The United States popular toe amputation “beautiful feet”, beautiful big feet to “thin” Shenzhou foot plastic wind, in the United States, every 6 people will have a problem with the feet, and 36% of patients believe that the foot problems have been serious enough to see a doctor. The cost of foot surgery has reached a staggering $200 million. The cost of foot surgery has reached $2 billion per year, resulting in $1.5 billion in man-hours lost.
Foot bones: These include the tarsus (7), metatarsus (5), and phalanges (14).
The main clinical manifestation is lateral deviation of the bunion, or in severe cases, lateral subluxation. The first metatarsal is deviated medially, and the first metatarsal head protrudes significantly medially. The metatarsal head and soft tissues are subjected to long-term compression and abrasion by shoes, which can form a bony bunion. In terms of x-ray performance, the normal first and second intermetatarsal angles (IMA) are no greater than 9° and the bunion angle (HA) is no greater than 15°. Accordingly, bunions are classified into three types: mild deformity (bunion angle greater than normal but less than 20°, intermetatarsal angle less than 11°), moderate deformity (bunion angle between 20° and 40°, intermetatarsal angle between 11° and 18°) and severe deformity (bunion angle greater than 40°, intermetatarsal angle greater than 18°). In contrast, the simple medial bulge of the first metatarsal head is actually the result of abnormal osteophytes. Bunion, on the other hand, is a medial exposure of the metatarsal head due to outward dislocation of the metatarsophalangeal joint. The main feature is the abnormal first and second intermetatarsal angles. Therefore, a simple osteophytic bigfoot may look sexy, but a bunion with an abnormal pinch angle looks less aesthetically pleasing. In the past, the main goal of patients seeking treatment was to resolve the pain, but recently, many young women are seeking treatment simply for the aesthetic appearance of their feet. The treatment of bunions has attracted more and more attention from plastic surgeons.
The surgical treatment of bunions has received widespread attention as early as the late 18th century, but there was no definitive method until the early 20th century, when the Keller procedure emerged as the main surgical method for bunion correction at that time. In the subsequent treatment of bunions, there were numerous surgical approaches, most of which did more harm than good and were no longer used clinically. Some procedures have been proven effective and have been continuously improved and incorporated into modern treatment methods.
The following surgical procedures are available to correct bunions.
Conservative treatment
Conservative treatment is theoretically ineffective and to date no conservative treatment has been able to cure bunions. However, it can reduce symptoms and slow progression.
First metatarsophalangeal arthroplasty
This type of surgery is represented by the Keller and Mayo procedure, which is the representative procedure of first metatarsophalangeal arthroplasty and was the main method of bunion correction in the early 20th century. The Keller procedure corrects the bunion deformity by removing the flexion forces within the first metatarsophalangeal joint, but this arthrodesis often causes other metatarsalgia or painful hyperkeratosis, or even stress fractures. The Keller procedure is generally considered to be primarily indicated for older adults who cannot perform extensive joint reconstruction due to degenerative changes in the joint and contraindications posed by systemic health conditions. The Heuter Mayo procedure is a type of metatarsophalangeal arthroplasty and was first reported by Heruer [4] in 1871 to correct a bunion deformity.Mayo (1908) noted other metatarsal complications due to excessive reduction of the first metatarsal weight-bearing of this procedure and recommended the use of a Mayo (1908) noted the other metatarsalgia complications of this procedure due to excessive reduction of the first metatarsal bearing and suggested a modified first metatarsal head arthroplasty. The Mayo procedure has been rarely used in modern treatments for bunions and is now used primarily in the repair of rheumatoid deformities of the forefoot.
Bunion removal and soft tissue surgery
In 1932, Silver noted that the medial bulge of the first metatarsal head was not actually the result of abnormal osteophytes, but was more likely the result of an outward dislocation of the metatarsophalangeal joint resulting in medial exposure of the metatarsal head. The Silver procedure is the simplest bunionectomy, and he believes that permanent correction of the deformity can be achieved through robust repair of the soft tissue of the medial joint capsule. In fact, robust repair of the medial joint capsule of the metatarsophalangeal bunion joint is an aspect to be considered in any bunion surgery, but it is difficult to achieve the desired permanent repair by relying solely on soft tissue repair.The McBride procedure is the representative procedure for soft tissue repair techniques in bunion correction and has been widely used to date, having been first described by McBrides [7] in 1928. The principle is to remove the lateral elements of the bunion, move the bunion tendon to the lateral aspect of the first metatarsal head, and remove the lateral seed bone and the prominent bone of the medial metatarsal head. It works by not only removing the bunion deformity factor but also having an energetic muscle to pull the first metatarsal, thus correcting the inversion deformity.McBride procedure is a soft tissue procedure, so it is not suitable for severe bunion deformity and is prone to recurrence after surgery and has a high chance of bunion after surgery.
