Revision of the Failed Bunion

Surgery
Iatrogenic Hallux Varus Treatment Algorithm
Carl Larusson
Fourth year Podiatric student
California School of Podiatric Medicine
08/2022
Complications and failures of corrective surgery for hallux valgus are not rare.
Some of the most common reasons for failure include:
Recurrence
Hallux varus
Nonunion & malunion

There are about 130 surgical techniques for the correction of hallux valgus.
Frequency of surgical revision is comparatively low.
Chevron osteotomies with revision rate of 1.85%
Lapidus (first tarsometatarsal joint) arthrodesis 2.92%
First metatarsal closing base wedge osteotomies 2.294%
Factors for development of recurrent deformities include:
Patient factors
Deformity characteristics
Technical features (relevant to the primary surgical procedure)

It is important to consider these potential etiologic factors when evaluating patients with
hallux recurrence.
Anatomic consideration
If (PASA) is large enough, than the lateral tilt of the articular surface contributes to the
deformity.
It maintains complete or partial congruence with the phalanx’s articular surface.
Thus, the MPJ is more or less congruent with the hallux that is deviated laterally.
Proximal articular set angle (PASA) and joint congruency must be carefully examined in
recurrent deformities.

A corrective periarticular osteotomy should be considered, such as a biplanar distal

chevron osteotomy with medial closing wedge.
The first TMT joint instability is paramount to the development of hallux valgus.
Arthrodesis of the first TMT joint for management of dorsal bunion and pain localized to
TMT joint has shown excellent results.
TMT joint should be assessed for tenderness and painful motion in patient with recurrence.
Clinical finding: assessing the degree of relative dorsiflexion of the first metatarsal to
second with manual testing.

Radiographic findings of TMT joint instability include plantar gapping and dorsal
translation.
Metatarsus adductus is associated with HV recurrence.
Metatarsus adductus artificially diminishes the measurable IMA because the lesser
metatarsals are also medially deviated.
Thus, primary surgery have been selected on the basis of an IMA that is measured less
than its true value.
Ture IMA = IMA +(metatarsal adductus angle -15’)
Analysis of preoperative radiographs will help to determine if the primary surgery was
appropriate for the deformity or not.
Measuring the IMA can be challenging postoperatively.
The “center of head” technique is used to mitigate the effect of previous osteotomies
on the IMA.
The green X is established by center of a circle mirroring the radius of crvature of the
articular surface.
Iatrogenic Hallux Varus
Anatomy
Intrinsic muscles serve to stabilize the hallux by influence on rotation as well as medial and lateral
deviation; FHB, EHB, AbH,
Extrinsic muscles mobilize the MTP joint into flexion and extension; FHL, EHL

Pathogenesis
The static type results from osseous disruption at the MTP joint following overcorrection
(aggressive medial eminence resection or overcorrection of the IMA) during the osteotomy
procedures.
The dynamic type is the result of disruption of muscle balance at the base of the proximal phalanx.
Clincal evaluation
A patient history should be focuse on the timing of the previous surgery, the
procedure type, and the chronicity of symptoms. A patient’s chief complaint is more
often due to cosmetic deformity, rather than pain.
Evaluation should determine if the deformities of the MTP and IP joint are flexible or
rigid as this will influence treatment plans.
Radiographic findings
The hallux varus angle: the first metatarsal and the longitudinal axis of the proximal phalanx (5’ to
15’ normal and 0’ or negative pathogenic).
Excessive medial eminence resection.
Medial subluxation of the tibial sesamoid out of the sesamoid groove.
Absence of a fibular sesamoid.

Decrease IMA (0’ to 8’ normal, 0’ or negative hallux varus).

Longer first metatarsal than second metatarsal.
Phalangeal varus or malunion from previous phalangeal osteotomy.
Cystic or arthritic changes at the MTP and/or IP joint.
Arthritic, deformed or hypertrophied sesamoid bone.
Early tratment
(2 to 4 weeks after surgery)
Weekly dressing and tapings of the hallux to 10’ to 15’ of valgus for 8 to 12 weeks.
Followed by 3 months of night splinting. Shoe wear modification and antiinflammatories.
If treatment is unsuccessful after 6 to 8 weeks, surgery is warranted.
Medial capsule closure released or Z-lengthened on the medial aspect of the first MTP joint.
Late treatment
Determined by joint flexibility, joint integrity, and soft tissue balance of the deformity.
In order for tendon transfer or tenodesis to correct the deformity, the joint needs to be
reducible.
If there is an arthritis or a rigid contracture of the MTP or IP joint, arthrodesis is warranted.
Soft tissue
Include the use of autograft (tendon transfer or tenodesis), allograft.
Soft tissue correction is indicated in the case of flexible, nonarthritic deformity (ligament
insufficiency, tendon contracture).

Tendon transfer or Tenodesis

Tendon transfers are for dynamic correction whereas a tenodesis provides static correction.
Advantages of tendon transfer include the preservation of motion and restoration of the
dynamic balance of forces about the first MTP joint.
Contraindications to tendon transfer or tenodesis alone include deformity of the first
metatarsal and the presence of arthritis or rigidity of the MTP joint.
ABH tendon transfer
The tendon is released from the base of the proximal phalanx, routed deep to the
intermetatarsal ligament and anchored to the lateral side of the base of the proximal
phalanx.
The medial capsular and AbH tendon relesed, which are requirement for medial joint
contracture.
Concerns: inadequate length of the harvested tendon and residual supination of the
phalanx.
ABH tenodesis
One-third of AbH tendon width is harvested, detached proximally, and completely
released from the tibial sesamoid.
The tendon is passed through two bone tunnels, from medial to lateral through the
proximal phalanx, then from lateral to medial through the first metatarsal.
Advantage: the tendon which is resposible for the deformity is used to reconstruct the
lateral capsular ligament.
First dorsal interosseous tendon transfer
Detachment of the distal insertion from the base of the phalanx of the second toe and
trasfering it through a bone tunnel in the base of the proximal phalanx of the hallux.
Concerns: technically difficult reinsertion due to the small size of the tendon and
unknown long-term effects on the second toe, which has lost its interosseous muscle.
EHL transfer
After detachment of the distal insertion, the EHL is redirected beneath the first
intermetatarsal ligament, which acts as a pulley, to the plantar-lateral aspect of the
proximal phalanx.
Due to unopposed pull of the FHL, IP joint fusion is proposed to avoid a mallet deformity.
Advantage: long length of the EHL tendon, which makes it appropriate for transfer.
Limitation: reduced extension of the hallux and complete loss of IP motion.
Split EHL transfer
The lateral half of the EHL is transferred in a similar fashion to the complete EHL but half
of the EHL insertion is maintained on the proximal phalanx.
This makes IP joint fusion unnecessary and hypothetically does not affect the ability to
extend the hallux.
When tension is applied distally to the lateral portion of EHL tendon, it is also transferred
to the remaining medial half of EHL tendon, lengthening it and altering its function.
Lateral collateral ligament reconstruction
A. Resection of abductor hallucis.
B. Drilling of two tunnels of 2 mm in diameter in the head of the first metatarsal and base of the
proximal phalanx.
C. The parallel nature of the tunnels.
D. Division of intercapitometatarsial fibrosis.
E. Passage of the 1.5-mm Ligapro suture as directed by the arrows.
F. The Ligapro suture is tied in the first web space.
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