Daniel J. Hatch

Modified Kalish osteotomy: A simple approach to minimizing proximal dorsal stress risers

Proximal dorsal stress risers are a potential complication to the Kalish osteotomy. The authors describe a modification to this osteotomy that is simple and effective. Since performing the wing-clip modification, there have been no observed stress risers.

Tarsal-Metatarsal Joint Arthrodesis

Arthrodesis of the first tarsometatarsal joint is a common procedure for patients with HAV deformity. The acceptance of this procedure has gone through an evolution over several generations. Traditional observations such as hypermobility and atavism are commonly cited as indications for TMTJ level of correction; however there is a wealth of new information which calls into question some of these ideas. The most striking new concept is the addition of the evaluation and management of the frontal plane of the deformity. In this chapter the authors will introduce new techniques performed through a single limited incision at the tarsometatarsal site that do not require traditional surgical dissection, capsular balancing, or osteotomy of the first metatarsal phalangeal joint and that facilitate fixation constructs tailored to allow the patient immediate protected weight bearing. The procedure and modifications discussed in this chapter are much different both in indications and technical execution than what has been historically described. Specifically, we do not use high intermetatarsal angle and hypermobility of the medial column as necessary indications for the procedure but use the anatomic apex of the deformity to choose the level of correction. Since the metatarsal is not deformed, we feel that correction at a proximal level to correct the position of the deviated metatarsal gives the most anatomic result as well as being a convenient location for triplane correction.

Biomechanical Characteristics of Biplane Multiplanar Tension-Side Fixation for Lapidus Fusion

ABSTRACT Although plating on the plantar, tension‐side of the metatarsocuneiform joint provides an inherent biomechanical advantage for Lapidus arthrodesis, it has not been widely adopted owing to the morbidity associated with plantar application. To overcome these limitations, a modification to 90–90 locked biplanar plating was developed to provide the biomechanical advantages of multiplanar fixation and tension‐side fixation, allowing application through a conventional incision. We tested the hypothesis that biplanar plating with tension‐side fixation (low‐profile straight dorsal plate and anatomic medial‐plantar plate) would demonstrate improved mechanical stability compared with a previously tested 90–90 biplanar construct (small straight plate dorsally and medially) under cyclic loading. Both constructs were tested in static load to failure (3 pairs) and cyclic loading (10 pairs) with plantar cantilever bending using surrogate anatomic bone models. With static ultimate failure, the biplanar plate construct with tension‐side fixation failed at a significantly greater failure load than did the straight biplanar plate construct (247.3 ± 18.4 N versus 210.9 ± 10.4 N; p = .04). With cyclic failure testing, the biplanar plate construct with tension‐side fixation endured a significantly greater number of cycles (206,738 ± 49,103 versus 101,780 ± 43,273; p < .001) and a significantly greater dynamic failure load (207.5 ± 24.3 N versus 162.5 ± 20.6 N; p < .001) compared with the straight biplanar plate construct. These results have demonstrated that under simulated static and cyclic Lapidus arthrodesis loading, biplanar plating with tension‐side fixation provides superior strength compared with the straight biplanar construct. Thus, this construct shows promise for clinical application as a practical approach to tension‐side fixation and an early return to weightbearing after Lapidus fusion. Level of Clinical Evidence: 5

Intraoperative Mulitplanar Alignment System to Guide Triplanar Correction of Hallux Valgus Deformity

Hallux valgus surgery or “bunion surgery” is one of the most common surgical procedures for the foot and ankle surgeon. As we continue to gain understanding of this complex deformity, it has become clear that our understanding may be incomplete. The Lapidus procedure was described over 80 years ago and still offers many challenges. Often the choice of a Lapidus procedure is not considered due to the complexity or perceived complications. As the traditional Lapidus procedure relied on multiple freehand steps that can be fraught with error, it was often relegated to be used as a last resort. As our understanding of the hallux valgus deformity has grown it is becoming clear that the anatomic Center of Rotation of Angulation of the deformity may lie at the tarsometatarsal joint. There is also the component of the 3-dimensional nature of the deformity that may be best addressed at this anatomic Center of Rotation of Angulation. With those issues in mind, it was necessary to address the shortcomings of the traditional Lapidus procedure and progress toward more consistent, instrumented steps that could address the 3-dimensional nature of the deformity. Level of Evidence: Level IV—Technique presentation.

