03/05/2019    Don Peacock, DPM, MS

IM angle correction from Austin Bunionectomy (Greg Caringi, DPM)

I agree with most of what the posters have said in
this thread. I strongly disagree with the premise
that the Lapidus bunion surgery correction is
better than the Austin bunion correction. It
depends on what the deformity is and what the
goals are for both the surgeon and the patient. If
you use only one bunion surgical procedure for
every HAV deformity, you will experience unwanted
failures and this is proven in the literature.

We know that the head osteotomy is a good
procedure in HAV correction with IM deformities up
to 17. It can be used with a proximal phalanx
osteotomy giving excellent HAV results. Correcting
IM will help stabilize the 1st ray in many
patients. For larger IM angles, going proximal
makes perfect sense.

Which osteotomy or fusion type to choose based on
IM angle and its effectiveness has been reported
multiple times in the literature. Our procedures
should be chosen based on what we are trying to
achieve. For example, if you have a patient with
an IM angle of 22 and an excessively large PASA
deformity. It would be difficult to try to
correct it with only a Lapidus. You would not
correct one of the major components of this
particular HAV deformity which would be your PASA.
This does get rather complicated since the idea of
PASA cannot be readily assessed with x-ray alone.

I definitely agree that the Lapidus gives a nice
stable construct in a patient with medial column
instability. However, even this is not the only
way to correct this issue. We can even choose the
double osteotomy for extreme IM correction and
there are other ways of establishing stability.
For example, I have successfully treated large IM
bunions utilizing the minimally invasive Reverdin-
Isham head osteotomy in combination with a medial
wedge cotton bone graft procedure with excellent
results and a more stable medial column. By
performing this procedure we are not destroying
joints as a caveat and establishing length in the
1st metatarsal lost with the head osteotomy. There
are so many good approaches that this answer could
go on and on.

More importantly it depends on what the foot type
is. If you have a rigid deformity and rigid first
Ray the addition of a Lapidus would do nothing
except correct your IM angle and you will be left
with ongoing HAV. These patients do exist and have
bunion deformities despite their rigid first Ray.
There's just too many factors to take into account
to limit your HAV practice to one procedure or one
philosophy.

I have done numerous flexible HAV deformity
patients with a flexible rear foot in which I
stabilized the rear foot with a subtalar joint
implant and performed a head osteotomy with both
improvement in the patient's satisfaction and
radiological results. Literally the list goes on
how we can correct HAV deformity and get good
results. One size does not fit all.

I do not want to leave the impression that I'm
against the Lapidus procedure since I am aware
that is a great procedure and I perform it. I have
done a number of re-do Lapidus and proximal
osteotomy patients in which the proximal work
failed to completely correct the deformity (my own
patients and others). The Lapidus will never be
the only HAV procedure and is not the only way to
skin a cat.

Don Peacock, DPM, Whiteville, NC

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