for coming, I'm Lauren Ganey. I was given part of the lead on this as part of the education committee in this Allied Health Task Force that we've been working on. A lot of people here have also been involved, and so we've been trying to put together, you know, something interesting this year, often patients come into the office, whether it's been on the news or whether they've done their own research online, which everyone does, and brings up these ideas. You know, tell me about the 3D bunion, right? I mean, how many of you guys heard that question? And so the point of this is we wanted to bring up some of those controversies. You know, some of the docs that you work with, some of them may fix the deltoid, some of them may not. You know, who does and what's the data behind it? And so we wanted to bring some of that discussion to the forefront today. And so our first talk, we have a little bit of a switch in order. So we're gonna first start with Dr. Dana, who's coming up to talk to us about the different options with bunions. So, Dr. Dana, thank you so much for joining us today. Okay, good morning everyone. Natalie Dannem from the University of Maryland and thanks for starting your morning off today with a little talk about bunions. So, I have nothing to disclose. Oh, there's the monitor, sorry. Coffee is still making its way through the system here. Nothing to disclose here. Okay, so bunions, not the most glamorous part of foot and ankle surgery, but certainly important to the patients who have one and relevant for us as their providers. So, the bunion, the term bunion refers to that bump medially on the first metatarsal head and usually we think of this as being related to hallux valgus or synonymous with hallux valgus, which very often it is, but it is important to also note that there are other causes of a bunion that are not hallux valgus specifically, but bursitis, gout, arthritis of the first MTP joint. Anything basically that causes that medial prominence, which becomes a problem for the patient in several ways. So, we'll just do a brief etiology here of the word. The word bunion itself comes from the Greek for turnip. It's about as palatable. It sort of calls to mind that bulbous mass there on the medial side of the foot, which as you can see in this picture and know from your patients makes primarily difficulties with shoe wear in addition to other issues. So, we'll take a quick dive just through some background of hallux valgus. There are some risk factors that have been identified. The shape of the metatarsal head is one of them. Loss of the lateral restraint as in a second toe amputation or a second toe deformity can lead to hallux valgus formation. Ligamentous laxity either at the MTP joint or at the TMT joint can also contribute. Rheumatoid arthritis is a cause. Some will say that pes planus does contribute to development of a bunion, though this is controversial. And then there are post-traumatic causes that have been identified. So, there is a domino effect of changes in the bony structure that will lead to the formation of hallux valgus. Briefly, the proximal phalanx will start to drift laterally. The metatarsal head will drift medially. The medial capsule will stretch out while the lateral capsule will contract. The plantar sesamoid complex will start to drift laterally, eroding the cristae. And I point this out just to highlight the point that this is not one element of deformity here, but several contributing factors. So, for the patient, they experience, as a result of this domino effect, pain over that large medial eminence. Deformities of the second toe, most often hammer toe deformity. Transfer metatarsalgia as the weight shifts laterally to the lesser metatarsal heads. And then diminished efficacy of the windlass mechanism, which does change gait mechanics and increase the work of walking. So, okay. Once we see a patient with this, we talk about the conservative options, wider toe box shoes, some stretching, some bunion capes. Those all work plus minus for a particular patient. And then we start to talk about the operative techniques. So, some of the things we'll cover today will be the traditional open first metatarsal osteotomy, the minimally invasive distal osteotomy, or the lapoplasty. All right. So, the traditional approach. So, open metatarsal osteotomy, most often done through a large medial incision, leaving a large medial scar. There are several options for the configuration of this osteotomy. Many, many more than this have been described in the literature. And there are as many surgeons promoting or decrying various methods of metatarsal osteotomy. In short, this is sort of the more traditional approach. It has been considered tried and true over years. Because this metatarsal osteotomy often spans, is either proximal or spans most of the metatarsal, it has the potential for a powerful correction. And with a lot of bony contact, this is generally considered a stable osteotomy. So, the loss of fixation, loss of correction, nonunion concerns, very often less for this approach. The downsides, however, are