Immediate Weight Bearing after Bi-planar Plantar Fixation of Lapidus: A Multi-centered Study

Category: Bunion Introduction/Purpose: There are many options when choosing to repair HAV (hallux abducto-valgus) deformity of the foot. The Lapidus procedure and its modifications are often selected to correct these deformities due to multiplanar correction at the CORA (center of rotational angulation). As with any surgical procedure, there are advantages and disadvantages when selecting the correct technique. One drawback often identified with the Lapidus procedure is the need for extended immobilization and the inability to weight bear for an extended period of time. The objectives of this study were to demonstrate a new, novel construct that can allow for immediate weight bearing after Lapidus arthrodesis with predictable outcomes. Methods: This IRB approved study was comprised of 4 centers that performed a specific modification of the Lapidus procedure with an identical fixation construct. The construct consisted of 2 mini-plates that were applied across the first tarsometatarsal (TMT) joint. The plates were applied while the joint was held in compression. The plates were oriented dorsal and plantar-medial allowing for a greater than 90° spread between plates for appropriate distribution of the forces and a true multi-planar construct. This concept takes into account biplanar stability as described by Kolner[1] and micromotion to stimulate secondary bone healing as described by Perren[2]. All patients were placed into a protective, cushioned dressing with a rigid bottom shoe or boot depending on surgeon preference. The patients were allowed weight-bear as tolerated with walker or crutches for safety as soon as the regional anesthesia dissipated to allow for complete sensation in the operative limb. Results: Twelve months of consecutive cases with immediate weight bearing and minimum follow-up of 6 months were included in the study. All cases that met inclusion criteria were included in the analysis; inclusion criteria were primary corrections of a HAV deformity with correction done via the described technique performed within the approved date range. Procedures not utilizing the described technique, revision procedures and procedures that extended the arthrodesis outside of the first TMT joint were excluded. Conclusion: Preoperative and postoperative measurements of 50 patients were obtained in this study. Radiographic evaluation of the fusion site was used to determine if the arthrodesis demonstrated healing at a minimum of 6 months. Other studies have shown early weight bearing (<3 weeks) is possible after the Lapidus procedure [3], this study demonstrated that immediate weight bearing after a modified Lapidus procedure is possible with a decreased reported nonunion rate (4.0%). This modified procedure did not result in a recurrence of the deformity. We expect continuation of the study to demonstrate that there are no long-term issues.

Implementation and Validation of Anatomic Triplane Hallux Abducto Valgus Classification

Category: Bunion Introduction/Purpose: The most common classification system for HAV deformity is based on two-dimensional radiographs. This system relies upon measurements taken of the transverse plane. (IMA and HVA) to classify and deploy surgical options based on the severity of these angles [1]. Recently, the understanding of HAV deformity as a three-dimensional problem has been described. A study by Kim et al. [2] utilized WB-CT to describe a frontal plane rotational component in 87% HAV cases. To develop a better understanding of HAV, a unique anatomic classification system (see figure) was proposed. The aims of this study were: (1) To use traditional WB radiographs to confirm the findings of Kim’s WB-CT study. (2)To use inter-observer and intra-observer analysis to validate the classification of HAV into this new system. Methods: An Institutional Review Board approved multi-center retrospective study was performed utilizing four view WB radiographs (Anterior-Posterior, Oblique, Lateral and Axial Sesamoid) on patients presenting to the clinic for “bunion,” Hallux Valgus, HAV, Hallux Rigidus or “great toe pain.” The data were analyzed for the presence of frontal/coronal plane rotation of the first metatarsal, subluxation of the sesamoids, metatarsus adductus and degenerative joint disease of the first MTP (metatarsophalangeal) joint (Hallux Rigidus); these findings were compared to Kim’s study. Additionally, these data were used to categorize HAV deformities into a new 3D classification scheme and were tested for inter-observer and intra-observer reliability. Results: The results established the presence of frontal/coronal plane rotation and subluxation in similar ratios as reported by Kim et al. thus confirming the utility of a four-view WB radiograph series in recognition of 3D deformity of HAV. The results also confirmed good reliability of the classification from both the inter-observer and intra-observer standpoint. Conclusion: These data suggest that new protocols and tools are reliable in helping the surgeon recognize and better identify the three-dimensional components of HAV.