Distal first metatarsal osteotomy (now the most commonly used)
The ideal metatarsal osteotomy should have the following characteristics.
(1) High orthopedic capacity and easy adjustment and control;
(2) Rapid healing and minimal non-healing;
(3) The osteotomy surface should have good intrinsic stability;
(4) The shortening of the metatarsal bone after osteotomy should be low and not cause metatarsal elevation, while excessive shortening or metatarsal head elevation can cause metastatic metatarsalgia.
The main representatives are Reverdin, Mitchell, Wilson, Austin, and small incision. The distal first metatarsal osteotomy is the most popularly used of all bunion correction techniques. A major feature of this type of surgery is the relaxation of the contracted soft tissue that spans the head and neck of the first metatarsal and the metatarsophalangeal joint. The osteotomy effectively reduces the stereotaxic volume of the intra-articular portion of the metatarsal head capsule, and this volume reduction eliminates the lateral metatarsal contracture of the metatarsophalangeal joint. In addition, distal osteotomies can control the position of the metatarsal heads. However, a common problem with these procedures is the shortening of the first metatarsal, which alters the weight-bearing function of the metatarsal portion, and the dorsal displacement that occurs after the osteotomy, which leads to pain in the other metatarsals. The main procedures that fall into this category are the Reverdin procedure, Mitchell procedure, Wilson procedure, Austin procedure, and small incision procedure.
In 1881, Reverdin introduced the internal wedge osteotomy of the first metatarsal head. In 1958, Mitchell [9] introduced a classical transverse orthopedic osteotomy, in which the lateral bony cortex is not broken and the bunion is pushed inward, so that the lateral joint capsule acts as a hinge and the medial joint capsule is sutured to fix the osteotomy surface. Mitchell’s procedure is mainly suitable for elderly patients with moderate to severe bunion deformity, with the angle between the first and second metatarsal bones exceeding 10°, while it is contraindicated for patients with a short first metatarsal bone or significant degenerative changes in the metatarsophalangeal joint or bunion stiffness are contraindicated.
The Wilson procedure is an oblique osteotomy of the first metatarsal neck, which allows for outward displacement and shortening of the metatarsal head, and was first introduced by Wilson in 1963 and was popularized as the procedure with the smallest incision at that time. The basic principle of Austin’s procedure is to perform a “V” shaped osteotomy of the first metatarsal head and neck and to shift the first metatarsal head outward, i.e., the Chevron osteotomy. In 1981, Austin summarized more than 1,200 patients since 1962 and concluded that the Chevron osteotomy was effective in treating bunions, with no complications of ischemic necrosis of the metatarsal heads in all cases, and a few cases of other metatarsalgia, which was analyzed to be due to shortening of the first metatarsal bone. Austin bunionectomy can be chosen over other osteotomies for several reasons.
This procedure is easy to perform and has few complications. Because the morphology of the osteotomy surface and its distal apex produce a short force arm for weight-bearing displacement, this osteotomy is intrinsically stable and allows early weight-bearing even with bilateral surgery. Because of the large area of cancellous interosseous contact, nonunion or delayed healing is rare. In 1991, Van-Enoo reported the use of a small incision in the medial aspect of the first metatarsophalangeal joint to perform osteotomy of the distal head of the first metatarsal and resection of the soft tissue of the medial bunion for the treatment of mild to moderate bunion deformity. 58 cases were followed up for a maximum of 12 years, and the results were considered good and safe. Due to the advantages of small incision, simple and convenient external fixation, and relatively satisfactory orthopedics, it is very popular among patients, especially young female patients whose main purpose is foot aesthetics. The technique of minimally invasive treatment of bunions with small incisions is now also receiving increasing attention from plastic surgeons.
Proximal first metatarsal osteotomy
The inversion of the first metatarsal and the increased angle between the first metatarsal are important causative factors of bunion deformity. For patients with severe bunion deformity, bunion angle of 35° or more, and first and second intermetatarsal angles greater than 10°, especially those who reach or exceed 30°, proximal osteotomy is a better option to correct the first metatarsal inversion deformity through osteotomy, thus correcting the bunion. The main problems of proximal osteotomy of the first metatarsal are postoperative shortening and elevation of the first metatarsal, in addition to the bunion inversion Complications.
