title: Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy.
abstract: Of the >100 procedures that have been proposed to treat hallux valgus or the "bunion" deformity, most have focused on correction through metatarsal osteotomies at various levels combined with soft tissue balancing procedures at the first metatarsophalangeal joint. This paradigm of metatarsal osteotomy and soft tissue balancing has been so commonplace, any argument for a fundamental change to the approach becomes uncomfortable and seems unwarranted to most foot and ankle surgeons. However, the simple fact that so many procedures exist, with so many modifications of these procedures, can be interpreted as a failure of our basic paradigm of metatarsal osteotomy and soft tissue balancing. We have observed that failure to recognize frontal plane rotation of the first metatarsal and our willingness to ignore deformity correction principles and create osteotomies outside the center of rotation of angulation are factors that can result in inconsistent outcomes. Our current multiprocedural mindset drives the search for yet more procedures and modifications in an attempt to reduce the incidence of complications. We present an anatomic analysis of hallux abducto valgus and metatarsus primus adducto valgus and critically analyze some of the shortcomings of currently popular corrective procedures. We also review the available data regarding frontal plane rotation of the first metatarsal and propose a new paradigm that considers frontal plane rotation of the first metatarsal as a priority in choosing the most appropriate procedure for bunion correction.
authors.affiliation: Assistant Professor, College of Podiatric Medicine and Surgery, Des Moines University, UnityPoint Clinic, and Trinity Regional Medical Center, Fort Dodge, IA. Electronic address: daytonp@me.com.
authors.forename: Paul
authors.initials: P
authors.lastname: Dayton
authors.affiliation: Resident, College of Podiatric Medicine and Surgery, UnityPoint Health, Fort Dodge, IA.
authors.forename: Merrell
authors.initials: M
authors.lastname: Kauwe
authors.affiliation: Assistant Professor, College of Podiatric Medicine and Surgery, Des Moines University, Des Moines, IA.
authors.forename: Mindi
authors.initials: M
authors.lastname: Feilmeier
mesh_terms: D017760:Bone Malalignment / Q000000981:diagnostic imaging* / Q000601:surgery; D006214:Hallux / Q000000981:diagnostic imaging* / Q000601:surgery; D006215:Hallux Valgus / Q000000981:diagnostic imaging* / Q000601:surgery*; D006801:Humans; D008682:Metatarsal Bones / Q000000981:diagnostic imaging* / Q000601:surgery; D010027:Osteotomy / Q000379:methods*; D011859:Radiography; D012399:Rotation
keywords: Lapidus arthrodesis; center of rotation of angulation; hallux abducto valgus; metatarsal osteotomy; metatarsal pronation