Biplanar Plating with an Anatomic Tension-Side Plate for Lapidus Fusion: Improved Biomechanical Properties

Category: Bunion Introduction/Purpose: Fixation with relative stability has been shown to provide a rapid, more biological osseous incorporation than primary bone healing,1 theoretically supporting earlier weight bearing following osteotomy and or fusion. One such relative stability construct is 90-90 biplanar locked plating, which previously demonstrated superior biomechanical properties compared to a traditional Lapidus plate and interfragmentary-screw construct.2 Plantar, tension-side fixation is another approach for improved stability with Lapidus fusion, though the required plantar exposure has limited widespread adoption. Thus, a two-plate construct was designed to provide tension-side fixation and relative stability healing, while allowing application through a conventional incision. We tested the hypothesis that biplanar plating with tension-side fixation (low-profile straight dorsal plate and anatomic medial-plantar plate), would demonstrate improved mechanical stability versus the previously-tested biplanar construct.2 Methods: The straight biplanar plate construct consisted of two straight low-profile locking plates, one placed dorsally and the other medially, 90° to each other. The biplanar plate construct with tension-side fixation consisted of a straight locking plate dorsally and an anatomic tension-side plate wrapping from the medial surface of the cuneiform to the plantar surface of the metatarsal. Both constructs were fixed with 2.5 mm unicortical locking screws with no interfragmentary screw. Standardized surrogate fourth-generation anatomic Sawbones models (Vashon Island, WA) were used; loading was performed in cantilever bending on a Materials Testing Machine (Minneapolis, MN). Constructs were tested in static ultimate failure and ten pairs were tested in cyclic loading, applying a 120 N starting load for the? rst 50,000 cycles and then increasing by 25 N each successive 50,000 cycles until failure or 250,000 cycles was reached. T-tests were used to determine differences in mechanical performance between the two constructs (see figure). Results: For the three pairs of constructs tested to static ultimate failure in plantar cantilever bending, the biplanar plate construct with tension-side fixation failed at a 17% greater ultimate failure load than the straight biplanar plate construct (247.3±18.4 N vs 210.9±10.4 N; p=0.04). For the ten pairs of constructs tested in cyclic fatigue failure in plantar cantilever bending, the biplanar plate construct with tension-side fixation failed at 103% greater number of cycles (206,738±49,103 vs 101,780±43,273; p<0.001) and 35% greater cyclic failure load (207.5±24.3 N vs 162.5±20.6 N; p<0.001) than the straight biplanar plate construct. Conclusion: The results of the current study demonstrate that biplanar plate construct with tension-side fixation significantly improves the biomechanical properties of straight biplanar plating under both static and cyclic loading conditions simulating Lapidus post-operative weight bearing. Designed for application through a dorsal incision, this tension-side construct offers the mechanical advantages of tension-band fixation and biological benefits of relative stability healing, while avoiding the extensive plantar dissection associated with conventional plantar plating. Taken together, this novel construct shows promise for clinical application as a more practical approach to tension-side fixation and early return to weight bearing following Lapidus fusion.

Radiographic Relevance of the Distal Medial Cuneiform Angle in Hallux Valgus Assessment

The angle formed by the distal articular facet of the medial cuneiform has been evaluated and discussed by various investigators. However, no consistent method has been available to radiograph and measure this entity. The wide variability of the angle is not conducive to comparative analysis. Additionally, investigators have noted that the angles observed (obliquity) vary greatly because of changes in radiographic angle, foot position, rotation of the first ray, and declination of the first metatarsal. Recognizing that these variables exist, we propose a reproducible assessment using digital radiography and application of deformity of correction principles. Our results have indicated a mean distal medial cuneiform angle of 20.69° in normal feet, 23.51° with moderate hallux valgus, and 20.41° with severe hallux valgus deformity. The radiograph beam was kept at 15° from the coronal plane. An inverse relationship was found between the distal medial cuneiform angle and bunion severity. This was in contrast to our expected hypothesis. The overall angle of the first metatarsal-medial cuneiform did, however, correlate with the severity of the bunion deformity (p < .000). The obliquity values and intermetatarsal angles changed in direct relationship to the radiographic projection angle. This illustrates the importance of using standardized radiographic projection angles. We conclude that the 1-dimensional standard anteroposterior radiograph with assessment of the distal medial cuneiform angle cannot adequately demonstrate the pathologic features of hallux valgus. A better indicator appears to be the first metatarsal-medial cuneiform angle. This pathologic entity is a 3-dimensional one that incorporates the joint morphology of the first ray, triplane osseous positioning, and soft tissue imbalances. Perhaps, 3-dimensional computed tomography imaging will provide better insight into this entity.