Proximal Bunion Osteotomy
Akin first introduced the proximal phalangeal wedge osteotomy in 1925 to correct bunion abduction and valgus deformity. The main point of the procedure is to perform an inward wedge osteotomy at the basal metaphysis of the proximal phalanx of the bunion to correct severe distal joint angulation. The Akin procedure is effective for mild painless bunions with significant deformity of the proximal phalanx or mild recurrent bunion deformity combined with overlapping of the second toe, but is limited by its inability to correct true bony deformity alone, and is often ineffective in correcting severe bunions with increased intermetatarsal angles. The surgical results are often unsatisfactory in the correction of severe cases of bunion and increased intermetatarsal angles. The current trend is to use the Akin procedure as an important adjunct to the first metatarsal base or distal osteotomy or even in combination with soft tissue surgery.
Articular fixation or arthroplasty
This includes first metatarsophalangeal joint fixation and first metatarsocuneiform joint fusion. First metatarsophalangeal joint fixation is a reliable procedure with good long-term results in the correction of severe bunion abduction, bunion stiffness, and progressive first metatarsophalangeal joint degeneration, and is particularly useful in the correction of severe deformities. The representative procedure is the Mckeever procedure, which was reported by Mckeever in 1952 and consists of resection of the metatarsal and phalangeal articular surfaces, fusion of the metatarsophalangeal joint, and fixation with cortical screws. This procedure maintains the length of the first metatarsal, reduces the incidence of lateral metatarsal pain, and saves the other toes from further deformity. Relative contraindications to surgery include distal interphalangeal arthritis and proximal metatarsal cuneiform arthritis or ankylosed feet. Because of the fixation of the metatarsophalangeal joint, the symptoms of interphalangeal arthritis can be exacerbated. Its main disadvantage is the long immobilization time, which takes about 8 weeks, until bony healing. Indications for first metatarsal cuneiform joint fusion include severe hypermobile first metatarsal inversion, first metatarsal cuneiform arthritis, and elective revision surgery. This fusion, combined with distal soft tissue realignment, has been used with good results in the correction of bunions and is represented by the Lapidus procedure, which was first described in 1934 for the first metatarsal cuneiform joint fusion for severe bunions. The key to the procedure is to fuse the metatarsocuneiform joint in a mild plantarflexion position, which prevents lateral metatarsalgia. the Lapidus procedure has gained some popularity and has been used as a remedial procedure after other procedures have failed to treat bunions. However, this procedure has some shortcomings, with partial shortening of the first metatarsal phalanx and metastatic other metatarsalgia being its main postoperative complications.
Summary
Surgical treatment of bunions has a long history with hundreds of surgical approaches, most of which have been abandoned because of the severe trauma they cause, the high recurrence rate, and the instability of surgical results. Some controversial surgical approaches, such as the Scarf osteotomy, which was introduced in the 1980s to treat various degrees of bunions by performing a “Z” osteotomy on the first metatarsal, have had mixed results and complications and are still under further observation. The various surgical methods mentioned in this article have their own indications and contraindications, as well as varying degrees of complications, and therefore a combination of surgical approaches is recommended for the treatment of bunion deformities.
Bone removal alone is not beneficial in the treatment of bunions
The history of surgical treatment of bunions is more than 100 years old, and there are more than 200 different methods. Moreover, the so-called bunion is a part of the metatarsal head that should not be removed. The cause of bunions is mostly genetic. It is not the bunion itself that is inherited, but the cause of the bunion, which is why it is absent or very mild when you are young and only appears or worsens when you are older. In a normal person, the bunion can remain in a neutral position because of the dynamic balance of the bunion retractor and bunion extensor muscles on the inside and outside of the bunion. In bunion patients, abnormalities in the soft and bone tissue structure around the metatarsophalangeal joint disrupt this balance and lead to the development of the bunion. Treatment of bunions is about restoring this balance biomechanically with soft tissue and bone tissue surgery. The history of bunion treatment in the United States for more than 100 years has shown that simply removing the bones is detrimental to the patient and creates problems for subsequent osteotomies, while the Austin transverse V-slide osteotomy of the distal metatarsal is one of the most effective methods of treating bunions with the least complications.
How to look at minimally invasive or small incision bunion correction
There are two general categories of bunions: positional deformities, in which there is only a simple increase in the valgus angle, and structural deformities, in which in addition to a larger valgus angle, there is also a larger distal joint fixation angle, proximal joint fixation angle, and intermetatarsal angle. Positional deformities are purely soft tissue disorders and can be identified by different levels of joint disorders. This deformity is often the result of a dynamic imbalance of the seed bone structure. The resulting bunion abduction exerts a reverse force on the first metatarsal, which can increase the intermetatarsal angle by 2-4°. Correction of soft tissue disorders through tendon balancing surgery can often correct this type of deformity. However, the use of soft tissue correction alone is prone to undercorrection or deformity recurrence. Structural deformity of the first metatarsal toe is best measured by the proximal joint fixation angle and the first intermetatarsal angle. Many types of osteotomies have been designed to reduce this deformity. Each method has its advantages and disadvantages and should be selected based on the patient’s specific situation and the operator’s experience with the condition. The ideal metatarsal osteotomy should have the following characteristics.