the considerable soft tissue stripping in the approach. There is a large scar. So, that has the issues of cosmesis for the patient, as well as pain, as well as some soft tissue considerations. And then the risk of a vascular necrosis. So, with that large approach, the blood supply to the metatarsal may be compromised with that ADN risk resulting. So, some dissatisfaction with the open technique or desire for something new has led to the development of the minimally invasive technique. So, this very often is a distal metatarsal osteotomy. There may or may not be the addition of a proximal phalanx osteotomy, depending on the specific deformity. And these osteotomies are fixated with percutaneous screws. So, that leads to, as you can see in the image here, those small red dashes are fairly small incisions, which is one of the major differences between this technique and the traditional technique as far as the outside goes. On the inside, as you can see, there's also a difference in how the bony correction is achieved. So, these are small incisions. With small incisions comes improved cosmesis, which is important to some patients. But small incisions also leads to less soft tissue stripping. So, that may lead to post-operative pain, lower post-operative pain. And, debatably, there may be improved range of motion due to that decrease in soft tissue stripping. And proponents of this also point to the increased early post-op stability in the traditionally described method. That more lateral screw has bicortical fixation in the proximal fragment, giving it a pretty solid construct. And then there is two screws holding that metatarsal head in the corrected position. Oh, and I'll just go back for a second. So, referring to this as the minimally invasive technique, I've had patients come to me talking about the keyhole procedure, which I think is something sort of promoted online as minimally invasive because of the small incisions. And there may be some other terms that come across your plate as patients come to ask about these newer procedures. So, next, let's review the lapoplasty and discuss that technique. And so, this can be called the 3D bunion correction. The lapidus procedure is the first TMT joint fusion. With a lapoplasty, there is a fusion of the first TMT joint, but there also is, with the addition of that term plasty, the implication that the shape is changed here. So, in this procedure, the root cause of the bunion is targeted by changing the orientation of that first metatarsal to attempt to correct the deformity. So, proponents will argue that this is a 3D correction and therefore more anatomic than some of the other methods. The method described by one of the companies promoting this uses two plates on that first TMT joint, as you can see in the x-ray here. So, with that increased stability, proponents will advocate early weight-bearing for the patient. But this is probably, of the topics I've presented this morning, the most controversial. And those who are not supporters of the lapoplasty will cite the nonunion risk. Because this is an arthroplasty, the nonunion risk is higher than it might be for those osteotomy techniques. And there is less surface area for contact. So, nonunion risk is a big deal for this procedure. Shortening of the first ray, also a problem here, as there is bony resection and removal of the intervening cartilage. Shortening of the first ray becomes a problem because this can lead to transfer metatarsalgia with the patient's weight being transferred more laterally, causing pain at the lesser metatarsal heads. This is often a larger incision than the MIS, minimally invasive technique, especially if you're using the plates, again, promoted by one of the companies that advocates for this. They're bigger plates. And so, the incisions are bigger. And then, the fusion of a joint that previously enjoyed motion can lead to some altered gait mechanics. So, that is a consideration in a patient who, you know, that joint was not previously affected by arthritis. That joint was actually very often hypermobile. So, there is some consideration there. So, the key points here is that new techniques for addressing haloxyvalgus do continue to emerge. This is driven by desire to improve patient outcomes and also some patient concerns, such as cosmesis with that, you know, initial open technique as opposed to the minimally invasive techniques that have emerged. We can see with these new techniques improvement in cosmesis, improvement in the effect on the soft tissues, improvement in post-operative pain, and function. Each of the procedures does, of course, have pros and cons. These must be evaluated. And then, the bottom line is there's likely no one perfect procedure for every patient. So, it continues to be important to have the discussion with the patient, find out, you know, what bothers them the most about their issue, and then decide which is the best procedure for them. Thank you very much.

bunions

treatment options

surgical techniques

open metatarsal osteotomy

minimally invasive distal osteotomy