2001 OITE Question 28

Question

A 44-year-old woman has a painful bunion. Nonsurgical management and shoe wear modifications have failed to provide relief. Examination reveals a hypermobile first ray and generalized ligamentous laxity. Radiographs do not show any evidence of arthrosis. Treatment should now consist of a

1 – phalangeal (Akin) osteotomy.

2 – distal soft-tissue procedure.

3 – distal metatarsal osteotomy with an Akin osteotomy.

4 – first tarsometatarsal arthrodesis (Lapidus) with a distal soft-tissue procedure.

5 – first metatarsophalngeal arthrodesis.

Figures

Answer (click for answer)

ANSWER: 4

DISCUSSION: With bunions, always attempt nonoperative treatment first. Failure of nonoperative treatment then leads to an algorithm of operative decision-making, which is well depicted in OKU F+A 2 P 129. If there is significant DJD of the first MTPJ, the one must consider fusion vs prosthetic replacement vs Keller (resection-) arthroplasty. Next, consider if the joint is congruent or incongruent (subluxated). If congruent, then the deformity must be treated without rotating the metatarsal underneath the proximal phalanx, so a periarticular procedure may be done. If incongruent (the majority of adult bunions), then various corrective procedures may be considered based on the degree of deformity (especially considering the IM angle and the HV angle). However, the patient with hypermobility of the first metatarsal-cuneiform joint will likely develop recurrence unless a first metatarsal-cuneiform arthrodesis is performed along with a distal soft tissue procedure (correct answer 4). The phalangeal, or Aiken, osteotomy corrects deformity at the proximal phalanx as from halux valgus interphalngeus with a congruent first MTPJ, but this does not address hypermobility (wrong answer 1). A distal soft tissue procedure (as in modified McBride) alone achieves only mild correction and should be considered only of the IM angle is less than 13º and HV angle less than 30º with no hypermobility (wrong answer 2). The combination of a distal metatarsal osteotomy and Aiken procedure may preserve joint congruity but would not address hypermobility (wrong answer 3). Finally, fusion of the first MTPJ, as would be appropriate in the setting of first MTPJ arthrosis, does not address hypermobility of the first metatarsal-cuneiform joint (wrong answer 5).

Reference: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp123-134.


Hansen ST: The dysfunctional forefoot, in Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 2000, pp215-226.