(1) High orthopedic capacity and easy adjustment and control;
(2) Rapid healing and low non-healing rate;
(3) The osteotomy surface should have good intrinsic stability;
(4) The shortening of the metatarsal bone after osteotomy should be minimal and should not cause metatarsal elevation, while excessive shortening or elevation of the metatarsal head can cause metastatic metatarsalgia.
Akin [16] first introduced the wedge osteotomy of the proximal phalanx of the bunion in 1925 to correct bunion abduction and valgus deformity. The main point of the procedure is an inward wedge osteotomy at the basal metaphysis of the proximal phalanx of the bunion to correct severe distal joint angulation. The Akin procedure is effective for mild painless bunions with significant deformity of the proximal phalanx or mild recurrent bunion deformity combined with overlapping of the second toe, but is limited by its inability to correct true bony deformity alone, and is often ineffective in correcting severe bunions with increased intermetatarsal angles. The surgical results are often unsatisfactory in the correction of severe cases of bunion and increased intermetatarsal angles. The current trend is to use the Akin procedure as an important adjunct to the first metatarsal base or distal osteotomy or even in combination with soft tissue surgery.
Reverdin introduced the intra-cuneiform osteotomy of the first metatarsal head. The principle of the procedure is to remove the medial tuberosity of the first metatarsal head, make a wedge-shaped osteotomy on the proximal side of the articular surface of the first metatarsal head, leaving the lateral cortex unbroken and pushing the bunion inward, at which point the laterally attached portion of the cortex breaks off, allowing the lateral joint capsule to act as a hinge, and the medial joint capsule is sutured to hold the osteotomy surface in place. This procedure is mainly to correct the proximal joint fixation angle.
The distal osteotomy of the first metatarsal is the most popular of all bunion correction techniques. A major feature of this type of surgery is the relaxation of the contracted soft tissue that spans the head and neck of the first metatarsal and the metatarsophalangeal joint. The osteotomy effectively reduces the stereotaxic volume of the intra-articular portion of the metatarsal head capsule, and this volume reduction eliminates the lateral metatarsal contracture of the metatarsophalangeal joint. In addition, distal osteotomies can control the position of the metatarsal heads. However, a common problem with these procedures is the shortening of the first metatarsal, which alters the weight-bearing function of the metatarsal portion, and the dorsal displacement that occurs after the osteotomy, which leads to pain in the other metatarsals. The main procedures that fall into this category are the Reverdin, Mitchell, Wilson, Austin, and small incision procedures. This type of surgery focuses on the correction of the interphalangeal angle.
The minimally invasive or small incision bunion correction procedures that are popular nowadays consist of two elements: first, soft tissue surgery, with bunion tendon severance, lateral soft tissue release and medial measurement of joint capsule strengthening. The second is osteotomy, mainly phalangeal osteotomy and distal metatarsal osteotomy. The distal metatarsal osteotomy is similar to Wilson’s surgery, which is an oblique osteotomy of the first metatarsal neck that allows outward displacement and shortening of the metatarsal head, and was first introduced by Wilson in 1963 and was promoted as the procedure with the smallest incision at that time. The main problems are excessive shortening of the first metatarsal, recurrence of the deformity, and other metatarsalgia. Late complications were as high as 33%.
Conclusion: Minimally invasive or small incision bunion correction is only suitable for patients with mild to moderate positional deformities.
My approach
1, Silver surgery or minimally invasive surgery:excision of the bunion, release of the lateral soft tissue of the joint and detachment of the bunion tendon, and firm repair of the medial joint capsule, suitable for patients with a young age and a mild disease course.
2. Keller surgery: Removal of the base of the proximal phalanx to eliminate the bending force within the first metatarsophalangeal joint and correct the bunion deformity, and the surgery can shorten the bunion. It is only suitable for slightly older patients.
3.Austin surgery (structural correction): This method is one of the most advanced methods internationally and is the most commonly used method in the United States. Its innovation lies in the use of an axis-guided technique to perform a V-shaped osteotomy of the first metatarsal head and neck. It is suitable for mild to moderate patients of any age. Compared with other traditional methods, it has the advantages of less damage, no cast, faster healing, less pain, minimal complications, ability to move on the ground after surgery, and good long-term results, and is at the leading level at home and abroad.