patient I recently took care of using the approach advocated by Dayton and colleagues. I'll let you be the judge of the quality of my surgical correction, but since no one is more critical of me then I am, I can tell you I should have corrected the IM angle a little more (though it is down to a more normal angle from the preoperative 19 degrees). I think it's important to note the correction of the valgus rotation of the hallux as seen by the dorsally facing nail plate on the postoperative clinical image.
Figure 2
Preoperative and intraoperative clinical and radiographic images of patient's HAV
deformity corrected with modified Lapidus with frontal plane rotation. |
 |
|
In both cases, note the radiographic reduction of the parameters Dayton and colleagues discussed above. I can also tell you subjectively that the first case was perhaps the best result I had achieved to date, in the sense that the patient's range of motion postoperatively was excellent and with 100% return to long distance running (she was a track athlete in high school). However, note the very slight residual valgus rotation of the hallux. Interesting though, considering I did not address the frontal plane component. I don't know the long term results yet on the second patient, but I think she'll do very well.
During his address to the ACFAS conference, Dr. Dayton mentioned that he has not entered the 1st MTP joint with these procedures for years and has been achieving consistently good results with this method. A retrospective study performed by his group looked at 25 of these procedures (these actually included a limited 1st MTP joint release) and found corrections of all radiographic parameters, including the PASA (likely an artifact of the head rotation).5
Clearly more research is needed to examine the long-term effectiveness and clinical success of the procedure as well as potential long term ramifications. However, from early research and preliminary results it's fair to say that this may, in fact, be a paradigm shift in how we surgically handle hallux valgus deformities. The research done by Dr. Dayton and colleagues is the most exciting and potentially revolutionary work in recent years. My hat off to him and his associates for their strong work, and I urge all of you to read the references below and strongly consider them when you approach this deformity.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References
- Dayton P, Kauwe M, Feilmeier M. Is Our Current Paradigm for Evaluation and Management of the Bunion Deformity Flawed? A Discussion of Procedure Philosophy Relative to Anatomy. Journal of Foot and Ankle Surgery, 2015 (article in press);1-10.
- Dayton P, Feilmeier M, Kauwe M, et al. Observed Changes in Radiographic Measurements of the First Ray after Frontal and Transverse Plane Rotation of the Hallux: Does the Hallux Drive the Metatarsal in a Bunion Deformity? Journal of Foot and Ankle Surgery. 2014:53(5);584-587.
- Dayton P, Feilmeier M, Hirschi J, et al. Observed Changes in Radiographic Measurements of the First Ray after Frontal Plane Rotation of the First Metatarsal in a Cadaveric Foot Model. Journal of Foot and Ankle Surgery.2014:53(3);274-278.
- DiDomenico L, Fahim R, Rollandini J, et al. Correction of Frontal Plane Rotation of Sesamoid Apparatus during the Lapidus Procedure: A Novel Approach. Journal of Foot and Ankle Surgery. 2014:53(2);248-251.
- Dayton P, Feilmeier M, Kauwe M, et al. Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the Literature. Journal of Foot and Ankle Surgery. 2013;52(3):348-354.
Get a steady stream of all the NEW PRESENT Podiatry
eLearning by becoming our Facebook Fan.
Effective eLearning and a Colleague Network await you. |
 |
This ezine was made possible through the support of our sponsors: |
|
