Bunion Surgery: Are We Really Straightening Out the Problem?

by Duane J. Ehredt Jr., DPM, AACFAS
Wednesday, January 25, 2017

Bunionectomy procedures are one of the most common surgical procedures performed by podiatrists and other foot/ankle surgeons. There are currently 100+ surgical procedures described in the medical literature aimed at correcting the bunion deformity. Interestingly enough, the bunionectomy procedure rarely becomes the seasoned foot/ankle surgeon’s favorite procedure to perform. This is due in large part to the technical precision of the procedure, as well as the relative unpredictability of outcomes.

Until recently, most bunionectomy procedures centered around first metatarsal osteotomies and some level of soft tissue re-balancing around the first MPJ. These procedures were primarily aimed at correcting the obvious transverse and sometimes sagittal plane deformities that are easily evaluated with standard plain-film radiography of the foot. It is now known that the bunion deformity is a tri-plane deformity, with significant amounts of coronal plane involvement.1 Surgeons are now realizing that the traditional metatarsal osteotomy procedures are not correcting the apex of the deformity, but are instead deforming the first metatarsal in an attempt to “offset” the real deformity (Fig. 1).

Figure 1

A paradigm shift has been noted in the specialty, in an attempt to address this concern. Many surgeons now recognize the significant impact of first metatarsal pronation/external rotation on the development of a bunion deformity. Because of this, the aim of bunionectomy procedures has transitioned to correction of the apex of deformity, which is typically located at the first metatarsal-cuneiform joint. The first met-cuneiform arthrodesis, or Lapidus Bunionectomy, is the procedure of choice for addressing the apex of the HAV deformity (Fig. 2). This procedure allows for tri-planar correction, and potentially more predictable and longer lasting results.

Figure 2

There are downsides to the Lapidus procedure. This is a technically more challenging procedure, especially for the novice surgeon. Usually, a more prolonged non-weight bearing period is required in the post-operative phase for patients, and the inherent risk of non-union and potential revisional surgery are noted as compared to traditional distal metatarsal osteotomy procedures. All of these factors are currently being studied and debated amongst the foot/ankle community.

Dr. Duane Ehredt is board qualified in Foot and Reconstructive Rearfoot/Ankle Surgery by the American Board of Foot and Ankle Surgery, and an Associate of the American College of Foot and Ankle Surgeons. He is an Assistant Professor in Foot and Ankle Surgery at Kent State University College of Podiatric Medicine in Independence, OH.